Table 1

Health policy triangle framework for disease-related malnutrition policies: themes and subthemes

DRM policy themesSubthemesQuotes
ActorsChampions in healthcare‘I think the people from the Institute of Health, they know him [Physician researcher/Professor] and that’s why they contact him, so our connection is mainly because of him and because he did this really large study’. (Key informant 07, academic and healthcare professional)
‘We are educating a new generation of dietitians. So, for them it’s not a question of improving or learning new things. This is the method. This is a standard of care. […] We need a unique milieu that will include leading doctors and nurses that are more oriented to nutrition. And we also need the leading clinicians from hospital and community. […] We need representatives, from geriatrics, from psychiatrics’. (Key informant 21, academic and healthcare professional)
Senior leaders in healthcare administration‘[Health Authority] has a policy development framework that talks about how to develop policy, but it doesn’t necessarily talk about how to prioritize, or what kind of policy we need. The framework relies fairly heavily on a sponsorship model so sponsors within the organization, which are executive leaders, usually at the VP level, […] are the approval level for policy. To get something approved, you need to go there. Having that sponsorship support to say this is a priority and we’re going to put some resources behind it is really how you get the [Health Authority] to do it’. (Key informant 16, policy maker)
Individuals with lived experience‘I think that I have been to some extent, I would say even surprised that there’s no nutrition patient. The only patients that really are aware and care very much about nutrition are the obvious patients that are linked to home nutrition, long term, parenteral enteral intestinal failure. These patients, of course, are very much aware and they are the best advocates for the issue. But it’s very difficult to find patients outside of this very limited field that are aware or even willing to be aware’. (Key informant 09, academic and healthcare professional)
‘There was quite a lot of focus on patient voice, so we actually were able to bring together patients and public involvement from people who’ve had lived experience. But the one thing we stumbled upon which seemed, I don’t know if saying even more valuable is the right term, but something that seemed equally valuable but more informative in some ways, was actually to bring in the patient carer voice for those with chronic disease’. (Key informant 11, academic and healthcare professional)
ContentScreening DRM‘There is no screening tool that is a national standard’. (Key informant 02, academic and healthcare professional)
Diagnosing DRM‘It is one important piece in this puzzle. If there is a diagnosis, then there is a problem by definition. […] For example, if the patient is very ill, it is natural that the patient has no appetite or the patient is losing weight they would probably give some artificial nutrition. But, if there is a diagnosis and as you say that might be reimbursement connected to that, it is one part of the puzzle. I can’t say it will solve the whole puzzle, but it is one important piece’. (Key informant 17, healthcare professional and policy maker)
Treating DRM‘In long-term care, very much like food first focus [to policy] and very much a focus on providing choice. So, looking to improve the client experience with food and in doing so, hopefully improved intake. In hospital, I would say very similar’. (Key informant 18, nutrition professional and policy maker)
ContextSystem specifics matter‘If all hospitals had the same electronic system, then it would be way easier for screening’. (Key informant 02, academic and healthcare professional)
‘It really depends on the hospital. For example, in [name of hospital], [malnutrition] is more or less something of constant attention, but it comes and goes. But it always comes with campaigns. Now, it’s really focused on good food instead of malnutrition screening’. (Key informant 10, academic and healthcare professional)
Cost and capacity‘Showing cost savings is huge. We are in a place in government where we are looking at healthcare costs. So, I do think that’s a huge enabler. I think having it deemed a priority would help and I think it has been deemed a priority’. (Key informant 22, policy maker and healthcare professional)
Social determinants of health‘The research that we’ve done through so many different lenses has suggested that people who are food insecure are more likely to be captured in samples that are picking up DRM. They’re more likely to have diseases, they’re less able to manage them. There are many ways in which it feels like this topic [food insecurity] intersects with DRM’. (Key informant 20, academic)
ProcessesCross-sectoral and multi-level governance‘When we’re talking about change management and sponsorship, when you’re […] trying to impact change across a whole bunch of areas, there isn’t […] an obvious person who has control or capacity to make change across all those areas’. (Key informant 16, policy maker)
Mandating and other reinforcement strategies‘It’s a complex system. There are 20 small regions in the country, and they all are all entitled to some level of decision, although there are standards that are implemented at the national level. Some issues are local, and some are national. It’s very complicated. In general, […] there is neither local or national regulation for malnutrition screening or malnutrition diagnosis’. (Key informant 09, academic and healthcare professional)
‘I’m really excited from an accreditation perspective. That [malnutrition] standard, to me, will speak louder than any policy could within my organization. So, I think if that could become a required organizational practice (ROP) that would, give a lot of focus on the malnutrition, from an organizational perspective, and I even think from a national perspective’. (Key informant 17, healthcare professional and policy maker)
Windows of opportunity‘Government is interesting because you’re not just developing policies. It’s depending on what kind of policy window you’re in and what opportunities arise. So, we have found with the Food Guide being updated that has resulted in us being able to update a lot of policies to align with the Food Guide, whereas those policies maybe may not have been opened [if the food guide hadn’t been updated]’. (Key informant 22, policy maker and healthcare professional)
Evaluation and research‘I think there are some passive tracking systems that can be put in place that tell you a lot about whether something is wanted or not, and whether it’s appropriate. I guess whether the intervention is appropriate. I don’t think that’s hard to do passively … you’ve got a cause here that is indisputably important with very palpable impacts’. (Key informant 20, academic)
‘I think a really important piece of our work is policy evaluation, but then making sure that policy evaluation is implemented and integrated throughout the entire policy cycle. So, does the policy have a logic model? Does it have a theory of change? Does it have an evaluation framework? Kind of those key pieces too’. (Key informant 22, policy maker and healthcare professional)
  • DRM, disease-related malnutrition.