Barriers and facilitators to implementation of menu labelling interventions from a food service industry perspective: a mixed methods systematic review

Evaluation of an Environmental Nutrition Intervention at the 2018 Commonwealth Games

There has been an increasing expectation that the food provided for athletes at major competition events meets the specific dietary and performance needs of athletes. The aim of this study was to map the range of food service nutrition schemes that were implemented prior to and during a major competition event (2018 Commonwealth Games) and evaluate these schemes through staff training satisfaction, athlete feedback, and quality assurance checks. This study followed a case study design with nutrition schemes as follows: informing (nutrition labelling), enabling (staff training, nutrition service), and engineering (modification to menus and recipes). Overall, participants reported that they easily found items on the menu that met their nutritional/dietary needs. When asked how useful the schemes were in helping them to identify items that meet their needs, the majority of participants found the nutrition cards (n = 227, 71%) and serving staff (n = 212, 66%) 'useful/very useful'. 'Good/very good' ratings were received by >90% of respondents for speed of service, staff politeness, and knowledge of the menu. Participants (n = 316) who rated the nutrition staff as 'useful/very useful' gave a higher median rating for the menu. Past events have focused on the impact of a single component in the food environment; however, taking a whole systems approach resulted in more suitable food provision to meet the dietary needs of athletes.

Evaluating the outcomes and implementation determinants of interventions co-developed using human-centered design to promote healthy eating in restaurants: an application of the consolidated framework for implementation research

Background

Restaurants are an emerging yet underutilized setting to facilitate healthier eating, particularly among minoritized communities that disproportionately experience health inequities. The present study aimed to examine outcomes from interventions co-developed using Human-Centered Design (HCD) in two Latin American restaurants, including sales of healthier menu items (HMI) and the consumer nutrition environment. In addition, we aimed to assess implementation outcomes (acceptability, fidelity, and sustainability) and elucidate the determinants for implementation using the Consolidated Framework for Implementation Research.

Methods

This study used a mixed-methods, longitudinal design. Data were collected pre-, during, and post-intervention testing. Intervention outcomes were examined through daily sales data and the Nutrition Environment Measures Survey for Restaurants (NEMS-R). Changes in HMI sales were analyzed using interrupted time series. Implementation outcomes and determinants were assessed through site visits [observations, interviews with staff (n = 19) and customers (n = 31)], social media monitoring, and post-implementation key informant interviews with owners and staff. Qualitative data were analyzed iteratively by two independent researchers using codes developed a priori based on CFIR.

Results

The HCD-tailored interventions had different outcomes. In restaurant one (R1), where new HMI were introduced, we found an increase in HMI sales and improvements in NEMS-R scores. In restaurant two, where existing HMI were promoted, we found no significant changes in HMI sales and NEMS-R scores. Acceptance was high among customers and staff, but fidelity and sustainability differed by restaurant (high in R1, low in R2). Barriers and facilitators for implementation were found across all CFIR constructs, varying by restaurant and intervention. Most relevant constructs were found in the inner setting (restaurant structure, implementation climate), individual characteristics, and process (HCD application). The influence of outer setting constructs (policy, peer pressure) was limited due to lack of awareness.

Conclusion

Our findings provide insights for interventions developed in challenging and constantly changing settings, as in the case of restaurants. This research expands the application of CFIR to complex and dynamic community-based settings and interventions developed using HCD. This is a significant innovation for the field of public health nutrition and informs future interventions in similarly dynamic and understudied settings.

Implementation of e-Mental Health Interventions for Informal Caregivers of Adults With Chronic Diseases: Mixed Methods Systematic Review With a Qualitative Comparative Analysis and Thematic Synthesis

BACKGROUND

Informal caregivers commonly experience mental health difficulties related to their caregiving role. e-Mental health interventions provide mental health support in a format that may be more accessible to informal caregivers. However, e-mental health interventions are seldom implemented in real-world practice.

OBJECTIVE

This mixed methods systematic review aimed to examine factors associated with the effectiveness and implementation of e-mental health interventions for informal caregivers of adults with chronic diseases. To achieve this aim, two approaches were adopted: combinations of implementation and intervention characteristics sufficient for intervention effectiveness were explored using qualitative comparative analysis, and barriers to and facilitators of implementation of e-mental health interventions for informal caregivers were explored using thematic synthesis.

METHODS

We identified relevant studies published from January 1, 2007, to July 6, 2022, by systematically searching 6 electronic databases and various secondary search strategies. Included studies reported on the effectiveness or implementation of e-mental health interventions for informal caregivers of adults with cancer, chronic obstructive pulmonary disease, dementia, diabetes, heart disease, or stroke. Randomized controlled trials reporting on caregivers' mental health outcomes were included in a crisp-set qualitative comparative analysis. We assessed randomized controlled trials for bias using the Risk of Bias 2.0 tool, and we assessed how pragmatic or explanatory their trial design was using the Pragmatic Explanatory Continuum Indicator Summary 2 tool. Studies of any design reporting on implementation were included in a thematic synthesis using the Consolidated Framework for Implementation Research to identify barriers to and facilitators of implementation.

RESULTS

Overall, 53 reports, representing 29 interventions, were included in the review. Most interventions (27/29, 93%) focused on informal cancer or dementia caregivers. In total, 14 reports were included in the qualitative comparative analysis, exploring conditions including the presence of peer or professional support and key persuasive design features. Low consistency and coverage prevented the determination of condition sets sufficient for intervention effectiveness. Overall, 44 reports were included in the thematic synthesis, and 152 barriers and facilitators were identified, with the majority related to the intervention and individual characteristic domains of the Consolidated Framework for Implementation Research. Implementation barriers and facilitators in the inner setting (eg, organizational culture) and outer setting (eg, external policies and resources) domains were largely unexplored.

CONCLUSIONS

e-Mental health interventions for informal caregivers tend to be well-designed, with several barriers to and facilitators of implementation identified related to the intervention and individual user characteristics. Future work should focus on exploring the views of stakeholders involved in implementation to determine barriers to and facilitators of implementing e-mental health interventions for informal caregivers, focusing on inner and outer setting barriers and facilitators.

TRIAL REGISTRATION

PROSPERO (International Prospective Register of Systematic Reviews) CRD42020155727; https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020155727.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.1136/bmjopen-2019-035406.

The updated Consolidated Framework for Implementation Research based on user feedback

Background

Many implementation efforts fail, even with highly developed plans for execution, because contextual factors can be powerful forces working against implementation in the real world. The Consolidated Framework for Implementation Research (CFIR) is one of the most commonly used determinant frameworks to assess these contextual factors; however, it has been over 10 years since publication and there is a need for updates. The purpose of this project was to elicit feedback from experienced CFIR users to inform updates to the framework.

Methods

User feedback was obtained from two sources: (1) a literature review with a systematic search; and (2) a survey of authors who used the CFIR in a published study. Data were combined across both sources and reviewed to identify themes; a consensus approach was used to finalize all CFIR updates. The VA Ann Arbor Healthcare System IRB declared this study exempt from the requirements of 38 CFR 16 based on category 2.

Results

The systematic search yielded 376 articles that contained the CFIR in the title and/or abstract and 334 unique authors with contact information; 59 articles included feedback on the CFIR. Forty percent (n = 134/334) of authors completed the survey. The CFIR received positive ratings on most framework sensibility items (e.g., applicability, usability), but respondents also provided recommendations for changes. Overall, updates to the CFIR include revisions to existing domains and constructs as well as the addition, removal, or relocation of constructs. These changes address important critiques of the CFIR, including better centering innovation recipients and adding determinants to equity in implementation.

Conclusion

The updates in the CFIR reflect feedback from a growing community of CFIR users. Although there are many updates, constructs can be mapped back to the original CFIR to ensure longitudinal consistency. We encourage users to continue critiquing the CFIR, facilitating the evolution of the framework as implementation science advances.

Understanding Enablers and Barriers to the Implementation of Nutrition Standards in Publicly Funded Institutions in Victoria

Effective implementation of nutrition standards in publicly funded institutions can facilitate healthy food and beverage consumption by communities and populations, which can enable improvements in dietary intake and reduce disease burden. This study aimed to understand stakeholder perspectives on the implementation of government nutrition standards in publicly funded institutions in the Australian state of Victoria, as well as to determine enablers and barriers to successful implementation. Pre-interview questionnaires and semi-structured interviews were administered to stakeholders involved in the implementation of nutrition standards in publicly funded institutions in Victoria. The Interactive Systems Framework, which allows understanding of the infrastructure and systems needed to implement policies, was used to design the survey instruments and guide the data analysis. Forty-four stakeholders were interviewed, including program implementers, support personnel and food providers, across public sector hospitals and health services, workplaces, sport and recreation centres and schools. Though translated materials and resources have been developed for end-users to facilitate uptake and implementation, current nutrition standards were perceived to be long and complex, which hindered implementation. The existence of a government-funded implementation support service enabled action by providing technical support, troubleshooting and capacity-building. A specific pathway for successful guideline implementation was determined through the analysis. Opportunities to close the policy-implementation gap were identified. This will be crucial to maximising the impact of nutrition standards on population diets and reducing diet-related disease. Strengthening the guidelines and their governance, streamlining the support system and overcoming barriers within and outside of implementing organisations, are urgently required to propel statewide progress.

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.

OUP accepted manuscript

Context

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

Objective

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

Data sources

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

Data extraction

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

Data synthesis

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

Results

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

Conclusions

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

Systematic Review Registration

PROSPERO registration no. CRD42018115034.

A Proposed Research Agenda for Promoting Healthy Retail Food Environments in the East Asia-Pacific Region

PURPOSE OF REVIEW

This paper aimed to summarise existing literature on strategies to improve the healthiness of retail food environments in the East Asia and Pacific (EAP) region, and propose a prioritised research agenda on this topic.

RECENT FINDINGS

Little research on retail food environments has been conducted in the EAP region. Several approaches for measuring retail food environments were identified, although none have been tailored to the EAP context. A small number of policies and initiatives to promote healthy retail food environments have been implemented in EAP. Lessons learnt from successful implementation of initiatives in other regions could be applied in EAP. Retail food environments have a strong influence on food choices and health outcomes. Research can contribute to efforts to improve the healthiness of retail food environments in EAP by (1) describing the current state of retail food environments to highlight areas of good practice and concern and (2) identifying policies and initiatives that are likely to be effective, and mechanisms for their successful implementation.

Can Social Cognitive Theory Influence Breakfast Frequency in an Institutional Context: A Qualitative Study

Breakfast is considered an important meal, especially for people who are about to commence a long or demanding workday, and for roles that may involve physical tasks and a requirement to remain alert and vigilant in potentially high-risk situations. This study looks at breakfast consumption influences within two workplace institutional settings, namely military and mining. Semi-structured interviews were conducted with military personnel (n = 12) and mining employees (n = 12) to understand their breakfast consumption behaviour at work and at home, and the associated behavioural influences. The interview questions were framed by social cognitive theory. Overall, cognitive and environmental influences were the most prominent influences on breakfast consumption, less evident were behavioural influences. A negative stereotype of workplace institutional food services emerged as one of the most significant barriers to breakfast consumption for those already at work. Considerations of environmental influences on behaviour may need to be broadened beyond physical barriers and social influences, to include perceptions of the behavioural environment. Programs that aim to increase breakfast consumption must create areas where their employees want to go. Food systems need to ensure nutritious, quality, and appealing food is available. Interventions need to increase participants’ knowledge, improve their attitudes, and create positive expectations for breakfast.

Factors Influencing Fidelity to a Calorie Posting Policy in Public Hospitals: A Mixed Methods Study

Background: Labelling menus with nutrition information has increasingly become an important obesity policy option. While much research to-date has focused on determining its effectiveness, few studies report the extent to which menu labelling is implemented as designed. The aim of this study was to explore factors influencing fidelity to a calorie posting policy in Irish acute public hospitals.

Methods: A mixed methods sequential explanatory study design was employed, with a nested case study for the qualitative component. Quantitative data on implementation fidelity at hospitals were analysed first and informed case sampling in the follow-on qualitative phase. Maximum variation sampling was used to select four hospitals with high and low levels of implementation and variation in terms of geographic location, hospital size, complexity of care provided and hospital type. Data were collected using structured observations, unstructured non-participant observations and in-depth semi-structured interviews. The Consolidated Framework for Implementation Research guided qualitative data collection and analysis. Using framework analysis, factors influencing implementation were identified. A triangulation protocol was used to integrate fidelity findings from multiple sources. Data on influencing factors and fidelity were then combined using joint displays for within and cross-case analysis.

Results: Quantitative fidelity data showed seven hospitals were categorised as low implementers and 28 hospitals were high implementers of the policy. Across the four hospitals selected as cases, qualitative analysis revealed factors influencing implementation and fidelity were multiple, and operated independently and in combination. Factors were related to the internal hospital environment (e.g., leadership support, access to knowledge and information, perceived importance of calorie posting implementation), external hospital environment (e.g., national policy, monitoring), features of the calorie posting policy (e.g., availability of supporting materials), and the implementation process (e.g., engaging relevant stakeholders). Integrated analysis of fidelity indicated a pattern of partial adherence to the calorie posting policy across the four hospitals. Across all hospitals, there was a consistent pattern of low adherence to calorie posting across all menu items on sale, low adherence to calorie information displayed per standard portion or per meal, low adherence to standardised recipes/portions, and inaccurate calorie information.

Conclusion: Efforts to maximise fidelity require multi-level, multi-component strategies in order to reduce or mitigate barriers and to leverage facilitators. Future research should examine the relative importance of calorie posting determinants and the association between implementation strategies and shifts in fidelity to intervention core components.

Post-Secondary Food Service Manager Perspectives on Fruit and Vegetable Nudging Strategies: Qualitative Study

BACKGROUND

Changing the choice architecture in post-secondary food service contexts to "nudge" customers to choose more fruits and vegetables (FV) shows promise in intervention studies to date. If such approaches are to become more widely adopted, they must be feasible and acceptable to food service managers. Among possible early adopters, managers of food services in post-secondary education institutions may have unique insights on implementation of such approaches, as they have dual mandates to support student health and maintain profitability.

OBJECTIVE

The goal of this exploratory study was to examine current knowledge, practice, facilitators, and barriers to uptake of nudge strategies promoting FV in a sample of post-secondary food service managers.

METHODS

A qualitative telephone interview study was undertaken with food service managers across Canada (n = 10 institutions), recruited from a national professional organization. One or more representatives from each institution completed the interview. Interviews were audio-recorded, transcribed, and underwent framework descriptive and interpretative content analysis in NVivo (QSR International). Münscher's Taxonomy of Choice Architecture and the Ottawa Model for Research Use guided development and analysis.

RESULTS

Managers from 9 universities and 1 technical college participated. Local context, governance, and resources varied widely. Eight of 10 institutions used some form of FV nudging as part of their marketing and health promotion, most commonly to reduce the effort associated with choosing FV. Nudging strategies aimed at increasing the range and composition of FV offerings, providing a social reference (opinion leaders) for choosing FV, and changing consequences with loyalty cards were also common. Other nudging strategies were used infrequently. Cost, operational ease of implementation, and students' privacy and choices were critical issues in adoption.

CONCLUSIONS

The results can inform development and testing of locally adapted nudge interventions. It is critical that managers be involved from the outset of any planned academic implementation study.

Effects of Menu Labeling Policies on Transnational Restaurant Chains to Promote a Healthy Diet: A Scoping Review to Inform Policy and Research

There is insufficient evidence that restaurant menu labeling policies are cost-effective strategies to reduce obesity and diet-related non-communicable diseases (NCDs). Evidence suggests that menu labeling has a modest effect on calories purchased and consumed. No review has been published on the effect of menu labeling policies on transnational restaurant chains globally. This study conducted a two-step scoping review to map and describe the effect of restaurant menu labeling policies on menu reformulation. First, we identified national, state, and municipal menu labeling policies in countries from global databases. Second, we searched four databases (i.e., PubMed, CINHAL/EBSCO, Web of Science, and Google Scholar) for peer-reviewed studies and gray-literature sources in English and Spanish (2000–2020). Step 1 identified three voluntary and eight mandatory menu labeling policies primarily for energy disclosures for 11 upper-middle and high-income countries, but none for low- or middle-income countries. Step 2 identified 15 of 577 studies that met the inclusion criteria. The analysis showed reductions in energy for newly introduced menu items only in the United States. We suggest actions for governments, civil society organizations, and the restaurant businesses to develop, implement, and evaluate comprehensive menu labeling policies to determine whether these may reduce obesity and NCD risks worldwide.