Systematic review: a systems innovation perspective on barriers and facilitators for the implementation of healthy food-store interventions

Implementation of health-promoting retail initiatives in the Healthier Choices in Supermarkets Study-qualitative perspectives from a feasibility study

BACKGROUND

Improving food environments like supermarkets has the potential to affect customers' health positively. Scholars suggest researchers and retailers collaborate closely on implementing and testing such health-promoting interventions, but knowledge of the implementation of such interventions is limited. We explore the implementation of four health-promoting food retail initiatives selected and developed by a partnership between a research institution, a large retail group, and a non-governmental organisation.

METHODS

The four initiatives included downsizing of bags for pick'n' mix sweets and soda bottles at the check-out registers, shelf tags promoting healthier breakfast cereal options, and replacing a complimentary bun with a banana offered to children. The initiatives were implemented for 6 weeks (or longer if the store manager allowed it) in one store in Copenhagen, Denmark. Data were collected through observations, informal interviews with customers, and semi-structured interviews with retailers. We conducted a thematic analysis of transcripts and field notes inspired by process evaluation concepts and included quantitative summaries of selected data.

RESULTS

Two out of four initiatives were not implemented as intended. The implementation was delayed due to delivery issues, which also resulted in soda bottles not being downsized as intended. The maintenance of the shelf tags decreased over time. Retailers expressed different levels of acceptability towards the initiatives, with a preference for the complimentary banana for children. This was also the only initiative noticed by customers with both positive and negative responses. Barriers and facilitators of implementation fell into three themes: Health is not the number one priority, general capacity of retailers, and influence of customers and other stakeholders on store operation.

CONCLUSIONS

The retailers' interests, priorities, and general capacity influenced the initiative implementation. Retailers' acceptability of the initiatives was mixed despite their involvement in the pre-intervention phase. Our study also suggests that customer responses towards health-promoting initiatives, as well as cooperation with suppliers and manufacturers in the development phase, may be determining to successful implementation. Future studies should explore strategies to facilitate implementation, which can be applied prior to and during the intervention.

Creating a healthy and sustainable food environment to promote plant-based food consumption: clear barriers and a gradual transition

BACKGROUND

A shift away from diets high in animal-based foods towards diets high in plant-based foods is desirable considering human health, environmental sustainability, and animal welfare. As the food environment plays a crucial role in shaping consumption patterns, understanding of how changes in the food environment can facilitate plant-based consumption is crucial for the so-called protein transition. The current study aims to garner insight into barriers and facilitators for food outlet managers to take action to stimulate plant-based consumption within a local food environment.

METHODS

Using a maximum-variation sample approach, we examined possible barriers and facilitators to promote plant-based consumption across different types of food outlets located within a geographically shared food environment (a city in the Netherlands). We conducted in-depth semi-structured interviews among food outlet managers and applied multi-stage thematic analysis to the interview transcripts.

RESULTS

Most managers underscored the urgency of shifting towards more plant-based diets, and perceived a growing demand for plant-based products. However, three barriers hindered most of them from taking decisive action: Managers' perception of low consumer demand for plant-based food options; fear of consumer resistance when stimulating plant-based food options; and limited behavioral agency to offer attractive plant-based food options. The few managers who made changes, or intend to make changes, are individuals with high intrinsic motivation, knowledge and skills.

CONCLUSIONS

The present work suggests the key for change towards a food environment stimulating plant-based consumption lies in addressing three (perceived) barriers shared among diverse outlets. These are partly different from barriers for stimulating healthy consumption in general. Furthermore, current changes appear to be driven incidentally by individuals who are motivated and able to stimulate more plant-based purchases among a small targeted group of consumers.

Are Dutch adults equally susceptible to nudging and pricing strategies? Secondary analyses of the Supreme Nudge parallel cluster-randomised controlled supermarket trial

BACKGROUND

Supermarket interventions are promising to promote healthier dietary patterns, but not all individuals may be equally susceptible. We explored whether the effectiveness of nudging and pricing strategies on diet quality differs by psychological and grocery shopping characteristics.

METHODS

We used data of the 12-month Supreme Nudge parallel cluster-randomised controlled supermarket trial, testing nudging and pricing strategies to promote healthier diets. Participants were Dutch speaking adults aged 30-80 years and regular shoppers of participating supermarkets (n = 12) in socially disadvantaged neighbourhoods. Data on psychological characteristics (food-related behaviours; price sensitivity; food decision styles; social cognitive factors; self-control) and grocery shopping characteristics (time spent in the supermarket; moment of the day; average supermarket visits; shopping at other retailers; supermarket proximity) were self-reported at baseline. These characteristics were tested for their moderating effects of the intervention on diet quality (scored 0-150) in linear mixed models.

RESULTS

We included 162 participants from intervention supermarkets and 199 from control supermarkets (73% female, 58 (± 10.8) years old, 42% highly educated). The interventions had no overall effect on diet quality. Only five out of 23 potential moderators were statistically significant. Yet, stratified analyses of these significant moderators showed no significant effects on diet quality for one of the subgroups and statistically non-significant negative effects for the other. Negative effects were suggested for individuals with lower baseline levels of meal planning (β - 2.6, 95% CI - 5.9; 0.8), healthy shopping convenience (β - 3.0, 95% CI - 7.2; 1.3), and healthy food attractiveness (β - 3.5, 95% CI - 8.3; 1.3), and with higher levels of price consciousness (β - 2.6, 95% CI - 6.2; 1.0) and weekly supermarket visits (β - 2.4, 95% CI - 6.8; 1.9).

CONCLUSIONS

Adults with varying psychological and grocery shopping characteristics largely seem equally (un)susceptible to nudging and pricing strategies. It might be that certain characteristics lead to adverse effects, but this is not plausible, and the observed negative effects were small and statistically non-significant and may be explained by chance findings. Verification of these findings is needed in real-world trials based on larger sample sizes and with the use of more comprehensive interventions.

TRIAL REGISTRATION

Dutch Trial Register ID NL7064, 30th of May, 2018, https://onderzoekmetmensen.nl/en/trial/20990.

A Systems Innovation Perspective on Implementation and Sustainment Barriers for Healthy Food Store Interventions: A Reflexive Monitoring in Action Study in Dutch Supermarkets

BACKGROUND

Healthy food store interventions (HFIs) are an important health-promotion tool, but face implementation and sustainment barriers. This paper aims to explore the underlying factors that produce these barriers using an innovative systems innovation perspective, through the case study of a multi-component HFI. The HFI was implemented in a minor, national, cooperative supermarket chain, in the Netherlands, a competitive market where price-based competition is the norm.

METHODS

The HFI was implemented for 6-12 months, in six stores. It was implemented by the researchers, and maintained by store employees. The study applied a Reflexive Monitoring in Action (RMA) approach, meaning that the researchers monitored stores' adherence to the HFI, via store visits, to identify potential issues. Subsequently, the researchers interviewed the store managers responsible for the intervention, to have them reflect upon the barriers leading to these adherence issues, underlying systemic factors, and potential solutions. The stores implemented these solutions, and during the next monitoring visit the researchers evaluated whether the barrier had been resolved.

RESULTS

We found that the HFI often clashed with regular activities of the stores (eg, competing over the same spaces) and that store managers generally prioritized these regular activities. This prioritization was based on the greater commercial value of those regular activities (eg, selling unhealthy products) according to store managers, based on their beliefs and assumptions about commerce, health, and consumer preferences. Due to the limited resources of supermarkets (eg, people, time, space), and the HFI often not fitting within the existing structures of the stores as easily as traditional practices, store managers often neglected the HFI components in favor of regular store activities.

CONCLUSION

Our findings illustrate the systemic factors that produce implementation barriers for HFIs, and the dynamics by which this production occurs. These insights help future researchers to anticipate and respond to such barriers.

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.

Development of a survey tool to assess the environmental determinants of health-enabling food retail practice in Aboriginal and Torres Strait Islander communities of remote Australia

BACKGROUND

Environmental factors can impact the ability of food retail businesses to implement best practice health-enabling food retail.

METHODS

We co-designed a short-item survey on factors influencing food retail health-enabling practice in a remote Australian setting. Publicly available submissions to an Australian Parliamentary Inquiry into food pricing and food security in remote Indigenous communities were coded using an existing remote community food systems assessment tool and thematically analysed. Themes informed survey questions that were then prioritised, refined and pre-tested with expert stakeholder input.

RESULTS

One-hundred and eleven submissions were coded, and 100 themes identified. Supply chain related data produced the most themes (n = 25). The resulting 26-item survey comprised questions to assess the perceived impact of environmental factors on a store's health-enabling practice (n = 20) and frequency of occurrence (n = 6).

CONCLUSIONS

The application of this evidence-informed, co-designed survey will provide a first-time cross-sectional analysis and the potential for ongoing longitudinal data and advocacy on how environmental factors affect the operations of remote stores.

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.

A qualitative study exploring the perceptions of children, parents and school staff towards the development and implementation of school lunch provision within primary schools in the Netherlands

BACKGROUND

There is no tradition of serving school lunches in primary schools in the Netherlands. Most children tend to bring their own packed lunch, however these are often nutritionally suboptimal. While school lunch provision can aid healthy eating behavior amongst children, its introduction would constitute a profound change for children, parents and school staff. Therefore, this qualitative study aims to explore children's, parents and school staffs' perceptions of both the current lunch situation and the implementation of school lunch provision within primary schools in the Netherlands.

METHODS

In this qualitative study we conducted nine interviews with school principals, 98 interviews with children, and held six focus groups with teachers and six with parents at primary schools in two Dutch cities. The data was analysed via iterative coding.

RESULTS

The results showed that most children and parents are satisfied with the current lunch situation, although existing school food policies are not always put in place. Most teachers felt that children had insufficient time to consume their lunch in the current situation. The children were generally positive about the idea of a school lunch, and stressed that it was important to have the ability to choose. While both parents and school staff saw school lunch provision as an opportunity to educate families about healthy food options, they also expressed concern about who would be responsible, as well as the financial and organizational implications of its introduction.

CONCLUSIONS

Perceptions of children, parents and school staff about a school provided lunch are mixed. A complex intervention such as a new school lunch program is difficult to envisage for all parties involved and more research is needed regarding the effects, organization, logistics and the costs of school lunch provision in the Netherlands.

CO-Creation and Evaluation of Food Environments to Advance Community Health (COACH)

Introduction

Food environments are a key determinant of food intake and diet-related health. This paper describes the development of an iterative, adaptive, context-specific framework for health-enabling food environments embedded in cocreation theory.

Methods

A 3-stage multimethod framework for the coproduction and prototyping of public health interventions was followed in an iterative manner during the development of the framework. These 3 stages were (1) evidence review, including systematic review, consultation with experts, and observation of current work; (2) codesign of the framework prototype with multiple stakeholders; and (3) coproduction through refinement of the prototype through stakeholder workshops and expert reviews with incorporation of researcher notes and workshop evaluation. We use the term prototype during the development phase and the term framework to report on the final product.

Results

COACH (CO-creation and evaluation of food environments to Advance Community Health) is a process framework that describes what best practice application of cocreation in health-enabling food retail environments should involve. COACH consists of 10 interdependent factors within a 4-phase continuous quality improvement cycle. The 4 phases of the cycle are engagement and governance establishment, communication and policy alignment, codesign and implementation, and monitoring and evaluation.

Conclusions

Utilizing cocreation theory represents an innovative step in research and practice to improve the healthiness of food retail environments. COACH provides a specific, unique, and comprehensive guide to the utilization of cocreation to improve the healthiness of food environments in practice.

Real-life experiments in supermarkets to encourage healthy dietary-related behaviours: opportunities, challenges and lessons learned

BACKGROUND

Supermarkets are the primary source of food for many people yet their full potential as a setting to encourage healthy dietary-related behaviours remains underutilised. Sharing the experiences from research groups who have worked with supermarket chains to evaluate strategies that promote healthy eating could improve the efficiency of building such relationships and enhance the design quality of future research studies.

METHODS

A collective case study approach was used to synthesise experiences of engaging and sustaining research collaborations with national supermarket chains to test the effectiveness of health-focused in-store interventions. The collective narrative covers studies conducted in three high-income countries: Australia, the Netherlands and the United Kingdom.

RESULTS

We have distilled our experiences and lessons learned into six recommendations for conducting high quality public health research with commercial supermarket chains. These include: (i) using personal contacts, knowledge of supermarket activities and engaging executive management to establish a partnership and allowing time to build trust; (ii) using scientifically robust study designs with appropriate sample size calculations; (iii) formalising data exchange arrangements and allocating adequate resource for data extraction and re-categorisation; (iv) assessing effects at individual/households level where possible; (v) designing a mixed-methods process evaluation to measure intervention fidelity, dose and unintended consequences; and (vi) ensuring scientific independence through formal contract agreements.

CONCLUSIONS

Our collective experiences of working in non-financial partnerships with national supermarket chains could be useful for other research groups looking to develop and implement supermarket studies in an efficient manner. Further evidence from real-life supermarket interventions is necessary to identify sustainable strategies that can improve population diet and maintain necessary commercial outcomes.

Developing Co-Creation Research in Food Retail Environments: A Descriptive Case Study of a Healthy Supermarket Initiative in Regional Victoria, Australia

Research into the co-creation of healthy food retail is in its early stages. One way to advance co-creation research is to explore and understand how co-creation was applied in developing, implementing, and evaluating a heath-enabling initiative in a supermarket in regional Victoria, Australia. A case study design was used to explore and understand how co-creation was applied in the Eat Well, Feel Good Ballarat project. Six documents and reports related to the Eat Well, Feel Good Ballarat project were analyzed with findings from the focus groups and interviews. Motivations to develop or implement health-enabling supermarket initiatives differed among the participants. Participants considered that initial negotiations were insufficient to keep the momentum going and to propose the value to the retailers to scale up the project. Presenting community-identified needs to the supermarket helped gain the retailer's attention, whilst the co-design process helped the implementation. Showcasing the project to the community through media exposure kept the supermarket interested. Retailers' time constraints and staff turnover were considered significant barriers to partnership building. This case study contributes insights into applying co-creation to health-enabling strategies in food retail outlets using two co-creation frameworks.

Co-creation of health-enabling initiatives in food retail: academic perspectives

INTRODUCTION

Co-creation of healthy food retail comprises the systematic collaboration between retailers, academics and other stakeholders to improve the healthiness of food retail environments. Research into the co-creation of healthy food retail is in its early stages. Knowledge of the roles and motivations of stakeholders in intervention design, implementation and evaluation can inform successful co-creation initiatives. This study presents academic experiences of stakeholder roles and motivations in the co-creation of healthy food retail environments.

METHODS

Purposive sampling of academics with research experience in the co-creation of healthy food retail initiatives. Semi-structured interviews conducted between October and December 2021 gathered participants' experiences of multi-stakeholder collaborative research. Thematic analysis identified enablers, barriers, motivations, lessons and considerations for future co-creation of healthy food retail.

RESULTS

Nine interviewees provided diverse views and applications of co-creation research in food retail environments. Ten themes were grouped into three overarching areas: (i) identification of stakeholders required for changes to healthier food retail; (ii) motivations and interactions, which included the intrinsic desire to build healthier communities along with recognition of their work; and (iii) barriers and enablers included adequate resourcing, effective and trusting working relationships and open communications.

CONCLUSION

This study provides insights that could help future co-creation in healthy food retail environments. Trusting and respectful relationships and reciprocal acknowledgement between stakeholders are key practices in the co-creation process. These constructs should be considered in developing and testing a model that helps to systematically co-create healthy food retail initiatives that ensure all parties meet their needs while also delivering research outcomes.

Towards healthy food retail: An assessment of public health nutrition workforce capacity to work with stores

OBJECTIVE

This article aims to investigate the capacity of nutrition professionals to engage in food retail practice change to improve population diet.

METHODS

Convergent mixed method design was used that includes pre-interview surveys, in-depth interviews, and retrospective mapping of service provision. The study was conducted in organisations that provide a nutrition professional service to food retail stores in remote Australia. The study participants include 11 nutrition professionals and eight organisation representatives, including managers, organisation directors and policy officers. Systems-mapping and thematic analysis of the in-depth interviews were conducted using a capacity development framework. Descriptive analysis was applied to pre-interview survey and mapping data.

RESULTS

A gap between the aspirational work and current capacity of nutrition professionals to engage effectively with stores was identified. Engagement with stores to improve population health was valued by organisations. Dominance of the medical health model limited organisation strategic support for store work and created barriers. Key barriers included the limited access to training, decision-support tools, information, financial resources and organisational structures that directed store work.

CONCLUSIONS

Provision of adequate store-specific training, resources and organisational support may empower the nutrition professional workforce to be powerful leaders in co-design for healthy food retail.

IMPLICATIONS FOR PUBLIC HEALTH

Building capacity for this critical workforce to engage in food retail practice change must consider the influence of the broader health system and employer organisations and need for access to evidence-based decision-support tools.

Involving supermarkets in health promotion interventions in the Danish Project SoL. A practice-oriented qualitative study on the engagement of supermarket staff and managers

BACKGROUND

Supermarkets have been suggested as relevant settings for environmental and educational initiatives encouraging healthier shopping and eating decisions, but in the literature, limited attention has been paid to the context, perspectives, and everyday practices of supermarket staff. The aim of this study was to examine the engagement of supermarket staff in a health promotion project from a practice-oriented perspective.

METHODS

The study was based on qualitative data collected in the supermarket setting of Project SoL; a community-based health promotion project in Denmark. We conducted 26 in-depth interviews with store managers and other key staff members in seven participating supermarkets. In addition, we collected data on planning, implementation, and perceptions of supermarket staff of in-store interventions and other project-related activities. These field data included short telephone interviews, observational notes, photos, and audiotapes of meetings. Data were analysed from the perspective of practice theory.

RESULTS

Although supermarket staff found community-based health promotion meaningful to engage in, the study observed that their engagement was challenged by a business mindset, practical routines and structural requirements favouring sales promotion over health promotion. Nevertheless, there were also examples of how health promotion activities and ways of thinking were successfully incorporated in everyday staff practices during and after Project SoL.

CONCLUSIONS

Our findings point to both potentials and challenges for using supermarkets as settings for health promotion. The voluntary engagement of supermarket staff in community-based health projects cannot stand alone but should be supplemented by more long-lasting strategies and policies regulating this and other food environments. Context-sensitive and practice-oriented analyses in local food environments could inform such strategies and policies to make sure they target unwanted elements and practices and not just individual behavior.

Using the Exploration, Preparation, Implementation, and Sustainment (EPIS) Framework to Advance the Science and Practice of Healthy Food Retail

Although healthy food retail strategies are widely used, there appears to be a limited understanding of the processes and determinants for successful adoption, implementation, and sustainment. To fill this gap, we recommend the Exploration, Preparation, Implementation, and Sustainment (EPIS) framework to be used to advance the science and practice of healthy food retail. In this perspective, we: (1) introduce EPIS and describe why it was chosen as a recommended implementation science framework for healthy food retail, (2) highlight healthy food retail evidence supporting EPIS, and (3) discuss research and practice needs moving forward.

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.

Designing a Healthy Food-Store Intervention; A Co-Creative Process Between Interventionists and Supermarket Actors

BACKGROUND

Without consideration for the food system in which healthy food-store interventions (HFIs) are implemented, their effects are likely to be unsustainable. Co-creation of HFIs by interventionists and food-store actors may improve contextual fit and therefore the effectiveness and sustainability of interventions, but there are few case studies on the topic. This study aims to provide insights into the integration of knowledge from contextual actors into HFI designs, through a co-creative process, to illustrate potential challenges, advantages, and outcomes.

METHODS

We describe the co-creative design of an HFI in a Dutch supermarket chain, conducted through three increasingly in-depth design phases. Each phase consisted of a cycle of theorizing (gather insights from literature, feedback, and pilot studies), building (develop intervention designs), and evaluating (interviews or workshops with supermarket actors, to explore barriers and facilitators for sustainable implementation), feeding back into the next phase (drafting adapted intervention designs, based on feedback, and research input). Interview transcripts underwent a qualitative content analysis.

RESULTS

We co-creatively designed four types of interventions to promote healthier food choices in supermarkets: (1) price strategies, (2) product presentation and positioning, (3) signage, and (4) interactive messaging. Interventions were aligned with the culture, structures and practices of the supermarket chain, while simultaneously challenging these system characteristics. For example, the idea of price promotions on healthy foods was well-received and encountered only practical barriers, which were easily resolved. However, the specification of tax-like price increases on unhealthy foods led to substantial resistance on cultural and commercial grounds, which were resolved through support from a key supermarket actor.

CONCLUSION

Our results illustrate the potential benefits of co-creation approaches in HFI design. We reflect on the value of more easily accepted interventions to develop collaborative momentum and more radical interventions to drive more substantial changes.

Implementation and sales impact of a capacity building intervention in Australian sporting facility food outlets: a longitudinal observational study

Background

Few studies have explored behavioural and financial impacts of retail initiatives after 2 years to address the unhealthy food environments common in local government sporting settings.

Aims

To evaluate the impact of a 2-year local government capacity building intervention in sporting facility food outlets on (1) the healthiness of refrigerated drink choices available and visible to customers, (2) healthiness of refrigerated drinks sold and (3) refrigerated drink revenue.

Methods

52 sporting facilities within 8 local governments from Victoria, Australia, participated in an intervention between March 2018 and February 2020 by limiting 'red' (least healthy) drinks to ≤20% of refrigerator display and increasing 'green' (healthiest) drinks to ≥50% of display. Mixed models assessed changes in mean percentage of 'red', 'amber' and 'green' drinks displayed over time, compared with baseline.Facilities provided electronic weekly itemised sales data (December 2015 to February 2020). Weekly volume of 'red' or 'green' drinks sold as a proportion of total drinks sold, and total refrigerated drinks revenue were compared preimplementation and postimplementation using mixed models (seasonal facilities), and mixed-effect interrupted time series models (non-seasonal facilities).

Results

Display of 'red' drinks decreased by mean -17.1 percentage points (pp) (95% CI -23.9 to -10.3) and 'green' drinks increased 16.1 pp (95% CI 9.30, 22.9) between baseline and 18-month audits.At nine seasonal facilities, compared with the summer preimplementation, the mean volume of 'red' drinks sold decreased by -19.0 pp (95% CI -28.6, to -9.51) and refrigerated drink revenue decreased by-AU$81.8 (95% CI -AU$123 to -AU$40.8) per week. At 15 non-seasonal facilities, by February 2020, the volume of 'red' drinks sold decreased on average by -11.0 pp (95% CI -21.6 to -0.41) with no change in drink revenue.

Conclusion

Reducing the display of unhealthy drinks can be an effective public health policy to improve the healthiness of customer purchases, provided there is consideration of potential impacts on revenue.

Social, economic, political, and geographical context that counts: meta-review of implementation determinants for policies promoting healthy diet and physical activity

BACKGROUND

This meta-review investigated the context-related implementation determinants from seven domains (geographical, epidemiological, sociocultural, economic, ethics-related, political, and legal) that were systematically indicated as occurring during the implementation of obesity prevention policies targeting a healthy diet and a physically active lifestyle.

METHODS

Data from nine databases and documentation of nine major stakeholders were searched for the purpose of this preregistered meta-review (#CRD42019133341). Context-related determinants were considered strongly supported if they were indicated in ≥60% of the reviews/stakeholder documents. The ROBIS tool and the Methodological Quality Checklist-SP were used to assess the quality-related risk of bias.

RESULTS

Published reviews (k = 25) and stakeholder documents that reviewed the evidence of policy implementation (k = 17) were included. Across documents, the following six determinants from three context domains received strong support: economic resources at the macro (66.7% of analyzed documents) and meso/micro levels (71.4%); sociocultural context determinants at the meso/micro level, references to knowledge/beliefs/abilities of target groups (69.0%) and implementers (73.8%); political context determinants (interrelated policies supported in 71.4% of analyzed reviews/documents; policies within organizations, 69.0%).

CONCLUSIONS

These findings indicate that sociocultural, economic, and political contexts need to be accounted for when formulating plans for the implementation of a healthy diet and physical activity/sedentary behavior policies.

Factors Influencing Implementation, Sustainability and Scalability of Healthy Food Retail Interventions: A Systematic Review of Reviews

The aim of this systematic review of reviews was to synthesise the evidence on factors influencing the implementation, sustainability and scalability of food retail interventions to improve the healthiness of food purchased by consumers. A search strategy to identify reviews published up until June 2020 was applied to four databases. The Risk of Bias in Systematic Review tool was used. Review findings were synthesised narratively using the socio-ecological model. A total of 25 reviews met the inclusion criteria. A number of factors influenced implementation; these included retailers' and consumers' knowledge and preferences regarding healthy food; establishing trust and relationships; perceived consumer demand for healthy food; profitability; store infrastructure; organizational support, including resources; and enabling policies that promote health. Few reviews reported on factors influencing sustainability or scalability of the interventions. While there is a large and rapidly growing body of evidence on factors influencing implementation of interventions, more work is needed to identify factors associated with their sustainability and scalability. These findings can be used to develop implementation strategies that consider the multiple levels of influence (individual, intrapersonal and environmental) to better support implementation of healthy food retail interventions.

Meta-review of implementation determinants for policies promoting healthy diet and physically active lifestyle: application of the Consolidated Framework for Implementation Research

BACKGROUND

Although multiple systematic reviews indicate that various determinants (barriers and facilitators) occur in the implementation processes of policies promoting healthy diet, physical activity (PA), and sedentary behavior (SB) reduction, the overarching synthesis of such reviews is missing. Applying the Consolidated Framework for Implementation Research (CFIR), this meta-review aims to (1) identify determinants that were systematically indicated as occurring during the implementation processes and (2) identify differences in the presence of determinants across reviews versus stakeholder documents on healthy diet/PA/SB policies, reviews/stakeholder documents addressing healthy diet policies versus PA/SB policies targeting any population/setting, and healthy diet/PA/SB policies focusing on school settings.

METHODS

A meta-review of published systematic scoping or realist reviews (k = 25) and stakeholder documents (k = 17) was conducted. Data from nine bibliographic databases and documentation of nine major stakeholders were systematically searched. Included reviews (72%) and stakeholder documents (100%) provided qualitative synthesis of original research on implementation determinants of policies promoting healthy diet or PA or SB reduction, and 28% of reviews provided some quantitative synthesis. Determinants were considered strongly supported if they were indicated by ≥ 60.0% of included reviews/stakeholder documents.

RESULTS

Across the 26 CFIR-based implementation determinants, seven were supported by 66.7-76.2% of reviews/stakeholder documents. These determinants were cost, networking with other organizations/communities, external policies, structural characteristics of the setting, implementation climate, readiness for implementation, and knowledge/beliefs of involved individuals. Most frequently, published reviews provided support for inner setting and individual determinants, whereas stakeholder documents supported outer and inner setting implementation determinants. Comparisons between policies promoting healthy diet with PA/SB policies revealed shared support for only three implementation determinants: cost, implementation climate, and knowledge/beliefs. In the case of healthy diet/PA/SB policies targeting school settings, 14 out of 26 implementation determinants were strongly supported.

CONCLUSIONS

The strongly supported (i.e., systematically indicated) determinants may guide policymakers and researchers who need to prioritize potential implementation determinants when planning and monitoring the implementation of respective policies. Future research should quantitatively assess the importance or role of determinants and test investigate associations between determinants and progress of implementation processes.

TRIAL REGISTRATION

PROSPERO, # CRD42019133341.

Point-of-sale nutrition information interventions in food retail stores to promote healthier food purchase and intake: A systematic review

Providing simple information that identifies healthier/less healthy products at the point-of-sale has been increasingly recognized as a potential strategy for improving population diet. This review evaluated the effect on healthiness of food purchasing/intake of interventions that identify specific products as healthier/less healthy at the point-of-sale in food retail settings. Five databases were searched for peer-reviewed randomized controlled or quasi-experimental trials published 2000-2020. Effects on primary outcomes of the 26 eligible studies (322 stores and 19,002 participants) were positive (n = 14), promising (effective under certain conditions; n = 3), mixed (different effect across treatment arms/outcomes; n = 4), null (n = 3), negative (n = 1), or unclear (n = 1). Shelf-label studies (three studies of two rating systems across all products) were positive. Technology-delivered (mobile applications/podcast/kiosk) interventions were positive (n = 3/5) or promising/mixed (n = 2/5). In-store displays (n = 16) had mixed effectiveness. Interventions provided information on targeted healthier products only (n = 17), unhealthy products only (n = 1), both healthy and unhealthy (n = 2), and across all products (n = 5). No patterns were found between behavior change technique used and effectiveness. Study quality was mixed. These findings indicate that point-of-sale interventions identifying healthy/unhealthy options can lead to healthier customer purchasing behavior, particularly those delivered using shelf-labels or technology. Further research on discouraging unhealthy foods is needed.

Implementing Food Environment Policies at Scale: What Helps? What Hinders? A Systematic Review of Barriers and Enablers

Background: Policies that support healthier food environments, including healthy retail food availability and promotion, are an important strategy for obesity prevention. The aim of this systematic review was to examine the evidence for barriers and enablers to successful implementation of healthy food and drink policies, delivered at scale. Methods: MEDLINE, SCOPUS and INFORMIT were searched to May 2019 for peer-reviewed studies. Google and Google Scholar were searched for grey literature. Studies of any design relating to a healthy food and drink policy delivered at scale (≥10 sites) in non-commercial food settings, for specific retail outlets (e.g., vending machines, cafes, cafeterias, school canteens), and that reported on implementation barriers and/or enablers were included. Studies in commercial food retail environments (e.g., supermarkets) were excluded. Studies were appraised for quality and key information was extracted and summarised. Extracted information on barriers and enablers was further grouped into overarching themes relating to perceptions of the policy itself, organisational and contextual factors influencing policy implementation, stakeholder responses to the implemented policy and perceived policy impacts. Results: Of 19 studies, 16 related to policies implemented in schools, two in hospital/health facilities and one in a sport/recreation setting. Most studies were conducted in North America or Australia, and policy implementation occurred mainly at state/regional or federal levels. The most commonly cited barriers across overarching themes and intervention settings were: lack of stakeholder engagement or prioritisation of the policy (11 studies); resistance to change from school stakeholders or customers (8 studies); and concern over profitability, revenue and/or commercial viability (8 studies). Few studies reported on mitigation of barriers. Enablers most commonly raised were: stakeholder engagement, whole-school approach and/or prioritisation of the policy (9 studies); policy level or higher-level support in the form of information, guidance and/or training (5 studies); and leadership, school/policy champion, management commitment and/or organisational capacity (4 studies). Conclusions: Key considerations for policy implementation ranged from building stakeholder support, prioritising policy implementation within organisations, to implementing strategies that address financial concerns and implementation barriers.

Determinants of Food Choice and Perceptions of Supermarket-Based Nudging Interventions among Adults with Low Socioeconomic Position: The SUPREME NUDGE Project

Nudging has received ample attention in scientific literature as an environmental strategy to promote healthy diets, and may be effective for reaching populations with low socioeconomic position (SEP). Therefore, the objective of this study was to investigate how the determinants of food choice shape the perceptions regarding supermarket-based nudging strategies among adults with low SEP. We conducted semi-structured interviews among fifteen adults with low SEP using a pre-defined topic list and visual examples of nudges. Interviews were recorded and transcribed verbatim and content analysis was used to analyse the data. The results show that food costs, convenience, healthiness, taste, and habits were frequently mentioned as determinants of food choice. However, the relative importance of these determinants seemed to be context-dependent. Interviewees generally had a positive attitude towards nudges, especially when they were aligned with product preferences, information needs, and beliefs about the food environment. Still, some interviewees also expressed distrust towards nudging strategies, suspecting ulterior motives. We conclude that nudging strategies should target foods which align with product preferences and information needs. However, the suspicion of ulterior motives highlights an important concern which should be considered when implementing supermarket-based nudging strategies.

Healthy eating: a matter of prioritisation by households or policymakers?

I reflect upon the potential reasons why American low-income households do not spend an optimal proportion of their food budgets on fruits and vegetables, even though this would allow them to meet the recommended levels of fruit and vegetable consumption. Other priorities than health, automatic decision-making processes and access to healthy foods play a role, but solutions for the persistent socio-economic inequalities in diet should be sought in the wider food system which promotes cheap, mass-produced foods. I argue that, ultimately, healthy eating is not a matter of prioritisation by individual households but by policymakers.

Evaluating the implementation and impact of a healthier checkout programme at a regional convenience store chain

OBJECTIVE

To test the feasibility of implementing and evaluating a healthier checkout pilot study in a convenience store chain.

DESIGN

A quasi-experimental study was conducted comparing a 3-month 'healthier checkouts' intervention in ten convenience stores which stocked eight healthier items in the checkout space and ten comparison stores assigned to continue stocking their current checkout space product mix. All aspects of the intervention were implemented by the retailer. The research team conducted in-person fidelity checks to assess implementation. Sales data were collected from the retailer in order to compare mean baseline to intervention sales of the eight healthier items in intervention and comparison groups while controlling for overall store sales.

SETTING

Convenience store chain.

PARTICIPANTS

Twenty convenience stores in New Hampshire.

RESULTS

The increases in sales of healthier items between the baseline and intervention periods among the intervention and comparison stores were not statistically significant; however, the overall pattern of the results showed promising changes that should be expanded on in future studies. Intervention fidelity checks indicated that results may have been attenuated by variability in intervention implementation.

CONCLUSIONS

This study advances the evidence for effective promotion of healthier food purchases in the convenience store chain setting and adds to the current literature on retail checkout space interventions. Additional research is needed to confirm and expand these results.

Corner Store Retailers' Perspectives on a Discontinued Healthy Corner Store Initiative

Making fresh fruits and vegetables (FFV) more widely available has been a prominent focus of healthy retail interventions and may have an important role in improving food access and diet quality at the population level. 'Healthy retail' interventions in corner/convenience stores (CS) are increasingly being adopted by public health practitioners to address the diet-related risk factors, improve food access at the community level, and change food retail environments. Private sector retailers are integral to the success of public health retailing interventions, making their perspectives and experiences critical. There is a particular need for greater evidence from retailers in settings where evaluations of these interventions have yielded null or mixed results. Through semi-structured interviews with 8 CS retailers (7 from urban settings and 1 from rural) in Ottawa, Ontario, Canada, this study aimed to describe experiences and critical factors regarding the feasibility and sustainability of a healthy CS program that was not sustained following the pilot testing phase, with a specific focus on the sale of FFV. Thematic analysis was used to analyze the interview data, which indicated that retailers faced two dominant challenges with selling FFV in CS: both relate to how these stores are embedded in the larger local and global food system. We join others in arguing that efforts and support for retail interventions aiming to increase the availability of FFV in CS need to address the structure and relations of the food system, as an upstream determinant of CS retailer interest and motivation.

Supplemental Nutrition Assistance Program (SNAP)-Authorized Retailers' Perceived Costs to Use Behavioral Economic Strategies to Encourage Healthy Product Sales

SNAP-authorized retailers could use marketing-mix and choice-architecture (MMCA) strategies to improve SNAP purchases, but associated costs are unknown. Perceived cost and inconvenience to implement eight MMCA strategies were assessed among 29 U.S. retailers. Differences in perspective were explored (owners vs. managers, corporate vs. independent retailers, and by format). Place changes (e.g., added refrigeration) were perceived more costly and prompting (e.g., shelf labeling) less costly. Managers rated the perceived inconvenience to make proximity changes higher than owners (3.78 ± 1.4 and 2.33 ± 1.2, respectively) (p < .05). Results can inform strategies to improve the adoption and implementation of healthy food retail programs.

Urban vs. Rural Socioeconomic Differences in the Nutritional Quality of Household Packaged Food Purchases by Store Type

The U.S. food system is rapidly changing, including the growth of mass merchandisers and dollar stores, which may impact the quality of packaged food purchases (PFPs). Furthermore, diet-related disparities exist by socioeconomic status (SES) and rural residence. We use data from the 2010-2018 Nielsen Homescan Panel to describe the nutritional profiles of PFPs by store type and to assess whether these vary by household urbanicity and SES. Store types include grocery stores, mass merchandisers, club stores, online shopping, dollar stores, and convenience/drug stores. Food and beverage groups contributing the most calories at each store type are estimated using survey-weighted means, while the associations of urbanicity and SES with nutritional quality are estimated using multivariate regression. We find that households that are customers at particular store types purchase the same quality of food regardless of urbanicity or SES. However, we find differences in the quality of foods between store types and that the quantity of calories purchased at each store type varies according to household urbanicity and SES. Rural shoppers tend to shop more at mass merchandisers and dollar stores with less healthful PFPs. We discuss implications for the types of store interventions most relevant for improving the quality of PFPs.

Effect of restricted retail merchandising of discretionary food and beverages on population diet: a pragmatic randomised controlled trial

BACKGROUND

The effectiveness of healthy food promotion on food and beverage sales in real-world food retail settings has been shown in randomised trials. The effectiveness of restrictions on the promotion of unhealthy food is, however, less clear. We aimed to assess the effect of restricted unhealthy food promotion, specifically those items contributing most to free sugar sales, on food and beverage sales.

METHODS

In this community-level pragmatic, partially randomised, parallel group trial, stores were randomly assigned by a statistician using a single sequence of random assignments to the intervention group, in which a co-designed strategy restricted merchandising of unhealthy food, or to a control group of usual retail practice. The trial was done in partnership with an organisation operating 25 stores in remote Australia. The primary analysis was based on difference in weekly sales with the strategy compared with no strategy in free sugar from all foods and beverages (g/total MJ; primary outcome), targeted food or beverages (weight and free sugars; g/total MJ), and gross profit (AU$) using mixed models. This trial is registered with the Australian New Zealand Clinical Trials Registry, ACTRN12618001588280.

FINDINGS

Between June 13 and Aug 15, 2018, 20 stores were recruited; ten stores were randomly assigned to the intervention group and ten stores to the control group. The trial was done between Sept 2 and Dec 2, 2018. The Healthy Stores 2020 strategy resulted in a reduction in sales of free sugar of 2·8% (95% CI -4·9 to -0·7). Targeted beverages were reduced by 8·4% (-12·3 to -4·3) and associated free sugar by 6·8% (-10·9 to -2·6), sugar-sweetened soft drinks by 13·2% (-18·5 to -7·6), and associated free sugar by 13·4% (-18·7 to -7·7). Reductions in sales of free sugar from confectionery of 7·5% (-14·3 to -0·2) and in weight sold (-4·6%, -11·1 to 2·3) resulted; however, the reduction in weight was not statistically significant. No differences in sales of table sugar and sweet biscuits were observed. Gross profit was not impacted adversely; a small increase resulted (5·3%, 0·3 to 10·5).

INTERPRETATION

Restricted merchandising of unhealthy foods and beverages, while allowing for complementary merchandising of healthier foods and beverages in a real-world store setting and co-designed with retailers, can achieve both public health and business relevant gains.

FUNDING

Australian National Health and Medical Research Council.

Impact of a Healthy Retail Intervention on Fruits and Vegetables and Total Sales in Tribally Owned Convenience Stores: Findings From the THRIVE Study

BACKGROUND

Healthy retail interventions are a recommended intervention strategy to address diet-related diseases, such as obesity and diabetes; however, retail managers are concerned about their bottom line. This study's aim was to assess the impact of a healthy retail intervention on fruits and vegetables (FV) sales, as well as total sales, in tribally owned convenience stores where grocery stores are scarce.

METHOD

We analyzed weekly sales data over the first 6 months of a healthy retail intervention. We assessed the proportion of sales from two FV baskets. The FV basket included all fresh, canned, and dried FV sold at stores; while the fruits, vegetables, and salads (FVS) basket included all FV items as well as all salads sold. We compared mean weekly sales rates in intervention and control stores over the 6-month period using generalized estimating equations models to account for repeated measures.

RESULTS

Mean weekly FV basket sales rates were higher in intervention stores than control stores in both Nations. Mean weekly FVS baskets sales were significantly higher in intervention stores than control stores in one Nation and were higher, but not statistically significant, in intervention stores in the other Nation. Total sales remained steady throughout the intervention period.

CONCLUSIONS

The THRIVE (Tribal Health and Resilience in Vulnerable Environments) intervention increased FV sales without negatively affecting total sales. Policy and Practice Implications. Healthy retail interventions in tribal convenience stores, where many Native Americans living in rural areas shop due to scarcity of grocery stores, could improve diet-related disparities without reducing total sales.

Reducing cardiometabolic risk in adults with a low socioeconomic position: protocol of the Supreme Nudge parallel cluster-randomised controlled supermarket trial

Background

Unhealthy lifestyle behaviours such as unhealthy dietary intake and insufficient physical activity (PA) tend to cluster in adults with a low socioeconomic position (SEP), putting them at high cardiometabolic disease risk. Educational approaches aiming to improve lifestyle behaviours show limited effect in this population. Using environmental and context-specific interventions may create opportunities for sustainable behaviour change. In this study protocol, we describe the design of a real-life supermarket trial combining nudging, pricing and a mobile PA app with the aim to improve lifestyle behaviours and lower cardiometabolic disease risk in adults with a low SEP.

Methods

The Supreme Nudge trial includes nudging and pricing strategies cluster-randomised on the supermarket level, with: i) control group receiving no intervention; ii) group 1 receiving healthy food nudges (e.g., product placement or promotion); iii) group 2 receiving nudges and pricing strategies (taxing of unhealthy foods and subsidizing healthy foods). In collaboration with a Dutch supermarket chain we will select nine stores located in low SEP neighbourhoods, with the nearest competitor store at > 1 km distance and managed by a committed store manager. Across the clusters, a personalized mobile coaching app targeting walking behaviour will be randomised at the individual level, with: i) control group; ii) a group receiving the mobile PA app. All participants (target n = 1485) should be Dutch-speaking, aged 45–75 years with a low SEP and purchase more than half of their household grocery shopping at the selected supermarkets. Participants will be recruited via advertisements and mail-invitations followed by community-outreach methods. Primary outcomes are changes in systolic blood pressure, LDL-cholesterol, HbA1c and dietary intake after 12 months follow-up. Secondary outcomes are changes in diastolic blood pressure, blood lipid markers, waist circumference, steps per day, and behavioural factors including healthy food purchasing, food decision style, social cognitive factors related to nudges and to walking behaviours and customer satisfaction after 12 months follow-up. The trial will be reflexively monitored to support current and future implementation.

Discussion

The findings can guide future research and public health policies on reducing lifestyle-related health inequalities, and contribute to a supermarket-based health promotion intervention implementation roadmap.

Trial registration

Dutch Trial Register ID NL7064, 30th of May, 2018