Choice Architecture Cueing to Healthier Dietary Choices and Physical Activity at the Workplace: Implementation and Feasibility Evaluation

The role of the workplace food environment in eating behaviours of employees at small and medium-sized enterprises: a qualitative study in the Netherlands

BACKGROUND

Workplace food environments play a pivotal role in encouraging healthy and sustainable food choices. However, research on food environments in small and medium-sized enterprises (SMEs) without a workplace cafeteria is scarce, with much of the existing research concentrating on larger or specific types of companies. This qualitative study primarily aims to explore how employers and employees perceive the workplace food environment across different types of SMEs in the Netherlands, including desk-based, mobile workforce, and on-site manual labour settings. Second, it aims to gain insight into the perceived opportunities and barriers in SMEs to promote a healthy and sustainable diet.

METHODS

This qualitative study involved 27 interviews conducted between May 2021 and February 2022, engaging both employers and employees across different types of SMEs: 10 desk-based, 8 on-site manual labour, and 9 mobile workforce SMEs. The data was analysed via a hybrid coding process, including deductive coding based on themes included in the interview guide and allowing for further codes to emerge from the data inductively.

RESULTS

The results showed noticeable differences in the perceived workplace food environment between the three SME types. Although structural food offerings (such as those offered through a workplace cafeteria) were mostly lacking among all SMEs, most desk-based SMEs offered a daily facilitated lunch, whilst employees of mobile workforce SMEs typically received a daily allowance. However, similarities were also observed across the three SME types as there was a noticeable absence of financial incentives, or food policies regarding healthy and sustainable food. Barriers to promoting a healthy and sustainable diet among employees were that SMEs did not identify healthy and sustainable consumption at the workplace as their responsibility, or as a 'problem' that needed to be solved. Both employers and employees found it difficult to identify opportunities to promote healthy and sustainable diets in the workplace.

CONCLUSIONS

Across all three types of SMEs, both employers and employees described a food environment that was limited in actively encouraging healthy and sustainable food choices at the workplace. Future research should focus on developing tailored workplace policies and interventions addressing the unique food environment characteristics of different types of SMEs to improve employee eating behaviour.

Building a culture of healthy living in the workplace

Workplace settings, including hybrid, remote, and home-based environments, are key places to support employees and their families to live healthfully since so many adults spend significant amounts of time at work. Employers can create a culture of healthy living at their workplaces and do so intentionally through process and practice. They can establish organizational policies, systems, work processes, architectural design practices, and employment benefits designs to support healthy behaviors for their employees and their families. Employers also can ensure health insurance approaches that provide equitable access to quality health care. They can ensure livable wages for all staff and provide a host of other important healthy living support mechanisms, using incentives and communications. Organizational executives and upper managers play a critical role in modeling these shared values at the workplace and participatory approaches need to be implemented to give all workers opportunity to meaningfully engage. Corporate leaders can reinforce a healthy living culture with role modeling and by ensuring resources are available and accessible-to do so, a set of workplace factors should be implemented that, cumulatively, reach a tipping point toward the creation of a healthy workplace culture. Employers can both influence and be influenced by the communities in which they are located. Recognizing regional culture, participating in strategic relationships, investing in the community, and providing volunteer and civic engagement opportunities all contribute to the support of healthy living strategies in the workplace. When employers pursue a workplace culture of health, they not only do good by their employees, but they also increase the likelihood that their company may outperform their market competition.

The implementation of an integrated workplace health promotion program in Dutch organizations - A mixed methods process evaluation

OBJECTIVE

To gain insight into 1) the degree of implementation of an integrated workplace health promotion program (WHPP) 2) the perceptions of employers and employees regarding an integrated WHPP and 3) the contextual factors that hindered or enhanced implementation.

METHODS

Data were collected by means of questionnaires, interviews among 19 employees, supervisors and HR-professionals, monitoring charts and observations at 6-10 months after the start of the implementation of the integrated WHPP. To evaluate the implementation process, ten process indicators from the evaluation frameworks of Nielsen & Randall and Wierenga were assessed. Descriptive analyses were performed for the process indicators as measured by questionnaires, monitoring charts and observations. Interviews with employers and employees were recorded, transcribed and then coded by two researchers independently by means of thematic coding.

RESULTS

The results cover the following topics: implemented activities, the working group, engagement of employees, the role of management and policy and organizational preconditions. Although the criteria of the WHPP were not completely met, various activities were implemented in all participating organizations. Working groups consisting of Human Resources professionals, supervisors and employees, who selected and implemented activities, were composed within each organization. 22% of the employees did not feel involved in the implementation process. The absence of organizational policies regarding WHP hampered implementation. Organizations had the intention to continue with the integrated WHPP, which requires sufficient time and budget.

CONCLUSIONS

The implementation of the integrated WHPP appeared to be challenging and complex. Working groups indicated that they made the first important steps in integrating WHP in their organization and had the intention to continue with the implementation. However, to increase the impact, employers and employees should have the opportunity to implement and participate in WHP. Hence, organizational policies regarding WHP and active support of higher management are expected to be essential.

Effect of nutritional guidance on employee work ability, work well-being and quality of life (RAVI trial): Study protocol for a randomized controlled trial

BACKGROUND

The minority of working-age Finns eat according to the national and Nordic nutritional guidelines and increasing numbers of health problems affect the Finnish workforce. Coincidently recruiting new workers in the more rural areas of Finland, such as Satakunta, has been problematic. To optimize the use of the existing workforce, health promotion interventions focusing on nutrition have been suggested to improve the health and well-being of the current working age Finns.

METHODS AND ANALYSIS

The aim of this RCT study is to assess the effectiveness of a 12-month multifactorial nutritional guidance intervention to improve work ability (performance), work well-being, health-related quality of life, work productivity, sickness absence, dietary intake and eating habits. In total, six small or medium-sized companies and their employees (n = 170) from the Satakunta region will be recruited. Companies will be randomized 1:1 to a 12-month multifactorial nutritional guidance intervention group (INT) or a control group (CG). Comprehensive measurements are taken before randomization (baseline) and at the end of the 12-month study period. Primary outcomes (work ability, work well-being and health-related quality of life) are measured with Work Ability Index, Utrecht Work Engagement Scale short questionnaire and EQ-5D. Dietary intake and eating habits are measured with 3-day food records and Food Frequency Questionnaire (FFQ).

DISCUSSION

This study will provide nationally important data on how workplace nutrition guidance affects work-related outcomes, quality of life, and nutritional and overall health status among working age Finns.

Challenges and opportunities when moving food production and consumption toward sustainable diets in the Nordics: a scoping review for Nordic Nutrition Recommendations 2023

The terms 'Nordic countries' or 'The Nordics' include the five countries Denmark, Finland, Island, Norway, and Sweden. This review includes evaluation of the Nordic countries against Food and Agricultural Organisation (FAO)/World Health Organizations' (WHO) guiding principles for healthy, sustainable diets with respect to environmental impact (principles #9 - #13) and sociocultural aspects (principles #14 - #16). A food systems perspective is taken to summarize and discuss the most important challenges and opportunities for achieving sustainable diets. Food system, food security, self-sufficiency, and resilience perspectives are applied. The information can underpin decisions when developing and implementing Food Based Dietary Guidelines (FBDG) in the Nordics. None of the Nordic countries are on track to reach the 2030 UN climate and biodiversity goals. We describe how food production, processing, and consumption contribute to these and other environmental challenges, and what kinds of dietary changes/transitions consistent with these goals are required. A major challenge is the high production and consumption of meat and too low consumption of fish, vegetables, and fruits. Meat production is a major source of emissions and, together with farmed fish, heavily dependent on imported feed ingredients, leaving a large land-use and water footprint in exporting countries while domestic land resources are not used optimally. Dietary patterns have changed drastically over the past 50 years, and in large parts of the population, meat consumption has doubled since the 1970s, rendering historic food culture less useful as a basis for present-day recommendations. The Nordics have Europe's lowest use of antibiotics in animal and fish production and have made some progress in reducing food waste along the food chain. A major opportunity is better alignment of food production and consumption based on local or regional production potentials, in conjunction with better and more constructive integration with the global food system while integrating novel technologies to reduce emissions and resource use.

Effectiveness of workplace choice architecture modification for healthy eating and daily physical activity

BACKGROUND

Modifying the choice architecture of behavioural contexts can facilitate health behaviour change, but existing evidence builds mostly on small-scale interventions limited in duration, targets, strategies, and settings. We evaluated the effectiveness of a one-year hybrid type 2 implementation-effectiveness trial aimed at promoting healthy eating and daily physical activity with subtle modifications to the choice architecture of heterogeneous worksites. The intervention was contextualised to and integrated into the routine operations of each worksite. Effectiveness was evaluated in a quasi-experimental pre-post design.

METHODS

Intervention sites (n = 21) implemented a median of two (range 1-9) intervention strategies for healthy eating and one (range 1-5) for physical activity. Questionnaires pre (n = 1126) and post (n = 943) intervention surveyed employees' behavioural patterns at work (food consumption: vegetables/roots, fruit/berries, nuts/almonds/seeds, sweet treats, fast food, water; physical activity: restorative movement, exercise equipment use, stair use). The post-intervention questionnaire also measured employees' perception of and response to three intervention strategies: a packed lunch recipe campaign, a fruit crew-strategy, and movement prompts. Multi- and single-level regression models evaluated effectiveness, treating intervention as a continuous predictor formed of the site-specific dose (n intervention strategies employed) and mean quality (three-point rating per strategy halfway and at the end of the intervention) of implementation relevant to each outcome.

RESULTS

Multinomial logistic regression models found the intervention significantly associated with a favourable change in employees' fruit and berry consumption (interaction effect of time and implementation p = 0.006) and with an unfavourable change in sweet treat consumption (p = 0.048). The evidence was strongest for the finding concerning fruit/berry consumption-an outcome that sites with greater dose and quality of implementation targeted by using strategies that reduced the physical effort required to have fruit/berries at work and by covering multiple eating-related contexts at the worksite. The quality of implementation was positively associated with the perception of (p = 0.044) and response to (p = 0.017) the packed lunch recipes, and with response to the fruit crew-strategy (p < 0.001).

CONCLUSIONS

The results suggest that a contextualised, multicomponent choice architecture intervention can positively influence eating behaviour in diverse real-world settings over a one-year period, and that higher implementation quality can enhance intervention perception and response. However, outcomes may depend on the type of intervention strategies used and the extent of their delivery.

Acceptability of workplace choice architecture modification for healthy behaviours

BACKGROUND

Altering the choice architecture of decision contexts can assist behaviour change, but the acceptability of this approach has sparked debate. Considering hypothetical interventions, people generally welcome the approach for promoting health, but little evidence exists on acceptance in the real world. Furthermore, research has yet to explore the implementers' perspective, acknowledging the multidimensionality of the acceptability construct. Addressing these knowledge gaps, this study evaluated the acceptability of a quasi-experimental implementation-effectiveness trial that modified the worksite choice architecture for healthy eating and daily physical activity.

METHODS

Fifty-three worksites participated in the 12-month intervention and implemented altogether 23 choice architecture strategies (Mdn 3/site), including point-of-choice prompts and changes to choice availability or accessibility. Retrospective acceptability evaluation built on deductive qualitative content analysis of implementer interviews (n = 65) and quantitative analysis of an employee questionnaire (n = 1124). Qualitative analysis examined implementers' thoughts and observations of the intervention and its implementation, considering six domains of the Theoretical Framework of Acceptability: ethicality, affective attitude, burden, intervention coherence, opportunity costs, and perceived effectiveness. Quantitative analysis examined employees' acceptance (7-point Likert scale) of eight specific intervention strategies using Friedman test and mixed-effects logistic regression.

RESULTS

Implementers considered the choice architecture approach ethical for workplace health promotion, reported mostly positive affective attitudes to and little burden because of the intervention. Intervention coherence supported acceptance through increased interest in implementation, whereas low perceived utility and high intensity of implementation reduced cost acceptance. Perceived effectiveness was mixed and varied along factors related to the implementer, social/physical work environment, employer, and employee. Employees showed overall high acceptance of evaluated strategies (Mdn 7, IQR 6.4-7), though strategies replacing unhealthy foods with healthier alternatives appeared less supported than providing information or enhancing healthy option availability or accessibility (p-values < 0.02). Greater proportion of male employees per site predicted lower overall acceptance (OR 4.4, 95% CI 1.2-16.5).

CONCLUSIONS

Work communities appear to approve workplace choice architecture interventions for healthy eating and physical activity, but numerous factors influence acceptance and warrant consideration in future interventions. The study contributes with a theory-based, multidimensional evaluation that considered the perspectives of implementers and influenced individuals across heterogeneous real-world settings.

Perception of nudge interventions to mitigate medication errors risk in healthcare service delivery

BACKGROUND

Conventional cognitive interventions to reduce medication errors have been found to be less effective as behavioural change does not always follow intention change. Nudge interventions, which subtly steer one's choices, have recently been introduced.

METHODS

Conducted from February to May 2023, this study aimed to determine the relationships between perceived effectiveness and perceived ease of implementation of six nudge interventions to reduce medication errors, i.e., provider champion, provider's commitment, peer comparison, provider education, patient education and departmental feedback, and the moderating effects of seniority of job positions and clinical experience on nudge acceptability. Partial Least Square Structural Equation Modelling was used for data analysis.

RESULTS AND DISCUSSION

All six nudge strategies had significant positive relationships between perceived effectiveness and acceptability. In three out of six interventions, perceived ease of implementation was shown to have positive relationships with perceived acceptability. Only seniority of job position had a significant moderating effect on perceived ease of implementation in peer comparison intervention. Interventions that personally involve senior doctors appeared to have higher predictive accuracy than those that do not, indicating that high power-distance culture influence intervention acceptability.

CONCLUSION

For successful nudge implementations, both intrinsic properties of the interventions and the broader sociocultural context is necessary.

Creating healthy food environments in recreation and sport settings using choice architecture: a scoping review

Recreation and sport settings (RSS) are ideal for health promotion, however, they often promote unhealthy eating. Choice architecture, a strategy to nudge consumers towards healthier options, has not been comprehensively reviewed in RSS and indicators for setting-based multi-level, multi-component healthy eating interventions in RSS are lacking. This scoping review aimed to generate healthy food environment indicators for RSS by reviewing peer-reviewed and grey literature evidence mapped onto an adapted choice architecture framework. One hundred thirty-two documents were included in a systematic search after screening. Data were extracted and coded, first, according to Canada's dietary guideline key messages, and were, second, mapped onto a choice architecture framework with eight nudging strategies (profile, portion, pricing, promotion, picks, priming, place and proximity) plus two multi-level factors (policy and people). We collated data to identify overarching guiding principles. We identified numerous indicators related to foods, water, sugary beverages, food marketing and sponsorship. There were four cross-cutting guiding principles: (i) healthy food and beverages are available, (ii) the pricing and placement of food and beverages favours healthy options, (iii) promotional messages related to food and beverages supports healthy eating and (iv) RSS are committed to supporting healthy eating and healthy food environments. The findings can be used to design nested, multipronged healthy food environment interventions. Future research is needed to test and systematically review the effectiveness of healthy eating interventions to identify the most promising indicators for setting-based health promotion in RSS.

Nudging Finnish Adults into Replacing Red Meat with Plant-Based Protein via Presenting Foods as Dish of the Day and Altering the Dish Sequence

This study investigated whether Finnish working-aged omnivores (n = 163) could be nudged into replacing red meat with a fava-bean-based protein source via “Dish of the Day” (DoD) and main dish sequence alteration (SA) strategies in a controlled real-world Finnish self-service buffet restaurant with smart scales (Flavoria® Multidisciplinary Research Platform). A further aim was to study whether the effectiveness of the strategies differed by gender, age, and body mass index. The participants were assigned one of four experimental treatments: standard menu (T1), DoD (T2), standard menu + SA (T3), or DoD + SA (T4). The participants could choose any amount or combination of salad components and casseroles with minced meat or fava bean protein. Being subjected to a DoD menu and/or SA had no effect on main dish choice or the share of the meat-based dish in the meal weight. Men were more likely to choose a meat-based main dish and had a higher share of the meat dish in the meal weight compared to women, but no differences were observed between those aged 18–29, 30–44, or 45–65 years or those who were normal weight, overweight, or obese. Future studies should have a larger sample size and investigate food choice motives such as price or environmental awareness.

Sensory Appeal and Routines Beat Health Messages and Visibility Enhancements: Mixed-Methods Analysis of a Choice-Architecture Intervention in a Workplace Cafeteria

Easier recognition and enhanced visibility of healthy options supposedly increase healthy choices, but real-world evidence remains scarce. Addressing this knowledge gap, we promoted nutritionally favourable foods in a workplace cafeteria with three choice-architectural strategies-priming posters, point-of-choice nutrition labels, and improved product placement-and assessed their effects on visual attention, food choices, and food consumption. Additionally, we developed a method for analysing real-world eye-tracking data. The study followed a pretest-posttest design whereby control and intervention condition lasted five days each. We monitored visual attention (i.e., total number and duration of fixations) and food choices with eye tracking, interviewed customers about perceived influences on food choices, and measured cafeteria-level food consumption (g). Individual-level data represents 22 control and 19 intervention participants recruited at the cafeteria entrance. Cafeteria-level data represents food consumption during the trial (556/589 meals sold). Results indicated that the posters and labels captured participants' visual attention (~13% of fixations on defined areas of interest before food choices), but the intervention had insignificant effects on visual attention to foods, on food choices, and on food consumption. Interviews revealed 17 perceived influences on food choices, the most common being sensory appeal, healthiness, and familiarity. To conclude, the intervention appeared capable of attracting visual attention, yet ineffective in increasing healthier eating. The developed method enabled a rigorous analysis of visual attention and food choices in a natural choice setting. We discuss ways to boost the impact of the intervention on behaviour, considering target groups' motives. The work contributes with a unique, mixed-methods approach and a real-world setting that enabled a multi-dimensional effects evaluation with high external validity.