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.

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.

How healthy and affordable are foods and beverages sold in school canteens? A cross-sectional study comparing menus from Victorian primary schools.

OBJECTIVE: Government policy guidance in Victoria, Australia, encourages schools to provide affordable, healthy foods in canteens. This study analysed the healthiness and price of items available in canteens in Victorian primary schools and associations with school characteristics. DESIGN: Dietitians classified menu items (main, snack and beverage) using the red, amber and green traffic light system defined in the Victorian government's School Canteens and Other School Food Services Policy. This system also included a black category for confectionary and high sugar content soft drinks which should not be supplied. Descriptive statistics and regressions were used to analyse differences in the healthiness and price of main meals, snacks and beverages offered, according to school remoteness, sector (government and Catholic/independent) size, and socio-economic position. SETTING: State of Victoria, Australia. PARTICIPANTS: A convenience sample of canteen menus drawn from three previous obesity prevention studies in forty-eight primary schools between 2016 and 2019. RESULTS: On average, school canteen menus were 21 % 'green' (most healthy - everyday), 53 % 'amber' (select carefully), 25 % 'red' (occasional) and 2 % 'black' (banned) items, demonstrating low adherence with government guidelines. 'Black' items were more common in schools in regional population centres. 'Red' main meal items were cheaper than 'green'% (mean difference -$0·48 (95 % CI -0·85, -0·10)) and 'amber' -$0·91 (-1·27, -0·57)) main meal items. In about 50 % of schools, the mean price of 'red' main meal, beverages and snack items were cheaper than 'green' items, or no 'green' alternative items were offered. CONCLUSION: In this sample of Victorian canteen menus, there was no evidence of associations of healthiness and pricing by school characteristics except for regional centres having the highest proportion of 'black' (banned) items compared with all other remoteness categories examined. There was low adherence with state canteen menu guidelines. Many schools offered a high proportion of 'red' food options and 'black' (banned) options, particularly in regional centres. Unhealthier options were cheaper than healthy options. More needs to be done to bring Victorian primary school canteen menus in line with guidelines.

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.

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.

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.

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.

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.

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.

The long-term effectiveness and acceptability of the retailer-led removal of unhealthy drinks from display in a self-service café.

OBJECTIVE: In 2015, beverages were removed from display at a self-service café within a major health service, resulting in fewer purchases of unhealthy beverages. This initiative was continued following initial evaluation of the results. The current study aimed to determine customer acceptability of the initiative, and whether healthier purchases had continued, at 18 months following implementation. DESIGN: Drinks were categorised as 'green' (best choices), 'amber' (choose carefully) and 'red' (limit), based on the state government nutrient profiling system, for intervention and analysis purposes. In 2015, unhealthy 'red' drinks were removed from display. In 2017, weekly beverage sales were counted, through stock-taking, for 6 weeks, and customer surveys were conducted over 2 days. SETTING: A café located within a major Victorian health service. PARTICIPANTS: Café customers (hospital staff, patients and visitors). RESULTS: Eighteen months after the implementation of the initiative, the proportion of 'red' beverages sold was 7 % of total drink sales (compared with 33 % before the removal of unhealthy beverages from display in 2015 (P < 0·001), and 10 % immediately following the removal of unhealthy beverages from display). Customer surveys revealed high levels of acceptability for the initiative and low levels of awareness of the initiative. CONCLUSIONS: The removal of unhealthy beverages from display can result in customers making healthier purchases, and this appears to continue over the long-term. Such interventions have the potential to contribute to the sustained shift in population purchases and consumption needed to make meaningful improvements to population health.

Correction to: a narrative review of economic constructs in commonly used implementation and scale-up theories, frameworks and models.

An amendment to this paper has been published and can be accessed via the original article.

Recreation centre managers' perceptions of pricing interventions to promote healthy eating.

Retailers have the capacity to improve the food and beverage environment by making healthier options more affordable and attractive for their consumers. The perspectives of retailers on feasible and acceptable pricing strategies are not known. The aim of this study was to understand retailers' perceptions of factors that are relevant to feasible and acceptable health-promoting food and beverage pricing interventions. A convenience sample of 11 aquatic and recreation centre managers in Victoria, Australia was recruited to participate in semi-structured interviews. We took a pragmatic approach with the aim of understanding retailers' perceptions of factors that affect the feasibility and acceptability of pricing interventions within their facilities. Thematic analysis was used to synthesize and interpret retailers' perceptions of pricing interventions. Key themes identified were: structural and organizational characteristics (the internal and external characteristics of aquatic and recreation centres), characteristics of feasible pricing changes (type, magnitude and products targeted by pricing strategies) and business outcomes (profits and customer feedback). Results suggest that pricing interventions to promote healthy food and beverage choices can be feasible and acceptable to retailers, though contextual considerations are likely to be important. Future studies should use these findings to design interventions most likely to be acceptable to retailers, work with retailers to implement health-promoting food and beverage pricing interventions, evaluate the impact on business outcomes including customer perspectives and profitability, and test transferability to other retail settings.

Price Promotions by Food Category and Product Healthiness in an Australian Supermarket Chain, 2017-2018.

Objectives. To examine the prevalence and magnitude of price promotions in a major Australian supermarket and how they differ between core (healthy) and discretionary (less healthy) food categories.Methods. Weekly online price data (regular retail price, discount price, and promotion type) on 1579 foods were collected for 1 year (April 2017 to April 2018) from the largest Australian supermarket chain. Products audited were classified according to Australian Dietary Guidelines definitions of core and discretionary foods and according to their Health Star Rating (a government-endorsed nutrient profiling scheme).Results. On average, 15.1% (95% confidence interval [CI] = 14.7%, 15.3%) of core foods and 28.8% (95% CI = 28.6%, 29.0%) of discretionary foods were price promoted during a given week. Average discounts were -15.4% (95% CI = -16.4, -14.4) for core products and -25.9% (95% CI = -26.8, -25.1) for discretionary products. The percentage of products on price promotion and the size of the discount were larger for products with a lower Health Star Rating (P < .05).Conclusions. Price promotions were more prevalent and greater in magnitude for discretionary foods than for core foods. Policies to reduce the prevalence and magnitude of price promotions on discretionary foods could improve the healthiness of food purchased from supermarkets.

The effect of sugar-sweetened beverage price increases and educational messages on beverage purchasing behavior among adults.

There is a paucity of evidence regarding the impact of sugar sweetened beverage (SSB) price increases on beverage consumption, using individual-level data, for the population overall and for different socioeconomic groups. This study aimed to predict the impact of altered beverage prices and educational messages on consumer purchasing behavior. 2020 adults representative of the Australian population by age, gender and income completed a discrete choice experiment online in 2016. Each subject completed 20 choice scenarios in a hypothetical convenience store setting where subjects chose between seven SSB and non-SSB beverage options or a no beverage option. Beverage prices and volumes varied between scenarios. Half of participants (n = 1012) were randomly exposed to an educational poster discouraging SSB consumption prior to completing choice scenarios. We used discrete choice models to predict purchases under several policy proposals, overall and for income and SSB consumption frequency sub-groups. Compared to baseline prices, a 10% SSB price increase was predicted to reduce SSB purchases by 15.0% [95%CI -15.2, -14.7], and increase purchases of non-SSBs by +11.0% [95%CI 10.8, 11.2] and no beverage by +15.5% [95%CI 15.1, 15.9]. Effects were greater with a 20% SSB price increase. Across all policy scenarios, the highest income quintile had a similar absolute and slightly greater relative decrease in SSB purchases compared to the lowest quintile. Educational poster exposure reduced SSB choice for all groups, with a greater reduction in the lower compared to higher income group, and additively increased response to price changes. Our results support the use of population-wide SSB pricing and educational interventions to reduce demand across all income groups.

The effect of sugar-sweetened beverage front-of-pack labels on drink selection, health knowledge and awareness: An online randomised controlled trial.

PURPOSE AND AIM: Sugar-sweetened beverages (SSBs) provide little nutritional value and are associated with an increased risk of diet-related diseases. Despite this, SSB consumption is high globally. One emerging strategy aimed at reducing SSB consumption involves the use of front-of-pack (FOP) labels that clearly identify the risks associated with SSB consumption. The aim of this research study was to determine whether FOP labels with a graphic warning, text warning, sugar information (with the number of teaspoons of added sugar) or Health Star Rating (HSR) reduces intended choice of a SSB in an online choice experiment with young Australian adults. RESULTS: 994 participants were recruited and completed the online choice experiment. Compared to the control group who were not exposed to a label, the graphic warning, text warning, sugar information and HSR labels all significantly reduced selection of a SSB in the choice scenario. The magnitude of effect was greatest for the graphic warning label (OR 0.22 95% CI 0.14-0.35). Compared to the control group, only the HSR label significantly increased selections of the high HSR drinks (OR 2.18 95% CI 1.20-3.97). CONCLUSIONS: FOP labels, particularly those with graphic warnings, have the potential to reduce intended SSB purchases. Labels that also identify healthier alternatives may influence consumers to substitute SSBs with healthier drinks.

The effect on drink sales of removal of unhealthy drinks from display in a self-service café.

OBJECTIVE: The present study assessed the impact of the retailer-led removal of unhealthy beverages from display at a self-service café within a major health service. While unhealthy beverages remained available from behind the counter upon request, this was not communicated directly to customers. DESIGN: Drinks were categorised based on the state government nutrient profiling system, classifying drinks as 'green' (best choices), 'amber' (choose carefully) and 'red' (limit). Total drink sales (as number of items sold per week) in the café were measured for five weeks. All unhealthy 'red' beverages were removed from display (but were still available for purchase) and the sales of all beverages were measured for another six weeks. RESULTS: We found that, in response to this strategy, the proportion of 'red' drinks sold decreased from 33 % to 10 % of total drink sales. As 'amber' and 'green' drink sales increased in response to this strategy, total retailer sales remained steady. Most consumers appeared to switch to purchasing 'amber' drinks rather than the healthiest option, 'green' drinks. CONCLUSIONS: The removal of unhealthy beverages from display can result in consumers making healthier purchases, while not significantly affecting retailers' sales.

A mixed-methods impact evaluation of the feasibility of an initiative in small rural stores to improve access to fruit and vegetables.

Retail stores are a promising setting for improving access to nutritious food. This study opportunistically evaluated an initiative that supported stores in small rural Victorian towns to sell fresh fruit and vegetables. It aimed to measure whether the initiative showed a trend towards improved access to fruit and vegetables in these rural communities. A mixed-methods, pre-post evaluation was employed to measure the range and price of 39 fruits and 45 vegetables, together with 15 interviews with stakeholders 2.5 years after the commencement of the initiative. Twenty-one of 35 eligible stores took up the initiative. Analysis of qualitative and quantitative data showed that the initiative improved the availability of and access to fruit and vegetables, and that stores have a role in improving access to fruit and vegetables. The overall range of fruit and vegetables increased over 18 months from a median of 10 varieties (n=10) to 17 varieties (n=15) (P=0.028) and the prices decreased over 12 months in five out of seven stores where data was available. The capacity to influence availability of fruit and vegetables was affected by time, human resources and community support. Sustaining change to fruit and vegetables access is challenging. Using stores for health promotion may be an effective strategy for improving rural populations' fruit and vegetable intake.