Background
Methods
Study design
Theoretical framework
Framework components | Description | Examples |
---|---|---|
Attributes of the innovation | Perceived attributes of the innovation explain much of the variance in adoption rates | Relative advantage, complexity, observability |
Organizational antecedents for innovation | General features of the organization that make it more or less innovative | Receptive context for change, absorptive capacity |
Organizational readiness for innovation | Readiness and/or willingness of the organization to adopt a particular innovation | Power balances, tension for change, innovation-system fit |
Adopters and the adoption process | Influential aspects of adopters and of adoption as a process | Meaning of the innovation to potential adopters |
Processes of assimilation | Organizations may move back and forth between initiation, development and implementation of the innovation | Complex, non-linear processes |
Implementation process | Specific steps involved in putting a decision into practice | Effective management, feedback and monitoring |
Communication and influence | Means of spreading the innovation | Champions, diffusion, dissemination |
Outer context | External influences on the organization | Socio-political climate, environmental stability |
Linkage between developers and users | Connections that facilitate movement of the innovation from developers to users | Effective knowledge transfer from developers to users |
Case selection
Ethical approval
Data generation and analysis
Questionnaire
Qualitative assessments
Interviews
Observations
Document reviews
Analysis of qualitative data
Quantitative assessment of the food environment
Food and beverage availability
Nutritional profile of vending machine items
Nutrition Environment Measures Survey in Restaurants (NEMS-R) assessment
ANGCY adoption and implementation scores
Data transformation
Sales
Within case report
Cross-case analysis
Long-term follow up
Results
Context
Case | Full adopter | Semi-adopter | Non-adopter |
---|---|---|---|
Facility type
| Large modern multipurpose facility | Large modern multipurpose facility | Four small aging, single purpose facilities |
Funding
| Publicly funded | Publicly funded | Publicly funded |
Food service management
| General manager | General manager | Dedicated concession services manager |
Food service: concession(s)
| An international franchise that had adopted the ANGCY in schools and in the full adopter facility. Popular for its fries and poutine. | 1) An international franchise that had adopted the ANGCY in schools and was willing to adopt them in the semi-adopter facility. The company had a healthy brand image. | 4 municipally-operated concessions that were not associated with schools and were not willing to adopt the ANGCY in non-adopter facilities. The study focussed on concessions in 2 facilities: |
2) A small local company that had no school-based operations and was not willing to adopt the ANGCY in the semi-adopter facility. Popular for its fries and poutine. | 1) Pool café popular for its sandwiches, wraps, and baked goods. | ||
2) Arena concession with a fast-food style menu. | |||
Food service: vending machines
| 12 machines serviced by a company that had adopted the ANGCY in schools and in the full adopter facility. | 21 machines serviced by a company that had adopted the ANGCY in schools and in the semi-adopter facility. | 3 machines serviced by a company that had not adopted the ANGCY in schools or in non-adopter facilities. |
Relationship with schools
| Shared a field with 2 high schools. Students came to the facility at lunch primarily to purchase the unhealthy items they could not purchase on their campuses. | No schools within close proximity. | High school students came to the pool café at lunch, presumably to avoid long line-ups and because they preferred the café-style menu to their school’s cafeteria. |
Clients
| > 50% children1
| > 50% children1
| > 50% children1
|
Food environment quality
Case | Full adopter | Semi-adopter | Non-adopter |
---|---|---|---|
Adoption status
| Adopter in vending machines | Adopter in vending machines | Non-adopter in vending machines |
Food vending machines
| |||
ANGCY implementation score
| 67% High | 71% High | 41% Moderate |
Availability of CMO food items
| 2% Very limited | 4%1 Very limited | 0% None |
Nutrient content of food machine items
| 216 kcals, 42% fat, 54% CHO (13g sugar, 1g fibre), 6% protein, 198 mg sodium | 155 kcals, 29% fat, 62% CHO (6g sugar, 2g fibre), 8% protein, 218 mg sodium | 285 kcals, 35% fat, 60% CHO (22g sugar, 2g fibre), 3% protein, 277 mg sodium |
Beverage vending machines
| |||
ANGCY implementation score
| 85% Very high | 85% Very high | 83% Very high |
Availability of CMO beverages
| 31% Limited | 26% Limited | 13% Very limited |
Nutrient content of beverage machine items
| 126 kcals, 0% fat, 98% CHO (28g sugar, 0g fibre), 3% protein, 77 mg sodium | 107 kcals, 0% fat, 100% CHO (28g sugar, 0g fibre), 0% protein, 130 mg sodium | 138 kcals, 0% fat, 100% CHO (38g sugar, 0g fibre), 0% protein, 126 mg sodium |
Managers’ perceptions of the health of vending machine items
| “Our requirement is [that] 25% [of vending items be healthy] and they meet that, but it doesn’t move so it sits there and the other [unhealthy] stuff on top moves… I wish there was better options… to have stuff in there that is new and interesting and does sell.” | “In terms of vending, there are healthier choices. I wouldn’t say it’s successful… [but] it’s better than it was. .. Am I jumping up and down saying we did it? No, because there’s more to do.” | “I’ve actually never really told them what to put in the vending machines. I don’t eat chips, I don’t eat stuff like that, so I don’t even think about it… We did mention to them that we would like some healthy [items]… but other than that… he’s trying to maximize his sales for the stuff that the kids like.” |
Managers’ perception of the proportion of items that are healthy
| 25% | 25-30% | 15% |
Case | Full adopter | Semi-adopter | Non-adopter | ||
---|---|---|---|---|---|
Adoption status
| Franchised concession: adopter | Franchised concession: non-adopter | Local concession: non-adopter | Pool café: non-adopter | Arena concession: non-adopter |
Facility ANGCY adoption score
| 82% Very high | 0% No formal policies | 0% No formal policies | ||
ANGCY implementation score
| 75% High | 66% High | 69% High | 75% High | 47% Moderate |
Availability of CMO items:
| |||||
Overall
| 16% Very limited | 22% Limited | 11% Very limited | 17% Very limited | 11% Very limited |
Main dish and side items
|
23%
|
32%
|
14%
|
12%
|
0%
|
Snacks and desserts
|
7%
|
0%
|
0%
|
10%
|
0%
|
Beverages
|
16%
|
20%
|
15%
|
40%
|
24%
|
NEMS-R
1
| +28 Healthy food environment | Healthy food environment2
| + 12 Moderately healthy food environment | + 18 Moderately healthy food environment | + 3 Limited healthy aspects of food environment |
Managers’ perceptions of the concession food environment
| “My preference would be that we don’t have the poutine and the real unhealthy stuff here… I would like to [have] a different vendor… that doesn’t even have a deep fryer.” | “[We] didn’t have to have a discussion with the [franchised concession]… They don’t have any junk.” | “We think it would be great if they had more of a deli sandwich approach, you know, fresher, more healthy, instead of the focus on the usual high fat [items].” | “I think that what we do is pretty healthy… I mean when we make our muffins and stuff, we always try to make like a healthier option. But then there’s always the… kind of unhealthy option, sort of thing. But they’re both there.” | “We try to use 100% real beef and you know, we try to – we use a healthier oil and just things like that. I mean, I know that it’s still junk food but it’s kind of, it’s the healthier junk food… People always think a hamburger’s not healthy for you but…it’s beef… it’s got lettuce and tomato and cheese on it, you know? So it’s a burger. But it’s still got the protein…” |
Managers’ perception of the proportion of items that are healthy
| Not available | 100% | 10% | 90% | 60% |
Sales
Managers’ quotations regarding sales | Full adopter | Semi-adopter | Non-adopter |
---|---|---|---|
Sales of healthy items compared to sales of less healthy items
| “Whether we like it or not they don't want cucumbers with light organic dressing.. What sells is fries and poutine.” | “French fries is what I sell the most.” | “There’s nobody in this business can make money [selling healthy foods].” “If you’re offering the choices they’re always going to go for the unhealthy choice.” |
Perceived impact of the ANGCY on sales
| “It’s devastating… Horrible, our sales have been reduced.” | “Sales dropped 50%.” | “If we went into a high school doing $100,000 a year in sales, you’d be lucky to see $20,000 [if we implemented the ANGCY]. And I’ve done it – in [another province] not here.” |
Impact of factors on adoption and implementation of the ANGCY
Factors common across all cases
Factor | Definition and theoretically predicted impact on adoption and implementation | Study findings | Influence on adoption and implementation as reported by managers |
---|---|---|---|
Attributes of the ANGCY
| |||
Observability
| If the benefits of the ANGCY are visible to potential adopters they will be adopted more easily [27]. | Managers anticipated few visible positive outcomes from adoption: “There’s variety. But a positive outcome, because we have variety, I couldn’t tell you. Like it’s not something that’s a visual thing that I can tell you that I see”. Negative outcomes were expected and were highly visible because sales decreased significantly and many children continued to purchase unhealthy items. | Barrier to adoption and caused adopters to limit the extent of implementation to avoid larger negative financial consequences. |
Task Issues
| Innovations that are relevant to the performance of the user’s work, that improve task performance and are feasible to use are more readily adopted [27]. | The recreation sector had not typically incorporated nutritional considerations within its programming and services, and thus managers perceived some incompatibilities between the ANGCY and staff tasks. | Barrier to adoption and implementation. |
Trialability
| Innovations that can be experimented with on a limited basis are more likely to be assimilated [27]. | All managers perceived that that they could “test drive” the ANGCY: “I would say we wrote the policy knowing that we would be trying to change it, based on how things went with our contracts. That was sort of the test, I guess, is measuring over the three years whether it was feasible to have them, whether there was public acceptance or backlash.” | Facilitator of adoption. |
Adaptability
| Diffusion research suggests that innovations are not fixed entities and that innovations will be adopted more readily if potential adopters can modify them to suit their own needs [27]. | All managers felt free to adapt the ANGCY and recognized that they could implement them to a greater (ie. restrictive format) or lesser extent (ie. choice-based format) to suit their own needs. This perceived flexibility was important as managers attempted to balance competing priorities of a health and financial nature. | Facilitator of adoption and implementation. |
Augmentation
| Innovations are more easily assimilated if training and support are provided to staff [27]. | The Alberta government did not provide training nor did recreational facilities train their staff to implement the ANGCY. | No impact on adoption or implementation. |
Organizational antecedents for the ANGCY
| |||
Centralization
| Centralized decision making was present in all facilities. | Facilitator and barrier to adoption. It was not the hierarchical structure per se, but the priorities of those at the top of the hierarchy that mattered. | |
Managerial receptivity to change
| Adopters regarded the ANGCY as an opportunity for organizational growth. The manager of the non-adopter facilities also demonstrated a strong commitment to change in other areas. | Facilitator of adoption and implementation. | |
Slack resources
| Managers’ and employees’ time was fully occupied with their primary duties and responsibilities. Managers felt they had no spare resources to commit to ANGCY implementation. | Barrier to adoption and implementation. | |
Organizational readiness for the ANGCY
| |||
Assessment of implications
| Innovations are more likely to be assimilated if their implications are fully assessed and anticipated [27]. | All managers recognized the potential for revenue loss. Adopters selected a choice-based format to limit negative financial repercussions. The non-adopter chose not to adopt the ANGCY for this reason. | Barrier to adoption. |
Resource availability
| There were few tools available to support implementation. There was limited availability of ANGCY-compliant products in the marketplace. | Barrier to adoption and implementation. | |
Linkage
| |||
Linkage at the adoption and implementation stage
| Linkage agents can facilitate adoption of innovations by enhancing knowledge exchange between developers and users [46]. | The provincial government hired Health Promotion Coordinators were hired to support ANGCY adoption and implementation, however they did not have an influential role in any of the facilities in this study. | No impact on adoption or implementation. |
Outer context
| |||
Socio-political context
| The organization’s decision to adopt an innovation and efforts to implement it may be influenced by social norms and prevailing political ideologies. | Managers all believed to varying extents that it was up to individuals to “develop some personal choice skills where they [make] personal choices that are good for them.” While adopters felt their role was “to make sure that [patrons] have those healthy choices in our facilities and hope that they help themselves”, the non-adopter did not think it feasible to make healthy options available in all contexts. | The personal responsibility ethic was a barrier to adoption for the non-adopter and shaped how adopters implemented the ANGCY (ie. it was a barrier to a restrictive format). |
Factors unique to individual cases
Organizational antecedents for the ANGCY
Organizational readiness for the ANGCY
Factors that differed between adopters and the non-adopter
Adopters and the adoption process
Attributes of the ANGCY
Organizational antecedents for the ANGCY
Organizational readiness for the ANGCY
Communication and influence
Outer context
Factors related to the implementation process
Propositions
Theoretical domain | Proposition |
---|---|
Food environment analysis
| Profit-oriented food services are incompatible with healthy environmental defaults (ie. > 50% CMO items), regardless of whether they are municipally or privately operated. |
Sales analysis
| Patrons insufficiently choose healthy options when the environmental defaults are unhealthy (ie. < 50% CMO items). |
Adopters and the adoption process
| |
Meaning of the ANGCY to managers
| 1) Adoption and implementation of nutrition guidelines is greatest when the personal beliefs of managers, the organizational mandate and the aims of nutrition guidelines are all aligned. |
2) The personal beliefs of managers are highly influential and may motivate adoption when a window of opportunity arises. | |
Attributes of the ANGCY
| |
Complexity
| Guidelines that are easily understood may be more readily adopted. |
Relative advantage
| 1) Profitability is the most important barrier to adopting nutrition guidelines because managers perceive that selling healthy foods is unprofitable. |
2) A choice-based format may assist facilities to balance wellness and revenue concerns associated with nutrition guidelines, but may not support greater purchase of healthy items by patrons. | |
3) Nutrition guidelines are perceived to provide a relative advantage insofar as they assist recreational facilities to achieve their wellness mandate in a financially sustainable manner. Small financial losses may be accepted if implementation supports achievement of other important priorities. | |
Organizational antecedents for the ANGCY
| |
Formalization
| Short-term food service agreements provide greater flexibility to address emerging priorities. |
Professionalism
| 1) Managers who correctly perceive their food environment as unhealthy are more likely to adopt nutrition guidelines. |
2) Registered Dietitians are a source of critical expertise to support implementation of nutrition guidelines. | |
Size of operation, technical capacity
| Large recreational facilities may have greater technical capacity to implement the ANGCY. |
Absorptive capacity for new knowledge
| 1) Use of nutrition guidelines in schools can create a favourable climate and increase capacity for adopting nutrition guidelines in other contexts. |
2) Health promoting partnerships with industry can provide capacity to implement nutrition guidelines that recreational facilities lack. | |
Risk-taking climate
| Tolerance for financial risk is essential for adoption and implementation of nutrition guidelines. |
Managerial relations
| Where private industry is present, adoption and implementation of nutrition guidelines requires their full cooperation. When industry is committed to implementation, the stipulations of policies and contracts may be less important. |
Organizational readiness for the ANGCY
| |
Power balances
| Choice-based nutrition policies are better accepted by most stakeholders and may therefore facilitate adoption of nutrition guidelines. |
Fit of the ANGCY with the recreational facility context
| When food service is managed as a separate entity and is not under the direct purview of the general manager, its goals may not support adoption of nutrition guidelines. |
Tension for change
| Adoption of nutrition guidelines is more likely when management perceives a high tension for health-related change. |
Communication and influence
| |
Champion
| Managers act as gatekeepers of the food environment, and therefore an influential manager must champion adoption and implementation of nutrition guidelines. |
Diffusion and dissemination
| Use of nutrition guidelines in schools may facilitate spread to other contexts where diffusion networks are not yet active. |
Outer context
| |
Competitive environment
| Facilities that perceive fewer competitive pressures may be more likely to adopt nutrition guidelines. |
Interorganizational norm-setting
| 1) Early adopters must be willing to accept the risks inherent in contravening industry norms. |
2) Diffusion of nutrition guidelines may be slow to occur because of the association of unhealthy foods with sport spectatorship. | |
Implementation process
| The absence of clear goals and priorities for implementation and failure to monitor its progress can impede the implementation process. |