SCPHRP Final report form for SCPHRP grants
SCPHRP reference number:
Please complete this form in Verdana 10 point font size Project title: Feasibility trial of a Price Incentive Intervention to promote the uptake of healthy eating options in workplace canteens in Scotland Start date: 1st January 2012
Finish date: 30thSeptember 2012
Investigators: Professor Annie S Anderson (PI)
Dr Dionne Mackison
Mr John Mooney
Dr Maureen McLeod
Structure of final report: 1. Summary 2. Original aims 3. Methodology 4. Results 5. Discussion 6. Conclusions 7. Importance to NHS and possible implementation 8. Future research 9. Dissemination 10. Research workers 11. Financial statement 12. Executive summary (Focus on Research) Word 1. 2-6 7-11
Count: Summary Main Report Further details
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1. Summary Aim To assess the feasibility of implementing and evaluating a 10-week price incentive intervention to promote healthy eating options in workplace canteens in order to inform the design and implementation of a future RCT. Methods Workplace canteens with the Healthy Living Award (HLA) or participating in the Healthy Working Lives Programme (HWLP) were approached to take part in the study. The intervention design was informed by interviews with catering staff and focus group discussions with consumers. Assessments included observations of intervention implementation, measures of intervention uptake (till receipts) and individual level measures of food habits, canteen perceptions and usage and food expenditure using online pre- and post-intervention questionnaires. Post intervention qualitative measures of consumer acceptability and caterers perspective of the intervention were also undertaken. Results Three (of a possible 13) worksites initiated and two completed the intervention study involving 151 emails, 58 telephone calls and 53 visits. Pre-intervention qualitative findings indicated that price, product quality and quick service were considered fundamental to the intervention design. Of various price incentives discussed consumers and caterers agreed a preference for a meal combination deal of soup and sandwich/salad with a nutrient composition consistent with the FSA traffic lights guidance at a 10-20% original price reduction and an on-site marketing programme (EatSMART). Site observations of the ten week intervention reported that items were available at the agreed price and marketing approaches were in position. Till data indicated that the uptake of promoted items varied by week (range 60 to 187 items) and by site but at all points there was greater uptake of intervention soup (range 44 to 138 items) than the price incentivised intervention meal deal (range 4 to 31) suggesting that consumers may have been more influenced by the choice of new menu items than the price incentivised meal deal option. Till data could not be used to identify individual level analysis of food choices and expenditure. The response rate for both pre and post questionnaires was poor (2.9% and 1.6% of workforce at site A and 15% and 9.6% of workforce at site B of which 22 (17%) completed at both time points) which limited evaluation of intervention impact. In focus group discussions consumers reported perceived value for money of the targeted foods and improved quality. However, they also expressed dissatisfaction with limited choice and quantities and inadequate marketing. Caterers indicated that considerable support was required initially to implement the intervention although both sites reported an intention to continue the intervention after the project ended and extend to other catering sites within their group. Caterers also reported the importance of meeting customer preference through maintaining current selections (e.g. pies, confectionery and crisps) and maintaining current sales figures. Conclusions A price incentivised healthy eating intervention designed in collaboration with caterers and consumers was feasible to implement in two worksite canteens and merits further investigation. Key challenges included recruitment and retention of worksites and the amount of support required by caterers to deliver the intervention. Uptake of individual targeted foods was good and further work is required to motivate intervention engagement and reduce competition from less healthy items. The current quantitative evaluation procedures were not feasible for collecting individual level data on dietary change in a future RCT and further work is required to improve response rates and dietary intake tools.
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2.Original Aims This study aimed to investigate the feasibility of implementing and evaluating a 12 week price incentive intervention to promote healthy eating in 4 workplace canteens in Scotland in order to inform a future RCT.
3.Methodology Recruitment The Healthy Living Award (HLA) team contacted 37 awarded workplace canteens and 18 contract caterers (with a varying number of workplace canteens) regarding study participation. Those responding positively (n=4) were contacted by the study team to confirm interest in participation but none continued (Figure 1). A secondary recruitment strategy comprised personal contact by the HLA team to four further workplaces but none responded positively. Lastly, the Healthy Working Lives team approached four possible worksites (one of which had an interested sister site), two of whom completed the study (Table 1) Intervention development Formative work Intervention design was informed by qualitative research with canteen staff and users. Focus groups and interviews were conducted in each workplace. A topic guide allowed exploration of plausible interventions. Marketing strategies were also discussed. Focus groups and interviews were digitally recorded and transcribed verbatim. Transcripts were verified by two researchers independently for accuracy. Data analysis was performed using the principles of the Constant Comparative Method (CCM) and Framework Analysis (FA) (1). Study period The initial aim was to conduct the study over a 12 week period, however due to recruitment difficulties this was reduced to 10 weeks to allow completion within the study timeframe. Intervention components The intervention combined price incentives, healthy choices, and a marketing strategy (2). Price incentives focused on consumer and caterers preference for “healthy meal deals” at a 10 - 20% cost reduction. Recipes aimed to achieve a nutrient composition consistent with the FSA traffic light grading low (or maximum of one medium) for sugar, fat and salt. Marketing focussed on a value strategy by promoting reduced prices, products and key placing of target items within the canteen settings. Due to recently introduced EU regulation individual items could not be labelled as “healthy” but were labelled with value for money symbols. Support and promotional measures Workplaces were provided with substantial support during the intervention period: Promotional materials including stickers for intervention components and posters were displayed at entry points to the canteen. Point of sale, weekly and daily menus, materials for bulletin boards and electronic posting of weekly information on staff intranets was also utilised. Practical catering resources including nutrient analysed recipes, shopping lists and daily/weekly menu rotations. Mobile telephone and email details for the research team to ensure queries could be dealt with quickly. £1000 to compensate for any costs incurred during the intervention period. Observational measures Workplaces were visited at least three times during the intervention period by the study team to ensure fidelity of intervention implementation and promotions.
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Measures of uptake (canteen level) Sales data were provided by workplaces. In site A the till was programmed to record the intervention meal deal although no records were kept of individual component sales of soups and sandwiches. Intervention soup uptake could be estimated from amounts prepared and wastage. In site B catering staff were asked to manually record individual component items verified with portions prepared and till data. Individual level measures A pre– and post-intervention questionnaire was delivered online to all employees at the participating workplaces via their intranet. To maximise response rates “a word of mouth” strategy was activated by key employees to highlight the presence of the survey on their intranet. A prize draw was offered as an incentive to participation at site A (not permitted at site B). Questionnaires collected data on socio-demographic details, food habits, key dietary intake indicators, knowledge of five a day messages, purchasing behaviour at the workplace canteen. Participant perspectives on the canteen were also sought. Data analysis was undertaken using SPSS (Version 18.0 SPSS, Chicago, IL,). Post intervention acceptability measures Post-intervention qualitative work (focus group discussions and individual interviews) collected information on perception, acceptability, marketing and perceived benefits of the intervention with catering staff and users in each workplace. A topic guide was used and data was analysed as per formative work. Ethical Approval Ethical approval was provided by the University of Dundee Research Ethics Committee.
4 Results The recruitment strategies resulted in two workplace canteens being recruited to participate in the study, with site A, a private call centre employing approximately 1600 employees (with a maximum of 800 on site at any time), and site B, a government call centre employing approximately 550 employees. RQ1: Which practical approaches to intervention delivery and financial incentives are catering staff able and willing to test? Caterer’s perceptions of the design and acceptability of the proposed intervention were collated through pre-intervention semi-structured interviews with two members of the catering team at site A and the Catering Manager at site B and informal discussions with other catering personnel at each site. Overall, the price incentive concept was viewed positively by staff at both sites who were willing to try new ideas. Staff highlighted concerns for consideration in the design of the intervention package: Convenience for consumers (e.g. “grab n go”) and convenience for preparation Preparation time (for caterers) and eating time (consumers) Pricing of produce in line with other items on sale and consideration of sales margins Need to continue to offer “less healthy” items to maintain sales There were further concerns over items that are “centrally priced” by their parent catering company and limited access to “healthy ingredients” within current procurement contracts. Staff were keen to explore combination or meal deals that complemented items currently sold. They were hesitant about introducing too many new or perceived “fancy” healthy items that would not sell. RQ2: What are the views of canteen users on possible and desired approaches to price incentives? At both sites focus groups comprised 8 participants (6 men and 2 women at site A and 1 man and 7 women in site B).
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Key issues arising were: Price reductions were considered an incentive to all consumers (although sites differed on actual costs) General negative perception of existing menu choice, quality, price and portion size Concern that price reductions may equate to reduced food quality or smaller portion sizes Concern over food consumption time (break times short) so targeted items should be readily accessible and consumable quickly Need for foods to be portable (e.g. eaten out of canteen premises) Of possible options considered (loyalty schemes, free fruit, free veg/ salad, daily specials) the favoured response emerged as a meal deal comprising either a soup and a sandwich or soup, salad and brown roll at site A and soup and sandwich or soup, sandwich and fruit at site B with meal combinations offering a 10 to 20% price reduction. No other options (e.g. reduced prices of single items) were noted to be of interest (or provided the opportunity to improve canteen choices and menu quality). Table 2 illustrates the EatSMART intervention package at each site. Note the individual components of the meal deal continued to be sold at standard prices. RQ3: How well can price incentive strategies be implemented in workplace canteens and what barriers and solutions are experienced? Site observations reported that the intervention meal combination deal was available at the agreed price and marketing approaches were in position (Figure 2) throughout the intervention period. However, the availability (visible quantities on offer) of the meal deal appeared limited. Substantial support from the research team was required to initiate and develop these programmes and overcome caterer’s barriers. In addition caterers also sought assistance from local retailers in acquiring healthy ingredients unavailable on existing purchasing contracts. The time required by the research team to provide support was notable (Table 1) and was confounded by uncertainty regarding who provided ultimate approval for the intervention on site (i.e. on site caterer, catering company executive). It was clear that both sites differed in implementation needs (due to cooking, storage and serving facilities). RQ4: What is the uptake of the intervention? Uptake has been estimated from till receipt data (Table 3). Till data indicated that the uptake of promoted items varied by week (range 60 to 187 items) and by site but during all weeks there was greater uptake of intervention soup (range 44 to 138) compared to the price incentivised intervention meal deal (range 4 to 31) suggesting that consumers were more influenced by the availability of individual new options rather than the price incentive meal deal option. More detailed records were kept in site B and illustrated that the intervention soups provided significant proportion of all soups (37% - 82%). Total snack sales during the intervention period remained buoyant. RQ5: Can the following indicative impact diet and expenditure variables be reliably assessed from canteen users? consumption of lunchtime meal and drink components estimated change in lunchtime intake of key food and nutrients total daily fruit and vegetable intake and sugary drinks reported lunchtime spend Data on individual level variables was obtained from pre- and post-intervention questionnaires. At site A 46 questionnaires were returned pre-intervention (2.9% of workforce) and 28 post-intervention (1.6% of workforce). Two respondents completed the
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questionnaire at each time point, however, due to the small sample size, no comparative analysis between time points was undertaken. At site B 84 questionnaires were returned pre-intervention (15% of workforce) and 53 post-intervention (9.6% of workforce). Twenty respondents completed the questionnaires at both time points allowing an indicative comparative analysis. Response rates were too low to make reliable assessments and results should be interpreted with caution. At site A, respondents were predominantly male, early thirties, living in more deprived areas, in full time work, with few earning more than £40,000 per annum (Table 4). In comparison, site B respondents were more likely to be female, older, higher earners, were less likely to smoke and had lower levels of obesity. a) Consumption of lunchtime meal and drink components It was initially anticipated that till receipt data could be used at participating sites to identify individual level consumption of lunchtime meal and drink components. Whilst this information was possible to determine globally using till receipt data, individual level data was not readily accessible. Future studies, may wish to explore the benefits of “cashless” till systems to answer this objective. However, preliminary discussions with site personnel using cashless payment systems indicated that accessing this level of information may be commercially sensitive and technically challenging. In light of the challenges in interpreting till receipt data, where cashless systems are unavailable, future studies may need to introduce dietary recall methodologies to capture the consumption of meal and drink components at an individual level which add considerable subject burden and are time consuming. An alternative strategy may be to target up to five key foods e.g. fruits, snacks and offer a daily self-monitoring recording system which could be combined with healthy choice targets. Clearly any tool that impacts negatively on response rates would be undesirable. b) Estimated change in lunchtime intake of key foods and nutrients No individual level data was available from till receipts to assess change in lunchtime intake of key foods These findings highlight the importance of using individual smartcard systems (with access to nutrient composition data) to enable reporting of nutrient data at individual level. c) Total daily intake of fruit, vegetables and sugary drinks The original study proposal hypothesised that the intervention would target fruits and vegetables intake thus the pre- and post-intervention questionnaires recorded daily fruit and vegetable intake in the previous 24 hours using the validated FACET questionnaire (3) [Tables 5 a and 5 b]. In addition information on a range of key foods was collected. Our data suggests that intakes of fruits and vegetables were relatively high which was unexpected and indicates that the tool may benefit from further validation work in this population, particularly given the potential for reporting bias. d) Reported lunch time spend? Most respondents identified a preferred fixed amount of lunch time spend of less than £3 (Table 6). This was consistent in pre- and post-intervention questionnaires and indicates the potential of price incentives for promoting healthy options but also highlights the challenge consumers face to select healthy choices when energy dense (high fat/sugar/salt) options are cheap and often price promoted (e.g. chocolate sales during Olympics week).
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RQ6: What are the start-up and running costs associated with intervention implementation? The set up funding was sufficient to offset the purchase of additional food items required, subsidise the reduction in price for the intervention items and to cover any additional waste. No additional equipment or staff costs were reported. RQ7: How acceptable is the intervention to the consumer? Information on perceived changes in the canteen was derived from pre- and postintervention questionnaire data and from post-intervention focus groups with consumers. The focus groups consisted of 4 participants at site A and 6 participants at site B. a) Overall canteen perception Quantitative analysis of the repeated cross sectional data at both sites and paired data (n=20) from site B indicated more positive perceptions of all measures post intervention [Tables 7a and 7b]. b) Perception of intervention items In the post intervention focus groups the target foods were considered to be “tastier” and “healthier “and it was reported that there was more salad on the sandwiches and an improvement in overall quality. However, respondents didn’t always consider the intervention items to be healthy –“soups can be greasy”, “still lots of butter and mayo in sandwiches”. The quantity of sandwich fillings received mixed reviews with some being “not enough” and there was “not enough choice of soups and sandwiches”. Availability of the intervention foods could be an issue - soup sold out around 3-4pm and missed “back shift” staff. Availability of sandwiches was reported as relatively low. c) Changes to purchasing behaviour In focus groups some participants reported eating more than previously at lunch times but snacking less. Individual level data from both sites and from paired data in site B (Tables 5a and 5 b) also indicated a decrease in reported intake of crisps and chocolate in the previous 24 hours although this is not evident from till data. d) Perception of the marketing strategy At both sites, respondents had purchased an EatSMART promotional product (15% to 43% respectively) and reported having seen the promotional materials (36% and 58% respectively) [Table 8]. Participants in FGD at site A commented that the display boards were “crammed” and the message and impact of promotional posters were limited. Posters were only displayed within the canteen at site B as it operated a paperless environment. FGD participants commented that advertising in the canteen didn’t stand out with the journey of the posters stopping at the canteen door and limited follow through to the canteen floor. Posters were reported as giving little indication of what the promotion comprised and could have been more eye-catching and colourful. The use of green was more associated with football allegiances than healthy eating (as in traffic light labelling) in male consumers. The logo was, however, reported as a strength of the marketing strategy as it clearly indicated the potential for value for money. Qualitative data suggested that “word of mouth” was the most successful marketing strategy in particular verbal promotion by catering staff. It was also noted that employees who did not use the canteen would not have been exposed to canteen promotions. RQ8: What are catering staff perceptions of the intervention with respect to perceived customer response, workloads and ease of intervention delivery? Caterers viewed the price incentive approach as a positive promotion which provided good value for money, however, they noted that overall customers “do not like change and tended to prefer plain food”. Consumer feedback to caterers reported preferences for more
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traditional soups of a specific consistency, salads and plainer sandwich fillings. In addition, caterers re-iterated the following possible concerns (although none of these were evident during the intervention period) Promoted items may not be “filling” (sufficient to meet appetite) Targeted items might compete with concurrent promotions run by parent catering company Increased waste decrease in sales margins. Additional workload was reported initially as it took time for caterers to familiarise themselves with the new recipes and modify the menu to reduce waste. There were also difficulties in sourcing some ingredients, due to limitations in existing purchasing contracts, which were resolved by cash purchasing which would be unsustainable in the longer term. The continuation of the intervention was perceived as feasible at site A without the research teams support but potentially challenging from a financial perspective. At site B the caterer could not be seen to offer a price incentive at only one of their sites but aspects of it could be continued perhaps one day a week. Caterers also reported that recipes may need to be modified to suit customer tastes (e.g. soup consistency) although this may have an impact on the nutrient profile. Both sites spontaneously requested supplies of promotional materials for continued work. In addition, caterers reported that tracking of sales was not straightforward (see RQ4).
5 Discussion It is recognised that the catering sector can have a pivotal role in influencing dietary intake (4,5) with the potential to impact on obesity prevention (6). In Scotland, the Healthy Living Award (HLA) (7) is designed to encourage caterers to increase availability of healthier options. Preparatory work for the current proposal indicated interest from four catering sites (with HLA) and the research plan was designed to start immediate work with these sites. However, all four sites withdrew prior to intervention commencement and considerable efforts were needed to recruit further catering establishments (including identification of appropriate gatekeepers). Two sites completed the feasibility trial work with considerable support from the research team (in design and implementation) highlighting that future RCT work requires firm commitment from an appropriate number of sites and that time allocation (for design, delivery and evaluation) needs to be generously estimated. Work with caterers (both in recruitment and in site visits) highlighted the range of options for diners which reflected culturally popular food selections (pies, fries, crisps, confectionery), catering promotions (e.g. chocolate promotions during Olympics) and concerns about sales margins. All of these issues highlight the challenge of promoting “healthy eating” options and may account for the poor response rate from caterers and cautious approach by intervention sites, although it was clear that the £1000 token of appreciation helped to initiate discussions. The caterers that did respond positively were however, enthusiastic about the concept of a price incentive for promoting healthy eating options (as were consumers). The intervention components (target foods, prices and marketing) were tailored to consumer preferences and catering practicalities and although operationalized as planned consumer feedback suggested limited availability of meal deal items, possibly reflecting cautious caterers anticipating waste. Caterers invested considerable time in implementing the intervention initially including testing new soup recipes, accessing ingredients not available from contract suppliers, organisation and preparation of new menu items but did not report on going extra work or costs. Good working relationships between caterers and
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research staff and tailoring of the intervention to suit site requirements were considered key to intervention implementation. Interestingly, due to recently introduced EU regulations, the health values of promoted items could not be directly promoted but “value for money” labelling was used in marketing and green (signifying “low” in traffic light labelling) used as background in promotional materials. The marketing strategy clearly needed further development ensuring that multiple approaches are used (especially to target non canteen users) and that green coding is not seen to be associated with football allegiances. The uptake of price incentivised “meal deals” was modest although uptake of the healthier component parts without price reduction encouraging. These findings suggest that price incentives increase interest and engagement in new offers but that personal preference for component items may be more important than the price incentivised “meal deal” option. Whilst the pre-intervention work suggested that meal deals were desirable it is possible that in fact this was considered unattractive by some and exploration of a wider range of price incentivised approaches deserve further exploration (although consumer and catering perspectives must be considered in design). It is encouraging that both sites intend to continue to offer the intervention options and marketing materials. However, the widespread availability of energy dense snacks (plus any promotions of these) will seriously compete with intervention efforts. The poor response to quantitative methodology limited the evaluation on the impact of intervention on personal eating habits, canteen perceptions, usage and food expenditure. Ideally smartcard systems would enable reliable data at site and individual level to be collected. Till receipt data enabled group level data to be collected but was hampered by meal deal items being purchased separately resulting in manual recording of sales for these individual purchases. Post-interviews with catering staff suggest that with more time and planning this issue could be addressed in future.
6 Conclusions A price incentivised healthy eating intervention designed in collaboration with caterers and consumers was feasible to implement in two worksite canteens and merits further investigation. Key challenges included recruitment and retention of worksites and the amount of support required by caterers to deliver the intervention. Uptake of individual targeted foods was good and further work is required to motivate intervention engagement and reduce competition from less healthy items. The current quantitative evaluation procedures were not feasible for collecting individual level data on dietary change in a future RCT and further work is required to improve response rates and dietary intake tools. References (1) Ritchie J & Spencer L. 1994. Qualitative data analysis for applied policy research. In: Bryman A & Burgess RG (Editors) Analyzing Qualitative Data. London: Routledge (2) GAO (US Government Accountability Office) Food Stamp Programme: options for delivering financial incentives to participants for purchasing targeted foods. Washington (3) Ashfield-Watt et al (2007) Effect of a pilot community intervention on fruit and vegetable intakes: use of FACET (Five-a-day Community Evaluation Tool) Public Health Nutrition 10/7 671-680 (5) WHO/World economic Forum (2008) Preventing non-communicable diseases in the workplace through diet and physical activity: WHO World economic Forum report of a joint event Geneva WHO/WEF (6) Henriqu Bandoni et al 2011 Impact of an intervention on the availability and consumption of fruits and vegetables in the workplace. Public Health Nutrition 14 pp 975-
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981 (7) Mooney JD, Frank J, Haw S: Policy Interventions to Tackle the Obesogenic Environment - Focusing on adults of working age in Scotland. Scottish Collaboration for Public Health Research and Policy Edinburgh: CSO/MRC; 2011. (8)http://www.healthylivingaward.co.uk/ http://www.healthylivingaward.co.uk/coretalk/archive/february11/page5.html#2
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7 Importance to NHS and possible implementation Effective routes to altering diets high in calories, fat, sugar and salt and increasing wholegrains, fruits and vegetables are urgently needed to reduce the burden of diet related disease in within the NHS. The current study demonstrates that the catering sector is willing to test new approaches to healthy eating with the potential for significant health benefits in the working population if the current work can be implemented and expanded. 8 Future Research The current work highlights a number of issues that require to be addressed prior to undertaking a full randomised control trial of the impact of price incentives on uptake of healthy eating choices. These include 1. 2.
3. 4. 5. 6.
Identify routes for recruiting and gaining commitment from an appropriate number of workplace caterers (biggest risk for trial) Ensure availability of healthy options as agreed by consumers/caterers are already in place e.g. a. Work with caterers to modify recipes to meet FSA traffic light guidelines b. Work with catering contractors to ensure supply of ingredients and products which meet FSA guidelines c. Increase supply of fruits, vegetables and whole grains (and other single item options) d. Identify ways to reduce “less healthy options� Collect baseline data on sales of healthy items (canteen level data) Introduce a comprehensive promotion strategy of a 10-20% price reduction on all selected healthy items (agreed with caterer) over intervention period Repeat canteen level data collection on sales, costs and wastage Identify valid and reliable individual level data collection tools with specific exploration of smart cards which also allows objective data on demographics, purchase, and (change) in expenditure to be collected.
9. Dissemination At a public health level, the findings will be communicated at the annual faculty of Public health conference in Scotland (2013). The work will also be presented at the ISBNPA (international Society for Behaviour, Nutrition and Physical Activity) in June 2013. A specific report will be prepared for the Healthy Living Team, Public Health Division in Scottish government and FSA, Scotland, which in turn will form the basis of an academic publication for submission to Public Health Nutrition. 10. Research Workers Dr Dionne Mackison was the Research Fellow on this project 0.8 FTE for 7 months; Dr Maureen Macleod 0.3 FTE for 2 months; and Mrs Karen Barton 0.1 FTE for 2 months. The study was fortunate to benefit from undergraduate interns e.g. graphic design expertise from Ms Clare Doogan and administrative and analysis assistance from Ms Lyndsay Watkins. Table 9 summarises contributions of co-applicants. 11. Financial Statement To follow
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