Implementation Factors Related to Improving the Food Environment Within Health Care Institutions: A Multiple Case Study

Abstract Background Healthy food environment policies (HFEPs), such as sugar-sweetened beverage bans or nutritional standards for vending machines, can improve the healthfulness of retail food venues, particularly within health care institutions that have a health-focused mission. The degree to which operational managers’ and executive leaders’ perceptions of implementation challenges align or diverge, and the extent to which these perceptions affect HFEP implementation, is unknown. Methods We conducted ten semi-structured key informant interviews with managers and executive leaders who participated in HFEP development within five health care organizations. Interviews explored facilitators and barriers for HFEP adoption and maintenance. We transcribed, coded, and analyzed interviews and derived contextual facilitators and barriers. Results We identified 27 facilitators and 30 barriers, which were refined into six and five categories, respectively, and ultimately paired to create three overarching recommendations. Operational managers’ and executive leaders’ perceptions overlapped 44-75% when identifying facilitators but only 33-58% when identifying implementation barriers. Interpersonal issues such as over-delegation and mistrust were prominent among those organizations whose respondents’ perceptions diverged substantially. Conclusion As the obesity epidemic continues to increase, understanding key facilitators and barriers to HFEPs, as well as the influence on leaderships’ perceptions on the implementation process, will be key to addressing obesogenic food environments. Though leaders were generally aligned in perspectives regarding facilitators, there was greater divergence when barriers were discussed. Executive leaders are encouraged to familiarize themselves with operational barriers and refrain from over-delegating these challenges to their operational counterparts, who lack the institutional authority to override organizational or system-level decisions.