title: Implementing healthier foodservice guidelines in hospital and federal worksite cafeterias: barriers, facilitators and keys to success.
abstract: Healthy foodservice guidelines are being implemented in worksites and healthcare facilities to increase access to healthy foods by employees and public populations. However, little is known about the barriers to and facilitators of implementation. The present study aimed to examine barriers to and facilitators of implementation of healthy foodservice guidelines in federal worksite and hospital cafeterias.
  
  
  
  Using a mixed-methods approach, including a quantitative survey followed by a qualitative, in-depth interview, we examined: (i) barriers to and facilitators of implementation; (ii) behavioural design strategies used to promote healthier foods and beverages; and (iii) how implementation of healthy foodservice guidelines influenced costs and profitability. We used a purposive sample of five hospital and four federal worksite foodservice operators who recently implemented one of two foodservice guidelines: the United States Department of Health and Human Services/General Services Administration Health and Sustainability Guidelines ('Guidelines') in federal worksites or the Partnership for a Healthier America Hospital Healthier Food Initiative ('Initiative') in hospitals. Descriptive statistics were used to analyse quantitative survey data. Qualitative data were analysed using a deductive approach.
  
  
  
  Implementation facilitators included leadership support, adequate vendor selections and having dietitians assist with implementation. Implementation barriers included inadequate selections from vendors, customer complaints and additional expertise required for menu labelling. Behavioural design strategies used most frequently included icons denoting healthier options, marketing using social media and placement of healthier options in prime locations.
  
  
  
  Lessons learned can guide subsequent steps for future healthy foodservice guideline implementation in similar settings.
authors.affiliation: Department of Public Health, East Carolina University, Greenville, NC, USA.
authors.forename: S B
authors.initials: SB
authors.lastname: Jilcott Pitts
authors.affiliation: North Carolina Institute for Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
authors.forename: J
authors.initials: J
authors.lastname: Graham
authors.affiliation: Public Health Executive Leadership Program, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
authors.forename: A
authors.initials: A
authors.lastname: Mojica
authors.affiliation: Department of Nutrition, North Carolina Institute for Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
authors.forename: L
authors.initials: L
authors.lastname: Stewart
authors.affiliation: Department of Nutrition, North Carolina Institute for Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
authors.forename: M
authors.initials: M
authors.lastname: Walter
authors.affiliation: Department of Nutrition, North Carolina Institute for Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
authors.forename: C
authors.initials: C
authors.lastname: Schille
authors.affiliation: Department of Nutrition, North Carolina Institute for Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
authors.forename: J
authors.initials: J
authors.lastname: McGinty
authors.affiliation: Department of Nutrition, North Carolina Institute for Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
authors.forename: M
authors.initials: M
authors.lastname: Pearsall
authors.affiliation: Department of Public Health, East Carolina University, Greenville, NC, USA.
authors.forename: O
authors.initials: O
authors.lastname: Whitt
authors.affiliation: Odum Institute, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
authors.forename: P
authors.initials: P
authors.lastname: Mihas
authors.affiliation: Partnership for a Healthier America, Washington, DC, USA.
authors.forename: A
authors.initials: A
authors.lastname: Bradley
authors.affiliation: Partnership for a Healthier America, Washington, DC, USA.
authors.forename: C
authors.initials: C
authors.lastname: Simon
mesh_terms: D005521:Food Service, Hospital / Q000592:standards*; D005522:Food Services / Q000592:standards*; D017408:Guidelines as Topic; D006284:Health Plan Implementation; D006801:Humans; D018673:Nutrition Policy; D036301:Qualitative Research; D011795:Surveys and Questionnaires; D014481:United States; D017132:Workplace / Q000592:standards
keywords: health promotion; nutrition policy; qualitative; workplace nutrition