If you don't remember your password, you can reset it by entering your email address and clicking the Reset Password button. You will then receive an email that contains a secure link for resetting your password
If the address matches a valid account an email will be sent to __email__ with instructions for resetting your password
Gretchen Swanson Center for Nutrition, Omaha, NEDepartment of Human Nutrition, Foods and Exercise, Virginia Tech, Blacksburg, VASchool of Nutrition and Food Sciences, Louisiana State University (LSU) & LSU Agricultural Center, Baton Rouge, LA
Although healthy food retail strategies are widely used, there appears to be a limited understanding of the processes and determinants for successful adoption, implementation, and sustainment. To fill this gap, we recommend the Exploration, Preparation, Implementation, and Sustainment (EPIS) framework to be used to advance the science and practice of healthy food retail. In this perspective, we: (1) introduce EPIS and describe why it was chosen as a recommended implementation science framework for healthy food retail, (2) highlight healthy food retail evidence supporting EPIS, and (3) discuss research and practice needs moving forward.
healthy food retail strategies aim to make the healthy choice the easy choice by improving opportunities for consumers to choose food and beverage products aligned with the Dietary Guidelines for Americans.
Although healthy food retail strategies are widely used, there are a host of remaining research questions regarding their design and impact across contexts.
A better understanding of how healthy food retail strategies are adopted, implemented, and sustained in community settings is also needed, given the large national focus.
Implementation science, or “the scientific study of methods to promote the systematic uptake of research findings and other evidence-based practices into routine practice”
framework, in particular, be used to advance the science and practice of healthy food retail within the context of US public health sectors and settings. The EPIS framework has been applied widely across disciplines and public health issues.
To our knowledge, it has not been used for healthy food retail research and practice. In this perspective, we (1) introduce EPIS and describe why it was chosen as a recommended implementation science framework for healthy food retail, (2) highlight healthy food retail evidence supporting EPIS, and (3) discuss research and practice needs moving forward.
An Implementation Science Framework for Healthy Food Retail
Numerous implementation science frameworks are available for researchers and practitioners to choose from,
which can make selection difficult. Key considerations for choosing a framework include the framework's purpose and operationalization, ecological levels, and the intended setting or intervention.
We selected EPIS because it is a simple and practical framework connecting diverse, healthy food retail partners (eg, researchers, practitioners, advocates, and policymakers) and because of its design in relation to this topic. The EPIS framework was designed for public service settings and was originally used to translate social service and allied health treatments (ie, mental health, substance abuse) to practice.
Healthy food retail strategies are also often delivered among public sectors and settings in the US, given they are one of several policy, systems, and environmental (PSE) changes prioritized by federal and state agencies to mitigate nutrition inequities among Americans living in lower-income and low-resourced communities.
For example, The US Department of Agriculture Supplemental Nutrition Assistance Program-Education (SNAP-Ed) and, more recently, the Expanded Food and Nutrition Education Program fund nutrition education and PSE change initiatives within communities with lower incomes to remove barriers to meeting the Dietary Guidelines for Americans.
The Gus Schumacher Nutrition Incentive Program (GusNIP) funds nutrition incentive and produces prescription programs to incentivize fruit and vegetable purchases among lower-income consumers.
The Centers for Disease Control and Prevention (CDC) also funds community PSE changes through several mechanisms, including the High Obesity, Racial and Ethnic Approaches to Community Health, and State Physical Activity and Nutrition Programs.
Although the intended food retail settings for healthy food retail strategies are not usually public service settings, the food retailers who partner on these efforts often follow government guidance for product stocking (eg, SNAP or Special Supplemental Nutrition Assistance Program for Women, Infants, and Children authorization
US Department of Agriculture. Final rule: enhancing retailer standards in the Supplemental Nutrition Assistance Program (SNAP).https://www.fns.usda.gov/snap/fr-121516.
Minimum stocking requirements for retailers in the Special Supplemental Nutrition Program for Women, Infants, and Children: disparities across US states.
These national funding priorities and federal nutrition assistance program stocking standards provide 1 example of how the wider social and political context can influence public health practice, partnerships, and priorities, specifically in healthy food retail. The program examples described above are typically facilitated by public health researchers and practitioners among organizations such as Cooperative Extension Services, state and local health departments, and nonprofit organizations. There are several noted challenges with respect to public health practitioners’ capacity and resources to adequately facilitate PSE changes, including healthy food retail.
Local health departments’ capacity for workplace health promotion programs to prevent chronic disease: comparison of rural, micropolitan, and urban contexts.
As such, an implementation science approach that studies both the process and determinants of the success or failures of healthy food retail is necessary. The EPIS framework outlines a process to understand how public health researchers and practitioners can move from evidence to impact, emphasizing factors determining the success or failure of healthy food retail strategy adoption, implementation, and sustainment. That is, another advantage of consistently using EPIS for healthy food retail research and practice is that it is both a process and a determinant framework.
Finally, public health practitioners also frequently document various steps of programming (eg, needs assessments, impact evaluations) with respect to effectiveness outcomes (consumer diet quality, food security). We posit EPIS complements these already existing formative and outcome evaluations and is a key instrument in the public health practitioner toolkit.
The EPIS Framework
Regarding healthy food retail, we used process and determinant language for EPIS on the basis of a systematic review of EPIS applications across fields that informed the evolution of the framework from the original version.
There are 4 EPIS process phases, including exploration, preparation, implementation, and sustainment, and 16 EPIS constructs or determinants among multiple levels, including the outer context, bridging factors, innovation factors, and inner context that serve as a guide during each EPIS phase (see Table for definitions).
Once adopted, the EPIS Preparation phase is initiated, in which the focus is on identifying contextual and multilevel barriers and facilitators (determinants) to the selected healthy food retail strategy. Highlighting these factors informs the need for implementation strategies
Using implementation strategies in community settings: an introduction to the Expert Recommendations for Implementing Change (ERIC) compilation and future directions.
Importantly, planning for the end (ie, healthy food retail strategy implementation and sustainment) during the EPIS Exploration and Preparation phases is a key consideration.
During the EPIS Implementation phase, healthy food retail and selected implementation strategies are implemented in the intended setting (eg, food store, farmers’ market).
There is a focus on support/monitoring for quality and fidelity and on documenting any adaptations used to facilitate implementation, such as responsive changes to a healthy food retail or implementation strategy to improve feasibility.
The outcomes of selected implementation strategies regarding how well they facilitated implementation would also be captured during this phase. Finally, the EPIS Sustainment phase focuses on maintaining healthy food retail strategies over time while reassessing and documenting needed support.
Healthy Food Retail Evidence in Support of EPIS
We pull evidence supporting EPIS for healthy food retail from 3 review articles that provide a comprehensive account of the state of the science (Table).
A systematic review of factors that influence food store owner and manager decision making and ability or willingness to use choice architecture and marketing mix strategies to encourage healthy consumer purchases in the United States, 2005–2017.
A recently published review of reviews examined evidence across 25 reviews, including hundreds of original research studies regarding factors that influence the implementation, sustainability, and scalability of healthy food retail strategies
; however, the authors did not use an implementation science framework. In our opinion, this was a missed opportunity to move beyond characterizing what influences adoption, implementation, and sustainment (and eventual scaling) to understand how these decisions can best be supported across diverse communities or contexts.
TableEvidence in Support of the Exploration, Preparation, Implementation, and Sustainment (EPIS) Framework for Healthy Food Retail
A systematic review of factors that influence food store owner and manager decision making and ability or willingness to use choice architecture and marketing mix strategies to encourage healthy consumer purchases in the United States, 2005–2017.
Outer context (ie, everything external to the retail setting)
Service environment/policies
Definition: State and federal sociopolitical and economic contexts that influence the implementation and delivery/use of the innovation Examples: Policies, legislation, monitoring and review, auditing, mandates
A systematic review of factors that influence food store owner and manager decision making and ability or willingness to use choice architecture and marketing mix strategies to encourage healthy consumer purchases in the United States, 2005–2017.
A systematic review of factors that influence food store owner and manager decision making and ability or willingness to use choice architecture and marketing mix strategies to encourage healthy consumer purchases in the United States, 2005–2017.
A systematic review of factors that influence food store owner and manager decision making and ability or willingness to use choice architecture and marketing mix strategies to encourage healthy consumer purchases in the United States, 2005–2017.
Definition: Fiscal support provided by the system in which implementation occurs. Fiscal support can target multiple levels (eg, staff training, fidelity monitoring, provision of the innovation/EBP) involved in the implementation and delivery/use of the innovation Examples: Contracting arrangements, grants, fee-for-service, addition to the formulary, capitation fees, incentives
A systematic review of factors that influence food store owner and manager decision making and ability or willingness to use choice architecture and marketing mix strategies to encourage healthy consumer purchases in the United States, 2005–2017.
Definition: Characteristics and behaviors of key decision-makers pertinent at all levels which are necessary but not sufficient to facilitate or promote the implementation process and delivery/use of the innovation Examples: Transformational leadership, implementation leadership
Interorganizational environment and networks
Definition: Relationships of professional organizations through which knowledge of the innovation/EBP is shared and/or goals related to the innovation/EBP implementation are developed/established Examples: Interorganizational collaboration, commitment, competition, co-opetition
Patient/client (consumer) characteristics
Definition: Demographics and individual characteristics of the target population/end user. Examples: Socioeconomic status, health condition, comorbidities, age, gender, motivation
Barriers: Perception that consumers have low demand for healthy food and the perceived alignment of healthy food retail with consumer needs and preferences
Definition: Support or marketing for system change based on consumer needs, priorities and/or demographics. Examples: Client advocacy, class-action lawsuits, consumer organizations
Innovation factors (ie, characteristics of healthy food retail strategies)
Innovation/EBP developers
Definition: Characteristics of the individuals or team(s) responsible for creating the EBP/innovation that may be the subject of implementation efforts Examples: Engagement in implementation, continuous quality improvement, rapid-cycle testing, prototyping
Definition: The extent to which the innovation/EBP fits the needs of the population served or the context in which it is implemented Examples: Innovation/EBP structural and process fit with system, organizations, providers, patients/clients
Barrier: Business model alignment with healthy food retail strategies
Bridging factors (ie, partnerships and persons that facilitate healthy food retail)
Community academic (or public health) partnerships
Definition: Active partnerships between researchers and key community stakeholders, who can represent multiple levels involved in implementation (eg, system representatives, organizational leaders, providers, consumers), that can facilitate successful implementation and delivery/use of the innovation Examples: Community participation, partnerships, ongoing positive relationships, valuing multiple perspectives
Definition: Organizations or individuals providing support or consultation for implementation and/or training in the innovation Examples: Implementation readiness assessment, strategy development, training support
Inner context (ie, everything internal to the retail setting)
Organizational characteristics
Definition: Structures or processes that take place and/or exist in organizations that may influence the process of implementation Examples: Culture, climate, readiness for change, structure, leadership, receptive context, absorptive capacity, social network support
A systematic review of factors that influence food store owner and manager decision making and ability or willingness to use choice architecture and marketing mix strategies to encourage healthy consumer purchases in the United States, 2005–2017.
A systematic review of factors that influence food store owner and manager decision making and ability or willingness to use choice architecture and marketing mix strategies to encourage healthy consumer purchases in the United States, 2005–2017.
Definition: Characteristics and behaviors of individuals involved in oversight and/or decision-making related to EBP implementation within an organization. Examples: Competing priorities, use of climate/culture embedding mechanisms, transformational leadership, implementation leadership
Barriers: High cost of healthy foods, losing profit or sales, outsourcing, and business and public health priority conflict
Definition: Processes or procedures undertaken to ensure adherence to active delivery of the innovation/EBP and/or an implementation strategy Examples: Fidelity support system, quality assurance evaluation, continuous quality improvement
Organizational staffing processes
Definition: The processes or procedures in place at an organization related to the hiring, review, and retention of staff involved in the active delivery of the innovation/EBP and/or its implementation Examples: Professional training and qualification related to EBP delivery, staff turnover
Barriers: Lack of resources like retailer time and staff
Definition: Shared or unique characteristics of individuals (eg, provider, supervisor, director) that influence the process of implementation Examples: Attitudes toward EBP, demographics and/or background, client characteristics, job demands
Barriers: Retailer discontent and knowledge and beliefs.
Note: Blank cells indicate no results in the cited systematic reviews focused on these EPIS constructs. The inclusion of gray literature alongside peer-reviewed sources in applications of EPIS to healthy food retail is recommended.
a Constructs, definitions, and examples are verbatim from the source.
A systematic review of factors that influence food store owner and manager decision making and ability or willingness to use choice architecture and marketing mix strategies to encourage healthy consumer purchases in the United States, 2005–2017.
A systematic review of factors that influence food store owner and manager decision making and ability or willingness to use choice architecture and marketing mix strategies to encourage healthy consumer purchases in the United States, 2005–2017.
used a multilevel approach to examine 31 studies for determinants of US retailers’ decisions about healthy food retail and 41 studies for barriers and facilitators to healthy food retail in the international literature, respectively. We categorize results across these sources using EPIS in the Table
A systematic review of factors that influence food store owner and manager decision making and ability or willingness to use choice architecture and marketing mix strategies to encourage healthy consumer purchases in the United States, 2005–2017.
to show the potential value of using EPIS to understand implementation outcomes as they relate to adopting, implementing, and sustaining healthy food retail strategies.
These common barriers and facilitators to healthy food retail across various settings (Table),
A systematic review of factors that influence food store owner and manager decision making and ability or willingness to use choice architecture and marketing mix strategies to encourage healthy consumer purchases in the United States, 2005–2017.
Using implementation strategies in community settings: an introduction to the Expert Recommendations for Implementing Change (ERIC) compilation and future directions.
Given shared barriers, changing the physical structure and equipment, providing funding for evidence-based programming, and creating a learning collaborative or providing supervision are strategy examples likely needed to facilitate healthy food retail strategies.
Using implementation strategies in community settings: an introduction to the Expert Recommendations for Implementing Change (ERIC) compilation and future directions.
Furthermore, given the paucity of information in the literature, implementation strategies such as developing and implementing tools for quality monitoring or using an implementation advisor will also likely be useful to researchers and practitioners.
Using implementation strategies in community settings: an introduction to the Expert Recommendations for Implementing Change (ERIC) compilation and future directions.
A systematic review of factors that influence food store owner and manager decision making and ability or willingness to use choice architecture and marketing mix strategies to encourage healthy consumer purchases in the United States, 2005–2017.
to suggest gaps in and future directions for applying implementation science concepts to advance healthy food retail science and practice using EPIS. Future efforts to capture the process of healthy food retail and the determinants that influence adoption, implementation, and sustainment using EPIS are needed with respect to particular community contexts (eg, rural, high crime, historically low-resourced), food retail settings (eg, grocers, convenience/corner stores, farmers’ markets, corporate vs independent stores, etc), public health practice agencies (eg, Cooperative Extension Services, Department of Health), or funding mechanisms (eg, GusNIP, SNAP-Ed). This would allow for the specificity and standardization required to understand what works, for whom, and under what circumstances and identify shared implementation approaches that support healthy food retail across diverse contexts and settings.
This path forward to advance the science and practice of healthy food retail using EPIS is as important as understanding effectiveness in specific community settings. A common critique of our perspective questions the need to focus on implementation science without a proven, evidence-based practice regarding healthy food retail strategies. Although effectiveness research is important, healthy food retail strategies are already prioritized
and implemented widely without sufficient documentation of implementation approaches and outcomes. For example, 56% of SNAP-Ed implementing agencies in 2016 planned to facilitate PSE changes in places in which people shop (healthy retail), which was an increase from 31% in 2014.
GusNIP projects (nutrition incentive, produce prescription, or both) expanded reach from 17 to 33 states and the District of Columbia from 2019 to 2021.
However, in our opinion, not prioritizing implementation science for healthy food retail risks inefficiency or inability to establish a set of best practices for supporting public health practitioners to facilitate (through partnerships,
Co-creation of healthier food retail environments: a systematic review to explore the type of stakeholders and their motivations and stage of engagement.
Using implementation strategies in community settings: an introduction to the Expert Recommendations for Implementing Change (ERIC) compilation and future directions.
) healthy food retail adoption and implementation and threatens the likelihood these strategies are sustained. We also may thwart opportunities for de-implementing
potentially less effective healthy food retail strategies in favor of those more capable of population impact. Readers are directed to hybrid designs detailed by Curran et al
regarding balancing effectiveness and implementation outcomes in research and practice.
Outcomes of future studies and focused literature reviews that are planned using EPIS, in addition to practice-based knowledge, could inform any needed changes to EPIS phases or constructs on the basis of the type of healthy food retail strategy or practice organization. We recommend the implementation project adaptation worksheet
for documenting EPIS changes with appropriate rationale, as it provides a standardized tool for documentation and dissemination. The worksheet could be used alongside EPIS in applied training with Cooperative Extension or Department of Health agencies that facilitate healthy food retail, for example. Furthermore, some investigators have applied the Consolidated Framework for Implementation Research (CFIR), a comprehensive determinant framework,
CFIR could complement EPIS, especially if used to inform the potential expansion of construct determinants found important to healthy food retail, as shown in the Table. However, it is important to note that CFIR is not a process framework and may have limited application to this work in comparison.
The EPIS framework can also be used to develop a standard set of quantitative measures aligned with EPIS constructs to advance the science and practice of healthy food retail. For example, there are a few existing readiness measures for healthy food retail
that could help build the evidence base regarding EPIS. A host of other EPIS measures have also been developed for other public health topics that might be useful if adapted and validated among diverse, healthy food retail contexts.
Standard EPIS tools could help to determine how public health programming could support food store leadership (culture, climate) and procedures (staffing) to improve the likelihood healthy food retail strategies are successful while also creating a shared language between the 2 sectors, given retailers may care about these outcomes independent of healthy food retail.
A systematic review of factors that influence food store owner and manager decision making and ability or willingness to use choice architecture and marketing mix strategies to encourage healthy consumer purchases in the United States, 2005–2017.
Local health departments’ capacity for workplace health promotion programs to prevent chronic disease: comparison of rural, micropolitan, and urban contexts.
prioritize implementation needs for healthy food retail.
IMPLICATIONS FOR RESEARCH AND PRACTICE
Using EPIS for healthy food retail provides a process and structure for advancing healthy food retail science and practice. We used EPIS to highlight healthy food retail evidence regarding strategy adoption, implementation, and sustainment and outlined ways its use may help advance the field. Our examples primarily focused on food store retailers (as opposed to restaurants or work sites), given our interests and expertise and the overlap with US public health policies (stocking standards) and priorities (federal funding). Other researchers and practitioners may find value in using EPIS for other healthy food retail types or additional PSE change strategies where people live, eat, work, and play.
As EPIS outlines, more exploration into what is needed to align research and practice outcomes and priorities with implementation science outcomes is worthwhile moving forward. This perspective aimed to initiate an inquiry in this regard. Researchers and practitioners who may be less familiar with implementation science are encouraged to explore key sources cited throughout.
Others interested in operationalizing EPIS are encouraged to document and disseminate implementation processes and outcomes to ensure the comparison between and among settings and contexts.
ACKNOWLEDGMENTS
This work was partly supported by the Louisiana State University (LSU) Agricultural Center, the US Department of Agriculture (USDA) National Institute of Food and Agriculture (NIFA), Hatch project no. 1024670, and the Gus Schumacher Nutrition Incentive Grant Program grant no. 2019-70030-30415/project accession no. 1020863 from the USDA NIFA. Any opinions, findings, conclusions, or recommendations expressed in this publication are those of the authors and do not necessarily reflect the views of the LSU Agricultural Center or the USDA. The authors thank Erin McKinley, PhD, RDN, CLC, CHES, for comments on an earlier version of the perspective and Khawlah Kheshaifaty, MS, for helping with formatting to journal guidelines. The authors also thank reviewers of this perspective for helpful comments that strengthened our work.
References
US Department of Agriculture. Supplemental Nutrition Assistance Program Education Plan Guidance. Food and Nutrition Service; 2020.
US Department of Agriculture. Final rule: enhancing retailer standards in the Supplemental Nutrition Assistance Program (SNAP).https://www.fns.usda.gov/snap/fr-121516.
Minimum stocking requirements for retailers in the Special Supplemental Nutrition Program for Women, Infants, and Children: disparities across US states.
Local health departments’ capacity for workplace health promotion programs to prevent chronic disease: comparison of rural, micropolitan, and urban contexts.
Using implementation strategies in community settings: an introduction to the Expert Recommendations for Implementing Change (ERIC) compilation and future directions.
A systematic review of factors that influence food store owner and manager decision making and ability or willingness to use choice architecture and marketing mix strategies to encourage healthy consumer purchases in the United States, 2005–2017.
Co-creation of healthier food retail environments: a systematic review to explore the type of stakeholders and their motivations and stage of engagement.
00557-7&id=gr1.jpg){kind=link}