The development and adoption of the first statewide comprehensive policy on food service guidelines (Washington State Executive Order 13-06) for improving the health and productivity of state employees and institutionalized populations

The development and adoption of the first statewide comprehensive policy on food service... Abstract National health authorities uniformly express an urgent need for large-scale policies that incorporate population-based strategies to improve diet-related population health outcomes. On October 30, 2013, Washington State passed the first statewide comprehensive policy on food service guidelines (i.e., Executive Order 13-06: “Improving the Health and Productivity of State Employees and Access to Healthy Foods in State Facilities”) aimed at improving diet-related health outcomes and estimated to impact 73,000 individuals. The aim of this study was to examine the facilitators and constraints to the development and passage of Executive Order 13-06 to inform future food service guideline development and passage in other agencies, states, and municipalities. We conducted 17 semi-structured telephone interviews with key stakeholders involved in the development and/or passage of Executive Order 13-06. Recorded interviews were transcribed verbatim, coded, and analyzed using the Advocacy Coalition Framework. Interviewees were from local and state public health departments, Washington State government, public agencies, academia, advocacy coalitions, and national organizations. Two main coalitions (proponents and opponents) diverged in their support of the passage of Executive Order 13-06. Proponents supported it given its potential to increase access to healthy food and beverage options. Opponents felt that it was not feasible to meet food service guidelines without affecting sales and profit. Study findings highlight the importance of early engagement with stakeholders most impacted by proposed food service guidelines, using existing guidelines rather than developing new guidelines, and creating a workgroup to discuss the feasibility of food service guideline implementation and compliance. Implications Practice: Food service guidelines (FSG) policies can affect and improve millions of daily meals, simultaneously having a broad public health impact and driving system change. Policy: State and local governments can play a critical role in improving the food supply by increasing availability of, and demand for, healthier products via FSG policies. Research: Future research to inform policy efforts should include analyzing the differences between different legislative forms of FSGs, assessing the effectiveness of various regulatory and implementation efforts, and measuring and comparing the effects of FSGs on population health outcomes. INTRODUCTION In 2013, Washington State became the first to adopt statewide comprehensive food service guidelines (FSG) to increase the availability of healthy food and beverages sold to state employees and served to state institutionalized populations. The FSG are a component of the worksite wellness policy titled Executive Order 13-06: “Improving the Health and Productivity of State Employees and Access to Healthy Foods in State Facilities” (EO 13-06) [1] and impact an estimated 73,000 individuals across 39 executive agencies in Washington State [2]. The incorporation of FSG into EO 13-06 came after three unsuccessful attempts to pass a stand-alone FSG policy in the Washington State legislature. FSG have emerged recently as part of a more comprehensive approach to obesity prevention and control [3]. Research provides ample evidence that the increasing prevalence of obesity is a result of biological and behavioral limitations in the face of poor food environments with high-calorie availability, and physical environments with limited opportunities to be physically active [3]. As such, national health authorities uniformly express an urgent need for large-scale policies and population-based strategies to complement and support individual-based approaches in order to achieve broad and sustained impact [4–7]. In particular, the Institute of Medicine and U.S. Centers for Disease Control and Prevention have encouraged local government agencies to play a critical role in improving the food supply by increasing the availability of, and demand for, more healthful products via nutrition standards that align with the Dietary Guidelines for Americans [8–10]. Nationwide, public worksites and city, state, and federal agencies are looking to adopt FSG but not without challenges [11]. The purpose of this study is to examine the facilitators and constraints to EO 13-06 development and passage using the Advocacy Coalition Framework (ACF) in order to inform future FSG development and passage in other agencies, states, and municipalities. METHODS Advocacy coalition framework In this study, we used the ACF to understand the facilitators, constraints, and multiple levels of influence that contributed to the policy development and passage of the FSG component of EO 13-06. The overarching concepts of the ACF are that policymaking occurs inside a policy subsystem, and within this system is a network of advocacy coalitions [12]. Advocacy coalitions are made up of networks of policy actors who share a common belief system and coordinate activities over time to reach their objectives [13, 14]. Two coalitions differed in their support of EO 13-06: proponents and opponents. Although all policy actors were generally in support of creating a healthier work environment for state employees, they disagreed whether implementing FSG was the appropriate mechanism. Participants were recruited based on their involvement in FSG policy processes rather than specifically as opponents or proponents given the challenge of assigning people to distinct categories (i.e., fluctuating beliefs as the policy evolved). All interviewees identified themselves as proponents of the FSG and provided information on opponents’ perspectives and actions. Proponents included the governor and his cabinet, the state health department, state legislators, health advocacy coalitions, national health organizations, and some state employees; Opponents included most state vendors and cafeteria operators who sell food in government agencies. Proponents and opponents disagreed on whether compliance with FSG was feasible without affecting sales and profit. The ACF was also used to identify how factors outside the immediate policy development process interacted to influence coalition members’ beliefs and the policy process. Detailed explanations of ACF components are given in Table 1. Table 1 Key components of the Advocacy Coalition Framework. Adapted with permission from and Steinman et al. [15]. Key component  Definition  Relatively stable parameters  Factors external to the policy subsystem that are stable over long periods of time (e.g., societal values).  External events  Dynamic external factors that influence the policy subsystem and advocacy coalitions to affect policy change (e.g., a change in government).  Policy subsystem  A network of advocacy coalitions that focus on a specific policy arena (e.g., increasing access to healthy foods and beverages).  Advocacy coalitions  Advocacy coalitions are made up of members brought together by shared values and beliefs. Advocacy coalitions work together to advocate for similar policy outcomes.  Constraints and resources  A combination of relatively stable parameters and external events that either help or hinder advocacy coalitions and/or the policy subsystem.  Beliefs  The overarching driver for coalition members, divided into three categories:1Deep core beliefs: Essentially unchangeable deeply held personal beliefs about human nature, freedom, the role of distinctive justice, and similar ideas.2. Near core beliefs: Fundamental policy positions concerning the articulated policy goals of an advocacy coalition.3. Secondary policy beliefs: Concerned with issues related to the administration and implementation of policy.  Strategies  Tactics, messages, and actions taken by advocacy coalitions to further their policy objectives.  Policy outputs and impacts  The result of the policy process, usually passed legislations, that impacts the identified problem.  Policy-oriented learning  Occurs within the subsystem as a result of direct challenges to an advocacy coalition, accumulated experience, confrontation, and compromise.  Key component  Definition  Relatively stable parameters  Factors external to the policy subsystem that are stable over long periods of time (e.g., societal values).  External events  Dynamic external factors that influence the policy subsystem and advocacy coalitions to affect policy change (e.g., a change in government).  Policy subsystem  A network of advocacy coalitions that focus on a specific policy arena (e.g., increasing access to healthy foods and beverages).  Advocacy coalitions  Advocacy coalitions are made up of members brought together by shared values and beliefs. Advocacy coalitions work together to advocate for similar policy outcomes.  Constraints and resources  A combination of relatively stable parameters and external events that either help or hinder advocacy coalitions and/or the policy subsystem.  Beliefs  The overarching driver for coalition members, divided into three categories:1Deep core beliefs: Essentially unchangeable deeply held personal beliefs about human nature, freedom, the role of distinctive justice, and similar ideas.2. Near core beliefs: Fundamental policy positions concerning the articulated policy goals of an advocacy coalition.3. Secondary policy beliefs: Concerned with issues related to the administration and implementation of policy.  Strategies  Tactics, messages, and actions taken by advocacy coalitions to further their policy objectives.  Policy outputs and impacts  The result of the policy process, usually passed legislations, that impacts the identified problem.  Policy-oriented learning  Occurs within the subsystem as a result of direct challenges to an advocacy coalition, accumulated experience, confrontation, and compromise.  View Large Table 1 Key components of the Advocacy Coalition Framework. Adapted with permission from and Steinman et al. [15]. Key component  Definition  Relatively stable parameters  Factors external to the policy subsystem that are stable over long periods of time (e.g., societal values).  External events  Dynamic external factors that influence the policy subsystem and advocacy coalitions to affect policy change (e.g., a change in government).  Policy subsystem  A network of advocacy coalitions that focus on a specific policy arena (e.g., increasing access to healthy foods and beverages).  Advocacy coalitions  Advocacy coalitions are made up of members brought together by shared values and beliefs. Advocacy coalitions work together to advocate for similar policy outcomes.  Constraints and resources  A combination of relatively stable parameters and external events that either help or hinder advocacy coalitions and/or the policy subsystem.  Beliefs  The overarching driver for coalition members, divided into three categories:1Deep core beliefs: Essentially unchangeable deeply held personal beliefs about human nature, freedom, the role of distinctive justice, and similar ideas.2. Near core beliefs: Fundamental policy positions concerning the articulated policy goals of an advocacy coalition.3. Secondary policy beliefs: Concerned with issues related to the administration and implementation of policy.  Strategies  Tactics, messages, and actions taken by advocacy coalitions to further their policy objectives.  Policy outputs and impacts  The result of the policy process, usually passed legislations, that impacts the identified problem.  Policy-oriented learning  Occurs within the subsystem as a result of direct challenges to an advocacy coalition, accumulated experience, confrontation, and compromise.  Key component  Definition  Relatively stable parameters  Factors external to the policy subsystem that are stable over long periods of time (e.g., societal values).  External events  Dynamic external factors that influence the policy subsystem and advocacy coalitions to affect policy change (e.g., a change in government).  Policy subsystem  A network of advocacy coalitions that focus on a specific policy arena (e.g., increasing access to healthy foods and beverages).  Advocacy coalitions  Advocacy coalitions are made up of members brought together by shared values and beliefs. Advocacy coalitions work together to advocate for similar policy outcomes.  Constraints and resources  A combination of relatively stable parameters and external events that either help or hinder advocacy coalitions and/or the policy subsystem.  Beliefs  The overarching driver for coalition members, divided into three categories:1Deep core beliefs: Essentially unchangeable deeply held personal beliefs about human nature, freedom, the role of distinctive justice, and similar ideas.2. Near core beliefs: Fundamental policy positions concerning the articulated policy goals of an advocacy coalition.3. Secondary policy beliefs: Concerned with issues related to the administration and implementation of policy.  Strategies  Tactics, messages, and actions taken by advocacy coalitions to further their policy objectives.  Policy outputs and impacts  The result of the policy process, usually passed legislations, that impacts the identified problem.  Policy-oriented learning  Occurs within the subsystem as a result of direct challenges to an advocacy coalition, accumulated experience, confrontation, and compromise.  View Large Participants and procedures A list of 25 potential participants involved in EO 13-06 development and passage was identified in discussion with a state policy advocate and state public agency employee involved in EO 13-06 work. From June through August 2015, participants were approached via e-mail, up to three times. Interested participants responded to the principal investigator (J.J.O.) to schedule an in-person or phone interview. Inclusion criteria were that they had been involved in the policy processes of FSG for state agencies. Of the initial 25 participants approached, 4 declined because they stated they were not involved in policy processes of FSG for state agencies, 3 did not respond, 1 declined because a current job prohibited participation, and 2 were not locatable. After the initial set of 15 interviews was completed, an additional eight participants were identified for recruitment using the snowball sample method. Of these, the first five were contacted in the same manner as the initial set, and three were not contacted because responses had reached theme saturation. Of the five contacted, two completed interviews, two did not respond, and one declined stating privacy reasons. Interviews were conducted by phone (n = 16) and in-person (n = 1) and audio-recorded. Interviews lasted approximately 45–60 min and were conducted by one trained researcher to ensure consistency (J.J.O.). In total, 17 participants were interviewed until theme saturation had been reached [16]. Semi-structured interviews The ACF informed the design of the semi-structured interview guide. A semi-structured interview format allowed for uniformity but also flexibility to incorporate new topics and follow-up questions as they emerged [17]. A series of open-ended questions were designed to ask about beliefs regarding FSG, roles in EO 13-06 development and passage, past and current policy efforts to support FSG, and contextual factors. The initial interview guide was reviewed by collaborators from a public health coalition and the Washington State Department of Health (WADOH) for clarity and relevance. The final interview guide consisted of 20 open-ended questions that were covered in each interview. Description of data analysis All interviews were professionally transcribed verbatim. Qualitative data analysis software (Dedoose version 7.5.9) was used to support coding and analysis. Using a sample of two interviews and a thematic analysis approach, the research team (J.J.O., C.B., and L.R.) developed deductive codes based on the ACF. Major variations within categories were identified inductively as they emerged. This process continued until a preliminary codebook was developed. Two researchers (C.B. and L.R.) independently double-coded six interviews to reconcile codes and revise the code list. Discrepancies were discussed until consensus was reached, and the codebook was modified to final. The final codebook was used to double-code (C.B., L.R., and J.J.O.) two interviews to ensure reliability. The remaining interviews were coded by one researcher (C.B.) in conjunction with regular discussion meetings with team members (J.J.O.) trained in qualitative research. We used the ACF to describe EO 13-06 policy development (Fig. 1). Illustrative quotes are given in Table 2. Table 2 Selected illustrative quotes that describe the parameters, events, beliefs, strategies, resources, constraints, and recommendations that influenced the passage of Executive Order 13-06: “Improving the Health and Productivity of State Employees, and Access to Healthy Foods in State Facilities,” Key Players Involved in the Development and Passage of Executive Order 13-06, Washington State 2016 Theme/subtheme  Illustrative quote  Relatively stable parameters   Businesses need to make a profit  “They were scared because they so rely on customer choice for making a profit in their businesses.”   High rates of obesity and chronic disease have led to rising healthcare costs  “I think that just seeing the obesity epidemic and the rising costs to take care of people, folks started getting on the bandwagon of the healthy choice, making the healthy choice the easy choice.”  External events   Election of Governor Inslee  “I think just the Governor's interest in employee health and wellness. So it starts from there because if he wasn't interested this wouldn't happen.”   Increased local, state, and national health momentum to support health and wellness initiatives  “I think it helped to show that there was a push towards this going across the country. I think to show that nationally HHS was funding this, CDC was doing it, and then obviously it was happening within the HHS cafeterias…”  Beliefs   Prevention efforts should focus on shaping the environment  “…and so much of that is really shaping the environment where people live. If people don’t have the opportunity to make a healthy choice, then they can’t and won’t. And that can have an impact on their health”   The government should act as a role model  “This idea that government spends a lot of time telling people what to do. And this is sort of a walk the talk. Like government tells us to eat healthier, so they should serve healthier food. Like it's sort of a walking around practicing what they say.”   It is important to give people the opportunity to make the healthy choice at work  “…I do think that there is a benefit to trying to shape the environment by offering healthier choices. And I do think that businesses, management, companies, vendors, whomever, can play a role in that.”   The role of government does not involve telling people what to eat  “…there continues to be a real concern about any kind of policy change that tastes, smells or looks like what people call a nanny state.”   Cafeteria operators/vendors felt that they would lose revenue and profit  “I think their main concern was that they needed to keep their businesses viable.”  Coalition strategies   Balance between healthy and unhealthy options  “We spend a lot of our time here at work and I think that there's those people will say that they have their right to a Snickers bar; that's something we hear. Other people also have a right to healthy options. So at least for the healthy nutrition guidelines we are really striving for that balance of the two.”   Gradual implementation of the food service guidelines  “…and I think the gradual implementation of these standards…reassured that they were probably able to meet the majority of them...it was set up so it wasn't like we flip a switch and everybody's expected to do that.”   Flexibility in how the food service guidelines could be achieved  “We created cafeteria guidelines that really gave the cafeteria workers some choice so that it wasn't like they had to do everything on the list. They could choose what worked best for them."   Creating a workgroup  “I think it was valuing input from the folks who were most concerned of the impact…it was really including them in the process…and making space for them to share their concerns…Sometimes it was just listening but then not changing the criteria. And then trying to think about, okay, so how can we address that when we get to implementation? So not necessarily just always modifying based on their concerns, but really thinking through, okay, here's how we can do this when we do get to implementation. Here's where we can make some changes and make that more practical for operators.”   Framing the policy  “In the wellness arena, you can't just say, we have healthier employees, isn't that great? No. We have healthier employees that can now be more productive workers, right? There's the bottom line piece to it.”  Constraints and resources   Champions who support the policy  “What a state really has to do is find key leaders, whether it's in an agency like Services for the Blind or whether it's sort of in the health advocacy group…find people who have this vision and have them start the conversation everywhere.”   One full-time dedicated staff member  “I think that having the resource of a full FTE really helped working with the other stakeholders to get them involved in the process, engaged in the process ... which eventually led them to being somewhat supportive of it. I would never say everyone was 100 percent supportive, but it got people onboard and they weren't as scared of it.”   Dedicated team with diverse expertise  “Really dedicated staff that kept bringing research and evidence to key stakeholders was instrumental. I think they had a really strong team and strong consultants working on this issue who were really well-versed in policy and decision making, people who were familiar with how to frame things and messaging...”   Introducing the policy into the legislature first  “The legislative arena is a way to air out the issue and see who's with you, who's not and what the issues are. So even if you want to do an executive order, there's not this due diligence notion that a legislative approach can provide, because that's going to be some of the questions you're going to hear from the governor's staff which is, all right, this sounds like a good idea. Who have you talked to? Who likes it? Who doesn't like it and why? And so writing it out legislatively allows you to answer that question.”   Existing relationships between proponents of the policy  “All of the years of stakeholdering that had happened prior to that, I think a lot of compromise had already been reached and a lot of legwork already done to bring people together.”   Resources used from other states doing similar work  “So we did utilize the current work products from a number of different places, like New York City and Santa Clara County and Los Angeles, as well as Seattle, King County. There was some of the bigger city health departments who were grabbing this, not necessarily all aspects of food service, but, certainly, vending was there and then we started to see concession and cafeteria standards.”  Recommendations   Share success stories  “I think a lot of fear was that it wouldn’t be affordable, or there wouldn’t be enough healthy options to like fill the machines, or to fill a concession stand. And so the more kind of examples we could point to of where this was happening, the easier it got to kind of make the case for, no, this is available and there are people doing it; we can too.”   Understand the landscape  “I would say that people would want to be very clear…that they really educate themselves on all these different logistical elements around the food policy…what's involved in the contracting mechanism of how you would change the requirements.”   Shorter phase-in period  “I would encourage others to negotiate the phase-in period as strongly as they can. I think some phase-in is good, but two to three years for difference pieces is really super generous, so that could probably be shortened up.”   An EO may be a quicker way to get the policy passed  “I do think the EO is well suited for this issue area. So a legislative approach is another menu choice, another avenue to take. But if you can get the buy-in of governor and governor staff, you can accelerate this work quite a bit, because it’s just a lot less people to twist arms about.”   Early opposition engagement  “I think there are some states where the vendors have made this work very, very difficult. Engaging them early I think can be incredibly helpful, both from kind of neutralizing that opposition, but also, from a campaign’s perspective, really doing their learning and understanding of how this works and what the vendors have available to them, how it typically works in a vending machine setting, how a cafeteria setting might work.”  Theme/subtheme  Illustrative quote  Relatively stable parameters   Businesses need to make a profit  “They were scared because they so rely on customer choice for making a profit in their businesses.”   High rates of obesity and chronic disease have led to rising healthcare costs  “I think that just seeing the obesity epidemic and the rising costs to take care of people, folks started getting on the bandwagon of the healthy choice, making the healthy choice the easy choice.”  External events   Election of Governor Inslee  “I think just the Governor's interest in employee health and wellness. So it starts from there because if he wasn't interested this wouldn't happen.”   Increased local, state, and national health momentum to support health and wellness initiatives  “I think it helped to show that there was a push towards this going across the country. I think to show that nationally HHS was funding this, CDC was doing it, and then obviously it was happening within the HHS cafeterias…”  Beliefs   Prevention efforts should focus on shaping the environment  “…and so much of that is really shaping the environment where people live. If people don’t have the opportunity to make a healthy choice, then they can’t and won’t. And that can have an impact on their health”   The government should act as a role model  “This idea that government spends a lot of time telling people what to do. And this is sort of a walk the talk. Like government tells us to eat healthier, so they should serve healthier food. Like it's sort of a walking around practicing what they say.”   It is important to give people the opportunity to make the healthy choice at work  “…I do think that there is a benefit to trying to shape the environment by offering healthier choices. And I do think that businesses, management, companies, vendors, whomever, can play a role in that.”   The role of government does not involve telling people what to eat  “…there continues to be a real concern about any kind of policy change that tastes, smells or looks like what people call a nanny state.”   Cafeteria operators/vendors felt that they would lose revenue and profit  “I think their main concern was that they needed to keep their businesses viable.”  Coalition strategies   Balance between healthy and unhealthy options  “We spend a lot of our time here at work and I think that there's those people will say that they have their right to a Snickers bar; that's something we hear. Other people also have a right to healthy options. So at least for the healthy nutrition guidelines we are really striving for that balance of the two.”   Gradual implementation of the food service guidelines  “…and I think the gradual implementation of these standards…reassured that they were probably able to meet the majority of them...it was set up so it wasn't like we flip a switch and everybody's expected to do that.”   Flexibility in how the food service guidelines could be achieved  “We created cafeteria guidelines that really gave the cafeteria workers some choice so that it wasn't like they had to do everything on the list. They could choose what worked best for them."   Creating a workgroup  “I think it was valuing input from the folks who were most concerned of the impact…it was really including them in the process…and making space for them to share their concerns…Sometimes it was just listening but then not changing the criteria. And then trying to think about, okay, so how can we address that when we get to implementation? So not necessarily just always modifying based on their concerns, but really thinking through, okay, here's how we can do this when we do get to implementation. Here's where we can make some changes and make that more practical for operators.”   Framing the policy  “In the wellness arena, you can't just say, we have healthier employees, isn't that great? No. We have healthier employees that can now be more productive workers, right? There's the bottom line piece to it.”  Constraints and resources   Champions who support the policy  “What a state really has to do is find key leaders, whether it's in an agency like Services for the Blind or whether it's sort of in the health advocacy group…find people who have this vision and have them start the conversation everywhere.”   One full-time dedicated staff member  “I think that having the resource of a full FTE really helped working with the other stakeholders to get them involved in the process, engaged in the process ... which eventually led them to being somewhat supportive of it. I would never say everyone was 100 percent supportive, but it got people onboard and they weren't as scared of it.”   Dedicated team with diverse expertise  “Really dedicated staff that kept bringing research and evidence to key stakeholders was instrumental. I think they had a really strong team and strong consultants working on this issue who were really well-versed in policy and decision making, people who were familiar with how to frame things and messaging...”   Introducing the policy into the legislature first  “The legislative arena is a way to air out the issue and see who's with you, who's not and what the issues are. So even if you want to do an executive order, there's not this due diligence notion that a legislative approach can provide, because that's going to be some of the questions you're going to hear from the governor's staff which is, all right, this sounds like a good idea. Who have you talked to? Who likes it? Who doesn't like it and why? And so writing it out legislatively allows you to answer that question.”   Existing relationships between proponents of the policy  “All of the years of stakeholdering that had happened prior to that, I think a lot of compromise had already been reached and a lot of legwork already done to bring people together.”   Resources used from other states doing similar work  “So we did utilize the current work products from a number of different places, like New York City and Santa Clara County and Los Angeles, as well as Seattle, King County. There was some of the bigger city health departments who were grabbing this, not necessarily all aspects of food service, but, certainly, vending was there and then we started to see concession and cafeteria standards.”  Recommendations   Share success stories  “I think a lot of fear was that it wouldn’t be affordable, or there wouldn’t be enough healthy options to like fill the machines, or to fill a concession stand. And so the more kind of examples we could point to of where this was happening, the easier it got to kind of make the case for, no, this is available and there are people doing it; we can too.”   Understand the landscape  “I would say that people would want to be very clear…that they really educate themselves on all these different logistical elements around the food policy…what's involved in the contracting mechanism of how you would change the requirements.”   Shorter phase-in period  “I would encourage others to negotiate the phase-in period as strongly as they can. I think some phase-in is good, but two to three years for difference pieces is really super generous, so that could probably be shortened up.”   An EO may be a quicker way to get the policy passed  “I do think the EO is well suited for this issue area. So a legislative approach is another menu choice, another avenue to take. But if you can get the buy-in of governor and governor staff, you can accelerate this work quite a bit, because it’s just a lot less people to twist arms about.”   Early opposition engagement  “I think there are some states where the vendors have made this work very, very difficult. Engaging them early I think can be incredibly helpful, both from kind of neutralizing that opposition, but also, from a campaign’s perspective, really doing their learning and understanding of how this works and what the vendors have available to them, how it typically works in a vending machine setting, how a cafeteria setting might work.”  View Large Table 2 Selected illustrative quotes that describe the parameters, events, beliefs, strategies, resources, constraints, and recommendations that influenced the passage of Executive Order 13-06: “Improving the Health and Productivity of State Employees, and Access to Healthy Foods in State Facilities,” Key Players Involved in the Development and Passage of Executive Order 13-06, Washington State 2016 Theme/subtheme  Illustrative quote  Relatively stable parameters   Businesses need to make a profit  “They were scared because they so rely on customer choice for making a profit in their businesses.”   High rates of obesity and chronic disease have led to rising healthcare costs  “I think that just seeing the obesity epidemic and the rising costs to take care of people, folks started getting on the bandwagon of the healthy choice, making the healthy choice the easy choice.”  External events   Election of Governor Inslee  “I think just the Governor's interest in employee health and wellness. So it starts from there because if he wasn't interested this wouldn't happen.”   Increased local, state, and national health momentum to support health and wellness initiatives  “I think it helped to show that there was a push towards this going across the country. I think to show that nationally HHS was funding this, CDC was doing it, and then obviously it was happening within the HHS cafeterias…”  Beliefs   Prevention efforts should focus on shaping the environment  “…and so much of that is really shaping the environment where people live. If people don’t have the opportunity to make a healthy choice, then they can’t and won’t. And that can have an impact on their health”   The government should act as a role model  “This idea that government spends a lot of time telling people what to do. And this is sort of a walk the talk. Like government tells us to eat healthier, so they should serve healthier food. Like it's sort of a walking around practicing what they say.”   It is important to give people the opportunity to make the healthy choice at work  “…I do think that there is a benefit to trying to shape the environment by offering healthier choices. And I do think that businesses, management, companies, vendors, whomever, can play a role in that.”   The role of government does not involve telling people what to eat  “…there continues to be a real concern about any kind of policy change that tastes, smells or looks like what people call a nanny state.”   Cafeteria operators/vendors felt that they would lose revenue and profit  “I think their main concern was that they needed to keep their businesses viable.”  Coalition strategies   Balance between healthy and unhealthy options  “We spend a lot of our time here at work and I think that there's those people will say that they have their right to a Snickers bar; that's something we hear. Other people also have a right to healthy options. So at least for the healthy nutrition guidelines we are really striving for that balance of the two.”   Gradual implementation of the food service guidelines  “…and I think the gradual implementation of these standards…reassured that they were probably able to meet the majority of them...it was set up so it wasn't like we flip a switch and everybody's expected to do that.”   Flexibility in how the food service guidelines could be achieved  “We created cafeteria guidelines that really gave the cafeteria workers some choice so that it wasn't like they had to do everything on the list. They could choose what worked best for them."   Creating a workgroup  “I think it was valuing input from the folks who were most concerned of the impact…it was really including them in the process…and making space for them to share their concerns…Sometimes it was just listening but then not changing the criteria. And then trying to think about, okay, so how can we address that when we get to implementation? So not necessarily just always modifying based on their concerns, but really thinking through, okay, here's how we can do this when we do get to implementation. Here's where we can make some changes and make that more practical for operators.”   Framing the policy  “In the wellness arena, you can't just say, we have healthier employees, isn't that great? No. We have healthier employees that can now be more productive workers, right? There's the bottom line piece to it.”  Constraints and resources   Champions who support the policy  “What a state really has to do is find key leaders, whether it's in an agency like Services for the Blind or whether it's sort of in the health advocacy group…find people who have this vision and have them start the conversation everywhere.”   One full-time dedicated staff member  “I think that having the resource of a full FTE really helped working with the other stakeholders to get them involved in the process, engaged in the process ... which eventually led them to being somewhat supportive of it. I would never say everyone was 100 percent supportive, but it got people onboard and they weren't as scared of it.”   Dedicated team with diverse expertise  “Really dedicated staff that kept bringing research and evidence to key stakeholders was instrumental. I think they had a really strong team and strong consultants working on this issue who were really well-versed in policy and decision making, people who were familiar with how to frame things and messaging...”   Introducing the policy into the legislature first  “The legislative arena is a way to air out the issue and see who's with you, who's not and what the issues are. So even if you want to do an executive order, there's not this due diligence notion that a legislative approach can provide, because that's going to be some of the questions you're going to hear from the governor's staff which is, all right, this sounds like a good idea. Who have you talked to? Who likes it? Who doesn't like it and why? And so writing it out legislatively allows you to answer that question.”   Existing relationships between proponents of the policy  “All of the years of stakeholdering that had happened prior to that, I think a lot of compromise had already been reached and a lot of legwork already done to bring people together.”   Resources used from other states doing similar work  “So we did utilize the current work products from a number of different places, like New York City and Santa Clara County and Los Angeles, as well as Seattle, King County. There was some of the bigger city health departments who were grabbing this, not necessarily all aspects of food service, but, certainly, vending was there and then we started to see concession and cafeteria standards.”  Recommendations   Share success stories  “I think a lot of fear was that it wouldn’t be affordable, or there wouldn’t be enough healthy options to like fill the machines, or to fill a concession stand. And so the more kind of examples we could point to of where this was happening, the easier it got to kind of make the case for, no, this is available and there are people doing it; we can too.”   Understand the landscape  “I would say that people would want to be very clear…that they really educate themselves on all these different logistical elements around the food policy…what's involved in the contracting mechanism of how you would change the requirements.”   Shorter phase-in period  “I would encourage others to negotiate the phase-in period as strongly as they can. I think some phase-in is good, but two to three years for difference pieces is really super generous, so that could probably be shortened up.”   An EO may be a quicker way to get the policy passed  “I do think the EO is well suited for this issue area. So a legislative approach is another menu choice, another avenue to take. But if you can get the buy-in of governor and governor staff, you can accelerate this work quite a bit, because it’s just a lot less people to twist arms about.”   Early opposition engagement  “I think there are some states where the vendors have made this work very, very difficult. Engaging them early I think can be incredibly helpful, both from kind of neutralizing that opposition, but also, from a campaign’s perspective, really doing their learning and understanding of how this works and what the vendors have available to them, how it typically works in a vending machine setting, how a cafeteria setting might work.”  Theme/subtheme  Illustrative quote  Relatively stable parameters   Businesses need to make a profit  “They were scared because they so rely on customer choice for making a profit in their businesses.”   High rates of obesity and chronic disease have led to rising healthcare costs  “I think that just seeing the obesity epidemic and the rising costs to take care of people, folks started getting on the bandwagon of the healthy choice, making the healthy choice the easy choice.”  External events   Election of Governor Inslee  “I think just the Governor's interest in employee health and wellness. So it starts from there because if he wasn't interested this wouldn't happen.”   Increased local, state, and national health momentum to support health and wellness initiatives  “I think it helped to show that there was a push towards this going across the country. I think to show that nationally HHS was funding this, CDC was doing it, and then obviously it was happening within the HHS cafeterias…”  Beliefs   Prevention efforts should focus on shaping the environment  “…and so much of that is really shaping the environment where people live. If people don’t have the opportunity to make a healthy choice, then they can’t and won’t. And that can have an impact on their health”   The government should act as a role model  “This idea that government spends a lot of time telling people what to do. And this is sort of a walk the talk. Like government tells us to eat healthier, so they should serve healthier food. Like it's sort of a walking around practicing what they say.”   It is important to give people the opportunity to make the healthy choice at work  “…I do think that there is a benefit to trying to shape the environment by offering healthier choices. And I do think that businesses, management, companies, vendors, whomever, can play a role in that.”   The role of government does not involve telling people what to eat  “…there continues to be a real concern about any kind of policy change that tastes, smells or looks like what people call a nanny state.”   Cafeteria operators/vendors felt that they would lose revenue and profit  “I think their main concern was that they needed to keep their businesses viable.”  Coalition strategies   Balance between healthy and unhealthy options  “We spend a lot of our time here at work and I think that there's those people will say that they have their right to a Snickers bar; that's something we hear. Other people also have a right to healthy options. So at least for the healthy nutrition guidelines we are really striving for that balance of the two.”   Gradual implementation of the food service guidelines  “…and I think the gradual implementation of these standards…reassured that they were probably able to meet the majority of them...it was set up so it wasn't like we flip a switch and everybody's expected to do that.”   Flexibility in how the food service guidelines could be achieved  “We created cafeteria guidelines that really gave the cafeteria workers some choice so that it wasn't like they had to do everything on the list. They could choose what worked best for them."   Creating a workgroup  “I think it was valuing input from the folks who were most concerned of the impact…it was really including them in the process…and making space for them to share their concerns…Sometimes it was just listening but then not changing the criteria. And then trying to think about, okay, so how can we address that when we get to implementation? So not necessarily just always modifying based on their concerns, but really thinking through, okay, here's how we can do this when we do get to implementation. Here's where we can make some changes and make that more practical for operators.”   Framing the policy  “In the wellness arena, you can't just say, we have healthier employees, isn't that great? No. We have healthier employees that can now be more productive workers, right? There's the bottom line piece to it.”  Constraints and resources   Champions who support the policy  “What a state really has to do is find key leaders, whether it's in an agency like Services for the Blind or whether it's sort of in the health advocacy group…find people who have this vision and have them start the conversation everywhere.”   One full-time dedicated staff member  “I think that having the resource of a full FTE really helped working with the other stakeholders to get them involved in the process, engaged in the process ... which eventually led them to being somewhat supportive of it. I would never say everyone was 100 percent supportive, but it got people onboard and they weren't as scared of it.”   Dedicated team with diverse expertise  “Really dedicated staff that kept bringing research and evidence to key stakeholders was instrumental. I think they had a really strong team and strong consultants working on this issue who were really well-versed in policy and decision making, people who were familiar with how to frame things and messaging...”   Introducing the policy into the legislature first  “The legislative arena is a way to air out the issue and see who's with you, who's not and what the issues are. So even if you want to do an executive order, there's not this due diligence notion that a legislative approach can provide, because that's going to be some of the questions you're going to hear from the governor's staff which is, all right, this sounds like a good idea. Who have you talked to? Who likes it? Who doesn't like it and why? And so writing it out legislatively allows you to answer that question.”   Existing relationships between proponents of the policy  “All of the years of stakeholdering that had happened prior to that, I think a lot of compromise had already been reached and a lot of legwork already done to bring people together.”   Resources used from other states doing similar work  “So we did utilize the current work products from a number of different places, like New York City and Santa Clara County and Los Angeles, as well as Seattle, King County. There was some of the bigger city health departments who were grabbing this, not necessarily all aspects of food service, but, certainly, vending was there and then we started to see concession and cafeteria standards.”  Recommendations   Share success stories  “I think a lot of fear was that it wouldn’t be affordable, or there wouldn’t be enough healthy options to like fill the machines, or to fill a concession stand. And so the more kind of examples we could point to of where this was happening, the easier it got to kind of make the case for, no, this is available and there are people doing it; we can too.”   Understand the landscape  “I would say that people would want to be very clear…that they really educate themselves on all these different logistical elements around the food policy…what's involved in the contracting mechanism of how you would change the requirements.”   Shorter phase-in period  “I would encourage others to negotiate the phase-in period as strongly as they can. I think some phase-in is good, but two to three years for difference pieces is really super generous, so that could probably be shortened up.”   An EO may be a quicker way to get the policy passed  “I do think the EO is well suited for this issue area. So a legislative approach is another menu choice, another avenue to take. But if you can get the buy-in of governor and governor staff, you can accelerate this work quite a bit, because it’s just a lot less people to twist arms about.”   Early opposition engagement  “I think there are some states where the vendors have made this work very, very difficult. Engaging them early I think can be incredibly helpful, both from kind of neutralizing that opposition, but also, from a campaign’s perspective, really doing their learning and understanding of how this works and what the vendors have available to them, how it typically works in a vending machine setting, how a cafeteria setting might work.”  View Large Fig. 1 | View largeDownload slide A modified Advocacy Coalition Framework for the passage of Washington State Executive Order 13-06: “Improving the Health and Productivity of State Employees, and Access to Healthy Foods in State Facilities.” Adapted with permission from Breton et al. [19]. Fig. 1 | View largeDownload slide A modified Advocacy Coalition Framework for the passage of Washington State Executive Order 13-06: “Improving the Health and Productivity of State Employees, and Access to Healthy Foods in State Facilities.” Adapted with permission from Breton et al. [19]. Ethical issues The University of Washington Institutional Review Board approved the study. Participants received written and verbal information about the study prior to obtaining verbal informed consent. RESULTS Evolution of EO 13-06 The idea to develop a policy introducing FSG in Washington State government facilities originated in 2010 through collaboration between two proponent coalition members. Variations of the policy were introduced into the legislative arena three times (2011–2013) before being integrated into a worksite wellness executive order issued by Governor Inslee in 2013. Despite multiple failed attempts in the legislature, most interviewees agreed that introducing the policy in the legislature first was beneficial because it allowed proponents to identify opponents of the policy and to address the reasons behind their lack of support. Interviewees also agreed that positioning the policy as part of a larger executive order on worksite wellness, and framing the policy as a platform to improve worker productivity, was key to its passage. Important key players Collaboration between proponents and opponents was crucial to understanding and overcoming challenges perceived by opponents. Interviewees underscored the roles of two key players: Washington State Department of Services for the Blind (WADSB) and WADOH. WADSB oversees the state’s Randolph-Sheppard Business Enterprise Program, a vending business program that gives legally blind adults the opportunity to run and manage vending facilities on specific public properties across the USA. Many of the cafeterias, delis, and espresso stands in Washington State facilities are operated by WADSB vendors [18]. WADOH assisted with writing EO 13-06, convened the workgroup that developed the FSG, and was responsible for the rollout and implementation of the FSG in agencies. Parameters and external events Coalition members’ behaviors are influenced by stable and dynamic factors outside of the policy subsystem. Interviewees agreed on the relatively stable parameters that influenced the development and passage of EO 13-06 [13], which included improving the health of the general population; that high rates of obesity and diet-related chronic disease have led to rising healthcare costs; and that cafeteria operators and/or vendors need to make a profit. External events mentioned by interviewees that contributed to the passage and development of EO 13-06 included: growing local and national momentum to improve population health by focusing on prevention; Governor Inslee’s election into office; and support from Inslee’s staff and members of the legislature for a policy that increased access to healthier food and beverages. Interviewees mentioned that the economic recession in Washington State, and tight agency budgets, created a challenging environment to pass a new policy. Proponents argued that increasing healthier food and beverage choices would reduce long-term healthcare costs, and opponents argued that agencies did not have the financial resources to comply with FSG. Between 2011 and 2013, WADOH convened a stakeholder working group that explored how to meet the goals of FSG proponents and address the concerns of opponents. Core policy beliefs The ACF suggests that policy actors’ core policy beliefs are translated into policy-level actions; specifically, policy core beliefs are the foundation for forming coalitions, developing alliances, and coordinating collaboration between policy subsystem members [13]. Most proponents of EO 13-06 interviewed agreed that government should act as a role model to its employees by providing healthy food options at worksites, that it is important to give people the opportunity to make a healthy choice at work, and that employee demand for healthier options exists. Other beliefs mentioned included that productivity increases if employees are healthy, and providing healthier options will lower healthcare costs. The majority of interviewees also provided their perspectives on opponents’ beliefs, including: the role of government does not include telling people what to eat; EO 13-06 would reduce cafeteria operators’ profits; EO 13-06 would restrict people’s choice; and that employee support was mixed. Coalition resources Several resources mentioned by interviewees that contributed to the development of EO 13-06 included: precedent set by local and state agencies doing less widespread, but similar and successful FSG work (e.g., Massachusetts), a full-time WADOH staff member dedicated to mobilizing stakeholder support by engaging them in the early stages of the passage and implementation of EO 13-06, and a strong team of diverse experts among proponents (i.e., lobbyists, topic matter experts, and staff with coalition experience) who influenced key stakeholders by presenting them with research and evidence to support policy passage. Repeating the legislative process three times allowed various stakeholders to develop relationships with key players, including the governor’s staff, which helped streamline future communication efforts. Coalition constraints Constraints mentioned by some interviewees included: prioritizing other policies in the legislative sessions, perceived high cost of implementation, lack of precedent and evidence that a comprehensive FSG statewide policy could be successful, perceived difficulties with compliance, initial lack of support and collaboration between stakeholders, pushback from WADSB, and the amount of time required to develop, implement, and evaluate the policy. Coalition strategies A workgroup of stakeholders that would be affected by the policy, as well as nutrition professionals and agency leaders, was created to increase collaboration and garner opposition buy-in. The workgroup researched existing voluntary FSG as a basis for developing the Washington State FSG. Workgroup members provided feedback on the feasibility of adhering to the guidelines, and subsequent compromises were made. These compromises included flexibility on: how to meet the guidelines (i.e., cafeteria managers were able to choose which guidelines to follow as long as they earned enough points to reach compliance), when guidelines should be food based versus nutrient based, and making the implementation timeline feasible. Discussion within the workgroup also allowed insights into where implementation challenges might arise and thus where additional technical assistance might be needed. DISCUSSION Research into FSG policy processes is limited but critical to understanding how to approach future policy initiatives [20]. Implementing new policies to create an environment that supports healthy eating in the workplace has the potential to reach millions of people [21]. Based on the health impact pyramid framework, changing environments to make healthy options the default choice is the second most desirable intervention for achieving potential public impact after changing socioeconomic factors [22]. However, as of 2014, only 3% of U.S. municipalities had nutrition standards for foods served and sold in government buildings and worksites [21]. Resources, such as the CDC’s updated Food Service Guidelines for Federal Facilities (FSG for Federal Facilities) and Smart Food Choices: How to Implement Food Service Guidelines in Public Facilities (How to Implement FSG), are available to assist with the development of FSG standards and implementation [23, 24]. However, successful FSG policy development requires a comprehensive understanding of the complexity of FSG policy passage in unique political environments. To our knowledge, this is the first study to analyze the development and passage of statewide comprehensive FSG to increase the availability of healthier foods and beverages in state facilities. Exploring best practices and lessons learned from EO 13-06 provides insights for addressing challenges that prevent FSG policy development and passage. Our recommendations (see Table 3) complement those in CDC’s FSG for Federal Facilities and How to Implement FSG and illustrate ways that public agencies can apply knowledge to facilitate future policy adoption [23, 24]. Table 3 Recommendations to inform Food Service Guidelines development and passage in agencies, states, and municipalities, results from qualitative interviews with key players involved in the development and passage of Executive Order 13-06: “Improving the Health and Productivity of State Employees, and Access to Healthy Foods in State Facilities,” Washington State 2016 Thematic category  Recommendations  Initial policy development  Early stakeholder engagement, particularly with those most impacted by the policy, (vendors, cafeteria operators, and agency leaders) and developing partnerships with coalitions.  Convene a workgroup of diverse stakeholders to develop the guidelines and to discuss implementation challenges and strategies.  Assemble agency, coalition, and legislative champions.  Writing the food service guidelines/policy  Grant agency exemptions where existing legislation conflicts with the guidelines.  Consider the feasibility of, and barriers to, using food-based versus nutrient-based guidelines.  Model the food service guidelines after existing successful policies and guidelines.  Strategize the best policy vehicle (i.e., an executive order versus another form of legislation).  Policy passage strategies  Make sure the political environment and timing are conducive to passing the policy, and be prepared to jump when an opportunity presents itself.  Expand the frame beyond improving individual health.  Include both the public health and business perspective (i.e., businesses still need to make a profit).  Use an analysis of coalitions and policy beliefs to strategically market and frame the policy (i.e., it is not about taking away choices, but offering healthier choices; it is an opportunity for the state to be a leader).  Long-term sustainability of the policy  Develop a plan for evaluation, monitoring, recognition of successes, and long-term sustainability.  Continue to engage stakeholders and provide technical assistance if agencies need assistance strategizing how to follow the guidelines.  Provide educational resources to employees to help them understand the policy changes, and to agency leaders so they can help promote implementation.  Thematic category  Recommendations  Initial policy development  Early stakeholder engagement, particularly with those most impacted by the policy, (vendors, cafeteria operators, and agency leaders) and developing partnerships with coalitions.  Convene a workgroup of diverse stakeholders to develop the guidelines and to discuss implementation challenges and strategies.  Assemble agency, coalition, and legislative champions.  Writing the food service guidelines/policy  Grant agency exemptions where existing legislation conflicts with the guidelines.  Consider the feasibility of, and barriers to, using food-based versus nutrient-based guidelines.  Model the food service guidelines after existing successful policies and guidelines.  Strategize the best policy vehicle (i.e., an executive order versus another form of legislation).  Policy passage strategies  Make sure the political environment and timing are conducive to passing the policy, and be prepared to jump when an opportunity presents itself.  Expand the frame beyond improving individual health.  Include both the public health and business perspective (i.e., businesses still need to make a profit).  Use an analysis of coalitions and policy beliefs to strategically market and frame the policy (i.e., it is not about taking away choices, but offering healthier choices; it is an opportunity for the state to be a leader).  Long-term sustainability of the policy  Develop a plan for evaluation, monitoring, recognition of successes, and long-term sustainability.  Continue to engage stakeholders and provide technical assistance if agencies need assistance strategizing how to follow the guidelines.  Provide educational resources to employees to help them understand the policy changes, and to agency leaders so they can help promote implementation.  View Large Table 3 Recommendations to inform Food Service Guidelines development and passage in agencies, states, and municipalities, results from qualitative interviews with key players involved in the development and passage of Executive Order 13-06: “Improving the Health and Productivity of State Employees, and Access to Healthy Foods in State Facilities,” Washington State 2016 Thematic category  Recommendations  Initial policy development  Early stakeholder engagement, particularly with those most impacted by the policy, (vendors, cafeteria operators, and agency leaders) and developing partnerships with coalitions.  Convene a workgroup of diverse stakeholders to develop the guidelines and to discuss implementation challenges and strategies.  Assemble agency, coalition, and legislative champions.  Writing the food service guidelines/policy  Grant agency exemptions where existing legislation conflicts with the guidelines.  Consider the feasibility of, and barriers to, using food-based versus nutrient-based guidelines.  Model the food service guidelines after existing successful policies and guidelines.  Strategize the best policy vehicle (i.e., an executive order versus another form of legislation).  Policy passage strategies  Make sure the political environment and timing are conducive to passing the policy, and be prepared to jump when an opportunity presents itself.  Expand the frame beyond improving individual health.  Include both the public health and business perspective (i.e., businesses still need to make a profit).  Use an analysis of coalitions and policy beliefs to strategically market and frame the policy (i.e., it is not about taking away choices, but offering healthier choices; it is an opportunity for the state to be a leader).  Long-term sustainability of the policy  Develop a plan for evaluation, monitoring, recognition of successes, and long-term sustainability.  Continue to engage stakeholders and provide technical assistance if agencies need assistance strategizing how to follow the guidelines.  Provide educational resources to employees to help them understand the policy changes, and to agency leaders so they can help promote implementation.  Thematic category  Recommendations  Initial policy development  Early stakeholder engagement, particularly with those most impacted by the policy, (vendors, cafeteria operators, and agency leaders) and developing partnerships with coalitions.  Convene a workgroup of diverse stakeholders to develop the guidelines and to discuss implementation challenges and strategies.  Assemble agency, coalition, and legislative champions.  Writing the food service guidelines/policy  Grant agency exemptions where existing legislation conflicts with the guidelines.  Consider the feasibility of, and barriers to, using food-based versus nutrient-based guidelines.  Model the food service guidelines after existing successful policies and guidelines.  Strategize the best policy vehicle (i.e., an executive order versus another form of legislation).  Policy passage strategies  Make sure the political environment and timing are conducive to passing the policy, and be prepared to jump when an opportunity presents itself.  Expand the frame beyond improving individual health.  Include both the public health and business perspective (i.e., businesses still need to make a profit).  Use an analysis of coalitions and policy beliefs to strategically market and frame the policy (i.e., it is not about taking away choices, but offering healthier choices; it is an opportunity for the state to be a leader).  Long-term sustainability of the policy  Develop a plan for evaluation, monitoring, recognition of successes, and long-term sustainability.  Continue to engage stakeholders and provide technical assistance if agencies need assistance strategizing how to follow the guidelines.  Provide educational resources to employees to help them understand the policy changes, and to agency leaders so they can help promote implementation.  View Large This study finds early stakeholder engagement to be a critical component to successful FSG policy passage. Involving stakeholders who will be affected by the FSG early and proactively can provide opportunities to hear and address potential concerns and modify guidelines toward agreement. For example, during the first legislative attempt to adopt the FSG, opposing coalition members stated that compliance would negatively impact profits. This initial resistance stemmed from a misunderstanding regarding the goals of the FSG; proponent engagement with opponents shifted these attitudes from opposed to neutral by the third legislative session. Creation of a workgroup was considered the most effective method for stakeholder engagement and buy-in. The WADOH established a workgroup composed of diverse stakeholders from clinical and public health nutrition, state institutions, local health jurisdictions, and other parties affected by the policy (i.e., WADSB, cafeteria, and vending operators). This gave opponents an opportunity to voice their concerns so guidelines could be appropriately modified. Workgroup meetings also allowed stakeholders to understand how existing vendor contracts might interfere with FSG compliance, explore available and feasible vending options, and provide anonymous feedback. The recommendation to create a workgroup is included in CDC’s How to Implement FSG [23]. Other examples of workgroups used to facilitate FSG include the Iowa Capitol Complex Vending Project, an internal Department of Public Health ad hoc committee in Massachusetts, and The Los Angeles County Department of Public Health advisory committee [23]. Another successful strategy identified in this study was the assembly of FSG champions within agencies, coalitions, and the community to rally partner organizations, thus broadening the coalition and building support over time. This finding aligns with recommendations made in How to Implement FSG which encourages the identification of champions and partners—such as governors, mayors, local council members, wellness coordinators, public health staff, and blind entrepreneurs—to assist with the adoption of FSG [23]. In Washington State specifically, the Governor, Secretary of Health, and leadership in the Senate and House of Representatives collectively shared a strong interest in employee health and wellness. Support from these actors, especially the Governor, was essential for EO 13-06 passage and highlighted the importance of considering the political environment when choosing the FSG policy vehicle. At the time that EO 13-06 passed in Washington State, interviewees believed that the political environment favored integrating FSG into an executive order and that this required flexibility with the scope of the FSG impact. While a governor-issued executive order is difficult to enforce and applies only to public agencies under the executive branch, an executive order accelerated the policy process and aligned well with the policy goals. This study also revealed the importance of expanding the frame of FSG policy beyond improving individual health. By focusing on increasing worker productivity as part of a comprehensive worksite wellness policy, EO 13-06 was able to build traction as part of a larger worksite benefit. Other recent examples of FSG-related legislation that have passed under a worksite wellness frame include EO 17-15 “Healthy Vending” [25], signed by Governor John Bel Edwards of Louisiana on June 30, 2017, and the DC Department of Human Resources (DCHR) Instruction No. 20B-9, “Workplace Wellness Program,” effective on April 18, 2016 [26]. Modeling a FSG policy after existing successful policies and guidelines can make it more accepted and ease opposition anxiety. Several contrasting beliefs existed between proponents and opponents of EO 13-06 regarding whether healthy food would cause vendors and cafeteria operators to lose money and whether implementing FSG was feasible given monetary and staffing constraints. The ability of the workgroup to provide examples of success stories reassured vendors and cafeteria operators that selling healthy food could be profitable. Examples of existing successful FSG work in the USA which can be drawn upon include the Healthy Food Promotion in Los Angeles County Food Service Contracts, the Iowa Healthiest State initiative, the MA State Agency Food Standards, the Chicago Park District Healthier Snack Initiative, and the Munch Better at Delaware State Parks intervention. Lessons learned and success stories from these policies, initiatives, and interventions are available in the 2015 Center for Disease Control (CDC) report, Food Services Guidelines: Case Studies States and Communities [27]. The development of FSG parameters can be uniquely challenging, causing dissidence even among proponents. In this study, some participants supported the use of food-based guidelines, rather than nutrient-based guidelines, to decrease implementation and compliance barriers. The latest FSG for Federal Facilities [24] published by Health and Human Services also recommends food-based standards. The Federal Guidelines for Food Service Facilities are based on the 2015–2020 Dietary Guidelines for Americans, which differs from its predecessors by focusing less on individual dietary components (i.e., nutrients) and more on recommendations that support healthy eating patterns [8]. Interviewees recommended starting with existing FSG, such as the New York City Food Standards [28], and collaborating with stakeholders to identify strengths and weaknesses to determine whether adoption in their own state/facility is feasible. Developing a set of guidelines that all stakeholders can readily understand and apply may increase the likelihood of compliance and achieving the goal of greater access to healthy food options. This study also found that it may be important to exempt agencies where existing legislation—such as the National School Lunch Program—conflict with new guidelines to prevent pushback. In this study, framing and promotion of FSG were important for gaining acceptance from employees working in state facilities. When asked whether employees supported FSG policy, interviewees reported that feelings were mixed. Emphasizing that the FSG would increase the amount of healthy food offered without taking away existing options helped to ease contention. Stakeholders emphasized the importance of providing technical assistance and support (e.g., promotional materials and training for cafeteria operators) during the implementation phase of the Healthy Nutrition Guidelines to help assure success. This recommendation aligns with CDC’s How to Implement FSG recommendations. Other examples of stakeholder education efforts include annual food policy forums organized by the Los Angeles County Department of Public Health to share best practices in procurement, promotion, and placement of healthy foods and training provided by the Division of Nutrition and Health Promotion staff in the Iowa Department of Public Health to track the sales of healthier options and show how to balance a mix of health and unhealthy items, as needed, to remain profitable [23]. Finally, when considering the long-term sustainability of an FSG policy, interviewees in this study mentioned it was important to develop a policy evaluation plan concurrently with implementation goals to better identify the necessary resources, tools, and funding to support staff evaluation and technical assistance efforts after policy adoption. Ensuring that an evaluation plan is in place at the time of FSG adoption may improve the chances of long-term sustainability if and when leadership changes. An evaluation plan can also help monitor challenges in adhering to the guidelines and detect need for technical assistance. This is consistent with CDC’s How to Implement FSG recommendations which suggest developing an evaluation plan alongside initial guideline development to consider both the purpose of the evaluation and how evaluation findings will be used [23]. In sum, use of the ACF helped to identify key players, resources needed, and strategies for essential collaboration that facilitated the development and passage of EO 13-06 (Fig. 1). The ACF has widespread application and has been used to analyze two previous legislative efforts in Washington State: the development and passage of a restaurant menu-labeling initiative [29] and the development of breastfeeding friendly policies [15]. Some of the lessons shared from these policy efforts, such as framing the policy beyond individuals and health, and engaging stakeholders early in the policy process to proactively address concerns, align with our recommendations. Future studies should use the ACF to identify comparable and additional lessons learned from public health-related policy development and adoption. Limitations Results may not be generalizable to other states due to the political environment that favored the passage of EO 13-06 in Washington State. While a diverse group of proponents were interviewed, interview data from opponents were limited. In some cases, proponents’ perception of opponents’ beliefs was reported. Qualitative data analysis is subject to personal bias. Researchers are challenged with presenting findings that preserve the original intent of interviewees, while also allowing for analysis and interpretation. The research team included people who were familiar and unfamiliar with EO 13-06. This dynamic increased awareness of potential biases and improved attentiveness during the data analysis process. In addition, the majority of data were double-coded to ensure that themes were accurately represented. CONCLUSION Elements that contributed to successful policy development and passage of a statewide comprehensive FSG have been identified using an ACF. This study can inform other entities who seek to develop and pass FSG. Future research to inform policy efforts should include analyzing the differences between FSG as part of an executive order versus another form of legislation, and measuring and comparing the effects of these policies on population health outcomes. Acknowledgements: We thank the interviewees for their time and insights. This work was supported by a CDC Intergovernmental Personnel Act Agreement to J.J.O., titled Evaluation of Washington State Food Service Guidelines, and a UW Nutritional Sciences Program research support stipend to C.B.. The content is solely the responsibility of the authors and does not represent the official views of CDC. These findings have not been previously published, and this manuscript is not being simultaneously submitted elsewhere. Manuscript findings have not appeared elsewhere. The authors had full control of all primary data and agree to allow the journal to review their data if requested. Compliance with Ethical Standards Conflict of Interest: The authors report no conflicts of interest and have had full control of all primary data and agree to allow the journal to review data if requested. Ethical Approval: No animals were used in this study. Institutional Review Board approval was given by the University of Washington IRB to conduct this study. Informed Consent: All study participants gave verbal informed consent to participate in the study. References 1. State of Washington. Executive Order 13-06: Improving the Health and Productivity of State Employees and Access to Healthy Foods in State Facilities . Washington State Executive Order 13-06; 2013. Available at https://www.governor.wa.gov/sites/default/files/exe_order/eo_13-06.pdf . Accessibility verified January 3, 2018. 2. Thomas JG, Doshi S, Crosby RD, Lowe MR. Ecological momentary assessment of obesogenic eating behavior: combining person-specific and environmental predictors. Obesity (Silver Spring) . 2011; 19( 8): 1574– 1579. Google Scholar CrossRef Search ADS PubMed  3. Institute of Medicine of the National Academies. Bridging the Evidence Gap in Obesity Prevention: A Framework to Inform Decision Making . Washington DC: National Academies Press; 2010. 4. Ball K, Timperio AF, Crawford DA. Understanding environmental influences on nutrition and physical activity behaviors: where should we look and what should we count? Int j Behav Nutr Phys Act . 2006; 3: 33. doi:10.1186/1479-5868-3-33. Google Scholar CrossRef Search ADS PubMed  5. Mozaffarian D, Fahimi S, Singh GMet al.   Global sodium consumption and death from cardiovascular causes. New England J Med . 2014; 371( 7): 624– 634. Google Scholar CrossRef Search ADS   6. Kumanyika SK, Obarzanek E, Stettler Net al.   Population-based prevention of obesity the need for comprehensive promotion of healthful eating, physical activity, and energy balance: a scientific statement from American Heart Association council on epidemiology and prevention, interdisciplinary committee for prevention (formerly the expert panel on population and prevention science). Circulation . 2008; 118( 4): 428– 464. Google Scholar CrossRef Search ADS PubMed  7. Institute of Medicine. Committee on Childhood Obesity Prevention Actions for Local Governments. Local Government Actions to Prevent Childhood Obesity . Washington DC: The National Academies Press; 2009. 8. U.S. Department of Health and Human Services and U.S. Department of Agriculture. 2015–2020 Dietary Guidelines for Americans . 8th ed. December 2015. Available at http://health.gov/dietaryguidelines/2015/guidelines/. Accessibility verified January 3, 2018. 9. Centers for Disease Control and Prevention. Recommended community strategies and measurements to prevent obesity in the United States. MMWR. July 24, 2009; 58(RR07):1–26. Available at https://www.cdc.gov/mmwr/preview/mmwrhtml/rr5807a1.htm. Accessibility verified January 3, 2018. 10. Transportation Research Board, Institute of Medicine, and National Research Council. Local Government Actions to Prevent Childhood Obesity. 2009. Washington, DC: The National Academies Press. doi:10.17226/12674. Available at https://www.nap.edu/read/12674/chapter/1. Accessibility verified January 3, 2018. 11. Centers for Disease Control and Prevention. Strategies to Prevent Obesity and Other Chronic Diseases: A CDC Guide to Strategies to Increase the Consumption of Fruits and Vegetables . Atlanta, GA: U.S. Department of Health and Human Services; 2011. 12. Johnson DB, Quinn EL, Podrabsky Met al.   Perceived impact and feasibility of strategies to improve access to healthy foods in Washington State, USA. Public Health Nutr . 2013; 16( 12): 2178– 2187. Google Scholar CrossRef Search ADS PubMed  13. Weible CM, Sabatier PA, McQueen K. Themes and variations: taking stock of the advocacy coalition framework. Policy Stud J . 2009; 37( 1): 121– 140. Google Scholar CrossRef Search ADS   14. Sabatier PA. Theories of the Policy Process . Boulder, CO: Westview Press; 2007. 15. Steinman LE, Bradford V, Quinn Eet al.   Examining the Washington State breastfeeding-friendly policy development process using the advocacy coalition framework. Matern Child Health J . 2016; 21( 3): 659– 669. Google Scholar CrossRef Search ADS   16. Miles MB, Huberman AM, Saldana J. Qualitative Data Analysis: A Methods Sourcebook . Thousand Oaks, California: SAGE Publications, Inc.; 2013. 17. Brinkmann S. Qualitative Interviewing (Series in Understanding Qualitative Research) . New York, NY: Oxford University Press; 2013. 18. Washington State Department of Health. The Department of Services for the Blind’s Business Enterprise Program. Available at http://www.doh.wa.gov/CommunityandEnvironment/WorksiteWellness/HealthyNutritionGuidelines/BusinessEnterpriseProgram. Accessibility verified December 18, 2016. 19. Breton E, Richard L, Gagnon F, Jacques M, Bergeron P. Fighting a tobacco-tax rollback: A political analysis of the 1994 cigarette contraband crisis in Canada. J Public Health Pol . 2006; 27(1): 77– 99. Google Scholar CrossRef Search ADS   20. Brenton E, De Leeuw E. Theories of the policy process in health promotion research: a review. Health Promot Int . 2011; 26( 1): 82– 90. Google Scholar CrossRef Search ADS PubMed  21. Onufrak SJ, Zaganjor H, Moore LV, Carlson S, Kimmons J, Galuska D. Nutrition standards for food service guidelines for foods served or sold in municipal government buildings or worksites, USA, 2014. Prev Chronic Dis . 2016; 13: 160364. Google Scholar CrossRef Search ADS   22. Frieden TR. A framework for public health action: the health impact pyramid. Am J Public Health . 2010; 100( 4): 590– 595. Google Scholar CrossRef Search ADS PubMed  23. Centers for Disease Control and Prevention. Smart Food Choices: How to Implement Food Service Guidelines in Public Facilities . Atlanta, GA: Centers for Disease Control and Prevention, U.S. Department of Health and Human Services; 2014. 24. Food Service Guidelines Federal Workgroup. Food Service Guidelines for Federal Facilities . Washington, DC: U.S. Department of Health and Human Services; 2017. 25. State of Louisiana. Executive Order 17-15: Healthy Vending . State of Louisiana Executive Order 17-15; 2017. Available at http://www.doa.la.gov/osr/other/JBE%202017/JBE17-15.htm. Accessibility verified January 3, 2018. 26. DC Department of Human Resources. District Personnel Instruction No. 20B-9: Workplace Wellness Program ; 2016. Available at https://dchr.dc.gov/sites/default/files/dc/sites/dchr/publication/attachments/edpm_20b_9_workplace_wellness_program.pdf . Accessibility verified January 3, 2018. 27. Centers for Disease Control and Prevention. Food Service Guidelines: Case Studies States and Communities . U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Division of Nutrition, Physical Activity, and Obesity Prevention. August 2015. Available at https://www.cdc.gov/obesity/downloads/fsg_casestudies_508.pdf. Accessibility verified January 3, 2018. 28. New York City Department of Health. New York City Food Standards for Meals/Snacks Purchased and Served. Available at https://www1.nyc.gov/assets/doh/downloads/pdf/cardio/cardio-meals-snacks-standards.pdf. Accessibility verified November 2, 2017. 29. Johnson DB, Payne EC, McNeese MA, Allen D. Menu-labeling policy in King County, Washington. Am J Prev Med . 2012; 43( 3 suppl 2): S130– S135. Google Scholar CrossRef Search ADS PubMed  © Society of Behavioral Medicine 2018. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Translational Behavioral Medicine Oxford University Press

The development and adoption of the first statewide comprehensive policy on food service guidelines (Washington State Executive Order 13-06) for improving the health and productivity of state employees and institutionalized populations

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Abstract

Abstract National health authorities uniformly express an urgent need for large-scale policies that incorporate population-based strategies to improve diet-related population health outcomes. On October 30, 2013, Washington State passed the first statewide comprehensive policy on food service guidelines (i.e., Executive Order 13-06: “Improving the Health and Productivity of State Employees and Access to Healthy Foods in State Facilities”) aimed at improving diet-related health outcomes and estimated to impact 73,000 individuals. The aim of this study was to examine the facilitators and constraints to the development and passage of Executive Order 13-06 to inform future food service guideline development and passage in other agencies, states, and municipalities. We conducted 17 semi-structured telephone interviews with key stakeholders involved in the development and/or passage of Executive Order 13-06. Recorded interviews were transcribed verbatim, coded, and analyzed using the Advocacy Coalition Framework. Interviewees were from local and state public health departments, Washington State government, public agencies, academia, advocacy coalitions, and national organizations. Two main coalitions (proponents and opponents) diverged in their support of the passage of Executive Order 13-06. Proponents supported it given its potential to increase access to healthy food and beverage options. Opponents felt that it was not feasible to meet food service guidelines without affecting sales and profit. Study findings highlight the importance of early engagement with stakeholders most impacted by proposed food service guidelines, using existing guidelines rather than developing new guidelines, and creating a workgroup to discuss the feasibility of food service guideline implementation and compliance. Implications Practice: Food service guidelines (FSG) policies can affect and improve millions of daily meals, simultaneously having a broad public health impact and driving system change. Policy: State and local governments can play a critical role in improving the food supply by increasing availability of, and demand for, healthier products via FSG policies. Research: Future research to inform policy efforts should include analyzing the differences between different legislative forms of FSGs, assessing the effectiveness of various regulatory and implementation efforts, and measuring and comparing the effects of FSGs on population health outcomes. INTRODUCTION In 2013, Washington State became the first to adopt statewide comprehensive food service guidelines (FSG) to increase the availability of healthy food and beverages sold to state employees and served to state institutionalized populations. The FSG are a component of the worksite wellness policy titled Executive Order 13-06: “Improving the Health and Productivity of State Employees and Access to Healthy Foods in State Facilities” (EO 13-06) [1] and impact an estimated 73,000 individuals across 39 executive agencies in Washington State [2]. The incorporation of FSG into EO 13-06 came after three unsuccessful attempts to pass a stand-alone FSG policy in the Washington State legislature. FSG have emerged recently as part of a more comprehensive approach to obesity prevention and control [3]. Research provides ample evidence that the increasing prevalence of obesity is a result of biological and behavioral limitations in the face of poor food environments with high-calorie availability, and physical environments with limited opportunities to be physically active [3]. As such, national health authorities uniformly express an urgent need for large-scale policies and population-based strategies to complement and support individual-based approaches in order to achieve broad and sustained impact [4–7]. In particular, the Institute of Medicine and U.S. Centers for Disease Control and Prevention have encouraged local government agencies to play a critical role in improving the food supply by increasing the availability of, and demand for, more healthful products via nutrition standards that align with the Dietary Guidelines for Americans [8–10]. Nationwide, public worksites and city, state, and federal agencies are looking to adopt FSG but not without challenges [11]. The purpose of this study is to examine the facilitators and constraints to EO 13-06 development and passage using the Advocacy Coalition Framework (ACF) in order to inform future FSG development and passage in other agencies, states, and municipalities. METHODS Advocacy coalition framework In this study, we used the ACF to understand the facilitators, constraints, and multiple levels of influence that contributed to the policy development and passage of the FSG component of EO 13-06. The overarching concepts of the ACF are that policymaking occurs inside a policy subsystem, and within this system is a network of advocacy coalitions [12]. Advocacy coalitions are made up of networks of policy actors who share a common belief system and coordinate activities over time to reach their objectives [13, 14]. Two coalitions differed in their support of EO 13-06: proponents and opponents. Although all policy actors were generally in support of creating a healthier work environment for state employees, they disagreed whether implementing FSG was the appropriate mechanism. Participants were recruited based on their involvement in FSG policy processes rather than specifically as opponents or proponents given the challenge of assigning people to distinct categories (i.e., fluctuating beliefs as the policy evolved). All interviewees identified themselves as proponents of the FSG and provided information on opponents’ perspectives and actions. Proponents included the governor and his cabinet, the state health department, state legislators, health advocacy coalitions, national health organizations, and some state employees; Opponents included most state vendors and cafeteria operators who sell food in government agencies. Proponents and opponents disagreed on whether compliance with FSG was feasible without affecting sales and profit. The ACF was also used to identify how factors outside the immediate policy development process interacted to influence coalition members’ beliefs and the policy process. Detailed explanations of ACF components are given in Table 1. Table 1 Key components of the Advocacy Coalition Framework. Adapted with permission from and Steinman et al. [15]. Key component  Definition  Relatively stable parameters  Factors external to the policy subsystem that are stable over long periods of time (e.g., societal values).  External events  Dynamic external factors that influence the policy subsystem and advocacy coalitions to affect policy change (e.g., a change in government).  Policy subsystem  A network of advocacy coalitions that focus on a specific policy arena (e.g., increasing access to healthy foods and beverages).  Advocacy coalitions  Advocacy coalitions are made up of members brought together by shared values and beliefs. Advocacy coalitions work together to advocate for similar policy outcomes.  Constraints and resources  A combination of relatively stable parameters and external events that either help or hinder advocacy coalitions and/or the policy subsystem.  Beliefs  The overarching driver for coalition members, divided into three categories:1Deep core beliefs: Essentially unchangeable deeply held personal beliefs about human nature, freedom, the role of distinctive justice, and similar ideas.2. Near core beliefs: Fundamental policy positions concerning the articulated policy goals of an advocacy coalition.3. Secondary policy beliefs: Concerned with issues related to the administration and implementation of policy.  Strategies  Tactics, messages, and actions taken by advocacy coalitions to further their policy objectives.  Policy outputs and impacts  The result of the policy process, usually passed legislations, that impacts the identified problem.  Policy-oriented learning  Occurs within the subsystem as a result of direct challenges to an advocacy coalition, accumulated experience, confrontation, and compromise.  Key component  Definition  Relatively stable parameters  Factors external to the policy subsystem that are stable over long periods of time (e.g., societal values).  External events  Dynamic external factors that influence the policy subsystem and advocacy coalitions to affect policy change (e.g., a change in government).  Policy subsystem  A network of advocacy coalitions that focus on a specific policy arena (e.g., increasing access to healthy foods and beverages).  Advocacy coalitions  Advocacy coalitions are made up of members brought together by shared values and beliefs. Advocacy coalitions work together to advocate for similar policy outcomes.  Constraints and resources  A combination of relatively stable parameters and external events that either help or hinder advocacy coalitions and/or the policy subsystem.  Beliefs  The overarching driver for coalition members, divided into three categories:1Deep core beliefs: Essentially unchangeable deeply held personal beliefs about human nature, freedom, the role of distinctive justice, and similar ideas.2. Near core beliefs: Fundamental policy positions concerning the articulated policy goals of an advocacy coalition.3. Secondary policy beliefs: Concerned with issues related to the administration and implementation of policy.  Strategies  Tactics, messages, and actions taken by advocacy coalitions to further their policy objectives.  Policy outputs and impacts  The result of the policy process, usually passed legislations, that impacts the identified problem.  Policy-oriented learning  Occurs within the subsystem as a result of direct challenges to an advocacy coalition, accumulated experience, confrontation, and compromise.  View Large Table 1 Key components of the Advocacy Coalition Framework. Adapted with permission from and Steinman et al. [15]. Key component  Definition  Relatively stable parameters  Factors external to the policy subsystem that are stable over long periods of time (e.g., societal values).  External events  Dynamic external factors that influence the policy subsystem and advocacy coalitions to affect policy change (e.g., a change in government).  Policy subsystem  A network of advocacy coalitions that focus on a specific policy arena (e.g., increasing access to healthy foods and beverages).  Advocacy coalitions  Advocacy coalitions are made up of members brought together by shared values and beliefs. Advocacy coalitions work together to advocate for similar policy outcomes.  Constraints and resources  A combination of relatively stable parameters and external events that either help or hinder advocacy coalitions and/or the policy subsystem.  Beliefs  The overarching driver for coalition members, divided into three categories:1Deep core beliefs: Essentially unchangeable deeply held personal beliefs about human nature, freedom, the role of distinctive justice, and similar ideas.2. Near core beliefs: Fundamental policy positions concerning the articulated policy goals of an advocacy coalition.3. Secondary policy beliefs: Concerned with issues related to the administration and implementation of policy.  Strategies  Tactics, messages, and actions taken by advocacy coalitions to further their policy objectives.  Policy outputs and impacts  The result of the policy process, usually passed legislations, that impacts the identified problem.  Policy-oriented learning  Occurs within the subsystem as a result of direct challenges to an advocacy coalition, accumulated experience, confrontation, and compromise.  Key component  Definition  Relatively stable parameters  Factors external to the policy subsystem that are stable over long periods of time (e.g., societal values).  External events  Dynamic external factors that influence the policy subsystem and advocacy coalitions to affect policy change (e.g., a change in government).  Policy subsystem  A network of advocacy coalitions that focus on a specific policy arena (e.g., increasing access to healthy foods and beverages).  Advocacy coalitions  Advocacy coalitions are made up of members brought together by shared values and beliefs. Advocacy coalitions work together to advocate for similar policy outcomes.  Constraints and resources  A combination of relatively stable parameters and external events that either help or hinder advocacy coalitions and/or the policy subsystem.  Beliefs  The overarching driver for coalition members, divided into three categories:1Deep core beliefs: Essentially unchangeable deeply held personal beliefs about human nature, freedom, the role of distinctive justice, and similar ideas.2. Near core beliefs: Fundamental policy positions concerning the articulated policy goals of an advocacy coalition.3. Secondary policy beliefs: Concerned with issues related to the administration and implementation of policy.  Strategies  Tactics, messages, and actions taken by advocacy coalitions to further their policy objectives.  Policy outputs and impacts  The result of the policy process, usually passed legislations, that impacts the identified problem.  Policy-oriented learning  Occurs within the subsystem as a result of direct challenges to an advocacy coalition, accumulated experience, confrontation, and compromise.  View Large Participants and procedures A list of 25 potential participants involved in EO 13-06 development and passage was identified in discussion with a state policy advocate and state public agency employee involved in EO 13-06 work. From June through August 2015, participants were approached via e-mail, up to three times. Interested participants responded to the principal investigator (J.J.O.) to schedule an in-person or phone interview. Inclusion criteria were that they had been involved in the policy processes of FSG for state agencies. Of the initial 25 participants approached, 4 declined because they stated they were not involved in policy processes of FSG for state agencies, 3 did not respond, 1 declined because a current job prohibited participation, and 2 were not locatable. After the initial set of 15 interviews was completed, an additional eight participants were identified for recruitment using the snowball sample method. Of these, the first five were contacted in the same manner as the initial set, and three were not contacted because responses had reached theme saturation. Of the five contacted, two completed interviews, two did not respond, and one declined stating privacy reasons. Interviews were conducted by phone (n = 16) and in-person (n = 1) and audio-recorded. Interviews lasted approximately 45–60 min and were conducted by one trained researcher to ensure consistency (J.J.O.). In total, 17 participants were interviewed until theme saturation had been reached [16]. Semi-structured interviews The ACF informed the design of the semi-structured interview guide. A semi-structured interview format allowed for uniformity but also flexibility to incorporate new topics and follow-up questions as they emerged [17]. A series of open-ended questions were designed to ask about beliefs regarding FSG, roles in EO 13-06 development and passage, past and current policy efforts to support FSG, and contextual factors. The initial interview guide was reviewed by collaborators from a public health coalition and the Washington State Department of Health (WADOH) for clarity and relevance. The final interview guide consisted of 20 open-ended questions that were covered in each interview. Description of data analysis All interviews were professionally transcribed verbatim. Qualitative data analysis software (Dedoose version 7.5.9) was used to support coding and analysis. Using a sample of two interviews and a thematic analysis approach, the research team (J.J.O., C.B., and L.R.) developed deductive codes based on the ACF. Major variations within categories were identified inductively as they emerged. This process continued until a preliminary codebook was developed. Two researchers (C.B. and L.R.) independently double-coded six interviews to reconcile codes and revise the code list. Discrepancies were discussed until consensus was reached, and the codebook was modified to final. The final codebook was used to double-code (C.B., L.R., and J.J.O.) two interviews to ensure reliability. The remaining interviews were coded by one researcher (C.B.) in conjunction with regular discussion meetings with team members (J.J.O.) trained in qualitative research. We used the ACF to describe EO 13-06 policy development (Fig. 1). Illustrative quotes are given in Table 2. Table 2 Selected illustrative quotes that describe the parameters, events, beliefs, strategies, resources, constraints, and recommendations that influenced the passage of Executive Order 13-06: “Improving the Health and Productivity of State Employees, and Access to Healthy Foods in State Facilities,” Key Players Involved in the Development and Passage of Executive Order 13-06, Washington State 2016 Theme/subtheme  Illustrative quote  Relatively stable parameters   Businesses need to make a profit  “They were scared because they so rely on customer choice for making a profit in their businesses.”   High rates of obesity and chronic disease have led to rising healthcare costs  “I think that just seeing the obesity epidemic and the rising costs to take care of people, folks started getting on the bandwagon of the healthy choice, making the healthy choice the easy choice.”  External events   Election of Governor Inslee  “I think just the Governor's interest in employee health and wellness. So it starts from there because if he wasn't interested this wouldn't happen.”   Increased local, state, and national health momentum to support health and wellness initiatives  “I think it helped to show that there was a push towards this going across the country. I think to show that nationally HHS was funding this, CDC was doing it, and then obviously it was happening within the HHS cafeterias…”  Beliefs   Prevention efforts should focus on shaping the environment  “…and so much of that is really shaping the environment where people live. If people don’t have the opportunity to make a healthy choice, then they can’t and won’t. And that can have an impact on their health”   The government should act as a role model  “This idea that government spends a lot of time telling people what to do. And this is sort of a walk the talk. Like government tells us to eat healthier, so they should serve healthier food. Like it's sort of a walking around practicing what they say.”   It is important to give people the opportunity to make the healthy choice at work  “…I do think that there is a benefit to trying to shape the environment by offering healthier choices. And I do think that businesses, management, companies, vendors, whomever, can play a role in that.”   The role of government does not involve telling people what to eat  “…there continues to be a real concern about any kind of policy change that tastes, smells or looks like what people call a nanny state.”   Cafeteria operators/vendors felt that they would lose revenue and profit  “I think their main concern was that they needed to keep their businesses viable.”  Coalition strategies   Balance between healthy and unhealthy options  “We spend a lot of our time here at work and I think that there's those people will say that they have their right to a Snickers bar; that's something we hear. Other people also have a right to healthy options. So at least for the healthy nutrition guidelines we are really striving for that balance of the two.”   Gradual implementation of the food service guidelines  “…and I think the gradual implementation of these standards…reassured that they were probably able to meet the majority of them...it was set up so it wasn't like we flip a switch and everybody's expected to do that.”   Flexibility in how the food service guidelines could be achieved  “We created cafeteria guidelines that really gave the cafeteria workers some choice so that it wasn't like they had to do everything on the list. They could choose what worked best for them."   Creating a workgroup  “I think it was valuing input from the folks who were most concerned of the impact…it was really including them in the process…and making space for them to share their concerns…Sometimes it was just listening but then not changing the criteria. And then trying to think about, okay, so how can we address that when we get to implementation? So not necessarily just always modifying based on their concerns, but really thinking through, okay, here's how we can do this when we do get to implementation. Here's where we can make some changes and make that more practical for operators.”   Framing the policy  “In the wellness arena, you can't just say, we have healthier employees, isn't that great? No. We have healthier employees that can now be more productive workers, right? There's the bottom line piece to it.”  Constraints and resources   Champions who support the policy  “What a state really has to do is find key leaders, whether it's in an agency like Services for the Blind or whether it's sort of in the health advocacy group…find people who have this vision and have them start the conversation everywhere.”   One full-time dedicated staff member  “I think that having the resource of a full FTE really helped working with the other stakeholders to get them involved in the process, engaged in the process ... which eventually led them to being somewhat supportive of it. I would never say everyone was 100 percent supportive, but it got people onboard and they weren't as scared of it.”   Dedicated team with diverse expertise  “Really dedicated staff that kept bringing research and evidence to key stakeholders was instrumental. I think they had a really strong team and strong consultants working on this issue who were really well-versed in policy and decision making, people who were familiar with how to frame things and messaging...”   Introducing the policy into the legislature first  “The legislative arena is a way to air out the issue and see who's with you, who's not and what the issues are. So even if you want to do an executive order, there's not this due diligence notion that a legislative approach can provide, because that's going to be some of the questions you're going to hear from the governor's staff which is, all right, this sounds like a good idea. Who have you talked to? Who likes it? Who doesn't like it and why? And so writing it out legislatively allows you to answer that question.”   Existing relationships between proponents of the policy  “All of the years of stakeholdering that had happened prior to that, I think a lot of compromise had already been reached and a lot of legwork already done to bring people together.”   Resources used from other states doing similar work  “So we did utilize the current work products from a number of different places, like New York City and Santa Clara County and Los Angeles, as well as Seattle, King County. There was some of the bigger city health departments who were grabbing this, not necessarily all aspects of food service, but, certainly, vending was there and then we started to see concession and cafeteria standards.”  Recommendations   Share success stories  “I think a lot of fear was that it wouldn’t be affordable, or there wouldn’t be enough healthy options to like fill the machines, or to fill a concession stand. And so the more kind of examples we could point to of where this was happening, the easier it got to kind of make the case for, no, this is available and there are people doing it; we can too.”   Understand the landscape  “I would say that people would want to be very clear…that they really educate themselves on all these different logistical elements around the food policy…what's involved in the contracting mechanism of how you would change the requirements.”   Shorter phase-in period  “I would encourage others to negotiate the phase-in period as strongly as they can. I think some phase-in is good, but two to three years for difference pieces is really super generous, so that could probably be shortened up.”   An EO may be a quicker way to get the policy passed  “I do think the EO is well suited for this issue area. So a legislative approach is another menu choice, another avenue to take. But if you can get the buy-in of governor and governor staff, you can accelerate this work quite a bit, because it’s just a lot less people to twist arms about.”   Early opposition engagement  “I think there are some states where the vendors have made this work very, very difficult. Engaging them early I think can be incredibly helpful, both from kind of neutralizing that opposition, but also, from a campaign’s perspective, really doing their learning and understanding of how this works and what the vendors have available to them, how it typically works in a vending machine setting, how a cafeteria setting might work.”  Theme/subtheme  Illustrative quote  Relatively stable parameters   Businesses need to make a profit  “They were scared because they so rely on customer choice for making a profit in their businesses.”   High rates of obesity and chronic disease have led to rising healthcare costs  “I think that just seeing the obesity epidemic and the rising costs to take care of people, folks started getting on the bandwagon of the healthy choice, making the healthy choice the easy choice.”  External events   Election of Governor Inslee  “I think just the Governor's interest in employee health and wellness. So it starts from there because if he wasn't interested this wouldn't happen.”   Increased local, state, and national health momentum to support health and wellness initiatives  “I think it helped to show that there was a push towards this going across the country. I think to show that nationally HHS was funding this, CDC was doing it, and then obviously it was happening within the HHS cafeterias…”  Beliefs   Prevention efforts should focus on shaping the environment  “…and so much of that is really shaping the environment where people live. If people don’t have the opportunity to make a healthy choice, then they can’t and won’t. And that can have an impact on their health”   The government should act as a role model  “This idea that government spends a lot of time telling people what to do. And this is sort of a walk the talk. Like government tells us to eat healthier, so they should serve healthier food. Like it's sort of a walking around practicing what they say.”   It is important to give people the opportunity to make the healthy choice at work  “…I do think that there is a benefit to trying to shape the environment by offering healthier choices. And I do think that businesses, management, companies, vendors, whomever, can play a role in that.”   The role of government does not involve telling people what to eat  “…there continues to be a real concern about any kind of policy change that tastes, smells or looks like what people call a nanny state.”   Cafeteria operators/vendors felt that they would lose revenue and profit  “I think their main concern was that they needed to keep their businesses viable.”  Coalition strategies   Balance between healthy and unhealthy options  “We spend a lot of our time here at work and I think that there's those people will say that they have their right to a Snickers bar; that's something we hear. Other people also have a right to healthy options. So at least for the healthy nutrition guidelines we are really striving for that balance of the two.”   Gradual implementation of the food service guidelines  “…and I think the gradual implementation of these standards…reassured that they were probably able to meet the majority of them...it was set up so it wasn't like we flip a switch and everybody's expected to do that.”   Flexibility in how the food service guidelines could be achieved  “We created cafeteria guidelines that really gave the cafeteria workers some choice so that it wasn't like they had to do everything on the list. They could choose what worked best for them."   Creating a workgroup  “I think it was valuing input from the folks who were most concerned of the impact…it was really including them in the process…and making space for them to share their concerns…Sometimes it was just listening but then not changing the criteria. And then trying to think about, okay, so how can we address that when we get to implementation? So not necessarily just always modifying based on their concerns, but really thinking through, okay, here's how we can do this when we do get to implementation. Here's where we can make some changes and make that more practical for operators.”   Framing the policy  “In the wellness arena, you can't just say, we have healthier employees, isn't that great? No. We have healthier employees that can now be more productive workers, right? There's the bottom line piece to it.”  Constraints and resources   Champions who support the policy  “What a state really has to do is find key leaders, whether it's in an agency like Services for the Blind or whether it's sort of in the health advocacy group…find people who have this vision and have them start the conversation everywhere.”   One full-time dedicated staff member  “I think that having the resource of a full FTE really helped working with the other stakeholders to get them involved in the process, engaged in the process ... which eventually led them to being somewhat supportive of it. I would never say everyone was 100 percent supportive, but it got people onboard and they weren't as scared of it.”   Dedicated team with diverse expertise  “Really dedicated staff that kept bringing research and evidence to key stakeholders was instrumental. I think they had a really strong team and strong consultants working on this issue who were really well-versed in policy and decision making, people who were familiar with how to frame things and messaging...”   Introducing the policy into the legislature first  “The legislative arena is a way to air out the issue and see who's with you, who's not and what the issues are. So even if you want to do an executive order, there's not this due diligence notion that a legislative approach can provide, because that's going to be some of the questions you're going to hear from the governor's staff which is, all right, this sounds like a good idea. Who have you talked to? Who likes it? Who doesn't like it and why? And so writing it out legislatively allows you to answer that question.”   Existing relationships between proponents of the policy  “All of the years of stakeholdering that had happened prior to that, I think a lot of compromise had already been reached and a lot of legwork already done to bring people together.”   Resources used from other states doing similar work  “So we did utilize the current work products from a number of different places, like New York City and Santa Clara County and Los Angeles, as well as Seattle, King County. There was some of the bigger city health departments who were grabbing this, not necessarily all aspects of food service, but, certainly, vending was there and then we started to see concession and cafeteria standards.”  Recommendations   Share success stories  “I think a lot of fear was that it wouldn’t be affordable, or there wouldn’t be enough healthy options to like fill the machines, or to fill a concession stand. And so the more kind of examples we could point to of where this was happening, the easier it got to kind of make the case for, no, this is available and there are people doing it; we can too.”   Understand the landscape  “I would say that people would want to be very clear…that they really educate themselves on all these different logistical elements around the food policy…what's involved in the contracting mechanism of how you would change the requirements.”   Shorter phase-in period  “I would encourage others to negotiate the phase-in period as strongly as they can. I think some phase-in is good, but two to three years for difference pieces is really super generous, so that could probably be shortened up.”   An EO may be a quicker way to get the policy passed  “I do think the EO is well suited for this issue area. So a legislative approach is another menu choice, another avenue to take. But if you can get the buy-in of governor and governor staff, you can accelerate this work quite a bit, because it’s just a lot less people to twist arms about.”   Early opposition engagement  “I think there are some states where the vendors have made this work very, very difficult. Engaging them early I think can be incredibly helpful, both from kind of neutralizing that opposition, but also, from a campaign’s perspective, really doing their learning and understanding of how this works and what the vendors have available to them, how it typically works in a vending machine setting, how a cafeteria setting might work.”  View Large Table 2 Selected illustrative quotes that describe the parameters, events, beliefs, strategies, resources, constraints, and recommendations that influenced the passage of Executive Order 13-06: “Improving the Health and Productivity of State Employees, and Access to Healthy Foods in State Facilities,” Key Players Involved in the Development and Passage of Executive Order 13-06, Washington State 2016 Theme/subtheme  Illustrative quote  Relatively stable parameters   Businesses need to make a profit  “They were scared because they so rely on customer choice for making a profit in their businesses.”   High rates of obesity and chronic disease have led to rising healthcare costs  “I think that just seeing the obesity epidemic and the rising costs to take care of people, folks started getting on the bandwagon of the healthy choice, making the healthy choice the easy choice.”  External events   Election of Governor Inslee  “I think just the Governor's interest in employee health and wellness. So it starts from there because if he wasn't interested this wouldn't happen.”   Increased local, state, and national health momentum to support health and wellness initiatives  “I think it helped to show that there was a push towards this going across the country. I think to show that nationally HHS was funding this, CDC was doing it, and then obviously it was happening within the HHS cafeterias…”  Beliefs   Prevention efforts should focus on shaping the environment  “…and so much of that is really shaping the environment where people live. If people don’t have the opportunity to make a healthy choice, then they can’t and won’t. And that can have an impact on their health”   The government should act as a role model  “This idea that government spends a lot of time telling people what to do. And this is sort of a walk the talk. Like government tells us to eat healthier, so they should serve healthier food. Like it's sort of a walking around practicing what they say.”   It is important to give people the opportunity to make the healthy choice at work  “…I do think that there is a benefit to trying to shape the environment by offering healthier choices. And I do think that businesses, management, companies, vendors, whomever, can play a role in that.”   The role of government does not involve telling people what to eat  “…there continues to be a real concern about any kind of policy change that tastes, smells or looks like what people call a nanny state.”   Cafeteria operators/vendors felt that they would lose revenue and profit  “I think their main concern was that they needed to keep their businesses viable.”  Coalition strategies   Balance between healthy and unhealthy options  “We spend a lot of our time here at work and I think that there's those people will say that they have their right to a Snickers bar; that's something we hear. Other people also have a right to healthy options. So at least for the healthy nutrition guidelines we are really striving for that balance of the two.”   Gradual implementation of the food service guidelines  “…and I think the gradual implementation of these standards…reassured that they were probably able to meet the majority of them...it was set up so it wasn't like we flip a switch and everybody's expected to do that.”   Flexibility in how the food service guidelines could be achieved  “We created cafeteria guidelines that really gave the cafeteria workers some choice so that it wasn't like they had to do everything on the list. They could choose what worked best for them."   Creating a workgroup  “I think it was valuing input from the folks who were most concerned of the impact…it was really including them in the process…and making space for them to share their concerns…Sometimes it was just listening but then not changing the criteria. And then trying to think about, okay, so how can we address that when we get to implementation? So not necessarily just always modifying based on their concerns, but really thinking through, okay, here's how we can do this when we do get to implementation. Here's where we can make some changes and make that more practical for operators.”   Framing the policy  “In the wellness arena, you can't just say, we have healthier employees, isn't that great? No. We have healthier employees that can now be more productive workers, right? There's the bottom line piece to it.”  Constraints and resources   Champions who support the policy  “What a state really has to do is find key leaders, whether it's in an agency like Services for the Blind or whether it's sort of in the health advocacy group…find people who have this vision and have them start the conversation everywhere.”   One full-time dedicated staff member  “I think that having the resource of a full FTE really helped working with the other stakeholders to get them involved in the process, engaged in the process ... which eventually led them to being somewhat supportive of it. I would never say everyone was 100 percent supportive, but it got people onboard and they weren't as scared of it.”   Dedicated team with diverse expertise  “Really dedicated staff that kept bringing research and evidence to key stakeholders was instrumental. I think they had a really strong team and strong consultants working on this issue who were really well-versed in policy and decision making, people who were familiar with how to frame things and messaging...”   Introducing the policy into the legislature first  “The legislative arena is a way to air out the issue and see who's with you, who's not and what the issues are. So even if you want to do an executive order, there's not this due diligence notion that a legislative approach can provide, because that's going to be some of the questions you're going to hear from the governor's staff which is, all right, this sounds like a good idea. Who have you talked to? Who likes it? Who doesn't like it and why? And so writing it out legislatively allows you to answer that question.”   Existing relationships between proponents of the policy  “All of the years of stakeholdering that had happened prior to that, I think a lot of compromise had already been reached and a lot of legwork already done to bring people together.”   Resources used from other states doing similar work  “So we did utilize the current work products from a number of different places, like New York City and Santa Clara County and Los Angeles, as well as Seattle, King County. There was some of the bigger city health departments who were grabbing this, not necessarily all aspects of food service, but, certainly, vending was there and then we started to see concession and cafeteria standards.”  Recommendations   Share success stories  “I think a lot of fear was that it wouldn’t be affordable, or there wouldn’t be enough healthy options to like fill the machines, or to fill a concession stand. And so the more kind of examples we could point to of where this was happening, the easier it got to kind of make the case for, no, this is available and there are people doing it; we can too.”   Understand the landscape  “I would say that people would want to be very clear…that they really educate themselves on all these different logistical elements around the food policy…what's involved in the contracting mechanism of how you would change the requirements.”   Shorter phase-in period  “I would encourage others to negotiate the phase-in period as strongly as they can. I think some phase-in is good, but two to three years for difference pieces is really super generous, so that could probably be shortened up.”   An EO may be a quicker way to get the policy passed  “I do think the EO is well suited for this issue area. So a legislative approach is another menu choice, another avenue to take. But if you can get the buy-in of governor and governor staff, you can accelerate this work quite a bit, because it’s just a lot less people to twist arms about.”   Early opposition engagement  “I think there are some states where the vendors have made this work very, very difficult. Engaging them early I think can be incredibly helpful, both from kind of neutralizing that opposition, but also, from a campaign’s perspective, really doing their learning and understanding of how this works and what the vendors have available to them, how it typically works in a vending machine setting, how a cafeteria setting might work.”  Theme/subtheme  Illustrative quote  Relatively stable parameters   Businesses need to make a profit  “They were scared because they so rely on customer choice for making a profit in their businesses.”   High rates of obesity and chronic disease have led to rising healthcare costs  “I think that just seeing the obesity epidemic and the rising costs to take care of people, folks started getting on the bandwagon of the healthy choice, making the healthy choice the easy choice.”  External events   Election of Governor Inslee  “I think just the Governor's interest in employee health and wellness. So it starts from there because if he wasn't interested this wouldn't happen.”   Increased local, state, and national health momentum to support health and wellness initiatives  “I think it helped to show that there was a push towards this going across the country. I think to show that nationally HHS was funding this, CDC was doing it, and then obviously it was happening within the HHS cafeterias…”  Beliefs   Prevention efforts should focus on shaping the environment  “…and so much of that is really shaping the environment where people live. If people don’t have the opportunity to make a healthy choice, then they can’t and won’t. And that can have an impact on their health”   The government should act as a role model  “This idea that government spends a lot of time telling people what to do. And this is sort of a walk the talk. Like government tells us to eat healthier, so they should serve healthier food. Like it's sort of a walking around practicing what they say.”   It is important to give people the opportunity to make the healthy choice at work  “…I do think that there is a benefit to trying to shape the environment by offering healthier choices. And I do think that businesses, management, companies, vendors, whomever, can play a role in that.”   The role of government does not involve telling people what to eat  “…there continues to be a real concern about any kind of policy change that tastes, smells or looks like what people call a nanny state.”   Cafeteria operators/vendors felt that they would lose revenue and profit  “I think their main concern was that they needed to keep their businesses viable.”  Coalition strategies   Balance between healthy and unhealthy options  “We spend a lot of our time here at work and I think that there's those people will say that they have their right to a Snickers bar; that's something we hear. Other people also have a right to healthy options. So at least for the healthy nutrition guidelines we are really striving for that balance of the two.”   Gradual implementation of the food service guidelines  “…and I think the gradual implementation of these standards…reassured that they were probably able to meet the majority of them...it was set up so it wasn't like we flip a switch and everybody's expected to do that.”   Flexibility in how the food service guidelines could be achieved  “We created cafeteria guidelines that really gave the cafeteria workers some choice so that it wasn't like they had to do everything on the list. They could choose what worked best for them."   Creating a workgroup  “I think it was valuing input from the folks who were most concerned of the impact…it was really including them in the process…and making space for them to share their concerns…Sometimes it was just listening but then not changing the criteria. And then trying to think about, okay, so how can we address that when we get to implementation? So not necessarily just always modifying based on their concerns, but really thinking through, okay, here's how we can do this when we do get to implementation. Here's where we can make some changes and make that more practical for operators.”   Framing the policy  “In the wellness arena, you can't just say, we have healthier employees, isn't that great? No. We have healthier employees that can now be more productive workers, right? There's the bottom line piece to it.”  Constraints and resources   Champions who support the policy  “What a state really has to do is find key leaders, whether it's in an agency like Services for the Blind or whether it's sort of in the health advocacy group…find people who have this vision and have them start the conversation everywhere.”   One full-time dedicated staff member  “I think that having the resource of a full FTE really helped working with the other stakeholders to get them involved in the process, engaged in the process ... which eventually led them to being somewhat supportive of it. I would never say everyone was 100 percent supportive, but it got people onboard and they weren't as scared of it.”   Dedicated team with diverse expertise  “Really dedicated staff that kept bringing research and evidence to key stakeholders was instrumental. I think they had a really strong team and strong consultants working on this issue who were really well-versed in policy and decision making, people who were familiar with how to frame things and messaging...”   Introducing the policy into the legislature first  “The legislative arena is a way to air out the issue and see who's with you, who's not and what the issues are. So even if you want to do an executive order, there's not this due diligence notion that a legislative approach can provide, because that's going to be some of the questions you're going to hear from the governor's staff which is, all right, this sounds like a good idea. Who have you talked to? Who likes it? Who doesn't like it and why? And so writing it out legislatively allows you to answer that question.”   Existing relationships between proponents of the policy  “All of the years of stakeholdering that had happened prior to that, I think a lot of compromise had already been reached and a lot of legwork already done to bring people together.”   Resources used from other states doing similar work  “So we did utilize the current work products from a number of different places, like New York City and Santa Clara County and Los Angeles, as well as Seattle, King County. There was some of the bigger city health departments who were grabbing this, not necessarily all aspects of food service, but, certainly, vending was there and then we started to see concession and cafeteria standards.”  Recommendations   Share success stories  “I think a lot of fear was that it wouldn’t be affordable, or there wouldn’t be enough healthy options to like fill the machines, or to fill a concession stand. And so the more kind of examples we could point to of where this was happening, the easier it got to kind of make the case for, no, this is available and there are people doing it; we can too.”   Understand the landscape  “I would say that people would want to be very clear…that they really educate themselves on all these different logistical elements around the food policy…what's involved in the contracting mechanism of how you would change the requirements.”   Shorter phase-in period  “I would encourage others to negotiate the phase-in period as strongly as they can. I think some phase-in is good, but two to three years for difference pieces is really super generous, so that could probably be shortened up.”   An EO may be a quicker way to get the policy passed  “I do think the EO is well suited for this issue area. So a legislative approach is another menu choice, another avenue to take. But if you can get the buy-in of governor and governor staff, you can accelerate this work quite a bit, because it’s just a lot less people to twist arms about.”   Early opposition engagement  “I think there are some states where the vendors have made this work very, very difficult. Engaging them early I think can be incredibly helpful, both from kind of neutralizing that opposition, but also, from a campaign’s perspective, really doing their learning and understanding of how this works and what the vendors have available to them, how it typically works in a vending machine setting, how a cafeteria setting might work.”  View Large Fig. 1 | View largeDownload slide A modified Advocacy Coalition Framework for the passage of Washington State Executive Order 13-06: “Improving the Health and Productivity of State Employees, and Access to Healthy Foods in State Facilities.” Adapted with permission from Breton et al. [19]. Fig. 1 | View largeDownload slide A modified Advocacy Coalition Framework for the passage of Washington State Executive Order 13-06: “Improving the Health and Productivity of State Employees, and Access to Healthy Foods in State Facilities.” Adapted with permission from Breton et al. [19]. Ethical issues The University of Washington Institutional Review Board approved the study. Participants received written and verbal information about the study prior to obtaining verbal informed consent. RESULTS Evolution of EO 13-06 The idea to develop a policy introducing FSG in Washington State government facilities originated in 2010 through collaboration between two proponent coalition members. Variations of the policy were introduced into the legislative arena three times (2011–2013) before being integrated into a worksite wellness executive order issued by Governor Inslee in 2013. Despite multiple failed attempts in the legislature, most interviewees agreed that introducing the policy in the legislature first was beneficial because it allowed proponents to identify opponents of the policy and to address the reasons behind their lack of support. Interviewees also agreed that positioning the policy as part of a larger executive order on worksite wellness, and framing the policy as a platform to improve worker productivity, was key to its passage. Important key players Collaboration between proponents and opponents was crucial to understanding and overcoming challenges perceived by opponents. Interviewees underscored the roles of two key players: Washington State Department of Services for the Blind (WADSB) and WADOH. WADSB oversees the state’s Randolph-Sheppard Business Enterprise Program, a vending business program that gives legally blind adults the opportunity to run and manage vending facilities on specific public properties across the USA. Many of the cafeterias, delis, and espresso stands in Washington State facilities are operated by WADSB vendors [18]. WADOH assisted with writing EO 13-06, convened the workgroup that developed the FSG, and was responsible for the rollout and implementation of the FSG in agencies. Parameters and external events Coalition members’ behaviors are influenced by stable and dynamic factors outside of the policy subsystem. Interviewees agreed on the relatively stable parameters that influenced the development and passage of EO 13-06 [13], which included improving the health of the general population; that high rates of obesity and diet-related chronic disease have led to rising healthcare costs; and that cafeteria operators and/or vendors need to make a profit. External events mentioned by interviewees that contributed to the passage and development of EO 13-06 included: growing local and national momentum to improve population health by focusing on prevention; Governor Inslee’s election into office; and support from Inslee’s staff and members of the legislature for a policy that increased access to healthier food and beverages. Interviewees mentioned that the economic recession in Washington State, and tight agency budgets, created a challenging environment to pass a new policy. Proponents argued that increasing healthier food and beverage choices would reduce long-term healthcare costs, and opponents argued that agencies did not have the financial resources to comply with FSG. Between 2011 and 2013, WADOH convened a stakeholder working group that explored how to meet the goals of FSG proponents and address the concerns of opponents. Core policy beliefs The ACF suggests that policy actors’ core policy beliefs are translated into policy-level actions; specifically, policy core beliefs are the foundation for forming coalitions, developing alliances, and coordinating collaboration between policy subsystem members [13]. Most proponents of EO 13-06 interviewed agreed that government should act as a role model to its employees by providing healthy food options at worksites, that it is important to give people the opportunity to make a healthy choice at work, and that employee demand for healthier options exists. Other beliefs mentioned included that productivity increases if employees are healthy, and providing healthier options will lower healthcare costs. The majority of interviewees also provided their perspectives on opponents’ beliefs, including: the role of government does not include telling people what to eat; EO 13-06 would reduce cafeteria operators’ profits; EO 13-06 would restrict people’s choice; and that employee support was mixed. Coalition resources Several resources mentioned by interviewees that contributed to the development of EO 13-06 included: precedent set by local and state agencies doing less widespread, but similar and successful FSG work (e.g., Massachusetts), a full-time WADOH staff member dedicated to mobilizing stakeholder support by engaging them in the early stages of the passage and implementation of EO 13-06, and a strong team of diverse experts among proponents (i.e., lobbyists, topic matter experts, and staff with coalition experience) who influenced key stakeholders by presenting them with research and evidence to support policy passage. Repeating the legislative process three times allowed various stakeholders to develop relationships with key players, including the governor’s staff, which helped streamline future communication efforts. Coalition constraints Constraints mentioned by some interviewees included: prioritizing other policies in the legislative sessions, perceived high cost of implementation, lack of precedent and evidence that a comprehensive FSG statewide policy could be successful, perceived difficulties with compliance, initial lack of support and collaboration between stakeholders, pushback from WADSB, and the amount of time required to develop, implement, and evaluate the policy. Coalition strategies A workgroup of stakeholders that would be affected by the policy, as well as nutrition professionals and agency leaders, was created to increase collaboration and garner opposition buy-in. The workgroup researched existing voluntary FSG as a basis for developing the Washington State FSG. Workgroup members provided feedback on the feasibility of adhering to the guidelines, and subsequent compromises were made. These compromises included flexibility on: how to meet the guidelines (i.e., cafeteria managers were able to choose which guidelines to follow as long as they earned enough points to reach compliance), when guidelines should be food based versus nutrient based, and making the implementation timeline feasible. Discussion within the workgroup also allowed insights into where implementation challenges might arise and thus where additional technical assistance might be needed. DISCUSSION Research into FSG policy processes is limited but critical to understanding how to approach future policy initiatives [20]. Implementing new policies to create an environment that supports healthy eating in the workplace has the potential to reach millions of people [21]. Based on the health impact pyramid framework, changing environments to make healthy options the default choice is the second most desirable intervention for achieving potential public impact after changing socioeconomic factors [22]. However, as of 2014, only 3% of U.S. municipalities had nutrition standards for foods served and sold in government buildings and worksites [21]. Resources, such as the CDC’s updated Food Service Guidelines for Federal Facilities (FSG for Federal Facilities) and Smart Food Choices: How to Implement Food Service Guidelines in Public Facilities (How to Implement FSG), are available to assist with the development of FSG standards and implementation [23, 24]. However, successful FSG policy development requires a comprehensive understanding of the complexity of FSG policy passage in unique political environments. To our knowledge, this is the first study to analyze the development and passage of statewide comprehensive FSG to increase the availability of healthier foods and beverages in state facilities. Exploring best practices and lessons learned from EO 13-06 provides insights for addressing challenges that prevent FSG policy development and passage. Our recommendations (see Table 3) complement those in CDC’s FSG for Federal Facilities and How to Implement FSG and illustrate ways that public agencies can apply knowledge to facilitate future policy adoption [23, 24]. Table 3 Recommendations to inform Food Service Guidelines development and passage in agencies, states, and municipalities, results from qualitative interviews with key players involved in the development and passage of Executive Order 13-06: “Improving the Health and Productivity of State Employees, and Access to Healthy Foods in State Facilities,” Washington State 2016 Thematic category  Recommendations  Initial policy development  Early stakeholder engagement, particularly with those most impacted by the policy, (vendors, cafeteria operators, and agency leaders) and developing partnerships with coalitions.  Convene a workgroup of diverse stakeholders to develop the guidelines and to discuss implementation challenges and strategies.  Assemble agency, coalition, and legislative champions.  Writing the food service guidelines/policy  Grant agency exemptions where existing legislation conflicts with the guidelines.  Consider the feasibility of, and barriers to, using food-based versus nutrient-based guidelines.  Model the food service guidelines after existing successful policies and guidelines.  Strategize the best policy vehicle (i.e., an executive order versus another form of legislation).  Policy passage strategies  Make sure the political environment and timing are conducive to passing the policy, and be prepared to jump when an opportunity presents itself.  Expand the frame beyond improving individual health.  Include both the public health and business perspective (i.e., businesses still need to make a profit).  Use an analysis of coalitions and policy beliefs to strategically market and frame the policy (i.e., it is not about taking away choices, but offering healthier choices; it is an opportunity for the state to be a leader).  Long-term sustainability of the policy  Develop a plan for evaluation, monitoring, recognition of successes, and long-term sustainability.  Continue to engage stakeholders and provide technical assistance if agencies need assistance strategizing how to follow the guidelines.  Provide educational resources to employees to help them understand the policy changes, and to agency leaders so they can help promote implementation.  Thematic category  Recommendations  Initial policy development  Early stakeholder engagement, particularly with those most impacted by the policy, (vendors, cafeteria operators, and agency leaders) and developing partnerships with coalitions.  Convene a workgroup of diverse stakeholders to develop the guidelines and to discuss implementation challenges and strategies.  Assemble agency, coalition, and legislative champions.  Writing the food service guidelines/policy  Grant agency exemptions where existing legislation conflicts with the guidelines.  Consider the feasibility of, and barriers to, using food-based versus nutrient-based guidelines.  Model the food service guidelines after existing successful policies and guidelines.  Strategize the best policy vehicle (i.e., an executive order versus another form of legislation).  Policy passage strategies  Make sure the political environment and timing are conducive to passing the policy, and be prepared to jump when an opportunity presents itself.  Expand the frame beyond improving individual health.  Include both the public health and business perspective (i.e., businesses still need to make a profit).  Use an analysis of coalitions and policy beliefs to strategically market and frame the policy (i.e., it is not about taking away choices, but offering healthier choices; it is an opportunity for the state to be a leader).  Long-term sustainability of the policy  Develop a plan for evaluation, monitoring, recognition of successes, and long-term sustainability.  Continue to engage stakeholders and provide technical assistance if agencies need assistance strategizing how to follow the guidelines.  Provide educational resources to employees to help them understand the policy changes, and to agency leaders so they can help promote implementation.  View Large Table 3 Recommendations to inform Food Service Guidelines development and passage in agencies, states, and municipalities, results from qualitative interviews with key players involved in the development and passage of Executive Order 13-06: “Improving the Health and Productivity of State Employees, and Access to Healthy Foods in State Facilities,” Washington State 2016 Thematic category  Recommendations  Initial policy development  Early stakeholder engagement, particularly with those most impacted by the policy, (vendors, cafeteria operators, and agency leaders) and developing partnerships with coalitions.  Convene a workgroup of diverse stakeholders to develop the guidelines and to discuss implementation challenges and strategies.  Assemble agency, coalition, and legislative champions.  Writing the food service guidelines/policy  Grant agency exemptions where existing legislation conflicts with the guidelines.  Consider the feasibility of, and barriers to, using food-based versus nutrient-based guidelines.  Model the food service guidelines after existing successful policies and guidelines.  Strategize the best policy vehicle (i.e., an executive order versus another form of legislation).  Policy passage strategies  Make sure the political environment and timing are conducive to passing the policy, and be prepared to jump when an opportunity presents itself.  Expand the frame beyond improving individual health.  Include both the public health and business perspective (i.e., businesses still need to make a profit).  Use an analysis of coalitions and policy beliefs to strategically market and frame the policy (i.e., it is not about taking away choices, but offering healthier choices; it is an opportunity for the state to be a leader).  Long-term sustainability of the policy  Develop a plan for evaluation, monitoring, recognition of successes, and long-term sustainability.  Continue to engage stakeholders and provide technical assistance if agencies need assistance strategizing how to follow the guidelines.  Provide educational resources to employees to help them understand the policy changes, and to agency leaders so they can help promote implementation.  Thematic category  Recommendations  Initial policy development  Early stakeholder engagement, particularly with those most impacted by the policy, (vendors, cafeteria operators, and agency leaders) and developing partnerships with coalitions.  Convene a workgroup of diverse stakeholders to develop the guidelines and to discuss implementation challenges and strategies.  Assemble agency, coalition, and legislative champions.  Writing the food service guidelines/policy  Grant agency exemptions where existing legislation conflicts with the guidelines.  Consider the feasibility of, and barriers to, using food-based versus nutrient-based guidelines.  Model the food service guidelines after existing successful policies and guidelines.  Strategize the best policy vehicle (i.e., an executive order versus another form of legislation).  Policy passage strategies  Make sure the political environment and timing are conducive to passing the policy, and be prepared to jump when an opportunity presents itself.  Expand the frame beyond improving individual health.  Include both the public health and business perspective (i.e., businesses still need to make a profit).  Use an analysis of coalitions and policy beliefs to strategically market and frame the policy (i.e., it is not about taking away choices, but offering healthier choices; it is an opportunity for the state to be a leader).  Long-term sustainability of the policy  Develop a plan for evaluation, monitoring, recognition of successes, and long-term sustainability.  Continue to engage stakeholders and provide technical assistance if agencies need assistance strategizing how to follow the guidelines.  Provide educational resources to employees to help them understand the policy changes, and to agency leaders so they can help promote implementation.  View Large This study finds early stakeholder engagement to be a critical component to successful FSG policy passage. Involving stakeholders who will be affected by the FSG early and proactively can provide opportunities to hear and address potential concerns and modify guidelines toward agreement. For example, during the first legislative attempt to adopt the FSG, opposing coalition members stated that compliance would negatively impact profits. This initial resistance stemmed from a misunderstanding regarding the goals of the FSG; proponent engagement with opponents shifted these attitudes from opposed to neutral by the third legislative session. Creation of a workgroup was considered the most effective method for stakeholder engagement and buy-in. The WADOH established a workgroup composed of diverse stakeholders from clinical and public health nutrition, state institutions, local health jurisdictions, and other parties affected by the policy (i.e., WADSB, cafeteria, and vending operators). This gave opponents an opportunity to voice their concerns so guidelines could be appropriately modified. Workgroup meetings also allowed stakeholders to understand how existing vendor contracts might interfere with FSG compliance, explore available and feasible vending options, and provide anonymous feedback. The recommendation to create a workgroup is included in CDC’s How to Implement FSG [23]. Other examples of workgroups used to facilitate FSG include the Iowa Capitol Complex Vending Project, an internal Department of Public Health ad hoc committee in Massachusetts, and The Los Angeles County Department of Public Health advisory committee [23]. Another successful strategy identified in this study was the assembly of FSG champions within agencies, coalitions, and the community to rally partner organizations, thus broadening the coalition and building support over time. This finding aligns with recommendations made in How to Implement FSG which encourages the identification of champions and partners—such as governors, mayors, local council members, wellness coordinators, public health staff, and blind entrepreneurs—to assist with the adoption of FSG [23]. In Washington State specifically, the Governor, Secretary of Health, and leadership in the Senate and House of Representatives collectively shared a strong interest in employee health and wellness. Support from these actors, especially the Governor, was essential for EO 13-06 passage and highlighted the importance of considering the political environment when choosing the FSG policy vehicle. At the time that EO 13-06 passed in Washington State, interviewees believed that the political environment favored integrating FSG into an executive order and that this required flexibility with the scope of the FSG impact. While a governor-issued executive order is difficult to enforce and applies only to public agencies under the executive branch, an executive order accelerated the policy process and aligned well with the policy goals. This study also revealed the importance of expanding the frame of FSG policy beyond improving individual health. By focusing on increasing worker productivity as part of a comprehensive worksite wellness policy, EO 13-06 was able to build traction as part of a larger worksite benefit. Other recent examples of FSG-related legislation that have passed under a worksite wellness frame include EO 17-15 “Healthy Vending” [25], signed by Governor John Bel Edwards of Louisiana on June 30, 2017, and the DC Department of Human Resources (DCHR) Instruction No. 20B-9, “Workplace Wellness Program,” effective on April 18, 2016 [26]. Modeling a FSG policy after existing successful policies and guidelines can make it more accepted and ease opposition anxiety. Several contrasting beliefs existed between proponents and opponents of EO 13-06 regarding whether healthy food would cause vendors and cafeteria operators to lose money and whether implementing FSG was feasible given monetary and staffing constraints. The ability of the workgroup to provide examples of success stories reassured vendors and cafeteria operators that selling healthy food could be profitable. Examples of existing successful FSG work in the USA which can be drawn upon include the Healthy Food Promotion in Los Angeles County Food Service Contracts, the Iowa Healthiest State initiative, the MA State Agency Food Standards, the Chicago Park District Healthier Snack Initiative, and the Munch Better at Delaware State Parks intervention. Lessons learned and success stories from these policies, initiatives, and interventions are available in the 2015 Center for Disease Control (CDC) report, Food Services Guidelines: Case Studies States and Communities [27]. The development of FSG parameters can be uniquely challenging, causing dissidence even among proponents. In this study, some participants supported the use of food-based guidelines, rather than nutrient-based guidelines, to decrease implementation and compliance barriers. The latest FSG for Federal Facilities [24] published by Health and Human Services also recommends food-based standards. The Federal Guidelines for Food Service Facilities are based on the 2015–2020 Dietary Guidelines for Americans, which differs from its predecessors by focusing less on individual dietary components (i.e., nutrients) and more on recommendations that support healthy eating patterns [8]. Interviewees recommended starting with existing FSG, such as the New York City Food Standards [28], and collaborating with stakeholders to identify strengths and weaknesses to determine whether adoption in their own state/facility is feasible. Developing a set of guidelines that all stakeholders can readily understand and apply may increase the likelihood of compliance and achieving the goal of greater access to healthy food options. This study also found that it may be important to exempt agencies where existing legislation—such as the National School Lunch Program—conflict with new guidelines to prevent pushback. In this study, framing and promotion of FSG were important for gaining acceptance from employees working in state facilities. When asked whether employees supported FSG policy, interviewees reported that feelings were mixed. Emphasizing that the FSG would increase the amount of healthy food offered without taking away existing options helped to ease contention. Stakeholders emphasized the importance of providing technical assistance and support (e.g., promotional materials and training for cafeteria operators) during the implementation phase of the Healthy Nutrition Guidelines to help assure success. This recommendation aligns with CDC’s How to Implement FSG recommendations. Other examples of stakeholder education efforts include annual food policy forums organized by the Los Angeles County Department of Public Health to share best practices in procurement, promotion, and placement of healthy foods and training provided by the Division of Nutrition and Health Promotion staff in the Iowa Department of Public Health to track the sales of healthier options and show how to balance a mix of health and unhealthy items, as needed, to remain profitable [23]. Finally, when considering the long-term sustainability of an FSG policy, interviewees in this study mentioned it was important to develop a policy evaluation plan concurrently with implementation goals to better identify the necessary resources, tools, and funding to support staff evaluation and technical assistance efforts after policy adoption. Ensuring that an evaluation plan is in place at the time of FSG adoption may improve the chances of long-term sustainability if and when leadership changes. An evaluation plan can also help monitor challenges in adhering to the guidelines and detect need for technical assistance. This is consistent with CDC’s How to Implement FSG recommendations which suggest developing an evaluation plan alongside initial guideline development to consider both the purpose of the evaluation and how evaluation findings will be used [23]. In sum, use of the ACF helped to identify key players, resources needed, and strategies for essential collaboration that facilitated the development and passage of EO 13-06 (Fig. 1). The ACF has widespread application and has been used to analyze two previous legislative efforts in Washington State: the development and passage of a restaurant menu-labeling initiative [29] and the development of breastfeeding friendly policies [15]. Some of the lessons shared from these policy efforts, such as framing the policy beyond individuals and health, and engaging stakeholders early in the policy process to proactively address concerns, align with our recommendations. Future studies should use the ACF to identify comparable and additional lessons learned from public health-related policy development and adoption. Limitations Results may not be generalizable to other states due to the political environment that favored the passage of EO 13-06 in Washington State. While a diverse group of proponents were interviewed, interview data from opponents were limited. In some cases, proponents’ perception of opponents’ beliefs was reported. Qualitative data analysis is subject to personal bias. Researchers are challenged with presenting findings that preserve the original intent of interviewees, while also allowing for analysis and interpretation. The research team included people who were familiar and unfamiliar with EO 13-06. This dynamic increased awareness of potential biases and improved attentiveness during the data analysis process. In addition, the majority of data were double-coded to ensure that themes were accurately represented. CONCLUSION Elements that contributed to successful policy development and passage of a statewide comprehensive FSG have been identified using an ACF. This study can inform other entities who seek to develop and pass FSG. Future research to inform policy efforts should include analyzing the differences between FSG as part of an executive order versus another form of legislation, and measuring and comparing the effects of these policies on population health outcomes. Acknowledgements: We thank the interviewees for their time and insights. This work was supported by a CDC Intergovernmental Personnel Act Agreement to J.J.O., titled Evaluation of Washington State Food Service Guidelines, and a UW Nutritional Sciences Program research support stipend to C.B.. The content is solely the responsibility of the authors and does not represent the official views of CDC. These findings have not been previously published, and this manuscript is not being simultaneously submitted elsewhere. Manuscript findings have not appeared elsewhere. The authors had full control of all primary data and agree to allow the journal to review their data if requested. Compliance with Ethical Standards Conflict of Interest: The authors report no conflicts of interest and have had full control of all primary data and agree to allow the journal to review data if requested. Ethical Approval: No animals were used in this study. Institutional Review Board approval was given by the University of Washington IRB to conduct this study. Informed Consent: All study participants gave verbal informed consent to participate in the study. References 1. State of Washington. 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Translational Behavioral MedicineOxford University Press

Published: Feb 23, 2018

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