Making hospital shops healthier: evaluating the implementation of a mandatory standard for limiting food products and promotions in hospital retail outlets

Applying Systems Thinking to Improve a Hospital Food Retail Environment

OBJECTIVE

To identify factors influencing the availability and sales of healthy food and drinks in a café located in a hospital setting in a rural area.

METHODS

Three online and 1 in-person group model building workshops were conducted with hospital staff members to develop a causal loop diagram.

RESULTS

Four areas in the causal loop diagram were identified, 5 teams were created to implement 15 identified action ideas, and an action registry was created to track their progress. By May 2023, 4 actions were active, 6 inactive, 4 completed, and 1 abandoned.

CONCLUSIONS AND IMPLICATIONS

The group model building process identified factors and actions to improve the healthiness of the hospital's café and motivated staff members to act for change. However, progress was limited by staff turnover, recruitment, and inadequate participation from decision-makers. Better leadership and support by senior management can ensure that long-term objectives are achieved and healthier hospital food environments are sustained.

The use of private regulatory measures to create healthy food retail environments: a scoping review

OBJECTIVE

Different forms of public and private regulation have been used to improve the healthiness of food retail environments. The aim of this scoping review was to systematically examine the types of private regulatory measures used to create healthy food retail environments, the reporting of the processes of implementation, monitoring, review and enforcement and the barriers to and enablers of these.

DESIGN

Scoping review using the Johanna Briggs Institute guidelines. Ovid MEDLINE, PsycINFO, Embase, CINAHL Plus, Business Source Complete and Scopus databases were searched in October 2020 and again in September 2023 using terms for 'food retail', 'regulation' and 'nutrition'. Regulatory measure type was described by domain and mechanism. Deductive thematic analysis was used to identify reported barriers and enablers to effective regulatory governance processes using a public health law framework.

SETTING

Food retail.

PARTICIPANTS

Food retail settings using private regulatory measures to create healthier food retail environments.

RESULTS

In total, 17 694 articles were screened and thirty-five included for review from six countries, with all articles published since 2011. Articles reporting on twenty-six unique private regulatory measures cited a mix of voluntary (n 16), mandatory (n 6) measures, both (n 2) or did not disclose (n 2). Articles frequently reported on implementation (34/35), with less reporting on the other regulatory governance processes of monitoring (15/35), review (6/35) and enforcement (2/35).

CONCLUSIONS

We recommend more attention be paid to reporting on the monitoring, review and enforcement processes used in private regulation to promote further progress in improving the healthiness of food retail environments.

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.

Co-creation Approach in Practice: Naming a Cafe Located within a Rural Health Service Provides Added Value to a Health Strategy

Objective. The Victorian Government in Australia has developed Healthy Choices guidelines to ensure that healthy foods and drinks are offered and promoted in places such as hospitals. This brief report aims to present complex theoretical attributes related to cocreation through an accessible example of a competition to create a new name for the previously understated hospital “kiosk.” Methods. A mixed-methods approach using an online survey and semistructured interviews were used to obtain detailed insights from hospital staff members to engage in a naming competition for a hospital-based cafe. Results. The level of engagement in this activity was higher than anticipated by the management staff. Conclusions. Active involvement of staff members through a cocreation process can enable the development of innovative healthy eating strategies and increase staff engagement to further changes in the cafe. Implications for public health cocreation in public health promises effective stakeholder engagement and requires significant scientific advancement. This brief report illustrates theoretical constructs of cocreation through a naming competition activity that occurred as part of a larger project to improve Wimmera Base Hospital’s food environment.

Implementation of a food retail intervention to reduce purchase of unhealthy food and beverages in remote Australia: mixed-method evaluation using the consolidated framework for implementation research

BACKGROUND

Adoption of health-enabling food retail interventions in food retail will require effective implementation strategies. To inform this, we applied an implementation framework to a novel real-world food retail intervention, the Healthy Stores 2020 strategy, to identify factors salient to intervention implementation from the perspective of the food retailer.

METHODS

A convergent mixed-method design was used and data were interpreted using the Consolidated Framework for Implementation Research (CFIR). The study was conducted alongside a randomised controlled trial in partnership with the Arnhem Land Progress Aboriginal Corporation (ALPA). Adherence data were collected for the 20 consenting Healthy Stores 2020 study stores (ten intervention /ten control) in 19 communities in remote Northern Australia using photographic material and an adherence checklist. Retailer implementation experience data were collected through interviews with the primary Store Manager for each of the ten intervention stores at baseline, mid- and end-strategy. Deductive thematic analysis of interview data was conducted and informed by the CFIR. Intervention adherence scores derived for each store assisted interview data interpretation.

RESULTS

Healthy Stores 2020 strategy was, for the most part, adhered to. Analysis of the 30 interviews revealed that implementation climate of the ALPA organisation, its readiness for implementation including a strong sense of social purpose, and the networks and communication between the Store Managers and other parts of ALPA, were CFIR inner and outer domains most frequently referred to as positive to strategy implementation. Store Managers were a 'make-or-break' touchstone of implementation success. The co-designed intervention and strategy characteristics and its perceived cost-benefit, combined with the inner and outer setting factors, galvanised the individual characteristics of Store Managers (e.g., optimism, adaptability and retail competency) to champion implementation. Where there was less perceived cost-benefit, Store Managers seemed less enthusiastic for the strategy.

CONCLUSIONS

Factors critical to implementation (a strong sense of social purpose; structures and processes within and external to the food retail organisation and their alignment with intervention characteristics (low complexity, cost advantage); and Store Manager characteristics) can inform the design of implementation strategies for the adoption of this health-enabling food retail initiative in the remote setting. This research can help inform a shift in research focus to identify, develop and test implementation strategies for the wide adoption of health-enabling food retail initiatives into practice.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry ACTRN 12,618,001,588,280.

Creating healthy hospital retail food environments: Multiple pathways to successful at scale policy implementation in Australia

OBJECTIVE

In 2017, the Australian state of New South Wales introduced a revised policy to provide a healthy food and drink environment for staff and visitors in the state's publicly funded health facilities. We sought to understand how contextual factors, intervention features and the responses of diverse stakeholders affected the policy's implementation in public hospitals.

METHODS

Ninety-nine interviews were conducted with chief executives, implementers and retailers in the health and food retail systems after the target date for the implementation of 13 initial policy practices. Stakeholder responses were analysed to understand commitment to, engagement with and achievement of these practices and the different contexts and implementation approaches that prompted these responses.

RESULTS

Key mechanisms that drove systemic change included stakeholders' broad acceptance of the policy premise; stakeholders' sense of accountability and desire for the policy to succeed; and the policy's perceived benefits, feasibility and effectiveness. Important underpinning factors were chief executives' commitment to implementation and monitoring, a flexible approach to locally tailored implementation and historical precedents.

CONCLUSIONS

This study provides policy and practice insights for the initial phase of state-wide implementation to achieve change in health facility food retail environments.

Availability of Healthy Food and Beverages in Hospital Outlets and Interventions in the UK and USA to Improve the Hospital Food Environment: A Systematic Narrative Literature Review

The aims of this systematic review are to determine the availability of healthy food and beverages in hospitals and identify interventions that positively influence the hospital food environment, thereby improving the dietary intake of employees and visitors. Embase, Medline, APA PsycInfo, Scopus, Google Scholar and Google were used to identify publications. Publications relating to the wider hospital food environment in the UK and USA were considered eligible, while those regarding food available to in-patients were excluded. Eligible publications (n = 40) were explored using a narrative synthesis. Risk of bias and research quality were assessed using the Quality Criteria Checklist for Primary Research. Although limited by the heterogeneity of study designs, this review concludes that the overall quality of hospital food environments varies. Educational, labelling, financial and choice architecture interventions were shown to improve the hospital food environment and/or dietary intake of consumers. Implementing pre-existing initiatives improved food environments, but multi-component interventions had some undesirable effects, such as reduced fruit and vegetable intake.

Inpatient Food Insecurity in Caregivers of Hospitalized Pediatric Patients: A Mixed Methods Study

BACKGROUND AND OBJECTIVE

Among US households with children, 14% are food insecure. Household food insecurity (FI) is associated with poorer health outcomes and increased hospital admissions. There is less known about caregivers' ability to obtain adequate food during hospitalization (inpatient FI).

METHODS

We conducted a mixed methods study of primary caregivers of hospitalized children 0 to 18 years. A modified US Household Food Security Survey was used to identify inpatient FI. Associated factors were identified using logistic regression adjusted for covariables. Caregiver semistructured interviews were conducted to elicit perceptions on food accessibility and effects of and solutions for inpatient FI.

RESULTS

The prevalence of inpatient FI was 43%. Household FI was present in 38% of families. Inpatient FI was associated with household FI (P < .01). In multivariable analysis, odds of inpatient FI were increased among caregivers with annual household income <$30,000 (adjusted odds ratio [aOR] 2.14), public transportation use (aOR 6.33), living >30 miles from the hospital (aOR 2.80), self-rated fair/poor health (aOR 3.31), maternity leave (aOR 4.75), and past/current Supplemental Nutrition Assistance Program benefit utilization (aOR 2.52). Qualitative analysis identified barriers to food access, such as lack of affordable options, and found that caregivers made sacrifices for their hospitalized child, including skipping meals. Caregivers viewed their presence at their child's bedside and personal nourishment as important factors affecting their child's care.

CONCLUSIONS

Inpatient FI may affect a significant proportion of hospitalized children's caregivers. Pediatric hospitals should ensure that caregivers have access to food in order to fully engage in their child's care.

Towards healthier food choices for hospital staff and visitors: impacts of a healthy food and drink policy implemented at scale in Australia

OBJECTIVE

To determine the impact of a healthy food and drink policy on hospital staff and visitors' food purchasing behaviours, and their awareness and support for the changes introduced.

DESIGN

Two repeated cross-sectional surveys, consisting of intercept interviews and observations of food items purchased, were conducted before (March-July 2018) and after (April-June 2019) the target date for implementation of thirteen food and drink practices (31 December 2018). Food purchases were coded as 'Everyday' (healthy) or 'Occasional' (unhealthy).

SETTING

Ten randomly selected New South Wales public hospitals, collection sites including hospital entrances and thirteen hospital cafés/cafeterias.

PARTICIPANTS

Surveys were completed by 4808 hospital staff and visitors (response rate 85 %). The majority were female (63 %), spoke English at home (85 %) and just over half had completed tertiary education (55 %).

RESULTS

Significant increases from before to after the implementation target date were found for policy awareness (23 to 42 %; P < 0·0001) and support (89 to 92 %; P = 0·01). The proportion of 'Everyday' food purchases increased, but not significantly (56 to 59 %; P = 0·22); with significant heterogeneity between outlets (P = 0·0008). Overall, younger, non-tertiary-educated adults, visitors and those that spoke English at home were significantly less likely to purchase 'Everyday' food items. Support was also significantly lower in males.

CONCLUSIONS

The findings provide evidence of strong policy support, an increasing awareness of related changes and a trend towards increased 'Everyday' food purchasing. Given the relatively early phase of policy implementation, and the complexity of individual food purchasing decisions, longer-term follow-up of purchasing behaviour is recommended following ongoing implementation efforts.

"Just So You Know, It Has Been Hard": Food Retailers' Perspectives of Implementing a Food and Nutrition Policy in Public Healthcare Settings

Mandated policies to improve food environments in public settings are an important strategy for governments. Most Australian governments have mandated policies or voluntary standards for healthy food procurement in healthcare facilities, however, implementation and compliance are poor. A better understanding of the support required to successfully implement such policies is needed. This research explored food retailers' experiences in implementing a mandated food and nutrition policy (the Policy) in healthcare settings to identify barriers, enablers, and impacts of compliance. Three 90-min workshops facilitated by two public health practitioners were undertaken with 12 food retailers responsible for operating 44 outlets across four hospitals in Perth, Western Australia. Workshop discussions were transcribed non-verbatim and inductive thematic content was analyzed. Three main themes were identified: (1) food retailers had come to accept their role in implementing the Policy; (2) the Policy made it difficult for food retailers to operate successfully, and; (3) food retailers needed help and support to implement the Policy. Findings indicate the cost of implementation is borne by food retailers. Communications campaigns, centralized databases of classified products, reporting frameworks, recognition of achievements, and dedicated technical expertise would support achieving policy compliance. Feasibility assessments prior to policy implementation are recommended for policy success.