{"id":7999,"date":"2026-04-03T10:23:18","date_gmt":"2026-04-03T10:23:18","guid":{"rendered":"https:\/\/www.proefschriftmaken.nl\/portfolio\/joline-wierda\/"},"modified":"2026-04-23T09:06:56","modified_gmt":"2026-04-23T09:06:56","slug":"joline-wierda","status":"publish","type":"us_portfolio","link":"https:\/\/www.proefschriftmaken.nl\/en\/portfolio\/joline-wierda\/","title":{"rendered":"Joline Wierda"},"content":{"rendered":"","protected":false},"excerpt":{"rendered":"","protected":false},"author":8,"featured_media":14190,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_acf_changed":false,"footnotes":""},"us_portfolio_category":[45],"class_list":["post-7999","us_portfolio","type-us_portfolio","status-publish","has-post-thumbnail","hentry","us_portfolio_category-new-template"],"acf":{"naam_van_het_proefschift":"The food environment in hospitals and long-term care facilities","samenvatting":"Er is geen Nederlandse samenvatting beschikbaar. De Engelse samenvatting vind je <a href=\"https:\/\/www.proefschriftmaken.nl\/en\/portfolio\/joline-wierda\/\">hier<\/a>.","summary":"There is growing attention to nutrition in healthcare settings (i.e., hospitals and long-term care facilities), with healthy nutrition increasingly recognized as one of the key solutions to improve health and support recovery. Improving the food environment, i.e. the surroundings, opportunities and conditions that influence people\u2019s food and beverage choices and nutritional status, can not only confer health and well-being benefits to patients, staff, and visitors, but also planetary benefits by offering more sustainable food and beverage options. Paradoxically, the healthcare setting does not always provide healthy food options, and may contribute to conditions they aim to prevent, manage or cure. Hospitals and long-term care facilities can fulfil an exemplary role in promoting health, via improvement of their food environment and making the healthy and sustainable choice the easy choice for patients, staff, and visitors. More recently, the importance of the food environment is increasingly recognized in the healthcare setting. However, there is a lack of knowledge about the food environment in healthcare settings and to what extent a shift towards healthy and sustainable food environments is ongoing. Therefore, the main aim of this thesis, as introduced in Chapter 1, was to gain insight into the food environment within the Dutch healthcare setting and to identify which factors, mechanisms, and actions contribute to shifting to a healthy and sustainable food environment in hospitals and long-term care facilities.\n\nChapter 2 provides a comprehensive characterization and comparison of the physical, socio-cultural, political and economic food environment in hospitals and long-term care facilities for patients, staff, and visitors. Semi-structured interviews were conducted with staff of hospitals and long-term care facilities to assess the food environment and staff of hospitals and long-term care facilities self-audited the food environment within their organization with a checklist. Results show that the food environment in the Dutch healthcare setting varies substantially and disclose differences and similarities between hospitals and long-term care facilities. The physical dimension of the food environment in the healthcare setting was affected by various factors, such as availability of facilities, logistic limitations and physical space. For example, hospitals and larger long-term care facilities featured more often restaurants and utilized central spaces for preparation of meals, while smaller long-term care facilities often operated as household-like settings. The type of healthcare setting shaped the socio-cultural food environment, with hospitals primarily emphasizing nutrition for fast recovery, while long-term care facilities more often used nutrition as an instrument (i.e., to structure the day of patients). The findings showed that most hospitals and long-term care facilities had a written policy, but that adequate implementation and receiving broad organizational support were important to operate effectively. Commercial interests, profit motives, contracts with external parties and strict budgets characterized the economic food environment and shaped the food available within hospitals and long-term care facilities. The results show that for designing effective approaches for the implementation of food environment improvements, it is imperative to incorporate various healthcare types, as well as patients, staff, and visitors and to attain sustainability alongside healthiness.\n\nChapter 3 provides a comprehensive, collectively acknowledged understanding of the system dynamics underlying the food environment in Dutch long-term care facilities. Stakeholders from five different long-term care facilities in the Netherlands participated in two GMB workshops and stakeholder perspectives about the process and progress towards action implementation were evaluated up to one-year follow-up. The created causal loop diagram (systems map) illustrated the causal structures and complexity of the food environment in long-term care facilities. The factors in the causal loop diagram could be divided over four subsystems, namely 1) the patient; 2) the healthcare organization; 3) purchasing, procurement, and budget; and 4) national governance and policy. Furthermore, participants identified 40 actions at different systems levels that could contribute to a system that promotes a healthy and sustainable food environment for patients, staff, and visitors. The one-year follow-up showed that actual implementation of actions and system change remained challenging. This illustrates that changing the food environment is a slow and long-term process and likely requires the inclusion of all stakeholders (system architects and users, e.g. policy makers, health care staff, suppliers) to foster impactful change.\n\nChapter 4 gives insight into factors influencing the implementation of a healthy and sustainable food environment in the hospitals setting. Three hospitals were participating in the national Dutch program \u2018A Taste of Excellent Healthcare\u2019 (TEH) and committed to have a healthy and sustainable food environment. The interviews with a variety of stakeholders (i.e. facility professionals, healthcare professionals, project coordinators and board of directors) in these three hospitals identified multiple influencing factors in various domains within and outside the hospital, ranging from internally available resources to external government established guidelines and from the personal drive of key stakeholders to societal momentum for change. The diverse stakeholder interests and experiences confirm again that changing the food environment in the hospital setting is complex, showing that it is important to ensure that all stakeholders throughout the entire organization are motivated and aligned when it comes to the realization of a healthy and sustainable food environment.\n\nThe implementation of actions for a healthy and sustainable food environment in diverse TEH hospitals and long-term care facilities was examined in Chapter 5. Hospitals and long-term care facilities participating in the national Dutch program TEH and committed to have a healthy and sustainable food environment were monitored and it was explored to what extent actions were implemented after one-year of commitment to the TEH program. After one year, the results showed that the largest improvements in the food environment of hospitals and long-term care facilities occurred in policy actions that support the creation of a healthy and sustainable food environment (e.g., having food a vision). Little action implementation was observed in the actual food offering (e.g., healthier food offerings) after one-year follow-up. Most of the action implementation was observed in the food environment of patients and less of staff and visitors. The findings underline that for actual realization of a healthy and sustainable food environment for patients, staff, and visitors, more time is required, as well as continuous monitoring and additional efforts.\n\nChapter 6 provides a reflection on the results of the studies presented in the previous chapters in terms of the contribution to knowledge development and the embedding of the findings within the broader literature. Moreover, methodological considerations, recommendations for practice and policy and future research priorities are discussed. Concluding, this thesis showed that the healthcare food environment is unique and complex and varies substantially within and between hospitals and long-term care facilities. The transformation of the healthcare food environment towards a healthy and sustainable food environment is commencing, however, this needs further shifting. To foster impactful change for healthy and sustainable food environments in the entire Dutch healthcare landscape, it is imperative to take a systems lens, incorporate all healthcare settings and engage all stakeholders. Moreover, it is important to extend the focus beyond patients and encompass the food environment for staff and visitors, and attain sustainability alongside healthiness of healthcare food environments. More structural actions and continuous monitoring are needed for system change of the healthcare food environment, thereby eventually contributing to transform the healthcare setting into a health promoting environment.","auteur":"Joline Wierda","auteur_slug":"joline-wierda","publicatiedatum":"2 juli 2025","taal":"NL","url_flipbook":"https:\/\/ebook.proefschriftmaken.nl\/ebook\/jolinewierda?iframe=true","url_download_pdf":"","url_epub":"","ordernummer":"FTP-202604031019","isbn":"","doi_nummer":"","naam_universiteit":"Wageningen University","afbeeldingen":14190,"naam_student:":"","binnenwerk":"","universiteit":"Wageningen University","cover":"","afwerking":"","cover_afwerking":"","design":""},"_links":{"self":[{"href":"https:\/\/www.proefschriftmaken.nl\/en\/wp-json\/wp\/v2\/us_portfolio\/7999","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.proefschriftmaken.nl\/en\/wp-json\/wp\/v2\/us_portfolio"}],"about":[{"href":"https:\/\/www.proefschriftmaken.nl\/en\/wp-json\/wp\/v2\/types\/us_portfolio"}],"author":[{"embeddable":true,"href":"https:\/\/www.proefschriftmaken.nl\/en\/wp-json\/wp\/v2\/users\/8"}],"replies":[{"embeddable":true,"href":"https:\/\/www.proefschriftmaken.nl\/en\/wp-json\/wp\/v2\/comments?post=7999"}],"version-history":[{"count":1,"href":"https:\/\/www.proefschriftmaken.nl\/en\/wp-json\/wp\/v2\/us_portfolio\/7999\/revisions"}],"predecessor-version":[{"id":8000,"href":"https:\/\/www.proefschriftmaken.nl\/en\/wp-json\/wp\/v2\/us_portfolio\/7999\/revisions\/8000"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/www.proefschriftmaken.nl\/en\/wp-json\/wp\/v2\/media\/14190"}],"wp:attachment":[{"href":"https:\/\/www.proefschriftmaken.nl\/en\/wp-json\/wp\/v2\/media?parent=7999"}],"wp:term":[{"taxonomy":"us_portfolio_category","embeddable":true,"href":"https:\/\/www.proefschriftmaken.nl\/en\/wp-json\/wp\/v2\/us_portfolio_category?post=7999"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}