Local government stakeholders' perceptions of potential policy actions to influence both climate change and healthy eating in Victoria: A qualitative study.

ISSUE ADDRESSED: Climate change is a defining public health issue of the 21st century. Food systems are drivers of diet-related disease burden, and account for 30% of global greenhouse gas emissions. Local governments play a crucial role in improving both the healthiness and environmental sustainability of food systems, but the potential for their actions to simultaneously address these two issues is unclear. This study aimed to explore the perceptions of Australian local government stakeholders regarding policy actions simultaneously addressing healthy eating and climate change, and the influences on policy adoption. METHODS: We conducted 11 in-depth semi-structured interviews with stakeholders from four local governments in Victoria, Australia. Data were analysed using reflexive thematic analysis. We applied Multiple Streams Theory (MST) 'problem', 'politics and 'policy' domains to explain policy adoption influences at the local government level. RESULTS: Key influences on local government action aligned with MST elements of 'problem' (e.g., local government's existing risk reports as drivers for climate change action), 'policy' (e.g., budgetary constraints) and 'politics' (e.g., local government executive agenda). We found limited evidence of coherent policy action in the areas of community gardens, food procurement and urban land use. CONCLUSION: Barriers to further action, such as resource constraints and competing priorities, could be overcome by better tailoring policy action areas to community needs, with the help of external partnerships and local government executive support. SO WHAT?: This study demonstrates that Victorian local stakeholders believe they are well-positioned to implement feasible and coherent interventions that address both healthy eating and climate.

A systems framework for implementing healthy food retail in grocery settings.

BACKGROUND: Food retailers can be reluctant to initiate healthy food retail activities in the face of a complex set of interrelated drivers that impact the retail environment. The Systems Thinking Approach for Retail Transformation (START) is a determinants framework created using qualitative systems modelling to guide healthy food retail interventions in community-based, health-promoting settings. We aimed to test the applicability of the START map to a suite of distinct healthy food marketing and promotion activities that formed an intervention in a grocery setting in regional Victoria, Australia. METHODS: A secondary analysis was undertaken of 16 previously completed semi-structured interviews with independent grocery retailers and stakeholders. Interviews were deductively coded against the existing START framework, whilst allowing for new grocery-setting specific factors to be identified. New factors and relationships were used to build causal loop diagrams and extend the original START systems map using Vensim. RESULTS: A version of the START map including aspects relevant to the grocery setting was developed ("START-G"). In both health-promoting and grocery settings, it was important for retailers to 'Get Started' with healthy food retail interventions that were supported by a proof-of-concept and 'Focus on the customer' response (with grocery-settings focused on monitoring sales data). New factors and relationships described perceived difficulties associated with disrupting a grocery-setting 'Supply-side status quo' that promotes less healthy food and beverage options. Yet, most grocery retailers discussed relationships that highlighted the potential for 'Healthy food as innovation' and 'Supporting cultural change through corporate social responsibility and leadership'. CONCLUSIONS: Several differences were found when implementing healthy food retail in grocery compared to health promotion settings. The START-G map offers preliminary guidance for identifying and addressing commercial interests in grocery settings that currently promote less healthy foods and beverages, including by starting to address business outcomes and supplier relationships.

Diet-Related Disease Prevention in a Rural Australian Setting: Understanding Barriers, Enablers, and the Role of Rural Health Services in Supporting Changes in Local Rural Food Environments.

Bold and comprehensive action is needed to prevent diet-related diseases in rural areas, which includes improving food environments to enable healthier dietary practices. Rural health services are integral to the health of rural populations, yet their role in community disease prevention is not swell understood. This study sought to understand health service, local government, and food outlet stakeholders' perspectives on (1) the drivers of unhealthy retail environments in a rural setting; (2) the role of rural health services in supporting changes in local food environments; and to (3) identify characteristics of potential interventions. Two Group Model Building workshops were held with health service and local government leaders (n = 9), and interviews were conducted with local food outlet participants (n = 13). Key themes included 'enablers to healthier food environments', 'barriers to healthier food environments', 'Rural health services are a leading broker of knowledge for healthy food environments', and 'characteristics of desirable healthy food environment interventions.'. Rural health services can play a key role in addressing the current barriers to healthy food environments in rural areas. Effective promotion of healthier diets in rural populations will require consideration of key stakeholder perspectives and the development of further evidence on the role that rural health services can play in improving the healthiness of food environments.

CO-Creation and Evaluation of Food Environments to Advance Community Health (COACH).

Introduction: Food environments are a key determinant of food intake and diet-related health. This paper describes the development of an iterative, adaptive, context-specific framework for health-enabling food environments embedded in cocreation theory. Methods: A 3-stage multimethod framework for the coproduction and prototyping of public health interventions was followed in an iterative manner during the development of the framework. These 3 stages were (1) evidence review, including systematic review, consultation with experts, and observation of current work; (2) codesign of the framework prototype with multiple stakeholders; and (3) coproduction through refinement of the prototype through stakeholder workshops and expert reviews with incorporation of researcher notes and workshop evaluation. We use the term prototype during the development phase and the term framework to report on the final product. Results: COACH (CO-creation and evaluation of food environments to Advance Community Health) is a process framework that describes what best practice application of cocreation in health-enabling food retail environments should involve. COACH consists of 10 interdependent factors within a 4-phase continuous quality improvement cycle. The 4 phases of the cycle are engagement and governance establishment, communication and policy alignment, codesign and implementation, and monitoring and evaluation. Conclusions: Utilizing cocreation theory represents an innovative step in research and practice to improve the healthiness of food retail environments. COACH provides a specific, unique, and comprehensive guide to the utilization of cocreation to improve the healthiness of food environments in practice.

Combining systems thinking approaches and implementation science constructs within community-based prevention: a systematic review.

BACKGROUND: Systems science offers methods for designing population health interventions while implementation science provides specific guidance for successful implementation. Integrating systems and implementation science may strengthen implementation and enhance and sustain systemic change to achieve system-level outcomes. Little is known about the extent to which these two approaches have been integrated to date. This review aimed to identify and synthesise the peer-reviewed literature that has reported the combined use of systems thinking approaches and implementation science constructs (within the same study), to deliver population health interventions. METHODS: A systematic literature search of peer-reviewed original research was conducted across six databases from 2009 to 2021. Journal manuscripts were included if they: (1) reported on a population health study conducted in a community, (2) reported the use of a systems method in the design of the intervention, and (3) used an implementation science theory, framework or model in the delivery of the intervention. Data extracted related to the specific systems methods and definitions and implementation science constructs used. The Mixed Methods Appraisal Tool (MMAT) was used to assess study quality. RESULTS: Of the 9086 manuscripts returned, 320 manuscripts were included for full-text review. Of these, 17 manuscripts that reported on 14 studies were included in the final extraction. The most frequently reported systems methods were a 'whole of community systems approach' (n = 4/14) and 'community-based system dynamics' (n = 2/14). Nineteen different implementation science theories, frameworks and models were used for intervention delivery, with RE-AIM being the only framework used in more than one study. CONCLUSION: There are few published peer-reviewed studies using systems thinking and implementation science for designing and delivering population health interventions. An exploration of synergies is worthwhile to operationalise alignment and improve implementation of systems thinking approaches. Review protocol registration PROSPERO CRD42021250419.

The implementation and effectiveness of outlet-level healthy food and beverage accreditation schemes: A systematic review.

Healthy food outlet accreditation schemes represent an avenue for incentivizing food retailers to promote healthy eating patterns by improving the healthiness of food environments. This systematic review aimed to (i) assess the impact of food outlet-level accreditation schemes on outlet practices and customer purchases and (ii) identify barriers and enablers to scheme implementation. Peer-reviewed and grey literature were systematically searched. Eligible studies related to outlet-level food and beverage accreditation schemes across any food retail setting. Findings were narratively synthesized by retailer type according to (i) scheme characteristics (governance, targeted products, support, and monitoring); (ii) scheme outcomes (rate of uptake, proportion of certified retailers, impact on purchasing, customer perspectives, and retailer perspectives); and (iii) barriers and enablers to implementation. From 21,943 records screened, 48 were included, covering 26 schemes. Most (18) targeted restaurants or convenience stores. Average uptake was 65% of all outlets approached to participate. Implementation of accreditation schemes was associated with healthier customer purchases in convenience stores, schools, and hospitals, but evidence from restaurants was mixed. Enablers of scheme implementation included support for implementation and maintenance, flexible scheme criteria, and motivated retail staff. Healthy food outlet accreditation schemes represent a promising mechanism for engaging retailers to improve the healthiness of food retail environments.

Integrating nutrition and obesity prevention considerations into institutional investment decisions regarding food companies: Australian investment sector perspectives.

BACKGROUND: There is growing recognition that current food systems are both unhealthy and unsustainable, and are increasingly shifting toward the supply and marketing of unhealthy, ultra-processed foods and beverages. Large food companies hold substantial power within food systems and present a significant barrier to progress on addressing issues related to nutrition and obesity prevention. Institutional investors (such as pension funds) play a key role in influencing corporate governance and practices, and are increasingly incorporating environmental, social and governance (ESG) considerations within investment decisions. By considering nutrition and obesity prevention, institutional investors present a potential avenue for driving increased food industry accountability for their population health impact. This study investigated views of stakeholders in the Australian investment sector on the incorporation of nutrition and obesity prevention considerations within institutional investment decision-making regarding food companies. METHODS: Fifteen in-depth, semi-structured interviews were conducted in 2020-21. Participants were predominantly Australian-based, and included representatives from asset management companies, superannuation funds, ESG advisory/consultancy firms, ESG research providers, and relevant advocacy groups. Interviews examined challenges and opportunities to the integration of nutrition and obesity prevention considerations within institutional investment decision-making. Interviews were analysed using deductive thematic analysis, informed by a theoretical change model. RESULTS: Several participants reported that their institution factored nutrition and obesity prevention considerations into their investment decisions; however, attention to nutrition-related issues was limited, generally perceived as 'niche', and not yet institutionalised. Key challenges and opportunities were identified at the employee, investment organisation, investment sector, government and non-government levels. These challenges and opportunities centred around experience and knowledge, quality and availability of ESG data and benchmarks, importance of investor coalitions, and demonstration of financial risks related to nutrition and obesity. CONCLUSION: There are a range of steps that could be taken to help ensure more systematic and effective consideration of issues related to nutrition and obesity prevention within institutional investment decision-making in Australia, including: (1) improved nutrition-related reporting metrics and benchmarking criteria for food companies; (2) better articulation of the financial risks that unhealthy diets and obesity pose to investors; (3) enhanced investor advocacy on unhealthy diets and obesity through investor coalitions and; (4) detailed guidance for investors on how to address unhealthy diets and obesity. Better engagement between the Australian public health community, institutional investors and government regulators is critical to drive changed investor practice in this area.

The impact of primary school nutrition policy on the school food environment: a systematic review.

School nutrition policies that aim to address unhealthy diets have been introduced in many countries. This systematic review aimed to synthesize the international literature to determine the impact (overall and by socioeconomic position [SEP]) of primary school nutrition policies on the availability of foods and beverages in schools. Seven databases were searched using keywords and medical subject headings related to nutrition policies and schools. Studies that reported on the impact of implemented school nutrition policies on food and beverage availability within primary schools were included. Eighteen studies (reported across 20 papers) were included. Fifteen of the included studies reported some positive impacts of policies, including increased availability of healthier foods and decreased availability of less healthy foods. Five studies focused specifically on schools in low-income communities and a further three specifically compared schools by SEP, with mixed findings. Two studies reported on factors influencing policy implementation, reporting a lack of financial resources as a barrier to schools offering a wider selection of healthy foods and additional school resources as increasing the likelihood of offering healthy foods. School nutrition policies appear to be effective at improving the healthiness of foods and beverages available at schools. Furthermore, the results suggest that well-implemented school nutrition policies that improve the healthiness of foods available are unlikely to exacerbate the socioeconomic gradient of poor nutrition. However, the number of studies that reported results by SEP limits drawing strong conclusions regarding equity impacts and we strongly recommend further studies analyze their findings according to SEP.

Exploring the effects of added sugar labels on food purchasing behaviour in Australian parents: An online randomised controlled trial.

BACKGROUND: Evidence of the effects of front-of-pack added sugar labelling remains limited, especially for foods other than sugary drinks. More information is needed about which labels are likely to be most effective in reducing intended purchases of products with higher added sugar content in realistic contexts to inform policymakers' decisions. OBJECTIVE: To determine the impact of added sugar labels on intended purchases of high sugar breakfast cereals, yoghurt, and non-alcoholic beverages. METHODS: Australian parents who were regular purchasers of relevant product categories completed an online parallel randomised controlled trial from 31 August 2020 to 13 February 2021. Participants selected their intended purchase from 10 products in each of packaged beverages, breakfast cereal, and yoghurt categories after randomisation to one of seven added sugar labelling conditions in current use or under consideration by the Australian Government. Logistic regressions assessed differences between intervention and control conditions in the odds of intended purchases of a high sugar product. RESULTS: 2825 eligible participants were randomised with 2582 valid surveys analysed (Control n = 367; 'Nutrition Information Panel (NIP) with Added Sugar' n = 364; 'Teaspoons of Sugar' n = 369; 'Warning' n = 371; 'Health Star Rating (HSR) using Total Sugar' n = 368; 'HSR with Added Sugar' n = 371; 'Sugar in the Ingredients List' n = 372). No consistent effects were found on intended purchases of high sugar products overall or within product categories for any of the tested labels compared to controls (overall, 'NIP with Added Sugar': OR 1.00 [95%CI 0.83,1.20]; 'Teaspoons of Sugar': 0.94[0.80,1.11]; 'Warning': 1.10[0.93,1.30]; 'HSR with Total Sugar': 1.01[0.85,1.21]; 'HSR with Added Sugar': 1.09[0.92,1.30]; 'Sugar in the Ingredients List': 1.01[0.85,1.21]). CONCLUSIONS: Findings reinforce the importance of ensuring nutrition labelling policies are introduced as part of a suite of interventions to influence both consumer and manufacturer behaviour. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry, ACTRN12620000858998. Registered 28 August 2020, https://anzctr.org.au/Trial/Registration/TrialReview.aspx?ACTRN=12620000858998.

Local government policies on healthy food promotion and obesity prevention: results from a national Australian survey.

OBJECTIVE: Local governments (LGs) often own or manage sport and recreation facilities and can promote health in these settings by implementing healthy food policies. The primary aim of this study was to assess the policies, attitudes and practices of Australian LGs relating to obesity prevention and the provision of healthy food in this setting. METHODS: In July 2020, all 539 Australian LGs were invited to complete a survey. We assessed LG priorities to obesity prevention, promoting healthy eating and public health as well as the presence of healthy food policies in sporting facilities. RESULTS: 203 (38%) LGs completed the survey. Improving public health was a high priority, while obesity prevention and promoting healthy eating were a medium priority. 22% of LGs reported that the priority given to promoting healthy food had increased over the previous year and stayed the same at 65%. Ten per cent of LGs had a healthy food and drink policy in sporting facilities, with 32% reporting having made changes without a policy. LGs located in major cities, with larger populations and with more facilities reported having made more healthy changes at their facilities. CONCLUSION: Promoting health is a priority for LGs across Australia, but very few have policies relating to the food environments in their sporting facilities. IMPLICATIONS FOR PUBLIC HEALTH: Ongoing monitoring is important to assess changes over time and identify LGs where greater support is required.

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.

Implementation and sales impact of a capacity building intervention in Australian sporting facility food outlets: a longitudinal observational study.

Background: Few studies have explored behavioural and financial impacts of retail initiatives after 2 years to address the unhealthy food environments common in local government sporting settings. Aims: To evaluate the impact of a 2-year local government capacity building intervention in sporting facility food outlets on (1) the healthiness of refrigerated drink choices available and visible to customers, (2) healthiness of refrigerated drinks sold and (3) refrigerated drink revenue. Methods: 52 sporting facilities within 8 local governments from Victoria, Australia, participated in an intervention between March 2018 and February 2020 by limiting 'red' (least healthy) drinks to ≤20% of refrigerator display and increasing 'green' (healthiest) drinks to ≥50% of display. Mixed models assessed changes in mean percentage of 'red', 'amber' and 'green' drinks displayed over time, compared with baseline.Facilities provided electronic weekly itemised sales data (December 2015 to February 2020). Weekly volume of 'red' or 'green' drinks sold as a proportion of total drinks sold, and total refrigerated drinks revenue were compared preimplementation and postimplementation using mixed models (seasonal facilities), and mixed-effect interrupted time series models (non-seasonal facilities). Results: Display of 'red' drinks decreased by mean -17.1 percentage points (pp) (95% CI -23.9 to -10.3) and 'green' drinks increased 16.1 pp (95% CI 9.30, 22.9) between baseline and 18-month audits.At nine seasonal facilities, compared with the summer preimplementation, the mean volume of 'red' drinks sold decreased by -19.0 pp (95% CI -28.6, to -9.51) and refrigerated drink revenue decreased by-AU$81.8 (95% CI -AU$123 to -AU$40.8) per week. At 15 non-seasonal facilities, by February 2020, the volume of 'red' drinks sold decreased on average by -11.0 pp (95% CI -21.6 to -0.41) with no change in drink revenue. Conclusion: Reducing the display of unhealthy drinks can be an effective public health policy to improve the healthiness of customer purchases, provided there is consideration of potential impacts on revenue.

Favorable Commercial and Health Behavior Impacts of a Healthy Vending Policy at an Australian University.

BACKGROUND: The World Health Organization recognizes universities as an important health-promotion setting, including in healthy food provision. Previous research shows that healthy food retail interventions also need to consider commercial sustainability, including financial outcomes, and should take a holistic approach to consumer experience. OBJECTIVE: Our aim was to determine the health behavior and commercial outcomes of a multicomponent traffic light-based healthy vending policy implemented as one part of a holistic university food policy. The hypothesis was that purchases of less healthy "red" beverages would decrease compared with predicted sales, that purchases of healthier "green" and "amber" alternatives would increase, and that there would be no change in revenue. DESIGN: A quasi-experimental design evaluated a real-world food policy using monthly aggregated sales data to compare pre-intervention (January 2016 to March 2018) and post-intervention period sales (December 2018 to December 2019). PARTICIPANTS/SETTING: Electronic sales data were collected from 51 beverage vending machines across 4 university campuses in Victoria, Australia. INTERVENTION: A multicomponent policy was implemented between April and November 2018. Beverages were classified using a voluntary state government traffic light framework. Policy included display ≤20% red beverages and ≥50% green beverages; machine traffic light labeling; health-promoting machine branding; review of machine placement; and recycled bottle packaging. MAIN OUTCOME MEASURES: Changes in red, amber, and green volume sales, and revenue compared with predicated sales. STATISTICAL ANALYSES PERFORMED: Interrupted time series analysis of sales data compared post-policy sales with predicted sales. RESULTS: In the 13th month post-policy implementation, there was a 93.2% (95% CI +35.9% to +150.5%) increase in total beverage volume sold and an 88.6% (95% CI +39.2% to +138.1%) increase in revenue. There was no change in red beverage volume sold, but increases in green (+120.8%; 95% CI +59.0% to +182.6%) and amber (+223.2%; 95% CI +122.4% to +323.9%) volume sold. CONCLUSIONS: Sustained behavior change and commercial outcomes suggest that holistic vending interventions can effectively promote healthier beverage sales.

Evaluating the implementation and customer acceptability of a sugar-sweetened beverage reduction initiative in thirty Australian aquatic and recreation centres.

OBJECTIVE: To assess the feasibility of implementation and customer perspectives of a sugar-sweetened beverage (SSB) reduction initiative across YMCA Victoria aquatic and recreation centres. DESIGN: Two data sources were used to assess implementation and customer acceptability. Photo audits were used to assess the type of drinks available for purchase 6 months prior to initiative implementation and 6 months after, in thirty centres. Change in the range of SSB targeted for removal, non-targeted SSB, as well as drinks classified as 'red' (limit), 'amber' (choose carefully) and 'green' (best choice), was reported. Customer surveys were conducted in three centres to assess acceptability and awareness of the initiative. Inductive and deductive thematic analysis was used to analyse customers' perspectives of the initiative. SETTING: 30 aquatic and recreation centres in Victoria, Australia. PARTICIPANTS: 806 customers. RESULTS: At post-implementation, 87 % of centres had removed targeted SSB. 'Red' drinks reduced by an average of 4·4 drink varieties compared to pre-implementation (11·9 varieties) and 'green' drinks increased by 1·4 varieties (3·2 varieties pre-implementation). Customers were largely unaware of the SSB-reduction initiative (90 %) but supported YMCA Victoria in continuing the initiative (89 %), with many believing it would support children in making healthier choices. CONCLUSIONS: Implementation of an initiative that limited SSB availability across a large number of aquatic and recreation centres was feasible and considered acceptable by customers. Customers frequently mentioned the importance of protecting children from consuming SSB.

Business outcomes of healthy food service initiatives in schools: A systematic review.

Fear of unfavorable business outcomes, including negative financial impacts, deters implementation of school food service initiatives to support healthy student eating behaviors. There have been no systematic reviews to guide feasible long-term healthy school food initiatives. This review aimed to synthesize evidence on the effect of school food service initiatives on business outcomes, including commercial viability, stakeholder perceptions, customer perceptions, and initiative maintenance and scale-up. Business, education, and health peer-reviewed databases, and grey literature were systematically searched. Eligible studies reported on the business impact of initiatives encouraging sales of healthier foods within school cafeterias, canteens, vending machines, or online canteens. Synthesis incorporated a count of studies addressing business outcomes, health behavior outcomes, and the favorability of those outcomes. Of 5173 studies screened, 16 studies were included for analysis. Commercial viability was the most frequent theme (n = 12/16 studies), followed by stakeholder perceptions (n = 9/16), customer perceptions (n = 6/16), and initiative maintenance and scale-up (n = 2/16). Favorable business outcomes were identified in cafeterias/canteens (n = 8/10) and online canteens (n = 1/1). All vending machine initiatives (n = 7/7) reported unfavorable, mixed, or neutral outcomes. Future research should determine which types of healthy food retail initiatives deliver the most favorable business outcomes long-term for schools while optimizing student nutrition outcomes.

The 'Eat Well @ IGA' healthy supermarket randomised controlled trial: process evaluation.

BACKGROUND: Successful implementation and long-term maintenance of healthy supermarkets initiatives are crucial to achieving potential population health benefits. Understanding barriers and enablers of implementation of real-world trials will enhance wide-scale implementation. This process evaluation of a healthy supermarket intervention sought to describe (i) customer, retailer and stakeholder perspectives on the intervention; (ii) intervention implementation; and (iii) implementation barriers and enablers. METHODS: Eat Well @ IGA was a 12-month randomised controlled trial conducted in 11 Independent Grocers of Australia (IGA) chain supermarkets in regional Victoria, Australia (5 intervention and 6 wait-listed control stores). Intervention components included trolley and basket signage, local area and in-store promotion, and shelf tags highlighting the healthiest packaged foods. A sequential mixed-methods process evaluation was undertaken. Customer exit surveys investigated demographics, and intervention recall and perceptions. Logistic mixed-models estimated associations between customer responses and demographics, with store as random effect. Supermarket staff surveys investigated staff demographics, interactions with customers, and intervention component feedback. Semi-structured stakeholder interviews with local government, retail and academic partners explored intervention perceptions, and factors which enabled or inhibited implementation, maintenance and scalability. Interviews were inductively coded to identify key themes. RESULTS: Of 500 customers surveyed, 33%[95%CI:23,44] recalled the Eat Well @ IGA brand and 97%[95%CI:93,99] agreed that IGA should continue its efforts to encourage healthy eating. The 82 staff surveyed demonstrated very favourable intervention perceptions. Themes from 19 interviews included that business models favour sales of unhealthy foods, and that stakeholder collaboration was crucial to intervention design and implementation. Staff surveys and interviews highlighted the need to minimise staff time for project maintenance and to regularly refresh intervention materials to increase and maintain salience among customers. CONCLUSIONS: This process evaluation found that interventions to promote healthy diets in supermarkets can be perceived as beneficial by retailers, customers, and government partners provided that barriers including staff time and intervention salience are addressed. Collaborative partnerships in intervention design and implementation, including retailers, governments, and academics, show potential for encouraging long-term sustainability of interventions. TRIAL REGISTRATION: ISRCTN, ISRCTN37395231 Registered 4 May 2017.

Retailer-led healthy pricing interventions: a pilot study within aquatic and recreation centres in Victoria, Australia.

This study aimed to pilot the feasibility, acceptability and effectiveness of three co-developed healthy food and beverage pricing interventions in a community retail setting. Aquatic and recreation centres in Victoria, Australia were recruited to co-develop and pilot pricing interventions within their onsite cafés, for 15 weeks from January 2019. A mixed method intervention evaluation was conducted. Interviews were conducted with food retail managers to understand the factors perceived to influence implementation, maintenance and effectiveness. Customer surveys assessed support for, and awareness of, interventions. Interrupted time series analysis estimated the impact of pricing interventions on food and beverage sales. Three centres each implemented a unique intervention: (i) discounted healthy bundles ('healthy combination deals'), (ii) offering deals at specific times of the day ('healthy happy hours') and (iii) increasing the prices of selected unhealthy options and reducing the prices of selected healthier options ('everyday pricing changes'). Café team leaders did not identify any significant challenges to implementation or maintenance of interventions, though low staff engagement was identified as potentially influencing the null effect on sales for healthy combination deals and healthy happy hours interventions. Customers reported low levels of awareness and high levels of support for interventions. Everyday pricing changes resulted in a significant decrease in sales of unhealthy items during the intervention period, though also resulted in a decrease in café revenue. Co-developed healthy food and beverage pricing interventions can be readily implemented with broad customer support. Everyday pricing changes have demonstrated potential effectiveness at reducing unhealthy purchases.

Benchmarking Food and Beverage Companies on Obesity Prevention and Nutrition Policies: Evaluation of the BIA-Obesity Australia Initiative, 2017-2019.

BACKGROUND: The potential role of the food and beverage industry in addressing diet-related disease is much debated, particularly amidst evidence of the targeted strategies, including voluntary self-regulation, used by the industry to influence policy in their favour. At the same time, the need for more comprehensive action to address unhealthy diets has led to a focus on increasing the accountability of different stakeholders. However, there has been limited evaluation of the impact of accountability initiatives on food and beverage company policies and practices. This study evaluated the impact of the BIA-Obesity (Business Impact Assessment - Obesity and population nutrition) Australia Initiative that benchmarked major Australian food and beverage companies on their nutrition-related policies. METHODS: Evaluation was conducted against the pre-specified logic model for BIA-Obesity and established frameworks for analysing organisational change and corporate political activity. Outcomes evaluated included company engagement with the Initiative, level of media coverage, and impact of the Initiative on company policies and practices based on the perspectives of company representatives. A mixed methods design was employed, including surveys and in-depth interviews with company representatives, and media reports. RESULTS: Approximately half of invited companies participated in the evaluation of the BIA-Obesity Australia Initiative. A number of company representatives indicated that the Initiative had influenced their company's nutrition policies, strategies, and disclosure practices, and had raised their company's awareness of the importance of addressing nutrition issues. CONCLUSION: Company representatives perceive benchmarking and accountability initiatives as helpful for provoking improvements in nutrition-related policies and practices in their companies. However, the benefits of these initiatives need to be assessed in the context of the broader political and economic environment. Whilst the focus of accountability initiatives, such as BIA-Obesity, are on industry self-regulation efforts, they can also play an important role in drawing attention to the need for increased government regulation.

Implementing a healthy food retail policy: a mixed-methods investigation of change in stakeholders' perspectives over time.

OBJECTIVES: To investigate (i) changes in stakeholder commitment and (ii) perceptions of the purpose, challenges and benefits of healthy food and beverage provision in community sports settings during the stepwise implementation of a healthy beverage policy. DESIGN: Convergent, parallel, mixed-methods design complemented (i) repeat semi-structured interviews with council stakeholders (n 17 interviews, n 6 interviewees), with (ii) repeat quantitative stakeholder surveys measuring Commitment to Organisational Change; (iii) weekly sales data examining health behaviour and revenue effects (15 months pre-intervention; 14 months post-intervention); (iv) customer exit surveys (n 458); and (v) periodic photographic audits of beverage availability. Interviews were analysed inductively. Stakeholder surveys, sales data, customer surveys and audits were analysed descriptively. SETTING: Four local government-owned sports and recreation centres in Melbourne, Australia, completed a 3-month trial to increase the availability of healthy beverages and decrease the availability of unhealthy beverages in food outlets. PARTICIPANTS: Interviews were conducted with council managers and those involved in implementation (September 2016-October 2017). Customers were surveyed (September-October 2017). RESULTS: Interviews and surveys indicated that stakeholders' commitment to policies varied such that, over time, optimism that changing beverage availability could increase the healthiness of customers' purchases became more widespread among interviewees. Stakeholder focus generally progressed from anticipatory concern to solutions-focused discussions. Sales, audit and customer survey data supported interview findings. CONCLUSIONS: We found a general increase in optimism regarding policy outcomes over time during the implementation of a healthy beverage policy. Stepwise trials should be further explored as an engagement tool within community retail settings.

The effect of front-of-package labels or point-of-sale signage on consumer knowledge, attitudes and behavior regarding sugar-sweetened beverages: a systematic review.

CONTEXT: Globally, the use of labels or signage targeting SSBs remains in its infancy and there is limited evidence available regarding its ability to decrease purchase and consumption of SSBs. OBJECTIVE: This systematic review aimed to synthesize the evidence on the effect of sugar- or health-related sugar-sweetened beverage (SSB) warning labels or signage on knowledge, attitudes, and beliefs, and SSB purchase and consumption. DATA SOURCES: Nine databases - Ovid Medline, Emerald Insight, Scopus, Informit, Business Source Complete, CINAHL, Global Health, PsychINFO, and SocIndex - were searched along with grey literature from inception to December 2019. The PRISMA guidelines were applied for reporting this systematic review. STUDY SELECTION: Studies examining the impact of front of pack (FOP) labels and/or point of sale (POS) signage highlighting added sugar content or its health risks were included. DATA EXTRACTION: Two authors independently extracted data on items, including study details, study design, population characteristics, intervention label details (type, duration, and settings), and outcomes measures. The Effective Public Health Practice Project tool was used to assess the study quality. DATA ANALYSIS: Findings were synthesized narratively. RESULTS: Twenty-one studies published between 1992 and 2019 were included. Of these, 16 studies examined the impact of FOP labels and 5 studies examined the impact of POS signage. Both FOP labels and POS signage were associated with improved health knowledge, attitudes, and beliefs regarding SSBs and reduced SSB purchases. Warning labels with diet-related health consequences were found to be particularly effective. Overall quality of studies was assessed as mixed. CONCLUSION: Health- or sugar-related FOP labels and POS signage for SSBs are promising public health measures and may improve consumers' health behaviors toward reduced SSB purchase and consumption.