A Systems Innovation Perspective on Implementation and Sustainment Barriers for Healthy Food Store Interventions: A Reflexive Monitoring in Action Study in Dutch Supermarkets

BACKGROUND: Healthy food store interventions (HFIs) are an important health-promotion tool, but face implementation and sustainment barriers. This paper aims to explore the underlying factors that produce these barriers using an innovative systems innovation perspective, through the case study of a multi-component HFI. The HFI was implemented in a minor, national, cooperative supermarket chain, in the Netherlands, a competitive market where price-based competition is the norm. METHODS: The HFI was implemented for 6-12 months, in six stores. It was implemented by the researchers, and maintained by store employees. The study applied a Reflexive Monitoring in Action (RMA) approach, meaning that the researchers monitored stores' adherence to the HFI, via store visits, to identify potential issues. Subsequently, the researchers interviewed the store managers responsible for the intervention, to have them reflect upon the barriers leading to these adherence issues, underlying systemic factors, and potential solutions. The stores implemented these solutions, and during the next monitoring visit the researchers evaluated whether the barrier had been resolved. RESULTS: We found that the HFI often clashed with regular activities of the stores (eg, competing over the same spaces) and that store managers generally prioritized these regular activities. This prioritization was based on the greater commercial value of those regular activities (eg, selling unhealthy products) according to store managers, based on their beliefs and assumptions about commerce, health, and consumer preferences. Due to the limited resources of supermarkets (eg, people, time, space), and the HFI often not fitting within the existing structures of the stores as easily as traditional practices, store managers often neglected the HFI components in favor of regular store activities. CONCLUSION: Our findings illustrate the systemic factors that produce implementation barriers for HFIs, and the dynamics by which this production occurs. These insights help future researchers to anticipate and respond to such barriers.