Barriers and facilitators to implementing a healthier food outlet initiative: perspectives from local governments

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.

A systems framework for implementing healthy food retail in grocery settings

BACKGROUND

Food retailers can be reluctant to initiate healthy food retail activities in the face of a complex set of interrelated drivers that impact the retail environment. The Systems Thinking Approach for Retail Transformation (START) is a determinants framework created using qualitative systems modelling to guide healthy food retail interventions in community-based, health-promoting settings. We aimed to test the applicability of the START map to a suite of distinct healthy food marketing and promotion activities that formed an intervention in a grocery setting in regional Victoria, Australia.

METHODS

A secondary analysis was undertaken of 16 previously completed semi-structured interviews with independent grocery retailers and stakeholders. Interviews were deductively coded against the existing START framework, whilst allowing for new grocery-setting specific factors to be identified. New factors and relationships were used to build causal loop diagrams and extend the original START systems map using Vensim.

RESULTS

A version of the START map including aspects relevant to the grocery setting was developed ("START-G"). In both health-promoting and grocery settings, it was important for retailers to 'Get Started' with healthy food retail interventions that were supported by a proof-of-concept and 'Focus on the customer' response (with grocery-settings focused on monitoring sales data). New factors and relationships described perceived difficulties associated with disrupting a grocery-setting 'Supply-side status quo' that promotes less healthy food and beverage options. Yet, most grocery retailers discussed relationships that highlighted the potential for 'Healthy food as innovation' and 'Supporting cultural change through corporate social responsibility and leadership'.

CONCLUSIONS

Several differences were found when implementing healthy food retail in grocery compared to health promotion settings. The START-G map offers preliminary guidance for identifying and addressing commercial interests in grocery settings that currently promote less healthy foods and beverages, including by starting to address business outcomes and supplier relationships.

Diet-Related Disease Prevention in a Rural Australian Setting: Understanding Barriers, Enablers, and the Role of Rural Health Services in Supporting Changes in Local Rural Food Environments

Bold and comprehensive action is needed to prevent diet-related diseases in rural areas, which includes improving food environments to enable healthier dietary practices. Rural health services are integral to the health of rural populations, yet their role in community disease prevention is not swell understood. This study sought to understand health service, local government, and food outlet stakeholders' perspectives on (1) the drivers of unhealthy retail environments in a rural setting; (2) the role of rural health services in supporting changes in local food environments; and to (3) identify characteristics of potential interventions. Two Group Model Building workshops were held with health service and local government leaders (n = 9), and interviews were conducted with local food outlet participants (n = 13). Key themes included 'enablers to healthier food environments', 'barriers to healthier food environments', 'Rural health services are a leading broker of knowledge for healthy food environments', and 'characteristics of desirable healthy food environment interventions.'. Rural health services can play a key role in addressing the current barriers to healthy food environments in rural areas. Effective promotion of healthier diets in rural populations will require consideration of key stakeholder perspectives and the development of further evidence on the role that rural health services can play in improving the healthiness of food environments.

The Bite of HOPE Small Food Business Development Program: a clinic-based culinary medicine program targeting local business owners

Culinary medicine is a popular approach to health promotion, but most programs focus on patient or provider-facing education. While laudable, these efforts do not represent the full potential for culinary medicine to impact community health. We describe a novel approach to culinary medicine at a federally qualified health center (FQHC), the HOPE Clinic: Bite of HOPE Small Food Business Development (SFBD) program. Describe the design and implementation of the Bite of HOPE SFBD program and examine initial response to the program through interviews and focus groups with past participants. The SFBD program aims to create healthy food outlets by supporting local small businesses with education, resources, and mentorship support. Former participants in the SFBD program were invited to participate in focus groups and interviews exploring their experience and perceived program impact. Three focus groups (n = 10) and nine in-depth interviews were conducted. Most participants were Black or Hispanic and all operated their businesses in the community surrounding HOPE Clinic. Five themes emerged from the data including perceived program purpose, program discovery, motivating factors to participation, perceived program impact, and suggestions for improvement. Participants expressed high satisfaction with the program and positive changes in both business development and personal eating habits. There is an opportunity to leverage the culinary medicine model to support local small food business and improve community health. The Bite of HOPE SFBD program offers an example of how clinic-based resources can expand into the surrounding environment.

The implementation and effectiveness of outlet-level healthy food and beverage accreditation schemes: A systematic review

Healthy food outlet accreditation schemes represent an avenue for incentivizing food retailers to promote healthy eating patterns by improving the healthiness of food environments. This systematic review aimed to (i) assess the impact of food outlet-level accreditation schemes on outlet practices and customer purchases and (ii) identify barriers and enablers to scheme implementation. Peer-reviewed and grey literature were systematically searched. Eligible studies related to outlet-level food and beverage accreditation schemes across any food retail setting. Findings were narratively synthesized by retailer type according to (i) scheme characteristics (governance, targeted products, support, and monitoring); (ii) scheme outcomes (rate of uptake, proportion of certified retailers, impact on purchasing, customer perspectives, and retailer perspectives); and (iii) barriers and enablers to implementation. From 21,943 records screened, 48 were included, covering 26 schemes. Most (18) targeted restaurants or convenience stores. Average uptake was 65% of all outlets approached to participate. Implementation of accreditation schemes was associated with healthier customer purchases in convenience stores, schools, and hospitals, but evidence from restaurants was mixed. Enablers of scheme implementation included support for implementation and maintenance, flexible scheme criteria, and motivated retail staff. Healthy food outlet accreditation schemes represent a promising mechanism for engaging retailers to improve the healthiness of food retail environments.

UK government's new placement legislation is a 'good first step': a rapid qualitative analysis of consumer, business, enforcement and health stakeholder perspectives

BACKGROUND

The current food system in England promotes a population diet that is high in fat, sugar and salt (HFSS). To address this, the UK government has implemented legislation to restrict the promotion of HFSS products in prominent locations (e.g. store entrances, checkouts) in qualifying retailers since October 2022. This study investigated the perceived impact of the legislation for affected stakeholders.

METHODS

A pre-implementation rapid qualitative evaluation of stakeholder interviews. One hundred eight UK stakeholders participated in the study including 34 consumers, 24 manufacturers and retailers, 22 local authority enforcement officers and 28 academic and charitable health representatives. A participatory conference was used to enable policy recommendations to be confirmed by stakeholders.

RESULTS

Stakeholders perceived the legislation to be a 'good first step' towards improving population diet but recognised this needed to be considered amongst a range of long-term obesity policies. Areas of further support were identified and these are presented as six recommendations for government to support the successful implementation of the legislation: (1) provide a free central HFSS calculator, (2) refine legislation to enhance intent and clarity, (3) conduct a robust evaluation to assess intended and unintended outcomes, (4) provide greater support for smaller businesses, (5) provide ring-fenced resources to local authorities and (6) create and communicate a long-term roadmap for food and health.

CONCLUSIONS

This legislation has the potential to reduce impulse HFSS purchases and makes a solid start towards creating healthier retail outlets for consumers. Immediate government actions to create a freely accessible HFSS calculator, support smaller businesses and provide additional resources to local authorities would support successful implementation and enforcement. Independent evaluation of the implementation of the legislation will enable monitoring of potential unintended consequences identified in this study and support refinement of the legislation. A long-term roadmap is necessary to outline strategies to support equal access to healthier and sustainable food across the whole food system within the next 20-30 years.

Dietitians Australia position statement on healthy and sustainable diets

It is the position of Dietitians Australia that to promote human and planetary health, a food system transformation is needed that enables the population to adopt healthy and sustainable diet-related practices. A healthy and sustainable diet must (i) be nutritionally adequate, healthy and safe, (ii) have low environmental impact and be protective of natural resources and biodiversity, (iii) be culturally acceptable and (iv) be accessible, economically fair and affordable. Dietitians Australia acknowledges that it is critical to prioritise Indigenous knowledges in consultation, policy-making and implementation processes to achieve these recommendations. In facilitating the uptake of healthy and sustainable diets, dietitians are contributing to the transformation of our current food system that is urgently required to nourish present and future generations within planetary boundaries. In developing this position statement, opportunities for future research have been identified including those to advance the professions' capacity to improve environmental sustainability outcomes across all areas of practice. To achieve a population-level shift towards this diet, Dietitians Australia recommends: (i) the development of a National Food and Nutrition Strategy which honours Indigenous knowledges on food systems, (ii) the integration of sustainability principles in Australia's dietary guidelines, (iii) the reorientation of our food environment to prioritise access to healthy and sustainable foods, and (iv) investment in capacity building activities to equip the current and future nutrition and dietetics workforce.

UK food and nutrition security during and after the COVID-19 pandemic

The COVID‐19 pandemic is a major shock to society in terms of health and economy that is affecting both UK and global food and nutrition security. It is adding to the ‘perfect storm’ of threats to society from climate change, biodiversity loss and ecosystem degradation, at a time of considerable change, rising nationalism and breakdown in international collaboration. In the UK, the situation is further complicated due to Brexit. The UK COVID‐19Food andNutritionSecurity project, lasting one year, is funded by the Economic and Social Research Council and is assessing the ongoing impact of COVID‐19 on the four pillars of food and nutrition security: access, availability, utilisation and stability. It examines the food system, how it is responding, and potential knock on effects on the UK’s food and nutrition security, both in terms of the cascading risks from the pandemic and other threats. The study provides an opportunity to place the initial lessons being learnt from the on‐going responses to the pandemic in respect of food and nutrition security in the context of other long‐term challenges such as climate change and biodiversity loss.