“Making sense of the holistic why:” Implementation of sustainable food in healthcare institutions in Ontario, Canada

Abstract

Background Health and food systems have deleterious consequences for planetary health. Health systems are responsible for between 4% and 8% of individual countries’ greenhouse gas emissions worldwide, contributing to climate change. Yet, health system emissions not only contribute to warming temperatures but also to poor air and water quality, with cascading effects on health. An estimated 25% of global emissions are attributable to food systems through direct emissions and land clearing, while producing significant waste and pollutants, including fertilizers, pesticides, and plastic packaging. Food systems are also associated with diet-related chronic diseases, leading to increased need for health services and high health costs. Paradoxically, health and food systems not only contribute to environmental change but are also directly impacted by its effects. Environmental change is predicted to increase burdens on health services, while reducing the nutrient quality of agricultural crops. Experts have called for transformations toward more sustainable health and food systems to address the multidimensional impacts on planetary health and increase resilience to future challenges. Foodservice within healthcare institutions is a leverage point for instigating such transformations. Sustainable foodservice would contribute to improving nutrition and health, minimizing environmental impacts, strengthening cultural inclusivity, and promoting local sustainable food systems. Healthcare institutions have begun implementing sustainable food interventions. Yet, progress is small and variable, especially in Canada. The complexity of the healthcare environment creates unique considerations for changing practices. Research on practice change, sustainability, and sustainable food in healthcare indicates multiple barriers and facilitators. There are gaps in understanding the specific factors at play across individual, institutional, and community levels; different political and social contexts; and varying stages of sustainable food implementation, as well as the interactions between different actors and foodservice options within the institutional food environment. Objectives This thesis aimed to 1) explore the barriers and facilitators to sustainable food interventions in the foodservice of an exemplar healthcare institution in Ontario, Canada, and 2) compare barriers and facilitators to two additional institutions at different stages of sustainable food implementation. Methodology The design of this thesis was informed by a critical research paradigm guided by my philosophical assumptions, which value planetary health as the well-being of the whole system, acknowledging that the worth of non-humans is not relative to humans. The thesis was informed by systems science, implementation science, and social science, which contributed to developing a theoretical framework merging the Consolidated Framework for Implementation Research with Institutional Theory, guiding data collection, analysis, and interpretation. I set out to conduct a collective case study of three healthcare institutions in Ontario, Canada, each in different stages of sustainable food implementation: an exemplar institution with multiple sustainable food interventions, a comparative institution with some evidence toward sustainable food, and a second comparative institution with less evidence toward sustainable food. I conducted ten semi-structured interviews with eight participants predominantly working in foodservice. Interviews were complemented by review of 47 documents, including strategic plans and sustainability reports, pertaining to the three institutions. Data were analyzed by institution and across institutions using a systems-based approach and a six-stage framework analysis method. Results Six conceptual themes, including efficiency meets sustainability, making sense of sustainable food, making sense through change management, development from the bottom-up, “the patient voice is at the center of what we do,” and a disconnected food environment, were generated. Themes were mapped to the theoretical framework, highlighting that implementation of sustainable food interventions cuts across all domains of the Consolidated Framework for Implementation Research, and is influenced by multiple pillars of Institutional Theory. The strongest barriers originated from the regulative pillar of Institutional Theory, and the strongest facilitators stemmed from the cultural-cognitive pillar of Institutional Theory. However, barriers and facilitators interacted with one another in complex ways. External partnerships and staff and visitor food options were identified as promising for expanding implementation and potentially weakening negative feedback channels maintaining efficient systems, particularly patient preferences that conflicted with sustainable menus. Accreditation standards incorporating sustainable food indicators were deemed a promising policy direction by participants, with the potential to weaken negative feedback channels by combining normative, cultural-cognitive, and regulative pillars of Institutional Theory to promote change. Conclusions Though there was some alignment with barriers and facilitators identified in prior research, the application of a systems lens in this research identified how barriers and facilitators interacted and seemed to combine into negative and positive feedback channels in a dynamic process, either constraining or reinforcing change toward sustainable food interventions. The findings provide insights into the institutions and individuals slowly shifting norms that dictate everyday practice in healthcare foodservice necessary to move toward sustainable health and food systems that address the negative consequences of such systems for planetary health.