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.