Diverting Food Waste From Landfill in Exemplar Hospital Foodservices: A Qualitative Study.

BACKGROUND: The US Environmental Protection Agency Food Recovery Hierarchy suggests methods for diverting food waste from landfill. Knowledge of how hospital foodservices implement food waste management strategies could help modernize food waste practices. OBJECTIVE: The aim of this study was to explore hospital staff members' experiences of implementing a food waste management strategy to divert food waste from landfill in their hospital foodservice, including the journey, challenges, and facilitators of this practice change. DESIGN: A qualitative study was conducted in 2022-2023 using semi-structured interviews. PARTICIPANTS/SETTING: Eighteen participants were staff members with knowledge of the food waste management strategy from 14 exemplar hospitals in United States, Spain, Scotland, and Australia using strategies to divert food waste from landfill within the last 10 years. ANALYSES PERFORMED: Mapping and thematic analysis were undertaken to code and identify themes from the interviews that described staff members' experiences of the journey to implement the strategy. RESULTS: Six hospitals donated food, 1 transferred food waste for animal feed, 4 used an industrial solution, and 3 sent food waste for composting. A common journey pathway for successful implementation was identified from participants' experiences. It features the following 6 phases: idea, preparation, roll out, maintenance, established practice, and evolution. Facilitators included legislation, enthusiastic staff members, executive support, and "luck." Challenges were smells, occasions when food waste was not collected, equipment breakage, and funding depletion. CONCLUSIONS: This study identified a common journey pathway for implementing a food waste management strategy in hospital foodservices that can be used to anticipate and prepare for the steps in the implementation process.

Applying the theoretical domains framework and behavior change wheel to inform interventions for food and food-related waste audits in hospital foodservices.

Background: Completing aggregate food and food-related waste audits in hospital foodservices is an intense practice, however they can demonstrate problem areas that require attention to reduce waste. Identifying interventions to facilitate and improve the implementation of these audits can be guided by behavior change science. The aims of this study were to use behavior change theories and frameworks to (1) describe the drivers of behavior to complete food and food-related waste audits and (2) identify possible interventions that support the implementation and uptake of these audits. Methods: Purposive sampling was used to recruit participants from hospitals in Victoria, Australia who worked in their foodservice system. Semi-structured interviews sought knowledge of participant's perceived barriers and enablers to completing food and food-related waste audits. Deductive analysis using the Theoretical Domains Framework (TDF) and Capability Opportunity Motivation Behavior theory (COM-B) identified dominant drivers of behavior. TDF domains were then matched to their corresponding intervention functions according to the Behavior Change Wheel framework (BCW) to identify relevant strategies that may support audit implementation. Results: Data from 20 interviews found the dominant COM-B constructs (TDF domains) were psychological capability (knowledge, skills), physical opportunity (environmental context and resources), and reflective motivation (social/professional role and identity, beliefs about capabilities). These dominant domains come from narratives that participants shared about foodservice staffs' lack of knowledge, labor, time, and the hospital avoiding responsibility for audit completion. Corresponding intervention functions that could have the most potential for implementing waste audits were education, training, environmental restructuring, modeling, and enablement. Participants' shared perspectives of audit enablers resembled these: for example, obtaining staff buy-in, reinforcing behavior through incentives and installing an audit champion. Conclusion: To transition toward regular food and food-related waste auditing practices in hospital foodservices these findings may help identify practice and policy change that delivers standardized auditing activities to encourage long term behavior change. Interventions to support audit completion should address each behavioral construct and relevant domain, as individual hospital sites will experience unique contextual factors and expectations influencing audit outcomes. A co-design process that includes staff and stakeholders of hospital foodservices is recommended to enable engagement and practical solutions to audit implementation.

The role of policy in supporting environmentally sustainable foodservice in healthcare: lessons from exemplar hospitals.

Background: Foodservice in hospitals contributes to the environmental footprint of healthcare delivery. There is little known about the role of policy in supporting environmentally sustainable foodservices. The aim of the study was to explore policy in exemplar environmentally sustainable hospital foodservices from the perspective of hospital staff, toward what makes a policy effective, the limitations of policy, and the influential levels and types of policy. Methods: A generic qualitative inquiry approach was utilized. Staff involved in foodservices were interviewed about the role of policy during 2020-2021 from 14 hospitals across nine countries. Data were analyzed using framework and thematic analysis. Results: Policies spanned across high level policies at the level of the healthcare organization, local hospital procedures and protocols, as well as public policy from local, state/provincial and national government. Internal organizational policy was used to embed practices within the organization in the long term and help to build a shared vision and goal where public policy had lacked guidance. The creation, content and methods of communication and creating accountability made internal organizational policy successful. Public policy was most effective when it was mandatory, had clearly defined targets and funding to assist implementation. These exemplar hospitals also demonstrated attributes of policy entrepreneurs by engaging with policy makers to share their stories and lobby government for policy change. Discussion: Policy from within the healthcare organization is an important mechanism for enabling hospitals to deliver and maintain environmentally sustainable foodservice. Public policy must be designed considering the unique implementation challenges hospitals face to ensure they are successful.

Towards healthy food retail: An assessment of public health nutrition workforce capacity to work with stores.

OBJECTIVE: This article aims to investigate the capacity of nutrition professionals to engage in food retail practice change to improve population diet. METHODS: Convergent mixed method design was used that includes pre-interview surveys, in-depth interviews, and retrospective mapping of service provision. The study was conducted in organisations that provide a nutrition professional service to food retail stores in remote Australia. The study participants include 11 nutrition professionals and eight organisation representatives, including managers, organisation directors and policy officers. Systems-mapping and thematic analysis of the in-depth interviews were conducted using a capacity development framework. Descriptive analysis was applied to pre-interview survey and mapping data. RESULTS: A gap between the aspirational work and current capacity of nutrition professionals to engage effectively with stores was identified. Engagement with stores to improve population health was valued by organisations. Dominance of the medical health model limited organisation strategic support for store work and created barriers. Key barriers included the limited access to training, decision-support tools, information, financial resources and organisational structures that directed store work. CONCLUSIONS: Provision of adequate store-specific training, resources and organisational support may empower the nutrition professional workforce to be powerful leaders in co-design for healthy food retail. IMPLICATIONS FOR PUBLIC HEALTH: Building capacity for this critical workforce to engage in food retail practice change must consider the influence of the broader health system and employer organisations and need for access to evidence-based decision-support tools.

Local food procurement by hospitals: a scoping review.

BACKGROUND: Local food procurement by hospitals is gaining traction as governments and advocacy groups seek to influence food systems and strengthen local communities, but there is little empirical evidence as to its practical application or efficacy. The aims of this review were to describe the extent, range and nature of local food procurement models in healthcare foodservices, and to understand the barriers and enablers to implementation, including from the perspective of stakeholders across the supply chain. METHOD: A scoping review was conducted following the protocol published in the Open Science Framework Registration (DOI: 10.17605/OSF.IO/T3AX2). Five electronic databases were searched for the following concepts: 'hospital foodservice', 'local food procurement practices', 'the extent, range and nature' and/or 'the barriers and enablers of procurement'. Eligible peer-reviewed original research published in English from the year 2000 was included following a two-step selection process. RESULTS: The final library included nine studies. Most studies (7 of 9) were from the United States. Three studies used survey methods and reported high rates (58%-91%) of US hospital participation in local food procurement. Studies offered minimal description of local procurement models, but two models, conventional ('on-contract') or off-contract, were typically used. Barriers to local food procurement included restricted access to suitable local food supply, limited kitchen resources and inadequate technology to trace local food purchase thereby limiting evaluation capabilities. Enablers included organisational support, passionate champions and opportunistic, incremental change. CONCLUSION: There is a paucity of peer-reviewed studies describing local food procurement by hospitals. Details of local food procurement models were generally lacking: categorisable as either purchases made 'on-contract' via conventional means or 'off-contract'. If hospital foodservices are to increase their local food procurement, they require access to a suitable, reliable and traceable supply, that acknowledges their complexity and budgetary constraints.

Packaged hospital food appears safe and feasible to reuse.

AIM: To determine the safety, operational feasibility and environmental impact of collecting unopened non-perishable packaged hospital food items for reuse. METHODS: This pilot study tested packaged foods from an Australian hospital for bacterial species, and compared this to acceptable safe limits. A waste management strategy was trialled (n = 10 days) where non-perishable packaged foods returning to the hospital kitchen were collected off trays, and the time taken to do this and the number and weight of packaged foods collected was measured. Data were extrapolated to estimate the greenhouse gasses produced if they were disposed of in a landfill. RESULTS: Microbiological testing (n = 66 samples) found bacteria (total colony forming units and five common species) on packaging appeared to be within acceptable limits. It took an average of 5.1 ± 10.1 sec/tray to remove packaged food items from trays returning to the kitchen, and an average of 1768 ± 19 packaged food items were per collected per day, equating to 6613 ± 78 kg/year of waste which would produce 19 tonnes/year of greenhouse gasses in landfill. CONCLUSIONS: A substantial volume of food items can be collected from trays without significantly disrupting current processes. Collecting and reusing or donating non-perishable packaged food items that are served but not used within hospitals is a potential strategy to divert food waste from landfill. This pilot study provides initial data addressing infection control and feasibility concerns. While food packages in this hospital appear safe, further research with larger samples and testing additional microbial species is recommended.

The origins of hospital food: Where does it come from and what do staff, patients and suppliers think about local food?

AIMS: To identify the origin of fresh and minimally processed foods served to hospital patients, and explore the challenges and enablers to local food procurement in hospitals. METHODS: A mixed methods study was conducted in a healthcare network in Victoria, Australia. Packaging labels and product information were used to audit fresh and minimally processed foods purchased in 1 week. Processed food items and meals made offsite were not audited. Interviews were conducted with patients, staff and suppliers to explore their perspectives towards local food in hospitals. Framework analysis was used to identify themes. RESULTS: Of 105 food products audited, 32% were imported, 25% were 'local' from Victoria and the remaining 43% were from within Australia (excluding Victoria). Qualitative interviews revealed several challenges including: increased cost of local food items, inconsistent supply and variable quality of local produce, difficulty accessing origin information, and lack of autonomy for hospitals to make food procurement choices. Enablers included: conducting a food origin audit to increase awareness, group purchasing organisation prioritising local food suppliers, and suppliers valuing local produce. CONCLUSION: A food origin audit and interviews with stakeholders provided a rich understanding of current practices and how to increase local food procurement.

Quantifying waste and its costs in hospital foodservices.

AIM: To measure the amount of different types of food and food packaging waste produced in hospital foodservice and estimate the cost associated with its disposal to landfill. METHOD: A foodservice waste audit was conducted over 14 days in the kitchens of three hospitals (15 wards, 10 wards, 1 ward) operating a cook-chill or cook-freeze model with food made offsite. The amount (kg) of plate waste, trayline waste and packaging waste (rubbish and recycling) was weighed using scales and the number of spare trays and the food items on them were counted. Waste haulage fees ($AU0.18/kg) and price per spare tray item were used to calculate costs associated with waste. RESULTS: On average there was 502.1 kg/day of foodservice waste, consisting of 227.7 kg (45%) plate waste, 99.6 kg (20%) trayline waste and 174.8 kg (35%) packaging waste. The median number of spare trays was 171/day, with 224 items/day on them worth $214.10/day. Only 12% (20.4 kg/day) of packaging waste was recycled and the remaining 88% (154.4 kg/day) was sent to landfill along with food waste at two hospitals. Overall 347.3 kg/day was sent to landfill costing $62.51/day on waste haulage fees, amounting to 126.8 tonnes and $22 816.15 annually. CONCLUSION: A substantial amount of waste is generated in hospital foodservices, and sending waste to landfill is usual practice. Australia has a target to halve food waste by 2030 and to achieve this hospital foodservices must invest in systems proven to reduce waste, solutions recommended by policy advisors (e.g., waste auditing) and waste diversion strategies.

'It's a constant changing environment, and we're just playing catch up': Hospital food services, food waste, and COVID-19.

AIMS: Hospital food service operations have been affected by the COVID-19 pandemic, particularly resulting in increased waste. The aim of this research was to explore the impact of the COVID-19 pandemic on hospital food services, particularly on food waste and the completion of food waste audits. METHODS: A qualitative interview research design was used. Semi-structured interviews were completed and recorded via Zoom, focusing on the barriers and enablers towards the completion of hospital food waste audits. Twenty-one participants were interviewed from 12 hospitals. No questions were related to the COVID-19 pandemic and its impact on hospital food services, however this issue frequently emerged during interviews. Data were coded following inductive thematic analysis. RESULTS: Five themes were generated from the interviews related to COVID-19 and hospital food services; impacts on practice, labour, change, technology and post-pandemic expectations. Participants reported COVID-19 negatively affected food service operations. Changes included increased food waste, contact restrictions, and labour shortages. Nonetheless, hospitals embraced the challenge and created new positions, trialled different food waste data collection methods, and utilised technology to support food service operations around COVID-19 restrictions. CONCLUSIONS: Despite the impact COVID-19 had on hospital food services, including their ability to audit food waste and increased food waste generation, the response from food services has demonstrated their adaptability to change. Sustainable healthcare, including the aggregate measuring and reduction of food waste in hospital food services, is an essential transition post-pandemic, and may be facilitated through the operational changes forced by COVID-19.

Food and food-related waste management strategies in hospital food services: A systematic review.

AIM: This review explored peer-reviewed and grey literature to describe the types and characteristics of food or food-related waste management strategies used in hospital food service settings; their financial, environmental and staffing outcomes; and the barriers and enablers associated with their implementation. METHODS: Six electronic databases, 17 Google Advanced searches, and 19 targeted websites were searched for peer-reviewed and grey literature. Literature reporting the financial, environmental, or staffing outcomes of food or food-related waste management strategies that reused, recovered energy from, or recycled waste instead of sending it to landfill were eligible. Document screening and review were completed in duplicate, and included peer-reviewed literature were assessed for quality using the Mixed Methods Appraisal Tool. Data were synthesised narratively. RESULTS: Four peer-reviewed and 81 grey literature records reported 85 strategies. When grouped from most to least favourable according to the food recovery hierarchy they managed waste by: donating surplus food (n = 21); feeding animals (n = 2); industrial use (n = 11); composting (n = 34) and other (n = 17). These approaches had the capacity to reduce waste hauling fees (n = 14), reduce staff handling of waste (n = 3), and decrease the amount of waste sent to landfill (n = 85). Barriers included contamination of waste streams, while enablers included leadership and time-neutral changes. CONCLUSION: This review summarises the waste management strategies used by hospitals worldwide that divert food and food-related waste from landfill, their outcomes, and position in the food recovery hierarchy to enable hospital food services to implement appropriate practice and policy changes to decrease their environmental footprint.

Factors influencing implementation of food and food-related waste audits in hospital foodservices.

Background: Designing a food waste audit tool for novel hospital foodservice practice does not guarantee uptake. Intended users must be consulted to understand the tool's feasibility and face validity. This study aimed to identify the perspectives of staff involved in the operation of hospital foodservices on (1) how an evidenced based consensus pathway food waste audit tool is perceived to translate into practice, and (2) to determine the factors that influence the completion of food and food-related waste audits within this setting. Materials and methods: Purposeful sampling was used to recruit staff with knowledge on the operation/governance of foodservices within hospitals in Victoria, Australia. Semi-structured interviews (n = 20) were conducted via Zoom to explore barriers and enablers to completing food and food-related waste audits and a previously published food waste audit tool. NVivo was used for inductive thematic analysis. Results: Three factors determined the completion of food and food-related waste audits in hospital foodservices, and each factor could be a barrier or an enabler; (1) capacity: the availability of time, labour and materials to complete an audit (2) change: staff resistance to audit procedures and how to gain their buy-in (3) processes, governance, and leadership: the opportunity for high level support, policy and structure to encourage waste audits if present. The consensus tool appeared to have face validity. Planning audit operations, conducting stakeholder meetings, providing education/training to foodservice team members, and facilitating communication between managers and staff were described to support consensus tool use and audit completion. Conclusion: The consensus tool can be used to support hospital foodservices to complete food and food-related waste audits, although it may need to be customised to be fit for purpose. Optimising the capacity, change management and processes, governance and leadership of the foodservice department may improve the experience and success of a food and food-related waste audit.

Harnessing the pillars of institutions to drive environmentally sustainable hospital foodservices.

Background: The cultural-cognitive, normative and regulative pillars of institutions influence the ability of hospitals to change how they function at an organizational and operational level. As more hospitals and their foodservices instigate changes to address their environmental footprint and impact on food systems, they move through the "sustainability phase model" from no response through to high level action and leadership. The aim of this study was to describe and compare the pillars of institutions between hospitals in different stages of achieving environmentally sustainable foodservices (business-as-usual vs. exemplar hospitals). Methods: For this qualitative inquiry study, interviews were conducted with 33 hospital staff from 3 business-as-usual hospitals in Melbourne, Australia and 21 hospital staff from 14 exemplar hospitals across 9 countries. Participants were asked questions about their perspectives on environmental sustainability in foodservices and the barriers, enablers and drivers they experienced. Each data set was analyzed thematically and then compared. Findings: There was a clear and distinct difference in responses and behaviors within each pillar between the exemplar and business-as-usual hospitals. The cultural-cognitive pillar identified a similarity in personal belief in the importance of addressing environmental impacts of foodservices, but difference in how staff saw and acted on their responsibility to drive change. The normative pillar uncovered a supportive culture that encouraged change in exemplar hospitals whilst business-as-usual hospital staff felt disheartened by the difficult processes and lack of support. The regulative pillar reflected business-as-usual hospital staff feeling restricted by government policy vs. exemplar hospital participants who were motivated to internalize government policy in different ways and work with other hospitals to advocate for better policy. Interpretation: These findings highlight strategies related to each of the three pillars of institutions that can be used to drive effective, sustainable long term change within hospitals. This includes staff education and training, revisiting hospital culture and values around environmental sustainability, embedding sustainable foodservices in internal policies, and a comprehensive government policy approach to sustainable healthcare.

Nutritional intake and foodservice satisfaction of adults receiving specialist inpatient mental health services.

AIM: Meeting the nutritional needs and foodservice expectations of hospital inpatients is challenging. This study aimed to determine whether adults receiving specialist inpatient mental health services meet their energy and protein requirements and are satisfied with the foodservice. METHODS: An observational study of adults admitted to three specialist inpatient mental health services within a large health service. Energy and protein intake were determined over 24 h via observation, and nutritional requirements were estimated using standard procedures. Validated questionnaires were used to assess satisfaction with the lunch meal, elements of the foodservice system, and overall foodservice satisfaction. RESULTS: Among 74 participants, the median (IQR) energy intake (6954 [5111-10 250]kJ/day) was less than estimated requirements (8607 [7319-9951]kJ/day), whilst protein intake (85 [62-120]g/day) exceeded requirements (59 [46-70]g/day). Food from external sources was consumed by 50% of participants. Satisfaction surveys found vegetables were rated more poorly than the meat or carbohydrate portion of the meal, food quality was rated lowest compared with meal service, staffing and physical environment. The majority of participants (89%) rated their last meal as average, with the remainder (11%) rating it as poor. CONCLUSION: There are opportunities to improve the meal and foodservice experience for this patient group to meet their nutritional requirements and expectations. Investment in quality food and menus that are appropriate for the demographics, exploration of the most appropriate foodservice system, and adequate dietetic resourcing are needed to improve nutrition care within specialist inpatient mental health services.

Daily Relations Between Stress and Electroencephalography-Assessed Sleep: A 15-Day Intensive Longitudinal Design With Ecological Momentary Assessments.

BACKGROUND: Recent studies have found bi-directional relations between stress and sleep. However, few studies have examined the daily associations between stress and electroencephalography (EEG) measured sleep. PURPOSE: This study examined the temporal associations between repeated ecological momentary assessments of stress and EEG-estimated sleep. METHODS: Ninety-eight international or interstate undergraduate students (Mage = 20.54 ± 1.64, 76.5% female, 84.7% Asian) reported their stress levels four times daily at morning awakening, afternoon, evening, and pre-bedtime across 15 consecutive days (>4,000 total observations). Next-day stress was coded as an average of morning, afternoon, and evening stress. Z-Machine Insight+ recorded over 1,000 nights EEG total sleep time (TST), sleep onset latency, wake after sleep onset, sleep efficiency (SE), slow-wave sleep (SWS), and rapid eye movement (REM) sleep duration. Multilevel models, adjusted for covariates (i.e., sociodemographic, health factors, and daily covariates) and lagged outcomes, tested the daily within- and between-level stress-sleep associations. RESULTS: After adjusting for covariates, within-person shorter TST (b = -0.11 [-0.21, -0.01], p = .04), lower SE (b = -0.02 [-0.03, 0.00], p = .04), less SWS (b = -0.38 [-0.66, -0.10], p = .008), and less REM sleep (b = -0.32 [-0.53, -0.10], p = .004) predicted higher next-day stress. Pre-bedtime stress did not predict same-night sleep. No significant results emerged at the between-person level. CONCLUSIONS: These findings demonstrate that poor or short sleep, measured by EEG, is predictive of higher next-day stress. Results for sleep architecture support the role of SWS and REM sleep in regulating the perception of stress. Given that only within-person effects were significant, these findings highlight the importance of examining night-to-night fluctuations in sleep affecting next-day stress and its impact on daytime functioning.

The Origins of Food Supplied to an Australian Public Hospital.

Local food procurement by public institutions such as hospitals offers multiple benefits including stimulating the local economy, creating jobs, and building resilience within the food supply. Yet no published study has attempted to quantify the local food purchase by hospitals. This baseline is needed to identify gaps, set targets, and monitor change. The objective of this study was to investigate the origin of food supplied to a metro tertiary public hospital and to describe the proportion of food budget spent on items with ingredients grown in Australia and "locally" within the state of Victoria. Food procurement data were collected and analyzed during October 2020-April 2021. All items purchased by the cook fresh kitchen supplying meals to inpatients and two childcare centres during an 8-day menu cycle period were audited. Following an inspection of food packaging labels to determine country of origin, data on the proportion of Victorian content were collected from manufacturers and suppliers of foods containing Australian ingredient. Almost 80% of the food budget (AU $17,748 and 200 items) was spent on items containing significant (at least 75%) Australian content, while 11% was spent on entirely imported foods. The specific geographic origins of 55% of the budget spent on "Australian" food remain unknown as information from manufacturers and suppliers was not available. Where data were available, 3% of food budget was attributed to entirely Victorian grown foods, including fresh fruit, vegetables, and poultry. A considerable proportion of Australian grown foods are purchased by this hospital, but it is largely unknown whether these are local, from the state of Victoria, or not. Tracing and sharing of food origin data, a clear definition for "local" food, and an understanding of Victorian food growing industries are needed to progress the "local food to hospital" agenda.

A systematic review of food waste audit methods in hospital foodservices: development of a consensus pathway food waste audit tool.

BACKGROUND: To understand, monitor and compare the scope of food waste in hospital foodservices, it is essential to measure food waste using a standardised method. The aims of this systematic review were to: (i) describe and critique the methodological features of waste audits used in hospital foodservice settings that measure aggregate food and food-related waste and (ii) develop a consensus tool for conducting a food waste audit in a hospital foodservice setting. METHODS: Seven electronic databases were searched for peer reviewed literature, and 17 Google Advanced searches located grey literature that described food waste audit methods previously used or developed for hospital foodservices. Study selection and quality assessment occurred in duplicate. Data describing the audit method, its feasibility, and strengths and limitations were extracted and synthesised to develop a consensus tool. RESULTS: Eight peer reviewed and nine grey literature documents describing a variety of food waste audit methods were found. The most common practices were 2-week data collection (n = 5), foodservice staff collecting data (n = 6), measuring food waste only (n = 11), measuring food waste at main meals (n = 5) and using electronic scales to measure waste (n = 12). A consensus tool was developed that proposes a method for preparing, conducting and analysing data from a food waste audit. CONCLUSIONS: This review used published evidence to develop the first ever food waste audit consensus tool for hospital foodservices to use and measure food and food-related waste. Future research is needed to apply and test this tool in practice.

Effectiveness of Strategies to Decrease Animal-Sourced Protein and/or Increase Plant-Sourced Protein in Foodservice Settings: A Systematic Literature Review.

BACKGROUND: Effective population-based strategies are required to move toward healthy sustainable diets that replace a proportion of animal- with plant-based protein. Food service can support this using a variety of strategies across the food supply chain. OBJECTIVE: This systematic review aimed to evaluate the effectiveness of strategies to decrease animal protein and/or increase plant protein in foodservice settings on uptake, satisfaction, financial, environmental, and dietary intake outcomes. METHODS: Seven databases were searched in November 2020 with no restriction on study dates to identify peer-reviewed study designs conducted in commercial and institutional food services using any strategy to decrease beef, lamb, pork, poultry, eggs, fish, or seafood and/or increase legumes/pulses and legume/pulse-based meat substitutes or nuts and reported this review's primary outcome, uptake by consumers, either quantitatively or qualitatively. Secondary outcomes were satisfaction and financial, environmental, and dietary intake outcomes. Titles/abstracts then full texts were screened independently by 2 authors. The Mixed Methods Appraisal Tool was used for quality appraisal. Results were described using a narrative synthesis by strategy type. The protocol is registered with PROSPERO (CRD42021235015). RESULTS: From 20,002 records identified, 38 studies met eligibility criteria, of which 16% were high quality. Strategies included forced restriction (n = 4), menu redesign (n = 6), recipe redesign (n = 6), service redesign (n = 4), menu labeling (n = 7), prompt at point of sale (n = 7), and multipronged strategies (n = 4). Menu labeling, prompting at the point of sale, and redesigning menus, recipes, and service increased uptake of target foods in most studies with the largest consistent changes in menu redesign. Few studies explored secondary outcomes. Recipe redesign, prompting at the point of sale, and menu labeling strategies that measured satisfaction found a positive or neutral effect. CONCLUSIONS: The most promising strategies are likely in menu redesign, followed by menu labeling and service redesign. Satisfaction appears to not be negatively impacted by recipe redesign, prompting at the point of sale and menu labeling. More studies are needed to evaluate financial, environmental, and dietary outcomes.

The Drivers of Environmentally Sustainable Hospital Foodservices.

Background: Hospital foodservices have the potential to positively contribute to the local food system and planetary healthcare. Understanding the factors contributing to the success of "exemplar hospitals" with environmentally sustainable foodservices gives an opportunity to reimagine foodservices and guide strategic planning. The aim of this study was to identify the drivers of sustainable hospital foodservices. Methods: For this qualitative multiple case study, purposive sampling was used to identify exemplar hospitals internationally. Semi-structured interviews were conducted with staff with extensive knowledge of their foodservices to explore the drivers of sustainable practices. Relevant documents provided background on the case. These documents and interview data were analyzed using the framework and thematic analysis. Findings: There were 21 participants from 14 hospitals recruited across nine countries. Sustainable foodservice practices included local and organic food procurement, gardens onsite, vegetarian menus, re-serving unopened portion-controlled items, traditional foods, and food waste composting. Four themes were identified: initiating drivers, supporting enablers, challenges, and influence. Initiating drivers that "sparked" sustainable practices included the values of individuals or the hospital (e.g., community, environmental, or religious values), logical solutions to a problem, or government requirements. Enablers that facilitated success included motivated individuals, dedicated personnel, supportive leadership, internal protocols, and perceived benefits. External enablers included being part of member organizations, government requirements, and learning from other hospitals. Exemplar hospitals had broader influence, including educating the hospital community, supporting other hospitals, and influencing government policies/targets. Common challenges were staff resistance and inadequate policy directive. Interpretation: These findings examine the successful international cases of sustainable hospital foodservices to provide a global overview to assist with strategic planning both within hospitals and within governing bodies.

The Value of Programmatic Assessment in Supporting Educators and Students to Succeed: A Qualitative Evaluation.

BACKGROUND: Programmatic assessment has been proposed as the way forward for competency-based assessment, yet there is a dearth of literature describing the implementation and evaluation of programmatic assessment approaches. OBJECTIVE: To evaluate the implementation of a programmatic assessment and explore its ability to support students and assessors. DESIGN: A qualitative evaluation of programmatic assessment was employed. PARTICIPANTS/SETTING: Interviews with graduates (n = 8) and preceptors (n = 12) together with focus groups with faculty assessors (n = 9) from the one Australian university explored experiences of the programmatic approach, role of assessment in learning, and defensibility of assessment decisions in determining competence. ANALYSIS PERFORMED: Data were analyzed into key themes using framework analysis. RESULTS: The programmatic assessment increased confidence in defensibility of assessment decisions, reduced emotional burden of assessment, increased value of assessment, and identified and remediated at-risk students earlier when philosophical and practice shifts in approaches to assessment were embraced. CONCLUSIONS: Programmatic assessment supports a holistic approach to competency development and assessment and has multiple benefits for learners and assessors.