'When operating a cafeteria, sales come before nutrition' - finding barriers and facilitators to serving reduced-sodium meals in worksite cafeterias

Barriers and facilitators to implementation of healthy food and drink policies in public sector workplaces: a systematic literature review

CONTEXT

Many countries and institutions have adopted policies to promote healthier food and drink availability in various settings, including public sector workplaces.

OBJECTIVE

The objective of this review was to systematically synthesize evidence on barriers and facilitators to implementation of and compliance with healthy food and drink policies aimed at the general adult population in public sector workplaces.

DATA SOURCES

Nine scientific databases, 9 grey literature sources, and government websites in key English-speaking countries along with reference lists.

DATA EXTRACTION

All identified records (N = 8559) were assessed for eligibility. Studies reporting on barriers and facilitators were included irrespective of study design and methods used but were excluded if they were published before 2000 or in a non-English language.

DATA ANALYSIS

Forty-one studies were eligible for inclusion, mainly from Australia, the United States, and Canada. The most common workplace settings were healthcare facilities, sports and recreation centers, and government agencies. Interviews and surveys were the predominant methods of data collection. Methodological aspects were assessed with the Critical Appraisal Skills Program Qualitative Studies Checklist. Generally, there was poor reporting of data collection and analysis methods. Thematic synthesis identified 4 themes: (1) a ratified policy as the foundation of a successful implementation plan; (2) food providers' acceptance of implementation is rooted in positive stakeholder relationships, recognizing opportunities, and taking ownership; (3) creating customer demand for healthier options may relieve tension between policy objectives and business goals; and (4) food supply may limit the ability of food providers to implement the policy.

CONCLUSIONS

Findings suggest that although vendors encounter challenges, there are also factors that support healthy food and drink policy implementation in public sector workplaces. Understanding barriers and facilitators to successful policy implementation will significantly benefit stakeholders interested or engaging in healthy food and drink policy development and implementation.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO registration no. CRD42021246340.

Perceptions, barriers and enablers on salt reduction in the out-of-home sectors in Malaysia (MySaltOH) from the perspective of street food vendors, caterers and consumers

OBJECTIVE

To explore the perspectives, barriers and enablers on salt reduction in out-of-home sectors in Malaysia among street food vendors, caterers and consumers.

DESIGN

A qualitative study involving twenty-two focus group discussions and six in-depth interviews was conducted, recorded and transcribed verbatim. An inductive thematic analysis approach was employed to analyse the data.

SETTING

Two in-depth interviews and twenty-two focus group discussions were conducted face-to-face. Four in-depth interviews were conducted online.

PARTICIPANTS

Focus group discussions were conducted among twenty-three street food vendors, twenty-one caterers and seventy-six consumers of various eateries. In-depth interviews were conducted among two street food vendors and four caterers, individually.

RESULTS

Consumers and food operators perceived a high-salt intake within Malaysia's out-of-home food sectors. Food operators emphasised the necessity for a comprehensive salt reduction policy in the out-of-home sector involving all stakeholders. Consumers faced limited awareness and knowledge, counterproductive practices among food operators and challenges in accessing affordable low-Na food products, whereas food operators faced the lack of standardised guidelines and effective enforcement mechanisms and uncooperative consumer practices. Both groups expressed that food quality and price of salt were also the barriers, and they advocated for awareness promotion, enhanced regulation of manufactured food products and stricter enforcement targeting vendors. Consumers also suggested promoting and recognising health-conscious food premises, whereas food operators suggested on knowledge enhancement tailored to them, strategies for gaining consumers acceptance and maintaining food quality.

CONCLUSIONS

These findings provide valuable insights that serve as foundational evidence for developing and implementing salt reduction policies within Malaysia's out-of-home sectors.

Comparison of participant and non-participant perceptions on healthy restaurant for sodium reduction: a qualitative study

BACKGROUND/OBJECTIVES

In the Republic of Korea, "Healthy Restaurant for Sodium Reduction (HRSR)" project have been designated as one of the representative policies for sodium intake reduction. However, as of 2021, only 879 restaurants, less than 0.1% of all restaurants, had been designated. Therefore, to increase the participation of restaurants in this policy, it is necessary to examine the in-depth perception and experience of participants and non-participants in the HRSR.

MATERIALS/METHODS

Two focus group discussions were conducted for HRSR project participants and non-participants.

RESULTS

A total of 260 semantic units were derived from the 2 groups. The units were further classified into 5 upper categories and 11 subcategories. All the study participants knew the importance of low sodium intake, but they had little information on HRSR project. Various attempts have been made to encourage low sodium practice in restaurants, and the participants reported that the amount of salt used in their restaurants currently is reduced compared to that used in the past. However, they were worried about customers' complaints about the low sodium in their diet and the insignificant beneficent associated with the policy, which makes restaurant owners reluctant to participate in this policy. All the participants agreed on the urgent need for the improvement of public awareness of low-sodium diets and for substantive government support for HRSR.

CONCLUSION

This study concluded that strategies such as more active publicity for the practice of sodium reduction in restaurants, identification of approaches to dispel the perception that low-salt diet is not tasty, and development of plans to increase the sale of food in of HRSR, are needed.

OUP accepted manuscript

Context

Policy-specific actions to improve food environments will support healthy population diets.

Objective

To identify cited barriers and facilitators to food environment policy (FEP) processes reported in the literature, exploring these according to the nature of the policy (voluntary or mandatory) and country development status.

Data sources

A systematic search was conducted of 10 academic and 7 grey-literature databases, national websites, and manual searches of publication references.

Data extraction

Data on government-led FEPs, barriers, and facilitators from key informants were collected.

Data synthesis

The constant-comparison approach generated core themes for barriers and facilitators. The appraisal tool developed by Hawker et al. was adopted to determine the quality of qualitative and quantitative studies.

Results

A total of 142 eligible studies were identified. Industry resistance or disincentive was the most cited barrier in policy development. Technical challenges were most frequently a barrier for policy implementation. Frequently cited facilitators included resource availability or maximization, strategies in policy process, and stakeholder partnership or support.

Conclusions

The findings from this study will strategically inform health-reform stakeholders about key elements of public health policy processes. More evidence is required from countries with human development indices ranging from low to high and on voluntary policies.

Systematic Review Registration

PROSPERO registration no. CRD42018115034.

Perceptions and Feasibility of Actions Related to Sodium Reduction among Restaurant Owners and Cooks in Seongnam, South Korea: Comparison According to Stages of Behavioral Change

With the increase in meals eaten outside the home, sodium reduction in restaurant foods is essential for reducing sodium intake. This study aimed to assess the stages of behavioral change for reducing sodium and the differences in perceptions among restaurant staff by stage. Restaurant owners and cooks (n = 313) in Seongnam, South Korea were surveyed on their stage of behavioral change, practices, and perceptive factors related to sodium reduction in restaurant meals using a questionnaire. The proportion of behavioral change by stage was 20.4% in the maintenance and action (MA) stage, 32.3% in the preparation (P) stage, and 47.3% in the pre-preparation (PP) stage, which included contemplation and pre-contemplation stages. The items that represent differences among the groups were recognition of social environment for sodium reduction, practice of weighing condiments and measuring salinity, and feasibility of actions related to low-sodium cooking. Logistic regression analysis was used to estimate odds ratios for practice and perceptive factors by using stage of behavioral change as the independent variable. Factors associated with being in the MA stage were weighing condiments, measuring salinity, and high feasibility of actions related to low-sodium cooking. Recognition of sodium labeling and anticipation of better taste by reducing sodium increased the odds of being in the P stage rather than the PP stage. These results suggest that customized stepwise education and support are needed for the efficacy of restaurant-based sodium reduction programs.

Barriers, Enablers, and Perceptions on Dietary Salt Reduction in the Out-of-Home Sectors: A Scoping Review

In this review, we have investigated the perceptions, barriers, and enabling factors that were responsible for a dietary salt reduction in the out-of-home sectors. For this purpose, we examined different knowledge databases such as Google Scholar, Ebscohost, MEDLINE (PubMed), Ovid, and Cochrane Library for research articles from September to December 2020. The inclusion criteria for the research articles were that they had to be published in English and had to be a qualitative or quantitative study that was conducted after 2010. These studies also had to report the various enablers, barriers, and perceptions regarding salt reduction in the out-of-home sectors. After implementing the inclusion criteria, we successfully screened a total of 440 studies, out of which 65 articles fulfilled all the criteria. The perceived barriers that hindered salt reduction among the out-of-home sectors included lack of menu and food variabilities, loss of sales due to salt reduction, lack of technical skills for implementing the salt reduction processes for cooking or reformulation, and an absence of environmental and systemic support for reducing the salt concentration. Furthermore, the enablers for salt reduction included the intervention programs, easy accessibility to salt substitutes, salt intake measurement, educational availability, and a gradual reduction in the salt levels. With regards to the behavior or perceptions, the effect of organizational and individual characteristics on their salt intake were reported. The majority of the people were not aware of their salt intake or the effect of salt on their health. These people also believed that low salt food was recognized as tasteless. In conclusion, the enablers, barriers, and perceptions regarding salt reduction in the out-of-home sectors were multifaceted. Therefore, for the implementation of the strategies, policies, and initiatives for addressing the barriers, the policymakers need to encourage a multisectoral collaboration for reducing the salt intake in the population.

Acceptability and feasibility of a café-based sustainable food intervention in the UK

Dietary change is needed to improve health and reduce the environmental burden of food production and consumption. Using an Intervention Mapping approach, this study aimed to explore the views caterers and customers held towards point-of-choice interventions that promote healthy and environmentally friendly (EF) food and beverage choices at the University of Sheffield. Intervention options proposed during focus groups were devised using the Nuffield Bioethics ladder of intervention. Ten focus groups were held involving caterers (n = 16) and customers (n = 45). Thematic analysis was conducted on the transcripts of caterer and customer focus groups seperately, and then comparisons were made to identify concerns about the acceptability and feasibility of intervention options. Attitudes towards intervention options varied considerably amongst stakeholders, with the greatest disparity of opinion in the acceptability of interventions that restrict or limit personal choice, particularly with regards to meat consumption. Information provision was favoured as an acceptable intervention by both customers and caterers. However, labelling products in terms of their environmental impact was considered practically unfeasible. Social norms around eating also emerged as influencing the acceptability and feasibility of interventions with concerns raised about: shaming customers who chose meat, the exclusivity of vegan choices and the limited availability and appeal of meatless café options. Financial considerations were the main priority of caterers when discussing point-of-choice interventions. An acceptable and feasible café-based intervention ought to increase awareness and understanding of healthy and EF food choices, protect customer choice and avoid additional costs.

RE-AIM evaluation of a one-year trial of a combined educational and environmental workplace intervention to lower salt intake in Switzerland

Reducing excessive dietary sodium may reduce cardiovascular disease risk. Environmental and behavioral interventions in workplaces may reduce salt consumption, but information on the effectiveness of workplace nutrition interventions is sparse. We used the RE-AIM framework to evaluate a one-year trial in 2015–2016 of an educational and environmental intervention to lower salt intake of employees in organizations with catering facilities in Switzerland. Five educational workshops for employees and assessments that included 24-hour urine collection were combined with five coaching sessions and food analyses in catering operations. We studied the adoption, reach, implementation, effectiveness, and maintenance of the intervention.

Eight of 389 candidate organizations participated in the trial in which 145 (50% men) out of 5794 potentially eligible employees consented to participate, and 138 completed the trial with 13 in the control group.

The overall mean change of daily salt intake was −0.6 g from 8.7 g to 8.1 g (6.9%). Though the mean daily salt intake of women was unaltered from 7 g, the mean intake of men declined by −1.2 g from 10.4 g to 9.2 g. Baseline salt intake, sex, and waist-to-height ratio were significant predictors of salt reduction. The analysis also highlighted pivotal determinants of low adoption and reach, and program implementation in catering operations. We conclude that a workplace program of nutrition intervention for employees and catering staff is feasible. The acceptance, effectiveness, and maintenance of nutrition interventions in the workplace require strong employer support. In a supportive food environment, interventions tailored to sex, age, and CVD risk inter alia could be successful.

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Leadership support is of vital importance to success of workplace nutrition trials.

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The observed overall salt intake reduction was not statistically significant.

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Baseline salt intake, sex, and waist-to-height ratio explained salt reduction.

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Habits and high-salt food environment were cited as barriers to reduced salt intake.

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Catering has not succeeded in strictly implementing a gradual salt reduction approach.

A qualitative assessment of the smoking policies and cessation activities at smaller workplaces

Background

To reduce the negative consequences of smoking, workplaces have adopted and implemented anti-smoking initiatives. Compared to large workplaces, less research exists about these initiatives at smaller workplaces, which are more likely to hire low-wage workers with higher rates of smoking. The purpose of this study was to describe and compare the smoking policies and smoking cessation activities at small (20–99 employees) and very small (< 20 employees) workplaces.

Methods

Thirty-two key informants coming from small and very small workplaces in Iowa completed qualitative telephone interviews. Data collection occurred between October 2016 and February 2017. Participants gave descriptions of the anti-smoking initiatives at their workplace. Additional interview topics included questions on enforcement, reasons for adoption, and barriers and facilitators to adoption and implementation. The data were analyzed using counts and content and thematic analysis.

Results

Workplace smoking policies were nearly universal (n = 31, 97%), and most workplaces (n = 21, 66%) offered activities to help employees quit smoking. Reasons for adoption included the Iowa Smokefree Air Act, to improve employee health, and organizational benefits (e.g., reduced insurance costs). Few challenges existed to adoption and implementation. Commonly cited facilitators included the Iowa Smokefree Air Act, no issues with compliance, and support from others. Compared to small workplaces, very small workplaces offered cessation activities less often and had fewer tobacco policy restrictions.

Conclusions

This study showed well-established tobacco control efforts in small workplaces, but very small workplaces lagged behind. To reduce potential health disparities in smoking, future research and intervention efforts in tobacco control should focus on very small workplaces.

Educating restaurant owners and cooks to lower their own sodium intake is a potential strategy for reducing the sodium contents of restaurant foods: a small-scale pilot study in South Korea

BACKGROUND/OBJECTIVES

This study was conducted to evaluate the feasibility of a sodium reduction program at local restaurants through nutrition education and examination of the health of restaurant owners and cooks.

SUBJECTS/METHODS

The study was a single-arm pilot intervention using a pre-post design in one business district with densely populated restaurants in Seoul, South Korea. The intervention focused on improving nutrition behaviors and psychosocial factors through education, health examination, and counseling of restaurant personnel. Forty-eight restaurant owners and cooks completed the baseline survey and participated in the intervention. Forty participants completed the post-intervention survey.

RESULTS

The overweight and obesity prevalences were 25.6% and 39.5%, respectively, and 74.4% of participants had elevated blood pressure. After health examination, counseling, and nutrition education, several nutrition behaviors related to sodium intake showed improvement. In addition, those who consumed less salt in their baseline diet (measured with urine dipsticks) were more likely to agree that providing healthy foods to their customers is necessary. This study demonstrated the potential to reduce the sodium contents of restaurant foods by improving restaurant owners' and cooks' psychological factors and their own health behaviors.

CONCLUSIONS

This small pilot study demonstrated that working with restaurant owners and cooks to improve their own health and sodium intake may have an effect on participation in restaurant-based sodium reduction initiatives. Future intervention studies with a larger sample size and comparison group can focus on improving the health and perceptions of restaurant personnel in order to increase the feasibility and efficacy of restaurant-based sodium reduction programs and policies.