Health is not the number one priority: Qualitative and ethnographic studies on the development and implementation of health-promoting food retail initiatives in supermarkets

Background
Supermarket marketing strategies, such as product placement, price, and availability, play a significant role in shaping people’s food purchases. Research shows that unhealthy foods are often more available and heavily promoted than healthy options. This is concerning as the consumption of unhealthy food increases the risk of, for example, obesity, heart disease, and cancer. Research suggests that health-promoting interventions in supermarkets may influence consumers’ food purchases, but retailers’ business interests challenge implementation. Therefore, scholars advocate for involving supermarket actors in intervention development and implementation, but the implications of partnerships between researchers and commercial actors are understudied. Moreover, food purchase decisions have been shown to be affected by many different factors, which sometimes cause dilemmas for consumers, especially families with smaller children. This calls for exploring how these dilemmas affect food purchases. This is important for the design of future effective interventions and the limiting of unintended harmful effects. 

Aim and research questions
My thesis aims to explore a partnership’s development and implementation of health-promoting food retail initiatives aimed at families with young children, including families’ perspectives on food purchase decisions. My thesis is structured around three research questions (corresponding to the three papers of my thesis):
1. How do partnerships with commercial actors in health promotion interventions unfold and affect intervention development and content? (Paper I)
2. What are the facilitators and barriers for implementing partnership-derived health-promoting food retail initiatives aimed at families in a physical supermarket, and how do supermarket actors and customers respond to the initiatives? (Paper II)
3. What shapes families’ food purchasing behaviour in supermarkets, and how do parents navigate dilemmas in food purchase decisions? (Paper III)

The case
In 2019, The National Institute of Public Health, University of Southern Denmark, established a partnership with the Danish retailer Salling Group, with the overall vision of making healthy choices easy. The partnership was effectuated through a researcher-led project called the Healthier Choices in Supermarket study, which aimed to develop, test, and evaluate novel and ongoing healthy food retail initiatives in physical supermarkets. NIPH enlisted The Danish Cancer Society, Department of Prevention & Information, to help select and develop novel retail initiatives based on their previous experience with supermarket interventions.

Methods
I was inspired by ethnography and used multiple methods to explore the aim. To explore the development process and implementation of the initiatives, I conducted document analyses of emails, screenshots of webpages, project descriptions, presentations, and work documents retrieved from the organisations’ webpages and the research group’s filing system and email inboxes. I also conducted participant observations of meetings between the involved actors and different project activities. Furthermore, I conducted around 40 observations in the test supermarket before, during, and after the implementation of the initiatives. I took notes during, or as soon as possible after, the observations. I also documented my in-store observations with photos. To explore stakeholders’ views on the development process, initiatives, and their implementation, I conducted eight semistructured, in-depth interviews with five key stakeholders (some participated in two interviews) from the three partner organisations involved in the Healthier Choices in Supermarkets study. To investigate families’ food purchase behaviour, I conducted at least two interviews with 15 families with children aged 0-19 years (a total of 37 interviews). The interviews used a combination of semi-structured, shopalong, and photo-elicited methods. All interviews were conducted online, over the phone, or in person. They were recorded with consent from the participants and transcribed verbatim. My analytical approach was abductive, implying a dynamic movement between the empirical material and theory. I applied various theoretical perspectives: institutional logics and concepts of negotiation (Paper I), implementation concepts such as motivation, capacity of implementation, and responsiveness (Paper II), and moral labour (Paper III).

Findings
Differences in the partnering organisations’ institutional logics, such as values, practices, and social structures, challenged the development process of impactful initiatives. Meanwhile, these differences also acted as learning points where the organisations challenged each other’s perspectives, which created room for mutual understanding. Ultimately, the market logic dominated the development process, causing the researchers to compromise the original intentions of the initiatives to uphold the partnership and meet the deliverables of the funded research project (Paper I). Four initiatives (downsizing bags for pick ‘n’ mix sweets, downsizing of fizzy drink bottles at the check-out, shelf tags indicating healthier breakfast cereal options, and a complimentary piece of fruit for children) were implemented during the test period. The implementation was delayed, and the shelf tags and downsized fizzy drink bottles were not implemented as intended. Despite supermarket actors’ involvement in the development of the initiatives, the interviewed retailers expressed different levels of acceptability of the initiatives. Data suggests that customers only noticed the initiative regarding the complimentary offer for children, to which they had mixed responses. Observations furthermore indicated that the customers’ behaviour sometimes undermined the anticipated working mechanism of the initiatives. Overall barriers and facilitators of retailers’ implementation fell into three themes: Health is not the number one priority, retailer’s general implementation capacity, and the influence of customers and other stakeholders on the operation of the store (Paper II). Questions of morality had a considerable influence on the interviewed families’ motives for buying specific food products. These questions were closely related to notions of parental responsibility and healthy and good food, climate concerns, and views on animal welfare. However, despite motives for purchasing specific food items, the actual shopping did not always align, as it was influenced by the availability and promotion of products, as well as the social situation, for example, if their children asked for food or drinks the parents would never have bought if they had gone grocery shopping by themselves (Paper III).

Conclusion
My thesis documents the challenges of partnerships with commercial actors, such as supermarket actors, and why they occur. Furthermore, it shows how such partnerships can challenge the scientific evidence base and potential public health impact of health-promoting initiatives. I found that implementing selected health-promoting initiatives in a corporate supermarket was feasible if the retailers wanted to, and the customers and other stakeholders supported it. Moreover, my findings illustrate how moral considerations influence families’ purchase behaviour and how the supermarket environment can trigger moral labour. Some would, therefore, experience negative emotions such as a guilty conscience if they did not make a “morally correct choice”. This suggests that it is necessary to change the supermarket environment and that some health-promoting food retail initiatives may have unintended outcomes, such as negative emotions or self-perception.

In conclusion, my thesis provides valuable insights for designing and implementing future health-promoting interventions in supermarkets and interventions involving commercial actors. It also questions the potential public health impact of such partnerships due to the market logic dominance and suggests future research to explore the potential of legal action, such as regulation.