Background
It is widely recognized that the childhood obesity epidemic is primarily driven by unhealthy environments that promote consumption of energy-rich, nutrient-poor foods, and that discourage physical activity [
1]. The food or nutrition environment refers to the context in which consumers purchase food, including the availability, cost, quality and promotion of healthy and unhealthy food choices [
2]. The current food environment has been described as unhealthy and even obesogenic [
3] because energy-dense and nutrient-poor foods are readily available, inexpensive, convenient, and heavily promoted. A predominance of unhealthy food environments has contributed to a high prevalence of dietary behaviours that increase the risk of obesity among children [
3]. School-based studies, by contrast, have shown that healthy food environments foster good dietary behaviours [
4‐
7] and appropriate body weights among children [
5,
6] and as such, there is significant momentum across North America to improve school nutrition environments. Many, however, overestimate time spent in school, which in reality accounts for 20% of children's waking hours over the course of a year [
8]. That this figure leaves 80% of time unaccounted for suggests a need to focus on obesity prevention in other settings [
8]. The current focus on school-based initiatives ignores the broader context of unhealthy food environments [
9] where less advantaged children, in particular, continue to be exposed to conditions that promote unhealthy dietary behaviours [
10,
11]. A predominance of healthy food environments throughout communities will help to reinforce healthy eating behaviours (i.e. eating patterns consistent with recommendations in
Eating Well with Canada's Food Guide) learned in school, ensure that intake of less healthful foods (i.e. foods with a high calorie, fat, sugar and/or sodium content, and a low micronutrient content) is not displaced from school to community food environments, and maintain and accrue further health benefits.
Although the mandate of recreational facilities is to enhance well-being, many offer foods inconsistent with recommendations for healthy eating [
12‐
14]. To this end, municipalities are being encouraged to improve the nutrition environment within recreational facilities [
15‐
20], and some mandated policies now exist [
21,
22]. The Canadian province of Alberta has included voluntary nutrition guidelines for recreational facilities in the Alberta Nutrition Guidelines for Children and Youth (ANGCY). Released in June, 2008, the ANGCY are intended to promote child health in Alberta by equipping facilities and organizations with the tools they need to ensure children and youth have access to healthy food choices within a variety of settings, including schools, childcare and recreational facilities [
17].
There are very few published studies of recreational facility food environments [
12‐
14,
23‐
25]. Additional data would be timely and relevant, as several jurisdictions have recently initiated action to improve recreational facility food environments [
17,
21‐
24,
26,
27]. The ANGCY represent a novel public health intervention with relevance for health policy in many nations. Therefore, we sought to investigate whether, and to what extent recreational facilities in Alberta were aware of, and had adopted and implemented the ANGCY, and the barriers to their adoption and implementation. We define awareness as having knowledge of the ANGCY, adoption as a one-time mental decision to follow the ANGCY, whereas implementation refers to multiple acts that must be repeated over time to put the decision into practice [
28]. The specific objectives of this study were three-fold: 1) to describe the organizational priority for healthy eating, 2) to assess awareness of, adoption and implementation of the ANGCY and 3) to describe barriers to adopting and implementing the ANGCY in recreational facilities.
Discussion
These findings demonstrate that awareness (50%), adoption (14%), and implementation (6%) of the ANGCY were low among this sample of recreational facilities approximately one year following their release. Similarly, evidence from the Treatment Improvement Protocols (TIPs) evaluation project suggests that awareness of government-developed best practice guidelines for substance abuse treatment spread slowly, as only 45% of professionals working in the substance abuse field were aware of the TIPs approximately seven years following their release [
36]. Diffusion of tobacco control policies was also a lengthy process [
37]. Initiatives to address recreational facility food environments are very recent [
23,
24], change will require support and thus it may not happen quickly [
13,
14]. Awareness of the ANGCY on the part of recreational facilities may actually be high relative to the short period of time that has elapsed since their release, and considering the fact that few resources were directed toward dissemination.
Although just over half of facilities had made changes to improve the nutritional quality of foods offered, only a small proportion (11%) of these changes were motivated by the ANGCY. This survey was not intended to assess the extent or fidelity of implementation of the ANGCY, however open-ended responses suggest that implementation was incomplete. Notably, adoption and implementation were more likely among facilities with an "ANGCY champion", a finding common in many other contexts [
38,
39]. Facilities with nutrition policies appeared to be more likely to adopt and implement the ANGCY, although it is not clear whether these policies were precipitated by, or existed prior to ANGCY adoption. These findings demonstrate that creating nutrition guidelines does not in itself constitute a sufficient stimulus for widespread change within the food environment of recreational facilities in the first year following their release. Similarly, awareness [
40] and even adoption [
41] of practice guidelines in other settings also did not guarantee their implementation. An important strength of the current study is its use of a mixed questionnaire which enabled further exploration of the distinct barriers to adoption and implementation of nutrition guidelines in this context.
It is unclear why facilities were less likely to implement the ANGCY if the priority for healthy eating was medium to high. Among the nine facilities deemed to have implemented the ANGCY, six indicated that healthy eating was a low priority. As was the case for adoption, it is possible that the change in priority is more relevant to implementation than the absolute priority, as the priority for healthy eating had increased among six of the nine implementers, and was unchanged in the other three. Furthermore, the survey was not designed to assess the extent of change made. Therefore, although these facilities had made ANGCY-motivated change, it is possible that these changes were minor, consistent with a low priority for healthy eating.
An extensive body of research supports the notion that the key attributes of innovations, as perceived by potential adopters, account for a significant proportion of the variability in adoption rates [
30]. Although other factors were also important, perceived negative characteristics of the ANGCY were consistently described as barriers to their adoption and implementation. These perceptions were strongly driven by the constructs of relative advantage and compatibility [
28,
42], in which managers perceived that adopting and implementing the ANGCY would limit their profit-making ability. Given managers' limited knowledge of the ANGCY it is possible that some of these negative perceptions may be amenable to change through the provision of training and technical assistance [
43] to enhance understanding and application of the ANGCY.
Food choices are primarily made on the basis of taste, cost and convenience, and to a lesser extent, health and variety [
44,
45]. Individuals vary in the importance they ascribe to each of these dimensions [
44,
45], however children are particularly vulnerable to external influences because they fail to take into account the future consequences of today's unhealthy dietary choices [
46,
47]. In this study, the perceived higher costs of healthy foods emerged as a particularly salient barrier that limited the marketability, and hence the availability, of healthier options. This finding was not surprising, as one of the most powerful ways to modify food purchases is to change food pricing [
48‐
51]. Indeed, when healthier foods are substituted for less healthy foods at competitive prices in both cafeterias [
52] and vending machines [
53‐
55], children's purchases of healthier foods increases with no loss of revenue [
56]. The threat of reduced profitability was also an important barrier to providing healthier food options in other studies of recreational facilities [
13,
14,
23‐
25], however in spite of these fears, many recreational facilities intended to continue to offer healthier options [
14,
23,
24]. This suggests that concerns related to profitability need not preclude adoption and implementation of the ANGCY.
Given that financial considerations figured prominently into the decision of managers not to adopt and implement the ANGCY, recreational facility managers could consider raising prices on less healthful foods to compensate for lowered prices of healthful options, and stipulate that food contractors do the same within negotiated contracts. This strategy may encourage substitution of healthy for unhealthy items while maintaining revenues [
52,
57]. In addition, environmental changes that increase availability and promotion of lower fat foods lead to greater purchase of these items among adolescents, with no adverse effects on school revenues [
58]. Thus, pricing and environmental modifications analogous to those recommended in the ANGCY may act in a complementary manner to support purchase of healthy items by children without adversely affecting food service revenues. Success will, however, require a fundamental shift in the managerial role, from one in which managers simply respond to consumer demand, to one in which they endeavour to shape demand by actively manipulating food availability towards a healthier mix.
Findings from this study suggest that recreational facility managers may not recognize the contribution made by unhealthy community nutrition environments to childhood obesity. Instead, some managers held to a personal responsibility frame, holding parents responsible for what is a predictable response to toxic environmental conditions [
59]. Strategies to improve problem recognition should therefore be enacted prior to proceeding further with ANGCY adoption and implementation [
43].
The dissemination strategy adopted by the provincial government for recreational facilities included mailing ANGCY resource binders to municipalities, presentations by government staff at educational events and posting the guidelines on the internet. Reliance on mailings and presentations has proven ineffective in other dissemination studies [
41,
60‐
62], and appears to have had limited efficacy in this context as well. Conversely, comprehensive, resourced dissemination guided by theoretical constructs similar to those underlying the current study has been successful [
41]. Awareness and uptake of the ANGCY might be improved in recreational facilities by adapting successful dissemination strategies used in other settings. It is also possible that the time frame used in this study may have been too short to see widespread awareness, adoption and implementation of the ANGCY.
Limitations
It is not clear to what extent these observations reflect the entire population of publicly funded recreational facilities in Alberta, however a larger sample size was not attainable within the timelines used to define early adoption. Future studies should anticipate challenges related to contacting and recruiting rural facilities, which may rely on part-time, volunteer staff. Alberta has 1275 publicly funded recreational facilities, however the number of facilities that serve food is unknown. Provincial officials and the Alberta Parks and Recreation Association estimate that approximately 80% of the 1275 serve food, suggesting that we sampled 15% of the relevant population with a response rate of 41%. In addition, we used random sampling to provide protection against sampling bias [
64]. We considered whether the inferences made would differ if our estimates were off by a margin of error of ± 7.5% with a 95% confidence interval (based on a population of 1275 recreational facilities). Under this scenario, 95% of the time the true proportion of facilities who have heard of the ANGCY would range from a low of 42% to a high of 58%. Similarly, the true proportion of adopters might range from 6% to a high of 22%, with implementers constituting between 0% and 14% of facilities. Thus, even under the worst case scenario, study findings of low levels of awareness, adoption and implementation of the ANGCY remain robust.
Given the limited nature of the qualitative data collected in this study, we were unable to fully assess the fit of Greenhalgh's framework in this context. The framework did provide a good fit for the data, however we noted several areas of overlap among subcategories, suggesting there may be areas in which the model can be rendered more concise for application in this setting. Findings from this study will be used to select a purposeful sample for a subsequent, in depth exploration of adoption and implementation of the ANGCY, thereby enabling a thorough exploration of the utility of Greenhalgh's model in this context.
Acknowledgements
The authors wish to acknowledge the assistance of Crystal Anschetz and Andrea Hill in completing the telephone surveys and Dr. Laki Goonewardene for statistical advice.
Funding
This research was funded by the Canadian Institutes of Health Research (CIHR). CIHR was not involved in study design, in the collection, analysis and interpretation of the data, or in the preparation or submission of the manuscript.
Dana Olstad is supported by a Vanier Canada Graduate Scholarship and a Canadian Institutes of Health Research/Heart and Stroke Foundation of Canada Training Grant in Population Intervention for Chronic Disease Prevention.
Kim Raine is funded by a Canadian Institutes of Health Research/Heart and Stroke Foundation of Canada Applied Public Health Chair.
Competing interests
The authors declare that they have no competing interests.
Authors' contributions
DLO analysed and interpreted the data and wrote the manuscript; SMD participated in the design of the study, participated in and supervised data collection, and participated in data interpretation; KDR participated in data interpretation and edited the manuscript; TRB participated in the design and implementation of the study; LJM designed the study, supervised data collection and analysis, participated in data interpretation and edited the manuscript. All authors read and approved the final manuscript.