Stories of policy change: City of Hamilton's healthy food and beverage policy.

Atkey, Kayla ; Elliott-Moyer, Pat ; Freimanis, Miri 等

Poor diet is the leading risk factor for chronic disease and early death in Canada. (1) This trend is due, in part, to the widespread availability of processed foods in settings outside of the home. (2, 3) The development of healthy food and beverage (HFB) policy is an important strategy for addressing this issue by increasing availability of and access to healthier options. (4, 5) HFB policy refers to laws, regulations, guidelines, strategies, or policy-making actions aimed at facilitating healthier dietary behaviours. (6)

Municipalities are important laboratories for policy innovation related to nutrition and chronic disease prevention. (7) Considering the large number of employees and individuals who access public settings, the development of municipal HFB policy has the potential to result in significant health benefits at the population level. (8) Further, development of public policy in one municipal setting can influence policy learning in another, helping to shift public and decision-maker understanding of an issue and contributing to the development of more comprehensive policies over time. (7)

Despite the potential of municipal action to improve diets, the majority of Canadian municipalities have yet to implement HFB policies. (9) Reasons for this may include a lack of priority given to healthy eating environments, barriers to implementation, and limited support for policy learning across jurisdictions. In the United States context, the cities of New York and Los Angeles have had nutrition policy in place since 2007 and 2010 respectively. (5, 8, 10) In the literature, key lessons from the New York experience include the importance of high-level support and technical assistance in facilitating policy development. (8) Further, a published case study on the Los Angeles experience highlights potential facilitators (e.g., examining institutional authority to adopt policies and practice, educating key stakeholders, and recruiting champions) and barriers (e.g., complex administrative processes and variable levels of consumer acceptance) to policy change. (5, 10) In Canada, a small number of municipalities have developed HFB policy and initiatives. However, there is a gap in the peer-reviewed literature documenting these changes and subsequent policy learnings. To help address this gap, this article explores the City of Hamilton's story of municipal HFB policy development, as well as key lessons learned throughout this process.

This article was part of a policy story project initiated by the Policy Opportunities Windows: Enhancing Research Uptake in Practice (POWER UP!) project. * In the health promotion literature, the use of stories has emerged as a promising approach for communicating information related to healthy public policy. (11) To develop the story, the research team recruited authors P.E.M. and M.F. to participate in the project as key informants. ([dagger]) At the time of the study, P.E.M. was a Public Health Nutritionist in the Healthy Living Division of the City's Public Health Services, while M.F. was a Healthy Workplace Specialist for the City. Both P.E.M. and M.F. were involved in the adoption and implementation of Hamilton's HFB policy. Informed by story development processes in the health promotion literature, (11, 12) author K.A. interviewed author P.E.M. to identify key details regarding the policy's development. Following synthesis of the interview data by K.A, authors P.E.M. and M.F. worked together to fill in gaps and generate key lessons learned throughout the process. The final story, chronicling the City of Hamilton's development of HFB policy, is detailed below. An earlier version of the story is available online. (13)

SETTING: THE CITY OF HAMILTON

The City of Hamilton is a mid-sized, industrial city located on the western end of Lake Ontario, in the province of Ontario, Canada. (14, 15) At the time of this article, Hamilton had a population of 536 91716 and a municipal staff of almost 8 000. (17) In recent decades, the City of Hamilton has experienced social and health issues, such as high poverty rates, exacerbated by declining employment opportunities, and higher-than-average rates of obesity. (14, 18) Indeed, in 2011/2012, 31.3% of adults in Hamilton were obese, exceeding Canada's national average of 24.8%.19 With these issues in mind, by the mid-2000s, creating healthy and sustainable communities had emerged as an important priority for the City of Hamilton. (18) Since that time, Hamilton has initiated a number of innovative healthy public policy initiatives over and above the HFB policy, including the development of active transportation and community garden policies. (20, 21)

INTERVENTION

To date, few Canadian municipalities have implemented policy to improve the food environment in public facilities. (9) Acting as an innovator in this area, in 2011 the City of Hamilton adopted an HFB policy. The aim of the policy is to demonstrate the municipality's commitment to healthy eating by being a community role model for "food service that is free of industrially produced trans fats, and by promoting a safe and sustainable local food system". (22) The policy was developed using Canada's Food Guide to Healthy Eating. (23) However, it is also broader in scope to align with other City policies related to recycling, trans fats, food safety, waste management, special dietary needs, and use of municipal tap water. Current application of the HFB policy is corporate-wide and concerns all city buildings and public events where the City offers and funds food and beverages. This ranges from the food and beverages offered at staff functions and the vending machines and concession stands within recreational facilities, to Hamilton's two long-term care centres. (22) To support implementation of the policy, a public health nutritionist is available who collaborates with caterers to develop menus that comply with the policy, based on a nutrition criteria checklist. Accountability measures focus on how the City spends money on food and beverages. Specifically, managers are accountable to ensure that staff understand and comply with the policy before signing off on food and beverage purchases, signifying that policy criteria has been adhered to. As outlined in the HFB policy, noncompliance may result in appropriate disciplinary measures. (22)

Origins of the HFB policy: A decade of preparation

The seed for the City of Hamilton's HFB policy was planted in 1989 when the Ontario Ministry of Health established mandatory program and service guidelines, which helped to chart a clear direction for boards of health across Ontario. (24) One aspect of this provincial initiative involved the development of healthy eating guidelines in workplace settings as part of overall workplace health. Recognizing the need to address the City of Hamilton's high rates of obesity and to act as a role model for healthy eating environments, Hamilton Public Health Services (PHS) began the development of healthy eating guidelines for employees. Although the City endorsed the guidelines in 2000, there was limited implementation at the time.

In 2004, Ontario's Society of Nutritional Professionals in Public Health released a report calling for legislation to create healthy school food environments. (25) This report reinvigorated the PHS's focus on creating healthy eating environments. PHS reviewed the healthy eating guidelines and started to explore how the formation of an HFB policy could give them more teeth. Around the same time, Hamilton's Board of Health and City Council began exploring strategies to support healthy eating in the community, spurred by action taking place in cities across North America to reduce trans fats and curb rising obesity rates. Although Council initially considered a bylaw to promote healthier food environments, they were legally advised to focus on an area over which they had immediate jurisdiction: how the City spent corporate money on food and beverages. As P.E.M. reflected, the PHS was developing an HFB policy that it hoped would go corporate, which provided Council with an opportunity to say, "That's what we can do."

With Council agreeing to the development of the policy, they tasked PHS Registered Dietitians to write a "gold star" policy. While the HFB policy was based on Canada's Food Guide to Healthy Eating, (23) the City also made a point to connect with other departments to see how it could support existing policies and initiatives (e.g., food safety, waste management, no bottled water), and take into consideration current vendor contracts for vending machines and concession stands.

Pilot testing

With a draft HFB policy formulated, the PHS presented the policy to the City of Hamilton's Senior Leadership Team (SLT) for corporate-wide adoption. The initial reaction from the SLT was that the policy presented a huge change for people outside of the PHS and that such a policy would require a significant shift in corporate culture and practice. For this reason, the PHS decided to pilot the policy within their department and then return to SLT for reconsideration of corporate-wide adoption at a future date.

Public Health Services piloted the policy for approximately two years. Ultimately, the time spent piloting the policy proved beneficial as it helped City officials keep the policy alive, understand barriers to policy change, and develop strategies for moving forward with policy implementation. It also showed that the policy could be applied successfully with accountability measures in place, such as having managers ensure staff compliance with the policy before signing off on food and beverage purchases.

Adoption

After the two-year pilot, in 2011, the PHS had an opportunity to get the HFB policy back on the corporate agenda. Following a large educational process for City management teams conducted by Human Resources (HR) and PHS, the policy was finally approved at the corporate level as a HR--Health, Safety and Wellness policy. Reflecting on the process, policy adoption was enhanced by high-level support from champions, such as the PHS Director of the Healthy Living Division, Manager of Health, Safety and Wellness, the Medical Officer of Health, and the City Manager. Having these leaders on board was important in terms of managing resistance at all levels and moving the policy into action. Existence of a piloted HFB policy was also beneficial. As P.E.M. and M.F. reflect, the two-year pilot showed that the City had caterers and staff who could comply with the policy, as long as there was consultation support and accountability measures in place.

Implementation

The City of Hamilton officially adopted the policy at the corporate level in 2011, but the story of policy change was far from over. Indeed, actual implementation of the policy was straightforward for some groups, such as those offering food during staff functions. However, it was far more complex for others, such as those managing recreational facilities with vending machines and concession stands.

To help groups make necessary changes, the City formed a one-year task force chaired by P.E.M. and M.F. A key activity of the task force was to conduct an environmental scan of other municipalities in Ontario for HFB guidelines and/or policies, with the goal of identifying successes and barriers to implementation and sustainability. At the time of scan, the task force found that some of the municipalities had HFB guidelines in place, but it did not identify any policies in place. However, it is worth noting that since the task force completed the scan, there has been progress in this area. For example, in 2014, the Region of Peel developed nutrition standards for workplaces. (26) Ultimately, lessons from this scan highlighted the importance of maintaining an accountability factor, providing education and supports, and keeping implementation as easy as possible for all stakeholders.

Since adoption of the policy, implementation has been an ongoing process as departments continue to make changes over time, with the goal of moving towards improved and consistent policy compliance across all city-owned land, events and facilities. Thus far, a key facilitator of policy implementation has been the provision of ongoing policy supports. For example, M.F. and P.E.M. work closely with caterers in the community to develop approved menus and provide nutrition consultation to City staff and committees requiring assistance formulating menus that fit with the policy. Further, they offer education through workshops and local TV spots, as well as resources, such as caterer lists and tip sheets. The City also incorporates the policy and its overarching philosophy into monthly corporate wellness challenges.

Throughout the implementation process, holding events, such as recipe contests, has been important in terms of winning people over, generating support, and overcoming the perception that HFB policies are restrictive. Such events highlight innovative menu items and generate excitement about the food offered in the approved menus. Another important aspect of the implementation process has been the continued involvement of high-level champions. For example, having the City Manager take time to judge a recipe contest shows the City is serious about healthy eating, which contributes to positive shifts in the corporate food culture.

On the flipside, a key barrier to policy implementation relates to inconsistent compliance and enforcement of the policy across corporate departments. Individual departments are responsible for their own day-to-day operations, which results in differences in terms of how departments uphold various corporate policies. This challenge is heightened by the understanding that the HFB policy applies to a wide variety of settings and populations where food and beverages are provided and funded by the City. According to P.E.M. and M.F., strategies that have helped to mitigate this barrier include ensuring easy compliance through ready-made menus and menu consultation, as well as regularly communicating the policy through newsletters, events, visual displays, and other initiatives.

OUTCOMES

Since adoption in 2011, the City of Hamilton has received a significant amount of feedback on the HFB policy, both positive (e.g., healthy and delicious meals) and negative (e.g., restrictive, paternalistic). However, as P.E.M. notes, even negative feedback can result in positive outcomes, such as shifts in knowledge and attitudes, as the resulting discussions can open the door to dialogue and awareness raising. In terms of key user perspectives on the policy, responses to a 2012 survey of staff and management reiterate the importance of making policy compliance easy (e.g., creating ready-made menus for caterers) in terms of achieving policy support. Further, P.E.M.'s and M.F.'s observations at corporate events have emphasized the need to integrate the policy into practice activities, such as recipe contests and taste testing, to win people over, generate support, and overcome negative perceptions. A wider corporate survey is planned for late 2017, which will explore corporate health, safety and wellness. Findings from this survey will, in turn, be used to inform ongoing policy implementation and development.

Looking back on the HFB policy's development, the provision of ongoing resources and support for implementation has been vital to the positive changes made thus far. Moving forward, it is clear that policy adoption and implementation takes time, and needs to be an ongoing active process to engrain the policy within corporate culture and practice. In terms of policy sharing across jurisdictions, a number of municipalities from across Canada have collaborated with P.E.M. and M.F. on how they can develop an HFB policy for their own community. Many local organizations and individuals in the City of Hamilton and beyond have also made use of the City's implementation resources, such as menus, for their own meetings and events.

IMPLICATIONS

Through exploration of the City of Hamilton's experience, we identified a number of key lessons for policy change (see Box 1). As many Canadian municipalities have yet to implement corporate-wide HFB policy, these lessons may help to inform policy change in other jurisdictions. Taken together, municipal representatives, health practitioners, decision-makers, and members of the public can use this policy story and lessons learned as a tool to facilitate the development of municipal HFB policy within their own communities.

Box 1: Lessons from the City of Hamilton Experience

* Avoid re-inventing the wheel: find out what works and collaborate internally and externally with partners and other municipalities to make change happen.

* Recruit champions: leaders need to become and continue to be positive role models for healthy cultural change.

* Timing is everything: be ready to move when your priorities align with other events and cultural readiness.

* Be willing to change and adapt to new circumstances and people: let go of what does not work and be open to changes in direction.

* Look for opportunities: when one door closes, another one opens.

* Ongoing recruitment of supporters: successful policy change requires a groundswell of people who believe in the policy and who influence others through their words and actions.

* Policies need to be supported by practice, including human resources, education, tools, promotion, and positive messaging.

* Make it as easy as possible for people to comply with the policy in question.

* Policies are successfully followed when clear accountability measures are in place and the leadership supports these measures through example and appropriate disciplinary action.

* There are many competing priorities in any municipality. For concrete change, consistent monitoring of the policy and efforts to keep the policy at the forefront of the City's everyday business practices are necessary.

* Be prepared for the long haul: cultural change takes years. Have patience and never give up.

* Build a team: you will need the synergy from teamwork to make it through the long haul.

doi: 10.17269/CJPH.108.6074

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Received: January 12, 2017

Accepted: September 10, 2017

Kayla Atkey, MSc, [1] Pat Elliott-Moyer, MHSc, RD, [2] Miri Freimanis, HBScKin, MEd, [3] Kim D. Raine, PhD, RD [4]

* Active during the years 2013-2016, POWER UP! brought together a team of researchers, practitioners and policy-makers from across Canada to gather and share evidence on policy for obesity and chronic disease prevention.

Author Affiliations

[1.] Policy Analyst, School of Public Health, University of Alberta, Edmonton, AB

[2.] Public Health Nutritionist, Public Health Services, City of Hamilton, Hamilton, ON

[3.] Healthy Workplace Specialist, City of Hamilton, Hamilton, ON

[4.] Professor, School of Public Health, University of Alberta, Edmonton, AB

Correspondence: Kim D. Raine, PhD, School of Public Health, University of Alberta, 4-077 Edmonton Clinic Health Academy, 11405-87 Avenue NW, Edmonton, AB T6G 1C9, Tel: 780-492-9415, E-mail: kim.raine@ualberta.ca

Acknowledgements: This work was funded by Health Canada through the Canadian Partnership Against Cancer's (CPAC) Coalitions Linking Action & Science for Prevention (CLASP) initiative.

Conflict of Interest: At the time of the article, authors P.E.M. and M.F. worked for the institution that was part of the case study.

([dagger]) This study received ethics approval from the Human Research Ethics Board at the University of Alberta.