This document summarizes research aimed at identifying systemic barriers preventing children in New Zealand from meeting fruit and vegetable intake guidelines. The researchers conducted cognitive mapping interviews with national food system actors and community workshops to understand barriers and propose solutions. Key barriers identified included negative perceptions of high produce prices, low family incomes, lack of time to purchase and prepare fruits and vegetables, and more marketing of junk food compared to produce. Proposed equitable solutions focused on expanding free fruit and vegetable school programs, subsidizing produce to lower prices, and restricting fast food marketing and availability near low-income neighborhoods.

1. Improving health equity by
addressing systemic barriers
to children’s nutrition
Dr Sarah Gerritsen
23rd World Conference on Health Promotion, Rotorua, April 2019
@sarahtweetle #IUHPE2019

2. 0
10
20
30
40
50
60
70
2012/13 2013/14 2014/15 2015/16 2016/17 2017/18
Proportion of 2-14 year olds (%)
Māori NZ-Euro/Other Pacific Asian
What proportion of NZ children meet fruit
and vegetable recommendations?
Source: New Zealand Health Survey, Ministry of Health

3. Aims of the research:
1. Identify current systemic barriers for children
aged 2-14 years to meeting the FV guidelines
2. Catalyze action on equitable interventions
which would improve children’s nutrition by
increasing FV intake.
System dynamics
methods
1. Cognitive
mapping interviews
with national actors
2. Community
group model
building

4. Cognitive mapping interviews
22 national actors, 5 different sectors of the food system:
Growers and produce industry, retail sector, health
promotion orgs, local and central government.
Interview process
Show graph of declining FV intake in children
and ask:
1. primary causes of pattern?
2. consequences if pattern continues?
3. consequence if pattern changes
(improved FV)?
4. how to bring about change?
Cognitive map is drawn while they are talking.

5. Composite cognitive
map from interviews
with national food
system actors
Drivers
Gerritsen, S. et al (2019, In Press) Int J Environ Res Public Health

6. Common themes from cognitive
mapping about barriers to eating FV
Theme Representative quote
Negative perceptions
about high price of FV
“Sure, cauliflower was $10, but you could still buy lettuce for 99 cents. When
people talk about the price, they’re not talking about if it’s old-season, new-
season, the quality or anything like that”
Low income and small
family food budgets
“…the difficulty of bringing up a family on current incomes where there hasn’t
been much of a move while costs have gone up and up… food is the last item
that you buy after rent, the bills, the outstanding debts.”
Lack of time to purchase
and prepare FV
“Although FV are very convenient, there’s an idea that takeaway foods are
more convenient, and you wouldn’t be getting lots of vegetables in takeaways
unless you choose very carefully.”
Lack of marketing of FV
compared to junk food
“You still see these big sponsors of huge events, like Coca-Cola Christmas in the
Park. We can’t match that, but that’s what we’re up against”
Urban sprawl “A grower sold all that land which is now developed with roads, no houses yet,
just roads, for 10 million. And of course, that’s really tempting.”

7. Community group model building
Workshops with 17 members of West Auckland local community
(parents, high school students, teacher, community leaders, public health
nurse, supermarket employee, caterer) to create a causal loop diagram
about barriers and solutions to FV intake in children.

8. AUCKLAND
Children (aged 2-14 years) eating 2 serves of
fruit and 3 serves of vegetables daily
Source: 2016/17 New Zealand Health Survey

9. Workshop 1
Changes over
time in their
community
Workshop 2
Causality
Workshop 3
Points for
intervention
Group model
building

10. 10

11. 11
“How do you change what is sold right
outside the school gates? … what
they’re selling is not good for our kids.”
“When I open the Uber Eats app
there are 117 places that can
deliver me food in 20 mins and
none are a healthy choice.”

12. Community
licences/
stickers for
healthy
outlets
Community solutions
‘Healthy
living bus’ at
community
events
Talk to local
MP about the
issue and
free fruit in
all schools
Sharing
healthy food
at church
and marae
School trips to
supermarket to
learn about
fresh F+V
Community
workshops:
• Gardening
• Bootcamps
• Cooking
• Holistic
wellbeing
Change school
BOT food
policies and
more children’s
books about F+V

13. Solutions proposed by food system actors
Bold = Suggested in a quarter or
more of interviews
Adams, J. et al. 2016 PLoS Medicine

14. Solutions proposed by food system actors
Adams, J. 2016 PLoS Medicine
Most likely to improve
equity (theoretically)

15. Solutions proposed by food system actors
Yellow tick = strong evidence that effective and equitable
Adams, J. 2016 PLoS Medicine

16. Summary
System dynamics methods were successful at engaging research
participants to explore barriers, and catalyzed local action to improve
children’s nutrition (partnership with local organisation key to success)
To ensure equitable solutions were proposed, researchers needed to
check suggested interventions against theory and evidence base.
Recommendations:
• Extend free FV school
programmes
• Subsidize FV (remove tax)
• FV in early childhood and
school curriculum
• Restrict fast food marketing
and density of outlets in
low socioeconomic
neighbourhoods

17. Researchers:
Dr Sarah Gerritsen
Dr Wilma Waterlander
Dr Ann Bartos
Sophia Harré
Ana Renker-Darby
Dr David Rees
Professor Boyd Swinburn
Acknowledgements
Kerry Allan
Debbie Raroa
Michele Eickstaedt
Zaynel Sushil
Explorer Grant #16/656
Contact
s.gerritsen@auckland.ac.nz
@sarahtweetle
Piha beach, West Auckland
Funder:

18. What proportion of NZ children meet
fruit and vegetable recommendations?
18
0
10
20
30
40
50
60
70
2012/13 2013/14 2014/15 2015/16 2016/17 2017/18
Proportion of 2-14 year olds (%)
Quintile 1-3 (least deprived) Quintile 4 Quintile 5 (most deprived)