First Advisor

Julia Marie Goodman

Term of Graduation

Fall 2020

Date of Publication


Document Type


Degree Name

Doctor of Philosophy (Ph.D.) in Health Systems and Policy


Health Systems and Policy




Health services administration -- Oregon -- Case studies, Obesity, Nutrition policy -- Oregon, Organizational sociology, Carbonated beverages -- Law and legislation, Soft drinks -- Law and legislation



Physical Description

1 online resource (xii, 232 pages)


A major driver of the obesity epidemic is obesogenic food environments, characterized by nutrient-poor and energy-dense foods that saturate the collective physical, economic and sociocultural conditions that influence nutritional status. Food environments in organizations such as hospitals and public health agencies warrant special consideration given their health-focused mission. Improving food environments within health care settings has been highlighted by the Centers for Disease Control and Prevention (CDC) as one of seven key strategies to prevent obesity. However, most of the refereed literature examining healthy food environment policies (HFEPs) within hospitals focuses on the inpatient dietary environment, leaving a paucity of information on facilitators of or barriers to implementation.

This dissertation study sought to examine the relationship between organizational characteristics and the selection, implementation, and outcomes of HFEPs within six health care organizations. The overarching research question was: How does the organizational context of health care organizations affect the implementation process and economic outcomes of healthy food environment policies? Aim 1 sought to qualitatively describe the barriers to and facilitators of implementing HFEPs among two levels of leadership: operational managers and executive leaders. Semi-structured key informant interviews revealed 27 facilitators and 30 barriers cited among ten respondents. Examining leadership perceptions, operational and executive leaders overlapped 44-75% when identifying facilitators but only 33-58% when identifying barriers to HFEP implementation. Aim 2 sought to evaluate the revenue and consumer behavior outcomes of a sugar-sweetened beverage (SSB) ban established within a non-profit regional health care system. Utilizing an interrupted time-series analysis, findings demonstrated no statistically significant decrease in gross monthly sales 6, 12, and 18 months after the ban. Increases in water, juice, coffee and sports drinks sales after the ban indicate that consumer purchasing shifted from SSBs toward healthier options. Despite the continued availability of diet SSBs offered post-ban, monthly SSB sales decreased by a mean of 44.7%. Finally, Aim 3 sought to describe the relationship between organizational contexts and HFEP selection. Findings showcased the spectrum of HFEPs adopted and how organizational contexts presented distinct opportunities and challenges during the implementation process. For example, centralized governance models were effective for HFEP development when coupled with resource commitments but not effective when adverse stakeholders created roadblocks for HFEP opportunities. Sustainability commitments drove HFEP development when coupled with an executive champion; otherwise, such commitments led to staff apathy. Contextual recommendations synthesized the experiences of each organization, noting similarities and differences.

Examined together, these three papers provide meaningful theoretical and practical insights into the selection, implementation, and outcomes of HFEP development. Earlier chapters initially discussed how the selection and implementation of HFEPs have historically underestimated the importance of organizational theory, with implementation toolkits and step-by-step guides often mentioning the need for a "champion" or "resources" but saying little else about the role of the organizational setting in determining what kinds of HFEPs would be better suited in which settings. Aims 1 and 3 introduced a rich examination of both the organizational contexts of six diverse health care organizations as well as the facilitators and barriers cited during the HFEP implementation processes of these institutions. When complementing the qualitative inquiries with the quantitative findings of Aim 2, the findings provide evidence of the revenue and consumer behavior outcomes of a sugar-sweetened beverage ban, a HFEP that is growing in popularity and uptake. By blending these process-oriented and outcome-oriented queries, prospective decision-makers can feel equipped and well-informed to proceed with HFEP selection, implementation, and evaluation.


© 2020 Elizaveta Walker

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Persistent Identifier

Available for download on Thursday, December 02, 2021