Factors that influenced adoption and implementation of nutrition guidelines
This study systematically applied a Diffusion of Innovations framework to better understand adoption and implementation of nutrition guidelines in recreational facilities in Alberta. We assumed causal complexity, that is, that there are multiple paths to adoption, and thus we used a set theoretic approach to discern three sets of factors : 1) Factors that were common to all cases and were therefore not sufficient to compel or dissuade adoption and implementation of nutrition guidelines. 2) Factors that were unique to individual cases and not consistently associated with adoption and implementation. These factors may be influential in particular contexts. 3) Factors that distinguished adopters from the non-adopter, and were therefore sufficient and perhaps also necessary for adoption and implementation. The specific paths by which adoption and implementation may occur are not known, however, as many different combinations of these factors are possible . In addition, it would be premature to discard factors within the first category as unimportant, as although they do not guarantee adoption and implementation, they may nevertheless prove essential in future studies . Our analysis suggests that it is primarily factors within the third and perhaps also the second categories that determine whether or not adoption and implementation of nutrition guidelines will occur within a given context.
Although the specific adoption trajectories differed among cases, several important findings emerged. First, the keys to adoption and implementation relate to the manager. The manager is a reflective decision-maker whose beliefs, perceptions, and knowledge shape his decisions and actions. Adoption and implementation of nutrition guidelines in recreational facilities is more likely when the manager personally values healthy eating, has a broad scope of responsibility encompassing wellness, regards nutrition guidelines in a positive light, perceives a high tension for health-related change within his facility’s food environment, is willing to champion changes that contravene industry norms and that may be financially risky, perceives few competitive pressures, maintains good relations with industry, and is willing to partner with them to achieve desired outcomes.
The fact that adopters were willing to eschew industry norms and adopt the ANGCY despite potential negative repercussions marks them as innovators . These individuals are critical to diffusion as they act as gatekeepers, importing new ideas into a system . Managers, however, do not have free reign. Their decisions are made within a particular micro and macroenvironmental context that is a source of facilitators and barriers. Barriers, including poor managerial relations, financial constraints, limited capacity to implement nutrition guidelines, unfavourable power balances, and the provisions of food service contracts impeded action on the part of managers. Financial constraints in particular, were a strong and consistent barrier to adopting and implementing the ANGCY in all facilities, as sales reductions caused managers to question the degree to which the ANGCY would provide them with an advantage relative to their previous practices. We were unable to objectively verify whether offering healthier foods was profitable in this context, and evidence from other studies in recreational facilities [15, 24, 51] and schools is conflicting [52–60] in this respect.
The challenge to balance support for affordable opportunities to be physically active with the need to promote healthy dietary behaviors is considerable in recreational facilities. Managers perceived that adopting the ANGCY in a choice-based format helped them to balance these competing priorities. Simply adding more healthy options to existing, largely unhealthy menus may not influence children’s dietary behaviors, however, as exhibited by students’ purchases in the full adopter facility. When given a choice, children tend to select unhealthy items [60–67]. Parents too, at times may make poor nutritional choices for their children because powerful social factors, time  and informational constraints  can easily take precedence over longer-term, intangible health concerns. Providing individuals with both healthy and unhealthy options (ie. a choice-based format) and trusting them to choose the healthiest option in spite of environmental conditions that overwhelmingly promote the opposite is unlikely to curtail escalating obesity rates.
The second major finding that emerged from this study is that although managers played a major role in adopting and implementing nutrition guidelines, they could not accomplish these tasks alone. Intersectoral linkages and formal health promoting partnerships were essential. Multisectoral, health promoting partnerships have long been recognized as a fundamental ingredient in effective health promotion practice . It is difficult to envision how effective solutions to obesity can be forged without active involvement from the corporations that control and shape the food supply . In the context of implementation of voluntary nutrition guidelines, adopters recognized that they lacked capacity to implement the ANGCY and therefore requested assistance from industry, leveraging their existing collaborative relationships in a new, health promoting direction. Where health promoting public-private partnerships existed, adoption and implementation proceeded, whereas no action was taken in their absence. The sustainability of these partnerships is unclear, however.
In addition to formal partnerships, informal linkages with schools were important. Adopters were motivated to seriously consider adopting the ANGCY when others within their social networks shared how they were using the ANGCY in schools, and encouraged them to do the same. Diffusion of the ANGCY therefore occurred within municipalities, from schools to recreational facilities, rather than among recreational facilities, as adoption of the ANGCY was too low for diffusion networks to become activated in this context . In addition, industry’s willingness to collaborate with recreational facilities was partially determined by their pre-existing capacity to implement the ANGCY, developed through their school-based operations. Thus, efforts to improve the school food environment provided a supportive context and capacity to implement similar measures in recreational facilities.
Voluntary initiatives such as the ANGCY are of limited effectiveness in counteracting the pervasive influence of macro-level forces within the food system, as the environmental supports for voluntary action are poor. ANGCY uptake may therefore continue to falter under the current voluntary approach, and where it does occur, our findings suggest changes to the food environment may be relatively minor. Stronger government action is required to promote healthy dietary behaviors among children. Such action could include relatively less coercive (eg. incentives) or more coercive measures (eg. regulation). First and foremost, funding models should not be antithetical to recreational facilities’ wellness mandates. Facilities derived a small percentage of their overall revenues from food services and sponsorships, and thus it would not be costly to replace this revenue. Next, the ANGCY should be revised to include specific, measurable and robust recommendations. Other actions could include financial incentives (eg. tax breaks) for industry to develop products that meet the definition of “choose most often” and for those corporations that succeed in selling, not simply offering, a high proportion of “choose most often” items. Similar to pay-for-performance schemes in health care, governments could incorporate guideline-related outcomes as performance accountabilities for recreational facilities to continue to receive a portion of their public funding. Finally, governments could simply mandate that all recreational facilities adhere to the ANGCY, ideally in a restrictive format. Although some may argue that such measures interfere with the individual’s right to choose, many current policies already constrain food choice within recreational facilities (eg. funding models that make facilities partially dependent on food service revenues) and therefore such measures would merely counter existing obesogenic policies. These findings illustrate the tension that exists among individual rights, profitability and public health within market-based economies, and will assist policy makers to formulate policies that balance these competing interests.
Strengths and limitations
This study was unique and had many strengths, including its in-depth nature and the range of cases studied. Mixed methods provided a more comprehensive understanding of the research questions than could have been achieved with a single approach. Multiple quantitative and qualitative perspectives of the food environment highlighted the many ways in which the food environment can be conceptualized, and showed that using a single tool is likely to yield incomplete and biased findings. We used a novel theoretical framework to discern factors that influenced uptake of the ANGCY, a model that may now provide a theoretical platform from which to investigate the uptake and operationalisation of a variety of obesity prevention policies. Finally, we contacted facilities 6–18 months following each case study to ascertain whether their adoption status had changed, and whether they had made any nutrition-related changes to food services.
ANGCY implementation scores were not consistently higher among adopters, and indeed, were high in some non-adopter facilities. This result was consistent with adopters’ perceptions that the food environment did not change substantially following ANGCY implementation. These results may also suggest a problem with the scoring system, as although the tool was judged to have good content validity, its construct validity may be poor. It is possible that the tool is not sensitive enough to differences between adopters and non-adopter facilities, as facilities could only receive a score of 0, 1 or 2 for each item. Others, however, have used similar scoring systems with good results . Alternatively, the inability of the scoring system to distinguish adopter from non-adopter facilities may reflect problems within the ANGCY themselves, as informants felt several ANGCY recommendations were simply good business practice and likely to be practiced in all facilities. The guidelines also lack specific, measurable targets, which made it difficult to judge the degree to which facilities had implemented the recommendations. All of these factors likely contributed to the poor performance of the scoring system, however we believe the latter two were particularly influential.
We used multiple, mixed tools to assess food environment quality, however even these tools could not fully capture its many dimensions. We focussed mainly on physical aspects of the micro food environment, and did not extensively investigate its political, sociocultural and economic aspects , nor did we capture the subjective perceptions of patrons. Because we assessed the food environment at a single time point we could only infer change in food environment quality from managers’ comments and from comparison of adopter and non-adopter facilities. There is no universally agreed upon definition of a healthy food, and it is likely that a higher percentage of items would have been classified as healthy (ie. “choose most often”) using different standards, as ANGCY standards for sodium, in particular, are very stringent.
We make no claim that cases in this study are representative of all recreational facilities in Alberta. However, we have highlighted broad areas to target for change and provided as much detail as possible to allow the reader to evaluate the opportunities for generalization to other contexts.