Economic incentives to promote healthier food purchases: exploring acceptability and key factors for success

Impact of a randomized controlled trial of discounts on fruits, vegetables, and noncaloric beverages in NYC supermarkets on food intake and health risk factors

The objective of this study was to observe the effects of a multi-level (30%, 15%, and 0%) randomized discount on fruits, vegetables, and non-caloric beverages on changes in dietary intake. This randomized controlled trial (RCT) comprised an 8-week baseline, a 32-week intervention, and a 16-week follow-up. 24-hour dietary recalls were conducted during the baseline period and before the intervention midpoint. In-person clinical measures were analyzed from Week 8 (end of baseline) and 24 (midpoint). This report is from an interim analysis up to the intervention period midpoint at Week 24, as the study is still ongoing. Participants with BMIs of 24.5-50 kg/m2 and ages 18-70 years old who were the primary household shoppers were recruited from several New York City supermarkets, starting in September 2018. Of these, we analyzed 20 in the 30% discount group, 25 in the 15% discount group, and 19 in the 0% discount group. The 30% discount group reported greater intake of vegetables (+98.4 g ± 48.9 SD, P = 0.049) and diet soda (+63.3 g ± 29.3, P = 0.035) relative to the baseline period, compared to the 0% discount group. The clinical measures including body weight remained unchanged. The participants who experienced the COVID-19 pandemic had a marginal increase in body weight of 1.5 kg, P = 0.053. In conclusion, we observed a significant increase in intake of vegetables and diet soda in the 30% discount group relative to the 0% discount group.

Experiences of conditional and unconditional cash transfers intended for improving health outcomes and health service use: a qualitative evidence synthesis

BACKGROUND

It is well known that poverty is associated with ill health and that ill health can result in direct and indirect costs that can perpetuate poverty. Social protection, which includes policies and programmes intended to prevent and reduce poverty in times of ill health, could be one way to break this vicious cycle. Social protection, particularly cash transfers, also has the potential to promote healthier behaviours, including healthcare seeking. Although social protection, particularly conditional and unconditional cash transfers, has been widely studied, it is not well known how recipients experience social protection interventions, and what unintended effects such interventions can cause.   OBJECTIVES: The aim of this review was to explore how conditional and unconditional cash transfer social protection interventions with a health outcome are experienced and perceived by their recipients.  SEARCH METHODS: We searched Epistemonikos, MEDLINE, CINAHL, Social Services Abstracts, Global Index Medicus, Scopus, AnthroSource and EconLit from the start of the database to 5 June 2020. We combined this with reference checking, citation searching, grey literature and contact with authors to identify additional studies. We reran all strategies in July 2022, and the new studies are awaiting classification.

SELECTION CRITERIA

We included primary studies, using qualitative methods or mixed-methods studies with qualitative research reporting on recipients' experiences of cash transfer interventions where health outcomes were evaluated. Recipients could be adult patients of healthcare services, the general adult population as recipients of cash targeted at themselves or directed at children. Studies could be evaluated on any mental or physical health condition or cash transfer mechanism. Studies could come from any country and be in any language. Two authors independently selected studies.  DATA COLLECTION AND ANALYSIS: We used a multi-step purposive sampling framework for selecting studies, starting with geographical representation, followed by health condition, and richness of data. Key data were extracted by the authors into Excel. Methodological limitations were assessed independently using the Critical Appraisal Skills Programme (CASP) criteria by two authors. Data were synthesised using meta-ethnography, and confidence in findings was assessed using the Confidence in the Evidence from Reviews of Qualitative research (GRADE-CERQual) approach.  MAIN RESULTS: We included 127 studies in the review and sampled 41 of these studies for our analysis. Thirty-two further studies were found after the updated search on 5 July 2022 and are awaiting classification. The sampled studies were from 24 different countries: 17 studies were from the African region, seven were from the region of the Americas, seven were from the European region, six were from the South-East Asian region, three from the Western Pacific region and one study was multiregional, covering both the African and the Eastern Mediterranean regions. These studies primarily explored the views and experiences of cash transfer recipients with different health conditions, such as infectious diseases, disabilities and long-term illnesses, sexual and reproductive health, and maternal and child health. Our GRADE-CERQual assessment indicated we had mainly moderate- and high-confidence findings. We found that recipients perceived the cash transfers as necessary and helpful for immediate needs and, in some cases, helpful for longer-term benefits. However, across conditional and unconditional programmes, recipients often felt that the amount given was too little in relation to their total needs. They also felt that the cash alone was not enough to change their behaviour and, to change behaviour, additional types of support would be required. The cash transfer was reported to have important effects on empowerment, autonomy and agency, but also in some settings, recipients experienced pressure from family or programme staff on cash usage. The cash transfer was reported to improve social cohesion and reduce intrahousehold tension. However, in settings where some received the cash and others did not, the lack of an equal approach caused tension, suspicion and conflict. Recipients also reported stigma in terms of cash transfer programme assessment processes and eligibility, as well as inappropriate eligibility processes. Across settings, recipients experienced barriers in accessing the cash transfer programme, and some refused or were hesitant to receive the cash. Some recipients found cash transfer programmes more acceptable when they agreed with the programme's goals and processes.   AUTHORS' CONCLUSIONS: Our findings highlight the impact of the sociocultural context on the functioning and interaction between the individual, family and cash transfer programmes. Even where the goals of a cash transfer programme are explicitly health-related, the outcomes may be far broader than health alone and may include, for example, reduced stigma, empowerment and increased agency of the individual. When measuring programme outcomes, therefore, these broader impacts could be considered for understanding the health and well-being benefits of cash transfers.

Young Adults’ Use of Mobile Food Delivery Applications and the Potential Impacts on Diets during COVID-19 Pandemic in Singapore: A Mixed Methods Study (Preprint)

BACKGROUND

Poor diet contributes significantly to the development of non-communicable diseases (NCDs). In Singapore, it is recommended to consume at least two servings of fruits and vegetables (FV) daily to reduce the risk of developing NCDs. However, the adherence rate among young adults is low. The COVID-19 pandemic has led to frequent users of Mobile Food Delivery Applications (MFDAs) adopting unhealthy eating habits including high consumption of sugar-sweetened beverages (SSBs), making it crucial to gain a deeper understanding of the underlying factors driving their usage patterns.

OBJECTIVE

This study aimed to examine the usage patterns of MFDAs among young adults during the COVID-19 pandemic; investigate the association between MFDA usage and socio-demographic factors, dietary factors, and body mass index (BMI); identify the underlying reasons for the observed usage patterns of MFDAs among users; compare the influences of MFDA usage between frequent and infrequent users.

METHODS

A sequential mixed methods design was used, involving an online survey and in-depth interviews with a subset of questionnaire respondents. Poisson regression and thematic analysis were employed to analyze the quantitative and the qualitative data respectively.

RESULTS

The quantitative results revealed that 41.7% (150/360) of the participants reported using MFDAs frequently, defined as at least once-a-week use. Although not significant, the study found that frequent users were less likely to consume two servings of vegetables per day and more likely to drink SSBs. Nineteen individuals who had participated in the quantitative component were selected for and completed the interviews. Qualitative analysis identified four primary themes: deliberations about other sources of meals versus meals purchased via MFDAs, convenience is vital, preference for unhealthy meals ordered from MFDAs most of the time, and cost is king. Before making any purchase, MFDA users consider all these themes at the same time, with the cost being the most significant influential factor. A conceptual framework based on these themes is presented. Lack of culinary skills and COVID-19 restrictions were also found to influence frequent usage.

CONCLUSIONS

The study suggests that interventions should focus on promoting healthy dietary patterns among young adults who frequently use MFDAs. Teaching cooking skills, especially among young males, and time management skills could be useful to reduce reliance on MFDAs. The study highlights the need for public health policies that make healthy food options more affordable and accessible. Given the unintended changes in behavior during the pandemic such as reduced physical activity or sedentary behavior and altered eating pattern, it is essential to consider behavior change in interventions aimed at promoting healthy lifestyles among young adults who frequently use MFDAs. Further research is needed to evaluate the effectiveness of interventions during COVID-19 restrictions and to assess the impact of the "new normal" post-COVID on dietary patterns and physical activity levels.

Acceptability and feasibility of a café-based sustainable food intervention in the UK

Dietary change is needed to improve health and reduce the environmental burden of food production and consumption. Using an Intervention Mapping approach, this study aimed to explore the views caterers and customers held towards point-of-choice interventions that promote healthy and environmentally friendly (EF) food and beverage choices at the University of Sheffield. Intervention options proposed during focus groups were devised using the Nuffield Bioethics ladder of intervention. Ten focus groups were held involving caterers (n = 16) and customers (n = 45). Thematic analysis was conducted on the transcripts of caterer and customer focus groups seperately, and then comparisons were made to identify concerns about the acceptability and feasibility of intervention options. Attitudes towards intervention options varied considerably amongst stakeholders, with the greatest disparity of opinion in the acceptability of interventions that restrict or limit personal choice, particularly with regards to meat consumption. Information provision was favoured as an acceptable intervention by both customers and caterers. However, labelling products in terms of their environmental impact was considered practically unfeasible. Social norms around eating also emerged as influencing the acceptability and feasibility of interventions with concerns raised about: shaming customers who chose meat, the exclusivity of vegan choices and the limited availability and appeal of meatless café options. Financial considerations were the main priority of caterers when discussing point-of-choice interventions. An acceptable and feasible café-based intervention ought to increase awareness and understanding of healthy and EF food choices, protect customer choice and avoid additional costs.

The Retail Food Sector and Indigenous Peoples in High-Income Countries: A Systematic Scoping Review

Indigenous Peoples in high-income countries experience higher burdens of food insecurity, obesity, and diet-related health conditions compared to national averages. The objective of this systematic scoping review is to synthesize information from the published literature on the methods/approaches, findings, and scope for research and interventions on the retail food sector servicing Indigenous Peoples in high-income countries. A structured literature search in two major international databases yielded 139 relevant peer-reviewed articles from nine countries. Most research was conducted in Oceania and North America, and in rural and remote regions. Several convergent issues were identified across global regions including limited grocery store availability/access, heightened exposure to unhealthy food environments, inadequate market food supplies (i.e., high prices, limited availability, and poor quality), and common underlying structural factors including socio-economic inequality and colonialism. A list of actions that can modify the nature and structure of retailing systems to enhance the availability, accessibility, and quality of healthful foods is identified. While continuing to (re)align research with community priorities, international collaboration may foster enhanced opportunities to strengthen the evidence base for policy and practice and contribute to the amelioration of diet quality and health at the population level.

Whole grain and high-fibre grain foods: How do knowledge, perceptions and attitudes affect food choice?

The health benefits of whole grains and dietary fibre are well established, however intakes of both remain low across the globe. Innovative added-fibre refined grain products may present a solution to increase fibre intakes given potential sensory barriers to whole grain intake. However, to consider the efficacy of such products, or potential alternative measures, an awareness of consumer knowledge, perceptions and attitudes towards both whole grain and added-fibre grain foods is needed. Focus groups (with adults with no formal nutrition education) were conducted to explore factors affecting consumer grain choice. Discussions were transcribed verbatim and analysed using inductive thematic analysis. Nine focus groups composed of 52 participants (23 men; 29 women) were conducted. Participants tended to report choosing 'grainy' bread but few other whole grain foods. Most participants were unaware of the long-term health benefits of whole grains, recommended whole grain intakes, or how to identify foods that were high in whole grains, thereby limiting motivation to increase intake. Additionally, scepticism surrounding the health value of carbohydrate-based foods appeared to hinder grain intakes in general. These findings suggest that further public education and promotion of whole grain benefits, with a focus on food-based targets and messaging, may be important in efforts to increase whole grain and subsequently fibre intakes. Added-fibre grain products may be a useful addition, specifically for avid whole grain-avoiders who are unlikely to accept whole grain sensory properties. However, as most participants were open to whole grain consumption, industry innovation should also focus efforts on increasing availability and variety of products high in whole grains.

Cost and Affordability of Diets Modelled on Current Eating Patterns and on Dietary Guidelines, for New Zealand Total Population, Māori and Pacific Households

The affordability of diets modelled on the current (less healthy) diet compared to a healthy diet based on Dietary Guidelines was calculated for population groups in New Zealand. Diets using common foods were developed for a household of four for the total population, Māori and Pacific groups. Māori and Pacific nutrition expert panels ensured the diets were appropriate. Each current (less healthy) diet was based on eating patterns identified from national nutrition surveys. Food prices were collected from retail outlets. Only the current diets contained alcohol, takeaways and discretionary foods. The modelled healthy diet was cheaper than the current diet for the total population (3.5% difference) and Pacific households (4.5% difference) and similar in cost for Māori households (0.57% difference). When the diets were equivalent in energy, the healthy diet was more expensive than the current diet for all population groups (by 8.5% to 15.6%). For households on the minimum wage, the diets required 27% to 34% of household income, and if receiving income support, required 41–52% of household income. Expert panels were invaluable in guiding the process for specific populations. Both the modelled healthy and current diets are unaffordable for some households as a considerable portion of income was required to purchase either diet. Policies are required to improve food security by lowering the cost of healthy food or improving household income.

Reducing Food Insecurity and Improving Fruit and Vegetable Intake Among Farmers' Market Incentive Program Participants

OBJECTIVE

To determine whether participation in a farmers' market incentive pilot program had an impact on food security and fruit and vegetable (F&V) intake of participants.

METHODS

Participants in the Supplemental Nutrition Assistance Program were eligible to receive a dollar-per-dollar match up to $10/wk in farmers' market incentives. The researchers used a pretest-posttest design to measure F&V intake and food security status of 54 adult participants before and after receiving farmers' market incentives. The 6-item Behavior Risk Factor Surveillance System questionnaire and US Household Food Security Survey Module were used to measure F&V intake and food security, respectively. Wilcoxon signed-rank test was used to compare scores of F&V intake.

RESULTS

After receiving incentives, fewer individuals reported experiencing food insecurity-related behaviors. A significantly increased intake (P < .05) was found among selected vegetables.

CONCLUSION AND IMPLICATIONS

Participation in a farmers' market incentive program was positively related to greater food security and intake of select vegetables among participants in the Supplemental Nutrition Assistance Program.

Acceptability of financial incentives for encouraging uptake of healthy behaviours: A critical review using systematic methods

OBJECTIVE

Financial incentives are effective in encouraging healthy behaviours, yet concerns about acceptability remain. We conducted a systematic review exploring acceptability of financial incentives for encouraging healthy behaviours.

METHODS

Database, reference, and citation searches were conducted from the earliest available date to October 2014, to identify empirical studies and scholarly writing that: had an English language title, were published in a peer-reviewed journal, and explored acceptability of financial incentives for healthy behaviours in members of the public, potential recipients, potential practitioners or policy makers. Data was analysed using thematic analysis.

RESULTS

Eighty one papers were included: 59 pieces of scholarly writing and 22 empirical studies, primarily exploring acceptability to the public. Five themes were identified: fair exchange, design and delivery, effectiveness and cost-effectiveness, recipients, and impact on individuals and wider society. Although there was consensus that if financial incentives are effective and cost effective they are likely to be considered acceptable, a number of other factors also influenced acceptability.

CONCLUSIONS

Financial incentives tend to be acceptable to the public when they are effective and cost-effective. Programmes that benefit recipients and wider society; are considered fair; and are delivered to individuals deemed appropriate are likely to be considered more acceptable.

Acceptability of financial incentives and penalties for encouraging uptake of healthy behaviours: focus groups

Background

There is evidence that financial incentive interventions, which include both financial rewards and also penalties, are effective in encouraging healthy behaviours. However, concerns about the acceptability of such interventions remain. We report on focus groups with a cross-section of adults from North East England exploring their acceptance of financial incentive interventions for encouraging healthy behaviours amongst adults. Such information should help guide the design and development of acceptable, and effective, financial incentive interventions.

Methods

Eight focus groups with a total of 74 adults were conducted between November 2013 and January 2014 in Newcastle upon Tyne, UK. Focus groups lasted approximately 60 minutes and explored factors that made financial incentives acceptable and unacceptable to participants, together with discussions on preferred formats for financial incentives. Verbatim transcripts were thematically coded and analysed in Nvivo 10.

Results

Participants largely distrusted health promoting financial incentives, with a concern that individuals may abuse such schemes. There was, however, evidence that health promoting financial incentives may be more acceptable if they are fair to all recipients and members of the public; if they are closely monitored and evaluated; if they are shown to be effective and cost-effective; and if clear health education is provided alongside health promoting financial incentives. There was also a preference for positive rewards rather than negative penalties, and for shopping vouchers rather than cash incentives.

Conclusions

This qualitative empirical research has highlighted clear suggestions on how to design health promoting financial incentives to maximise acceptability to the general public. It will also be important to determine the acceptability of health promoting financial incentives in a range of stakeholders, and in particular, those who fund such schemes, and policy-makers who are likely to be involved with the design, implementation and evaluation of health promoting financial incentive schemes.

Electronic supplementary material

The online version of this article (doi:10.1186/s12889-015-1409-y) contains supplementary material, which is available to authorized users.

Current salt reduction policies across gradients of inequality-adjusted human development in the WHO European region: minding the gaps

OBJECTIVE

To assess current salt reduction policies in countries of the WHO European Region against the backdrop of varying levels of human development adjusted for income, education and health (longevity) inequalities.

DESIGN

Population-based, cross-sectional study, with data gathered through systematic review of relevant databases and supplementary information provided by WHO Nutrition Counterparts.

SETTING

Member States of the WHO European Region.

SUBJECTS

Inequality-adjusted Human Development Index scores were analysed against assessed levels of development and implementation of national nutrition policies and initiatives targeting population-level salt reduction.

RESULTS

Within the WHO European Region, Inequality-adjusted Human Development Index values among countries with no existing salt reduction initiatives (mean 0·643 (se 0·022)) were significantly lower than among those with either partially implemented/planned salt initiatives (mean 0·766 (se 0·017), P < 0·001) or fully implemented salt initiatives (mean 0·780 (se 0·021), P < 0·001).

CONCLUSIONS

Where salt reduction strategies are implemented as an integral part of national policy, outcomes have been promising. However, low- and middle-income countries may face severe resource constraints that keep them from emulating more comprehensive strategies pursued in high-income countries. Care must be taken to ensure that gaps are not inadvertently widened by monitoring differential policy impacts of salt policies, particularly regarding trade flows.

Women, infants, and children cash value voucher (CVV) use in Arizona: a qualitative exploration of barriers and strategies related to fruit and vegetable purchases

OBJECTIVE

Women, Infants, and Children (WIC) cash value vouchers (CVV) have been inconsistently redeemed in Arizona. The objective of this study was to explore perceived barriers to use of CVV as well as strategies participants use to overcome them.

DESIGN

Eight focus groups were conducted to explore attitudes and behaviors related to CVV use.

SETTING

Focus groups were conducted at 2 WIC clinics in metro-Phoenix, AZ.

PARTICIPANTS

Participants in WIC who were at least 18 years of age and primarily responsible for buying and preparing food for their households.

PHENOMENON OF INTEREST

Perceived barriers to CVV use and strategies used to maximize their purchasing value.

ANALYSIS

Transcripts were analyzed using a general inductive approach to identify emergent themes.

RESULTS

Among 41 participants, multiple perceived barriers emerged, such as negative interactions in stores or confusion over WIC rules. Among experienced shoppers, WIC strategies also emerged to deal with barriers and maximize CVV value, including strategic choice of times and locations at which to shop and use of price-matching, rewards points, and other ways to increase purchasing power.

CONCLUSIONS AND IMPLICATIONS

Arizona WIC participants perceived barriers that limit easy redemption of CVV. Useful strategies were also identified that could be important to explore further to improve WIC CVV purchasing experiences.

Improving perceptions of healthy food affordability: results from a pilot intervention

Background

Despite strong empirical support for the association between perceived food affordability and dietary intake amongst families with a lower socioeconomic position (SEP), there is limited evidence of the most effective strategies for promoting more positive perceptions of healthy food affordability among this group. This paper reports findings from a pilot intervention that aimed to improve perceptions of healthy food affordability amongst mothers.

Findings

Participants were 66 mothers who were the parents of children recruited from primary schools located in socioeconomically disadvantaged suburbs. Intervention group participants viewed a slideshow focussed on healthy snack food affordability that illustrated cheaper healthier alternatives to common snack foods as well as food budgeting tips and price comparison education. A mixed between-within ANCOVA was conducted to examine group differences in perceived affordability of healthy food across three time points. Results revealed no difference in perceived affordability of healthy food between the two groups at baseline whereas at post-intervention and follow-up, mothers in the intervention group perceived healthy food as more affordable than the control group.

Conclusions

Focussing on education-based interventions to improve perceptions of healthy food affordability may be a promising approach that complements existing nutrition promotion strategies.

Optimisation modelling to assess cost of dietary improvement in remote Aboriginal Australia

BACKGROUND

The cost and dietary choices required to fulfil nutrient recommendations defined nationally, need investigation, particularly for disadvantaged populations.

OBJECTIVE

We used optimisation modelling to examine the dietary change required to achieve nutrient requirements at minimum cost for an Aboriginal population in remote Australia, using where possible minimally-processed whole foods.

DESIGN

A twelve month cross-section of population-level purchased food, food price and nutrient content data was used as the baseline. Relative amounts from 34 food group categories were varied to achieve specific energy and nutrient density goals at minimum cost while meeting model constraints intended to minimise deviation from the purchased diet.

RESULTS

Simultaneous achievement of all nutrient goals was not feasible. The two most successful models (A & B) met all nutrient targets except sodium (146.2% and 148.9% of the respective target) and saturated fat (12.0% and 11.7% of energy). Model A was achieved with 3.2% lower cost than the baseline diet (which cost approximately AUD$13.01/person/day) and Model B at 7.8% lower cost but with a reduction in energy of 4.4%. Both models required very large reductions in sugar sweetened beverages (-90%) and refined cereals (-90%) and an approximate four-fold increase in vegetables, fruit, dairy foods, eggs, fish and seafood, and wholegrain cereals.

CONCLUSION

This modelling approach suggested population level dietary recommendations at minimal cost based on the baseline purchased diet. Large shifts in diet in remote Aboriginal Australian populations are needed to achieve national nutrient targets. The modeling approach used was not able to meet all nutrient targets at less than current food expenditure.

Monitoring the price and affordability of foods and diets globally

Food prices and food affordability are important determinants of food choices, obesity and non-communicable diseases. As governments around the world consider policies to promote the consumption of healthier foods, data on the relative price and affordability of foods, with a particular focus on the difference between 'less healthy' and 'healthy' foods and diets, are urgently needed. This paper briefly reviews past and current approaches to monitoring food prices, and identifies key issues affecting the development of practical tools and methods for food price data collection, analysis and reporting. A step-wise monitoring framework, including measurement indicators, is proposed. 'Minimal' data collection will assess the differential price of 'healthy' and 'less healthy' foods; 'expanded' monitoring will assess the differential price of 'healthy' and 'less healthy' diets; and the 'optimal' approach will also monitor food affordability, by taking into account household income. The monitoring of the price and affordability of 'healthy' and 'less healthy' foods and diets globally will provide robust data and benchmarks to inform economic and fiscal policy responses. Given the range of methodological, cultural and logistical challenges in this area, it is imperative that all aspects of the proposed monitoring framework are tested rigorously before implementation.