How local stakeholders view the complex system underlying socioeconomic inequalities in health in the Netherlands - A group model building study

Introduction Socioeconomic inequalities in health remain a major public health concern. A complex systems perspective can help identify intervention opportunities beyond traditional health promotion strategies, which often focus on lifestyle behaviours. This study explores how experts, including individuals with lived experience of disadvantage, perceive the key dynamics within the complex system underlying socioeconomic health inequalities in the Netherlands. Methods Eight participants – residents of disadvantaged neighbourhoods, local policymakers, welfare professionals, and a municipal researcher – took part in three group model building sessions in Eindhoven in January 2024. Using established scripts, they identified drivers of socioeconomic health inequalities and developed a causal loop diagram (CLD). Qualitative analysis of session transcripts and the CLD helped identify key subsystems and the system's underlying paradigm. Results Participants produced a CLD comprising 34 elements, 100 causal links, and 1726 feedback loops. The diagram illustrates how environmental exposures, livelihood security, chronic stress, suitable work, skills, migration background, sense of belonging, and health interact within a highly interconnected system. Four subsystems were identified: (1) physical environment and health; (2) livelihood security; (3) suitable work, skills, and migration; and (4) sense of belonging. The overarching paradigm reflects how educational attainment confers multiple advantages that reinforce both improved health and further educational opportunities. Conclusions The co-created CLD highlights that structural and psychosocial conditions, rather than lifestyle behaviours, underpin socioeconomic health inequalities. Advancing health equity requires a shift from behaviour-focused interventions toward integrated strategies that address the systemic and structural drivers of inequality, including the system's underlying meritocratic paradigm.