The multiple case study was conducted in the province of Alberta, Canada. Recreational facilities are ubiquitous throughout urban and rural Alberta. The available infrastructure varies among facilities, but typically includes swimming pools, ice arenas, soccer centres, curling rinks and/or gymnasiums. Approximately 80% of publicly funded recreational facilities in Alberta sell food as a means of generating additional revenue, most commonly through vending machines, however many facilities also contain publicly or privately operated concessions. Features of the recreational facilities included in this study are presented in Table . The adopter and semi-adopter cases were each limited to a single facility, however the non-adopter case included observations from four small recreational facilities where food services were managed by a single manager.
Food environment quality
There were differences in the quality of items present within vending machines among facilities that had and had not adopted the ANGCY (Table ). Compared to non-adopters, facilities that had adopted the ANGCY in vending machines had higher ANGCY implementation scores for food vending machines, greater availability of “choose most often” items, and their vending machine items contained fewer calories on average. Notably, all food vending machines contained few “choose most often” items, as few were available that could be sold in unrefrigerated vending machines. Nevertheless, the semi-adopter attempted to provide healthier choices in food vending machines by filling them primarily with “choose sometimes” items (77% of food items were “choose sometimes”). Beverage vending machines scored better than food machines on all measures. Comments from managers revealed why this was the case, as bottled water was a top selling item, and therefore it was in the financial interests of food vendors to place this healthy item in machines.
Subjective and objective assessments of vending machine items
There were few clear differences in food environment scores between concessions that had and had not adopted the ANGCY (Table ). The only concession that had adopted the ANGCY scored well in terms of the overall quality of its food environment, with high NEMS-R and ANGCY implementation scores, yet it provided a very limited proportion of healthy items. Most other concessions that had not adopted the ANGCY also scored highly in terms of the quality of their food environments, and had a similarly low proportion of “choose most often” items available, making them virtually indistinguishable from the adopter. An arena concession, a non-adopter with no availability of “choose most often” food items, stood out as having the poorest quality food environment, with consistently low scores on all measures.
Subjective and objective assessments of the food environment in concessions
Interviews and observations provided new dimensions for understanding quantitative findings regarding the quality of the food environment. Agreement was good overall in that managers generally recognized the need to improve the quality of the food environment within their facilities, however in some instances managers perceived they had more healthy options than they actually did. Observations revealed evidence of action on the part of adopter facilities, but also showed just how prominent unhealthy food was within these facilities that claimed to promote healthy lifestyles. Access to food was particularly high in the case of the semi-adopter, with concessions on both floors, and a large number of vending machines throughout the facility. These findings highlight the value of using multiple modes of data collection.
Facilities that had implemented the ANGCY perceived that food and beverage sales had fallen as a consequence. In the semi-adopter, the commission they collected on vending machine sales decreased by 16% from 2009 to 2010, and they anticipated a further decline of 14% in 2011. Similarly, in the full adopter facility, annual sales decreased by 17% in the concession from 2009 to 2010 and the vending machine operator estimated that revenues had declined by 20% since implementation began. Data capture systems were too limited to accurately depict the proportion of revenue declines attributable to ANGCY implementation, and which might have been due to other factors such as the economic recession or declines in facility usage. The inability to disentangle the impact of each of these factors was a barrier to greater implementation of the ANGCY, as managers assumed that increasing the proportion of “choose most often” items might further reduce profitability. Notably, annual revenues in two non-adopter concessions declined by 5% and 9%, respectively, over the same period, declines that the manager attributed to reduced facility usage. Table presents industry’s perceptions of food service sales.
Industry’s perceptions of food service sales
Comparison of sales of healthy and unhealthy items was only possible in two non-adopter concessions as others did not provide itemized sales data. In one, a pool café, sales of healthy options closely mirrored their availability, as 17% of menu items available, and 14% of items sold were “choose most often”. In the other, an arena concession, 11% of items available were “choose most often”, while 4% of items sold were “choose most often”. Of the top 15 food and beverage items sold in the pool café, only two were “choose most often” (water, juice), whereas none were “choose most often” in the arena concession. Observations made by researchers and managers in all facilities supported findings of low sales of “choose most often” items, and in particular it was noticed that students from nearby schools came to the full adopter facility at lunch to purchase the unhealthy items they could not purchase on school grounds.
Impact of factors on adoption and implementation of the ANGCY
Factors common across all cases
The comparative analysis was aimed at distinguishing the factors that determined whether or not adoption and implementation occurred, and mirrors the presentation of findings by Savaya et al [43
]. First, in Table we detail factors from the theoretical framework that had a similar impact across all cases, acting as barriers, facilitators or neither within all of the facilities. Because they acted in a similar manner across all cases, the barriers in this list were therefore not strong enough to dissuade adoption and implementation, nor were the facilitators strong enough to compel adoption and implementation. We cannot conclude that these factors are not necessary to adoption and implementation, only that their presence, in the case of facilitators, or absence, in the case of barriers, is not sufficient for adoption and implementation to occur. A cause is sufficient if it is invariably (or almost invariably) followed by the outcome, whereas it is necessary if it is present in all instances of the outcome [44
Table 6 Factors from Greenhalgh et al’s Diffusion of Innovations frameworkthat were common across all cases
Factors unique to individual cases
Next, we describe factors from the theoretical framework that were influential for adoption and implementation, but were unique to individual cases. These factors may be important for adoption and implementation in particular contexts, and are therefore sufficient, but not necessary for adoption and implementation.
Organizational antecedents for the ANGCY
Formalization: Adopters contracted out their food service and as a result had to work within the constraints of food vendors whose values differed from their own. The multi-year nature of these contracts also committed them to particular courses of action for several years at a time. Thus, expiration of their three and five year concession and vending machine contracts, respectively, provided much of the initial impetus for adopting the ANGCY in the full adopter facility: “I really think I was motivated solely by the expiration of contracts and it was sort of a do it now or lose [many] years of opportunity… So I was kind of spurred on by the fact that it was kind of now or never.” The manager seized this window of opportunity to develop new vendor contracts that required adherence to the ANGCY.
Conversely, food service contracts were a major barrier to adoption for the semi-adopter, which was nine years into its 20 year food service agreements that allowed food vendors to sell virtually what they liked. Therefore, had its vending machine company not agreed to adopt the ANGCY, the facility would have remained a non-adopter for another 11 years. The degree of formalization was low within non-adopter facilities, as their concession-based food services were publicly delivered by the municipality and industry was not involved. The concession manager felt that the low degree of formalization had not impacted the decision not to adopt the ANGCY.
Organizational readiness for the ANGCY Power balances:
If supporters of adoption are more numerous and strategically placed than opponents, the ANGCY are more likely to be assimilated [27
]. The support of powerful persons and organizations proved to be key facilitators of adoption. Within adopter facilities, the support of facility and municipal leaders was a key prerequisite for adoption and implementation of the ANGCY. These individuals determined in what format the ANGCY would be implemented, either one based in choice (where all foods could be sold) or in a restrictive format (where unhealthy foods could not be sold). The support of food vendors was also essential to adoption and implementation. Public sentiment was influential in adopters’ decision to adopt the ANGCY in a choice-based format, but was accorded less importance within the semi-adopter facility.
Encouragement by local School Boards to adopt the ANGCY was an important catalyst for adoption within the full adopter facility. Given the proximity of the recreational facility to two high schools, the manager wanted to support the School Boards’ efforts to adopt the ANGCY by using them as well: “A facilitator also has been the pressure that’s been put on by the School Boards to do different… [they] were leading the charge… and we felt that we needed to support and/or follow that so it wasn’t just them out on a limb…” However, while most stakeholders preferred that the ANGCY be adopted in a choice-based format, School Boards wanted the facility to adopt the ANGCY in a restrictive format similar to their own. Although the facility did not ultimately adopt restrictive policies, continued interaction and dialogue between the recreational facility and the School Boards helped to sustain implementation. Schools were similarly influential in the adoption decision of the semi-adopter, which was strongly encouraged to adopt the ANGCY by a teacher who was also a member of the facility’s governance Board.
Adopters did not experience any overt opposition because adoption was limited in scope. Managers predicted that strong opposition would have emerged had they removed all unhealthy items from the facilities: “There’s no opposition because we [allowed] choice. There’s no threat because they can still sell what they want to sell. Yeah, I’ve felt no opposition.” The support of food vendors was, however, waning in the face of mounting revenue losses. In addition, apathy was a concern for the full adopter, as although his municipality verbally supported implementation, it had not made child health a priority: “I don’t think it ever became a priority for municipal government. So I’m one person, fairly far down the food chain… and so it’s like a fish trying to swim upstream when you’re just one person trying to effect change, you don’t have a whole bunch of time to commit to it, but you want to make some sort of impact… I wish there was someone further up the ladder who was more passionate or interested in [the ANGCY], because then it would probably move…”
The menus of non-adopter concessions reflected the fact that customers, through market forces, held the balance of power within these facilities. The manager was highly sensitive to customer demands and indicated that if customers had asked him to adopt the ANGCY, he would have given serious consideration to doing so. He also did not expect any stakeholders to overtly oppose adoption.
Factors that differed between adopters and the non-adopter
Thirdly, we provide an in-depth analysis of the factors that differed between adopters and the non-adopter. To be included in this list, the impact of the factor on adoption and implementation had to be similar in adopters and demonstrate an opposing, or no relationship in the non-adopter. The presence (in the case of facilitators) or absence (in the case of barriers) of these factors was therefore sufficient and may also be necessary for adoption and/or implementation of the ANGCY.
Adopters and the adoption process Meaning of the ANGCY to managers:
Individuals do not passively receive innovations, instead they engage with them in complex ways before coming to an adoption decision [27
]. The adoption process essentially began when the personal values of recreational facility managers regarding the importance of supporting healthy eating in recreational facilities intersected with timely opportunities to do so. For the full adopter, this opportunity came in the form of the near simultaneous expiry of its three and five year food service contracts. For the semi-adopter, a suggestion from a member of the facility’s governance Board provided the initial adoption stimulus. In both cases, managers, energized by their strong personal beliefs, took immediate action. They did not want to lose their window of opportunity to finally align their actions with their beliefs and to truly begin to “walk [their] talk.” Congruence between the ANGCY and the personal philosophies of managers provided a strong foundation for maintenance of the original adoption decision despite the negative financial outcomes that ensued: “If they really want to eat junk food… they can just go to 7–11 and get it because for us, dollars and cents are not - that’s not the motivating factor… [we] believe in what we’re offering and if it’s going to bring in less money, then so be it.”
The non-adopter believed the ANGCY to be a good initiative but saw no need for them, erroneously believing his menu items to be healthy. In addition to the ANGCY having little meaning for this manager, the coincidence of events that encouraged adopters to act on their beliefs was not present in this case.
Attributes of the ANGCY Complexity:
Practices that are easily understood and communicated are more readily adopted [47
]. Managers from adopter facilities described the recommendations and food rating system within the ANGCY as “practical, easy to understand, and user-friendly.” The full adopter appreciated that “the guidelines [spoke] directly to recreation”, and this allowed them to use wording “straight from the guidelines [in their contracts].” This simplicity facilitated policy development within short timelines. By contrast, simplicity was a quality lacking in the guidelines according to the non-adopter, who felt the 103 page ANGCY document was daunting.
Relative advantage is the degree to which managers expect that following the ANGCY will confer advantages over previous practices. If potential adopters do not perceive a relative advantage they will often not consider an innovation further [27
]. Managers within recreational facilities had to weigh the potential advantages to be gained from implementing the ANGCY against the negative consequences that might also result.
Food services within adopter facilities were overseen by the facilities’ general managers. These managers had a wide scope of responsibility and placed a high priority on achieving the community wellness aspect of their mandate. They believed the ANGCY could assist them to support wellness. This potential advantage had to be balanced with the possible negative impact of the ANGCY on revenue generation from food services, however, as funding models were often at odds with support for healthy eating: “I think it’s just trying to balance what’s sustainable in terms of support for the facilities because we get revenue or other assets from the sale of [unhealthy foods] at our facilities, and balancing our philosophy and our beliefs in terms of healthy lifestyles… We’re on a teeter-totter… [we] can’t do one without affecting the other one… like you start taking away the revenue and all of a sudden your fees go up and… so now you’ve got kids eating healthy but they’re not going in to swim. We’ve got to balance it somehow.” Therefore, in areas where ANGCY adoption had relatively small negative financial implications (ie. increasing the number of healthy items in concessions and vending machines), adoption proceeded. Conversely, in areas where ANGCY adoption came at a higher financial cost, the relative advantage of adopting the ANGCY was perceived to be low. For this reason, advertising and sponsorship agreements were maintained, and the sale of highly profitable unhealthy items continued (ie. the ANGCY were adopted in a choice-based format), even though managers would have personally preferred a restrictive format. Thus, the ANGCY offered a relative advantage to adopters insofar as they assisted them to achieve their wellness mandate in a financially sustainable manner. One manager found this a particularly troubling reality, and desired a new business model that did not make them dependent upon revenue from the sale of unhealthy foods.
Food services within non-adopter facilities were managed by a concession services manager with a narrow mandate of maintaining profitable food service operations. Thus, support for community wellness was relatively inconsequential for this manager, and he therefore perceived that adopting the ANGCY would put them at a competitive disadvantage. As a consequence, he had little interest in adopting them.
Organizational antecedents for the ANGCY Professionalism:
Professionalism refers to the professional knowledge of an organization’s specialties, and is positively associated with organizational innovativeness [27
]. Managers’ knowledge of nutrition influenced whether they perceived a need to improve the food environment in their facilities by adopting the ANGCY. The manager of the non-adopter facilities believed that foods that were homemade, fresh, and ‘real’ were healthy. As such, he saw no need to adopt the ANGCY because he considered the hamburgers and hot dogs made with 100% beef, homemade soups, hot chocolate made with fresh milk and most of the other items available in his concessions to be healthy. In keeping with the ANGCY, managers from adopter facilities understood nutritional quality to be a function of the micro and macronutrient content of foods. On this basis, they recognized that the majority of the foods available in their facilities were not healthy.
Professional knowledge was also highly important for ANGCY implementation, as in all cases of successful implementation Registered Dietitians assisted industry to reformulate menu items and/or to identify items that met the definition of “choose most often”.
Size of operation, technical capacity:
Organizations that are larger, more mature, and that have greater technical resources tend to be more innovative [27
]. Larger recreational facilities had a larger customer base and consequently their concessions had longer hours of operation. Their concessions also had more equipment, space for food storage and preparation and more highly skilled employees. These factors provided greater flexibility in their ability to prepare, store and sell healthier items and thus they could more easily adopt the ANGCY. Smaller concessions within single purpose facilities failed to adopt the ANGCY in part because they lacked this technical capacity.
Absorptive capacity for new knowledge:
Recreational facilities that are able to identify and integrate new knowledge into their existing knowledge base will be better able to assimilate the ANGCY [27
]. Prerequisites include the facility’s pre-existing technical infrastructure, formal expertise, organizational know-how and interpersonal networks [48
]. There was limited pre-existing capacity to implement the ANGCY within all facilities, and therefore adopters sought to leverage their existing food service partnerships with industry in a health promoting direction. Several of these food vendors had already developed capacity to implement the ANGCY in schools and were willing to transfer this learning to the recreational facility setting. Their willingness to adopt the ANGCY and to be responsible for implementation was an important facilitator: “What things made it easier? I guess just the simple fact that we didn’t have to do any work… We didn’t have to go out there and do research to find out how much of what is in what and how big and how is it made and how much salt… Thank goodness we didn’t have to do that!”
By contrast, food vendors within the semi- and non-adopter facilities that did not agree to adopt the ANGCY either had no school-based operations, or were not using the ANGCY within their school-based operations. Thus, industry’s use of the ANGCY in schools built transferable capacity for implementing the ANGCY in recreational facilities. When health promoting partnerships with industry were not present, ANGCY adoption and implementation did not occur.
Risk-taking climate: A risk-taking climate was present within all facilities, however managers differed on the type of risks they were willing to take. Adopters were willing to accept the small financial risk of implementing the ANGCY in a choice-based format, but not the much greater risks inherent in a restrictive format. Conversely, the non-adopter had little tolerance for experimentation with initiatives that were not specifically intended to improve profitability, such as the ANGCY: “Part of the problem that we have is that we are under a great deal of pressure to meet our budget – like a great deal of pressure. So to experiment with things, it has to be something that we know is going to do well and is not going to end up costing us money or add on staffing hours.”
Managerial relations: Good relations between managers from recreational facilities and the food vendors operating within these facilities were present in all cases of ANGCY adoption. The juxtaposition of good and bad relationships within the semi-adopter was instructive. A good relationship between the facility and the vending machine company was the means by which the barrier posed by the company’s 20 year contract with the facility was overcome, whereas a poor relationship with one concession manager cemented this barrier in place and ultimately determined the status of the facility as a “semi-adopter”. Similarly, the good working relationship between the semi-adopter and the vending machine company supported ongoing implementation of the ANGCY despite the decline in revenues that ensued.
Organizational readiness for the ANGCY Fit of the ANGCY with the recreational facility context:
The ANGCY are more likely to be assimilated if they fit the recreational facilities’ existing values, norms, goals, skills, supporting technologies and ways of working [27
]. Although nutrition was not a formal focus for the recreation sector, adopters sought to raise the priority of nutrition within their facilities by connecting the ANGCY to achievement of their organizational goals of supporting healthy lifestyles in the community. Because food services within non-adopter facilities were managed separately from the full facilities, they did not share the facilities’ overarching wellness goals and the priority of nutrition remained low. The ANGCY were a poor fit within this context.
Tension for change: For ANGCY adoption to occur, recreational facilities must perceive that their current food provision is not ideal, that the ANGCY can ameliorate the spread between their current and ideal food provision, and that change is an immediate imperative. The poor fit among adopters` personal beliefs, their organizational mandates and practices elevated tension for change and prompted organizational reform. By contrast, the manager for the non-adopter facilities was principally concerned with maintaining profitable food service operations, and perceived that ANGCY adoption might further compound existing financial stress.
Communication and influence Champion:
Champions are key individuals who are willing to throw their support behind an innovation and endeavour to overcome organizational indifference or resistance to a new idea [26
]. Managers in adopter facilities “championed” the ANGCY within their facilities. Their qualities as champions were particularly evident when they requested that food vendors remove some highly profitable, but unhealthy items from the premises and when they remained committed to implementation despite declining revenues. The non-adopter recognized that not having an influential leader to champion the ANGCY was a barrier to adoption.
Diffusion and dissemination of the ANGCY:
The influences available to help spread the ANGCY lie on a continuum from pure diffusion in which spread is largely unplanned, informal, and peer-mediated, to active dissemination, in which planned, formal programs and strategies are enacted to accelerate spread [27
]. Adopters became aware of the ANGCY through formal dissemination channels, although information distributed in this way did not reach the non-adopter. Formal dissemination did not, however, provide a sufficient stimulus for ANGCY adoption by adopters. Instead, managers were motivated to seriously consider adoption when others within their social networks shared how they were using the ANGCY in schools, and encouraged them to do the same. No one had ever discussed ANGCY adoption with the non-adopter.
Competitive environment: Competition was not a pressing issue for managers of adopter facilities. These facilities were the largest in their respective municipalities and there was little concern that patrons might frequent other facilities or bring in food from outside sources. Conversely, the opening of a new modern multiplex in the municipality where non-adopter facilities were located had the corollary effect of reducing facility and food service patronage. These competitive pressures created an uncertain environment that left little latitude for experimentation with menu items that might prove unprofitable, thereby discouraging ANGCY adoption.
The ANGCY are more likely to be adopted if a threshold proportion of organizations have adopted, or plan to adopt them [27
]. According to managers, most patrons regarded recreational facilities as venues for unhealthy eating and therefore industry norms favoured unhealthy options. Adopters were willing to contravene these norms. The non-adopter indicated that he would have been more likely to adopt the ANGCY if “it became common that it was just that’s what facilities do… and if you went into a facility and they didn’t have, you know, fresh fruit or fresh vegetables, it would be kind of like that’s weird, sort of thing.” Thus, the current environment in which unhealthy foods were the norm discouraged him from adopting the ANGCY.
Factors related to the implementation process
We conclude by describing factors related to the implementation process. These factors were similar among adopters, however comparison to non-adopter facilities was not possible because they had not implemented the ANGCY. We are therefore unable to judge to what extent these factors may have been sufficient and/or necessary for ANGCY implementation.
Managers perceived adoption as a simple matter, whereas they described implementation as much more challenging: “Adopting was as easy as writing a policy and now the work begins with trying to find people who are able to, you know, develop programming around that and really implement it properly.” Adopters expressed frustration with the unfinished state of implementation and its apparent ineffectiveness. Healthy options had always been available, implementation of the ANGCY simply meant there were now more of them. Meanwhile, unhealthy foods continued to dominate the food landscape. Notably, it was the manager of the full adopter facility who expressed the strongest sentiment in this regard: “I really think that we’ve missed the mark with implementing… It’s one thing to have it in paper and contracts but it’s another thing to deliver it… It’s disheartening to see what doesn’t happen. Like, it’s not as simple as writing a policy and people picking it up. It just doesn’t work that way.” Managers recognized that assimilation of the ANGCY within the organization’s systems and structures would take time: “Am I jumping up and down saying we did it? No, because there’s more to do. But at this point in time, in the short-term, we can’t see that changing. Maybe long-term… There’s a lot more we can do in terms of integrating [nutrition] within our services and programs. So that will come with time.”
Implementation ultimately depended on the leadership and direction of facility managers, and therefore when time limitations prevented them from focussing their attention on the ANGCY no progress was achieved: “Other priorities haven’t let me focus any energy here in quite some time… It just sits on the back burner. And so I’d say I’m a huge barrier, if you’re looking at barriers and facilitators… Nothing is actively happening… and there is no plan to do differently or roll out anything new.” Because of these time limitations managers attempted to devolve most of the responsibility for implementation to food vendors. Managers trusted them to implement the ANGCY, and did not monitor their progress in a formal and systematic manner. Instead, they gauged the status of implementation based on their own periodic observations and anecdotal reports from customers: “Probably every couple of weeks as I’m walking through the halls, I take note of what’s in there… but it’s not a checklist. It’s just, what do I see, what do I observe. If there’s something that catches my eye that’s kind of off, we’ll address it.” This lack of monitoring likely contributed to the ambivalence surrounding ANGCY implementation, as no one could be sure whether their efforts had been worthwhile.
The analysis culminated in the development of 25 propositions, presented in Table .
Table 7 Propositions regarding factors from Greenhalgh et al’s Diffusion of Innovations frameworkthat were not common across all cases
Long-term follow up
Six to 18 months following completion of each case study all facilities confirmed that their adoption status was stable, and that no major nutrition-related changes had been made to their food services.