Abstract for: Using Group Model Building to Identify Drivers and Levers of the Double Burden of Malnutrition in Cape Town, South Africa

The double burden of malnutrition (DBM) is a substantial threat in South Africa. The DBM arises from interactions between people, the food environment, and wider socio-economic and political contexts that influence food systems and dietary behaviors. Our study used group model building with multi-sectoral stakeholders in Cape Town, South Africa to develop causal loop diagrams of the drivers of the DBM across the micro- (individual, household) and meso- (community, local policy) level. We conducted 35 in-depth interviews with stakeholders across the micro-level (community health workers and their coordinators) and meso-level (academics, NGO representatives, and city and provincial government employees) to gather perspectives on drivers of the DBM. These data were then used to develop seed models for group model building workshops at micro- and meso-level and formed the basis of the causal loop diagrams. Two causal loop diagrams were developed with stakeholders and then iteratively refined by the research team. Stakeholders at the micro-level described drivers of the DBM in areas such as access to resources, personal and external food environment determinants, and community relationships. Across the meso-level, stakeholders described drivers relating to commercial determinants of health, governance principles, policy development, and social and equity awareness. Stakeholders used initial maps to propose leverage points. Stakeholders at the micro-level proposed levers relating to advocacy with ward councilors for changes to liquor permitting and food safety inspections, increasing access to food gardens, and strengthening nutrition literacy of community health workers. At the meso-level, levers focused on the areas of regulating food marketing, mobilizing civil society, increasing transparency of the influence of the corporate sector, supporting evidence uptake in agenda setting, and developing structures to enable a healthier food environment.