At-a-glance – "A tough sell": findings from a qualitative analysis on the provision of healthy foods in recreation and sports settings

Abstract

Recreation and sport settings (RSS) typically promote health in the form of physical activity, but the healthfulness of their food environment is often neglected. We explored stakeholder perspectives on barriers to healthy food provision in RSS through telephone interviews with ten representatives from RSS across Nova Scotia. Three key barriers were identified: 1) cultural norms associated with food in RSS and the broader environment, 2) the persisting notion of personal choice and responsibility, and 3) financial implications of healthy food provision. These barriers challenge healthy food provision in RSS and require multi-faceted strategies to overcome social norms that undermine health behaviours.

Keywords: food culture, health promotion, healthy eating, nutrition, recreation, sports, policy

Introduction

Around three-quarters of children in Canada participate in organized sports like soccer and swimming.^{Footnote 1} Recreation and sport settings (RSS)-a term that includes multi-purpose fitness centers, arenas, rinks, and sports fields-provide opportunities for such structured physical activity, as well as modelling other health promotion foci like injury prevention or smoke-free spaces.^{Footnote 2} Yet, paradoxically, the food environments within RSS often contradict overall health promotion messages through the provision of energy-dense, nutrient-poor foods that are quick to prepare and inexpensive to provide, yet profitable.^{Footnote 3-8} This apparent contradiction presents an opportunity for RSS to make improvements to their food environments to support health behaviours of the families that use them.^{Footnote 9}

Research from other provinces in Canada has identified barriers to healthy food provision within RSS, including financial concerns, the current food culture, and difficulty getting stakeholder buy-in^{Footnote 3-6} for changes in food provision. With the province of Nova Scotia having among the highest rates of chronic disease in Canada^{Footnote 10}, and prior to the release of voluntary guidelines to support healthy eating in RSS (HERSS guidelines) within the province^{Footnote 11}, we sought to qualitatively describe the barriers present within provincial RSS that may impact uptake of the HERSS guidelines prior to their release in October 2015.

Methods

We used Qualitative Description (QD) to describe the food provision experiences of ten key stakeholders from provincial RSS, as described in Table 1. Less interpretative than other methodologies, QD stays close to the data, permitting a summary of events "in the everyday terms of those events."^{Footnote 12} Participants were recruited from RSS via email using purposive sampling that focussed on those with the most insight into the factors that influences food provision within their RSS, such as facility or recreation managers.^{Footnote 13} The Dalhousie University Research Ethics Board approved this study.

Data collection involved individual semi-structured telephone interviews, lasting 45 to 60 minutes, on stakeholder experiences with food provision in RSS and perceptions about implementing healthy eating policies and practices. Data were collected between August and October 2014 and ended when no new data were emerging from interviews. Qualitative analysis software (QSR NVivo Version 10) was used for management and analysis. Open coding was conducted to inductively identify and define emerging codes, and an iterative approach was used.^{Footnote 14,Footnote 15} Two authors (Jarvis, Spencer) developed the codes, portions of interviews were coded by each author to allow comparison, and all authors contributed to theme development to enhance credibility, authenticity, and confirmability.^{Footnote 12,Footnote 16,Footnote 17}

Results

Three key themes emerged related to the implementation of healthy eating within RSS (quotes presented in Table 2): 1) cultural norms associated with food in RSS and the broader environment; 2) the persisting notion of personal choice and responsibility; and 3) financial implications of healthy food provision. A summary of each theme is provided below.

Cultural norms associated with food in RSS and the broader environment

This was the most predominant theme, represented as the social norms and patron expectations of the types of foods that should be available within RSS. Unhealthy food traditions were viewed as being associated with certain sports, e.g. hockey and baseball, resulting in resistance to change toward healthier options, for fear that patrons would be unwilling to purchase them. The belief that patrons expected less healthy foods to be available at special events was typically framed within the context of being an occasional "treat." There were some types of sports, however, e.g. figure skating, dancing and soccer, that were perceived to be more open to healthier options being provided.

The persisting notion of personal choice and responsibility

This theme is illustrated through the tension participants described between supporting personal choice through food provision and the responsibility of RSS to be leaders in changing food environments. Most participants felt that staff within RSS should not be telling people what they can and cannot eat. Willingness to offer more healthful items was framed as being acceptable only alongside less healthy options, to allow patrons to make their own choice. The personal beliefs of participants about choice emerged in relation to their perception of the role RSS should play in creating healthy food environments. Participants expressed concerns that changes to the food environment to support health may be beyond the mandate of RSS. Rather than individual RSS being responsible for initiating changes to support healthy eating, some participants felt that provincial sport or recreation organizations that provide overall direction for sport groups and facilities should be involved in leading change.

The financial implications of healthy food provision

This third theme represents the fear expressed by participants, particularly facility managers, that revenue would be lost if they sold healthier foods and/or stopped selling less healthy foods. Framed within the cultural context that less healthy foods were a "treat", despite their ubiquity, their provision was attributed to patrons wanting the less healthy options. Healthy foods were viewed as more costly, requiring more preparation time and different storage needs, and that waste would occur if the food did not sell. This was particularly salient for facilities that were not open every day, e.g. some arenas.

Discussion

Our findings reinforce the challenges facing health promoters in creating environments that support healthy behaviours. Allowing personal choice to dictate food provision, while preferred by participants in this analysis, has been found to limit the impact of changes designed to improve healthy food provision, which is particularly concerning in settings frequented by children and youth.^{Footnote 6} When healthy and unhealthy choices are available within RSS, children and youth continue to purchase primarily unhealthy options.^{Footnote 6,Footnote 18} Further, our current unhealthy food culture makes the notion of personal choice a complex one because many social norms, learned behaviours, and expectations about food are strongly influenced by marketing campaigns of the food industry.^{Footnote 19,Footnote 20} Adults are equally susceptible to selecting unhealthy foods, or wanting unhealthy foods such as hot dogs and fries to be readily available in RSS facilities.^{Footnote 21} This further highlights how the availability of unhealthy foods in settings like RSS is both normalized and entrenched.^{Footnote 22}

Consistent with other Canadian studies, participants perceived healthy foods to be more expensive to purchase, prepare and store, and overall less marketable than unhealthy foods.^{Footnote 2,Footnote 4,Footnote 5,Footnote 23}Emerging evidence from a recent intervention study challenges this perception^{Footnote 24}. In this intervention, resources were provided to an intervention group to help them change the food and beverage environment within sporting clubs, while the control group received no support. No significant differences in annual revenues were observed following the intervention between the control and intervention sporting clubs,^{Footnote 24} indicating that the intervention group did not lose revenue as a result of selling healthier options. This has also been found in research from Alberta.^{Footnote 23} Unhealthy food environments in RSS may be paradoxically an unintended consequence of improving accessibility to physical activity participation^{Footnote 25} with user fees for RSS services often being subsidized by food service revenues that are, in turn, heavily dictated by the social norms of RSS settings.^{Footnote 23} Ideally, physical activity and healthy eating should not be competing priorities in RSS to support overall health promotion goals but there remain obstacles to overcome the deeply entrenched values associated with food.

A strength of our study is the participation of stakeholders across different regions of Nova Scotia and diverse types of facilities with varying experiences of healthy eating initiatives. During the final stages of interviews and analysis there were no new emerging themes that developed, which suggested that we had sufficient representation of perspectives from stakeholders in the province. However, one limitation was the use of telephone interviews, as we may have missed important non-verbal cues that could have contributed to the analysis.

Conclusion

Our findings reinforce the need to address social norms that undermine health behaviours. This requires champions who can advocate for healthy eating and take action to overcome resistance to healthy eating guidelines.^{Footnote 5} Health promotion strategies that may support the implementation of healthy eating guidelines should also provide social supports, such as training and resources, and strategies that increase the availability and promotion of healthy foods, while limiting the marketing and advertising of unhealthy foods.^{Footnote 2,Footnote 26} Emerging evidence reveals that interventions using a combination of these strategies have a greater impact on healthy eating choices and behaviours.^{Footnote 17,Footnote 24} It is clear that a multifaceted approach is critical to address the complexity of changing social norms and promoting healthy choices in RSS.^{Footnote 21,Footnote 27} Changes to food environments within RSS as a result of voluntary guidelines implementation will likely only be modest,^{Footnote 5} without greater attention to perceptions surrounding the cost of healthy foods and the social norms that continue to shape unhealthy food provision in these settings.

Acknowledgements

The authors would like to thank all participants from recreation and sport settings in Nova Scotia for their support of this research.

This research was supported by the Nova Scotia Department of Health and Wellness, the Heart and Stroke Foundation of Canada and the Canadian Institutes of Health Research (CIHR) FRN 134228. McIsaac, J-L acknowledges funding from the Canadian Cancer Society (grant # 703878). Jarvis, S received salary support from the Heart and Stroke Foundation of Canada. Spencer, R acknowledges funding from a CIHR Doctoral Research Award. Kirk, SFL held a CIHR-funded Canada Research Chair at the time this study was conducted.

Conflicts of interest

The authors had no conflicts of interest to report.

Authors' contributions and statement

SFLK and JDM conceived and designed the study. SJ collected the data and SJ and RS conducted the data analysis. All authors drafted and wrote parts of the manuscript, were involved in the interpretation of data and critically revising the manuscript. All authors read and approve the final manuscript.

The content and views expressed in this article are those of the authors and do not necessarily reflect those of the Government of Canada.