Health Promotion International, Vol. 16, No. 1, 21-33,
March 2001
© Oxford University Press 2001
Strengthening environmental and educational nutrition programmes in worksite cafeterias and supermarkets in the Netherlands
Department of Health Education and Promotion, Maastricht University PO Box 616, 6200 MD Maastricht, the Netherlands and 1 Cancer Research Center of Hawai'i, University of Hawai'i, Honolulu, HI 96813, USA
Address for correspondence: I. H. M. Steenhuis, Department of Health Education and Promotion, Maastricht University, PO Box 616, 6200 MD Maastricht, The Netherlands
 |
SUMMARY |
|---|
 TOP SUMMARY INTRODUCTIONMETHODSRESULTSDISCUSSIONACKNOWLEDGEMENTSREFERENCES |
|---|
The purpose of this study was to assess conditions for the adoption and continued implementation of different healthy nutrition programmes in worksite cafeterias and supermarkets, i.e. an educational programme and two environmental programmes (a food labelling programme and a food supply programme). Twenty semi-structured interviews were conducted with representatives of worksite cafeterias and supermarkets. Concepts of theories of diffusion were used as a framework for the study. Questions were formulated about the attributes of the innovation, and organizational and personal characteristics that might influence programme adoption and implementation. Results indicated that educational and environmental programmes in both worksite cafeterias and supermarkets should meet specific requirements regarding programme design, methods and materials in order to be adopted and implemented. Besides, some important implementation strategies of the educational and environmental programmes were identified. It is concluded that it seems feasible to conduct educational and environmental intervention programmes in worksite cafeterias and supermarkets, but that certain conditions for adoption and continued implementation have to be met. Based on the implications of this study, the development of an educational programme, a labelling programme and a food supply programme was completed.
Key words: diffusion of innovation; nutrition; supermarket; worksite cafeteria
|
INTRODUCTION |
|---|
|
TOPSUMMARYINTRODUCTIONMETHODSRESULTSDISCUSSIONACKNOWLEDGEMENTSREFERENCES |
|---|
Different aspects in the diet have been found to be important in the prevention of cancer and coronary heart diseases (CHD), for example the consumption of fat, fruit and vegetables (Willet, 1994
). Although the exact role of dietary factors in cancer and CHD is still being studied, the evidence is sufficient to have resulted in official dietary guidelines in the Netherlands (Dutch Nutrition Council, 1986) and in many other countries (US Departments of Agriculture and Human Services, 1990; Benito, 1992). In the Netherlands, priority has been given to the implementation of the guideline on fat intake, i.e. to reduce dietary fat intake to 30–35% of total calories, especially by reducing intake of saturated fat to a maximum of 10% of total calories (Dutch Nutrition Council, 1986; Dutch Nutrition Council, 1991). The guidelines also recommend eating ample amounts of fruit and vegetables (Dutch Nutrition Council, 1986). A more specific recommendation for adults is given by the Netherlands Bureau for Food and Nutrition: 200 g of vegetables and two pieces of fruit per day (Netherlands Bureau for Food and Nutrition, 1992). The third Dutch National Food Consumption Survey showed that in 1997–1998, total fat intake was 36% of total calories, and the intake of saturated fat 14% of total calories. Mean consumption of vegetables was 123 g per day and mean consumption of fruit 105 g per day (Netherlands Bureau for Food and Nutrition, 1998). This discrepancy between dietary guidelines and actual intake shows that effective methods for achieving large scale dietary changes are needed. It is now widely accepted that contemporary health promotion strategies need to go beyond education and communication strategies to include environmental strategies. Strong pleas are being made for educational programmes to be extended with environmental programmes in order to achieve population-wide behavioural changes (Bracht, 1990; Glanz et al., 1990; Green and Kreuter, 1991; Glanz et al., 1996). According to Glanz, environmental programmes comprise all those strategies that do not require individuals to self-select into a defined educational programme (Glanz, 1993). Furthermore, environmental strategies can be defined as strategies that reduce barriers or increase opportunities for healthy choices, i.e. more healthy options, make healthy choices more accessible (convenient to find, not too expensive), and policies that require healthy options being available, or even prohibit/limit the number of ‘less healthy’ options. Examples of environmental strategies are nutrition labelling, regulation of health claims, shelf labelling in supermarkets, changes in food preparation, or offerings in supermarkets, restaurants and worksite food services and vending areas. Environmental interventions to encourage the adoption of healthful eating patterns can be implemented in different settings. Settings where food is provided, prepared, sold or served are especially suitable for environmental programmes (Glanz, 1993). Point-of-choice settings are, for example, worksite cafeterias, restaurants, school canteens and supermarkets. The present study was conducted as part of developing a nutrition education programme and two environmental programmes (a labelling programme and a food supply programme) aiming at reducing fat intake and increasing fruit and vegetable consumption, to be implemented in two point-of-choice settings (worksite cafeterias and supermarkets). The nutrition education programme was developed to be used alone or in combination with one or both environmental programmes. The educational programme provides, through various channels (e.g. brochures or posters), information about eating less fat and more fruit and vegetables, such as practical tips on how to do so, highlighting the advantages, and guidelines with respect to quantities. The labelling programme consists of the labelling (i.e. putting an extra label on the product or in front of a group of products) of low-fat products and fruit and vegetables in order to make the healthy choices easily recognizable. The food supply programme suggests that cafeterias and supermarkets enlarge their range of products with low-fat products and fruit and vegetables.
Before developing environmental and/or educational programmes for point-of-choice settings, it is important to assess the feasibility and the conditions for the adoption and continued implementation of the programmes in these settings. Information from potential adopters in the development of the programmes and in the development of implementation strategies might help to enhance the likelihood of adoption and continued implementation and maintenance (Orlandi et al., 1990; Oldenburg et al., 1997). The goals of the present study were to assess the feasibility of both the educational and environmental programmes, and to identify factors possibly influencing the adoption and continued implementation of these programmes by worksite cafeterias and supermarkets. Based on the results, implications for actual programme development and implications for development of implementation strategies were formulated.
|
METHODS |
|---|
|
TOPSUMMARYINTRODUCTIONMETHODSRESULTSDISCUSSIONACKNOWLEDGEMENTSREFERENCES |
|---|
Recruitment
Semi-structured interviews were conducted with key persons of worksite cafeterias and supermarkets. First, the worksite cafeterias and supermarkets were approached by means of a letter in which the purpose of the study was explained as well as the interview procedure. Subsequently, respondents were asked by telephone to participate in the study. Companies and supermarkets were selected based on several criteria. For companies, the presence of a worksite cafeteria was required. Both companies with a majority of white collar workers and those with a majority of blue collar workers were included. For supermarkets, different types of supermarket were recruited: those belonging to a national chain of supermarkets, those belonging to a regional chain, and franchise supermarkets. During the interviews, respondents were asked to point out other key persons in their company or supermarket who should also be interviewed. For example, a local supermarket manager might suggest that the manager of the chain's head office should also be interviewed.
Theoretical framework
Concepts of theories about the diffusion of innovations were used as a framework for the study. Rogers defines diffusion as the ‘process by which an innovation is communicated through certain channels over time among the members of a social system’ and an innovation is defined as a ‘policy, programme or technology that is new to its potential users’ (Rogers, 1983). Healthy nutrition educational and environmental interventions can be seen as innovations, while worksite cafeteria and supermarket representatives can be seen as potential adopters of these programmes. The diffusion of a programme can be seen as a five-stage process. First, an organization obtains knowledge about the programme. Secondly, the organization's decision makers form an attitude toward the programme. Thirdly, the organization, through its decision makers, adopts or rejects the programme. If the programme is adopted, the fourth stage is implementation. Finally, the programme is institutionalized or becomes part of the ongoing activities of the organization (Rogers, 1983).
Many factors have been suggested to be related to programme diffusion. Rogers, for example, defined several attributes of innovations that influence the rate of diffusion (Rogers, 1983):
- relative advantage: the unique benefits of the innovation over other practices;
- compatibility: the match between the innovation and the sociocultural, economic and ideological value system of the adopter;
- complexity: the degree of difficulty in understanding and using an innovation;
- trialability: the degree to which the innovation can be split up for small-scale experiments;
- observability: the visibility of the innovation's results.
Other attributes of innovations related to programme diffusion include, among others, reversibility, communicability and modifiability (Oldenburg et al., 1997).
Furthermore, characteristics of the adopting organization have been found to be related to diffusion, such as the organizational climate, concern and interest in the organization about the subject, social influence toward programme participation, size and structure of the organization, and the decision-making process (Rogers, 1983; Basch et al., 1986; Steckler et al., 1992; De Vries, 1993). Other factors that have been found to influence the diffusion process are characteristics of the adopting persons (e.g. socio-economic characteristics, self-efficacy expectations and personality), and the perceived level of success of programme implementation (Rogers, 1983; Steckler et al., 1992; De Vries, 1993).
Interview topics
Before the interview started, the three types of programmes (educational, labelling and food supply) were roughly explained to the respondents. It was also explained that the results of this study were going to be used to design the programmes further. Relevant constructs for this study from the theories about diffusion of innovations were used to formulate the interview questions. Questions were asked about attributes of the innovation, characteristics of the adopting organization and characteristics of the adopting persons (Table 1). Besides questions derived directly from theoretical constructs (e.g. what are the relative advantages of the programmes?), some practical questions concerning programme requirements and programme materials were added (e.g. what are the preferences regarding programme materials?). In order to give respondents the maximum opportunity to express their opinion, all questions were open ended. Depending on the answers of the respondent, the interviewer asked more detailed questions in order to obtain as much information as possible.
|
Analysis
The interviews were recorded to tape and full transcripts were made. Subsequently, the transcripts were divided into small text units. The text units were coded and categorized by the researcher according to the list of interview topics. Text units could be relevant and coded for more than one interview topic. After the coding process, the text units were sorted per interview topic. Finally, summary reports of each topic were written. In some cases the type of respondent (e.g. a local supermarket manager or a representative of the head office of the supermarket) was taken into account. In order to facilitate this, all text units were coded by the type of respondent. This so called ‘cut-and paste’ technique is described as a quick, cost-effective and very useful method for analysing trancripts (Stewart and Shamdasani, 1990
). A word processing programme was used to carry out the procedure. |
RESULTS |
|---|
|
TOPSUMMARYINTRODUCTIONMETHODSRESULTSDISCUSSIONACKNOWLEDGEMENTSREFERENCES |
|---|
In total, 12 interviews were conducted with worksite cafeterias and eight with supermarkets. Five worksite cafeterias and four supermarkets refused an interview, for reasons of time. Six representatives of the worksite cafeterias were head or employee of the Service Department of their company, five were local catering managers employed by a catering organization but attached to a specific worksite cafeteria, and two were employees at the head office of a catering organization. Different types of companies were included in the study, for example a hospital, a governmental organization and a cement factory. All the companies had a worksite cafeteria serving 70–600 customers a day. The greater part of the employees of the companies included in the study attended the cafeteria regularly, varying from 50 to 85% per company. With respect to the supermarkets, six interviews were conducted with local supermarket managers and two with head-office representatives of large national supermarket chains. All supermarkets were related to some chain. The mean number of customers per week varied from 2200 to 10 000 per week. Three supermarket managers were franchisers and three were branch managers. The duration of the interviews in both the worksite cafeterias and the supermarkets varied from 1 to 1.5 h.
Attributes of the innovation
Programme requirements
Tables 2 and 3 show requirements of the programmes and programme materials spontaneously mentioned by the respondents. Most frequently mentioned was that a nutrition education programme should not be too obtrusive, which means, according to the respondents, that people should not be forced to take part in a programme, and that people should not have feelings of guilt as a result of a nutrition education programme because of the way they eat. Among other requirements, the nutrition education programme should not be too time consuming (for both cafeteria or store personnel and clients), it should be practicable, and the programme materials should be attractive and eco-friendly. Specific to supermarkets is the fact that a programme should increase profit. Furthermore, the labelling programme should not be too time consuming for cafeteria or store personnel, it should be hygienic, the labelling should not be excessive and labels should not move around. Some respondents indicated that the food supply programme should be an extension of the range, while other respondents preferred a replacement of unhealthy products with healthy products. Other requirements for the changes in food supply programme included that the turnover rate of products should remain sufficiently high, and that the prices of the healthy products should be the same as those of other products. A specific requirement for worksite cafeterias is that the labelling programme and food supply programme should not cause delays at the counter.
|
|
Programme materials
Respondents were asked specifically about their preferences for certain programme materials. Brochures, flyers, handouts, posters, displays and self-help guides were seen as good intervention materials to use in worksite cafeterias by almost all respondents. Publicity in the worksite newsletter was also seen as a good option by most respondents. Table tents were preferred by all respondents, except two who gave the limited space on the tables as the main reason for not preferring them. Due to possible technical difficulties and the disturbance it might cause, using audio messages was not a good idea according to the respondents. Giving clients information on their receipt (about the amount of fat of the products purchased, for example) was not an option for several reasons: it is too obtrusive, most clients do not take their receipt, and some cash desks do not have the technical facility. Respondents came up with several other ideas for programme elements, namely placemats (four respondents), a video, lowering the prices of healthy products, change in composition of products and meals, a symposium about healthy nutrition, messages through the computer network or internal television circuits, special offers, putting all the healthy products together on one counter, giving clients recipes of healthy meals offered in the cafeteria, a flag in the cafeteria with the logo of the programme, and finally announcements via notice boards.
For supermarkets, nearly all respondents indicated brochures, flyers, posters, displays, information in the already existing store advertisements and self-help guides as good programme elements. Respondents had mixed feelings about audio messages. For some respondents, audio messages could be an option, while others did not think so because they thought it would be too complicated. Respondents also had some doubts about handouts (giving each client an information flyer at the pay desk). They were concerned that customers would leave the handouts in their grocery carts, thereby increasing the amount of rubbish in the store. No respondents were in favour of giving clients information on their receipts because clients do not read their receipts and it would be too much trouble technically to add the information to the receipts. Also, if something could be added to the receipts, respondents would add other information than information about healthy nutrition. Furthermore, respondents came up with some other ideas for a healthy nutrition programme in the supermarket, namely cooking or product demonstrations, healthy menu information together with special offers of the needed ingredients, connecting the labelling with some kind of saving system, billboards on the parking lot of the supermarket, test tasting of certain products, and creating a healthy products corner in the supermarket.
Specific questions about the format of the labelling intervention revealed that most respondents (both worksite cafeterias and supermarkets) prefer labelling of healthy products only, instead of labelling all products. This is more distinctive and requires less time. Moreover, respondents only want to promote products (positive labelling), instead of creating a negative image of products high in fat content. Also, labelling all kinds of products available in the supermarket is impossible according to the respondents, due to the number of products in a supermarket. One respondent thought that the labelling should be restricted to certain product categories in order to decrease the complexity of the labelling programme: labelling of fresh products was feasible, while labelling of pre-packed products would be more difficult. Concerning the information on the labels, some respondents indicated that product information such as the fat content or the calorific value would be desirable, but most respondents only wanted a programme logo and slogan (for example ‘healthy choice’) on the labels. The reason for this was because less time is required for clients to read the labels (in connection with possible delays at the counters). Furthermore, they thought that product information was irrelevant for clients and also difficult to count for prepared meals. Because of the limited time available to put on the labels in the cafeteria or supermarket, respondents preferred a label that could be used to label a group of items (for example shelf labelling) instead of labelling every single product. Most respondents would like to have both self-adhesive labels and little cards in bearers to put on the counter. Furthermore, the appearance of the labels should be colourful.
Complexity
Respondents mentioned several difficulties that increase the degree of complexity of the programmes. Possible difficulties in using the programmes included the amount of time, space and money the programme might cost, and possible decreases in sales of unhealthy products. Possible difficulties regarding participating in the labelling programme included the amount of time and money necessary, difficulties in deciding which products should be labelled, risk of irritating clients, the risk of labels moving around, and finally the risk of putting the labels on the wrong products. Respondents did not expect problems with manufacturers or the wholesale trade regarding labelling certain food products. Specific problems expected in the supermarkets included the risk of product discrimination and the lack of an efficient labelling updating system. Expected problems regarding the food supply programme were the availability of healthy products in the wholesale trade and the limited space in cafeterias and supermarkets. Possible problems mentioned specific to worksite cafeterias included the time required to prepare low-fat snacks, the higher price of healthy products, and the limited shelf-life of low-fat products. Possible restraints mentioned for the food supply programme in supermarkets were too much left-over stock if customers did not buy the new products, the preference of customers for products with a high fat content, and the fact that customers nearly always buy the same products out of habit.
Relative advantages
Respondents were asked to indicate relevant relative advantages with respect to current practices of the three programmes. Tables 4 and 5 show the relative advantages that were mentioned spontaneously by the respondents. Respondents indicated aspects relevant for the employees or clients as well as for the worksite cafeteria/company or supermarket itself.
|
|
Additionally, respondents were questioned about other possible relative advantages of programme participation. When asked specifically, respondents indicated that increasing customer satisfaction could be a possible relative advantage of programme participation as well as a positive influence on company or store image. Most respondents did not expect increased overall sales as a result of programme participation. Concerning worksite cafeterias, some respondents expected a positive effect on well-being of employees and less absence due to illness. A better competitive position towards other companies was not a reason to conduct a nutrition programme in the worksite cafeteria for either the company representatives or the local catering managers. However, for the representatives of the catering organizations it was an important reason. A better competitive positioning with respect to other supermarkets could be a relative advantage, according to the respondents, but only if their supermarket were the only supermarket/ chain with the programme. Finally, a majority of the respondents thought that a nutrition programme could possibly attract more customers for the supermarkets and could increase customer satisfaction.
Characteristics of the adopting organization
Concern and interest of organization about nutrition education
All company representatives and local catering managers acknowledged providing nutrition education in their worksite cafeteria as one of their tasks; however, they did not perceive it as a very important task. All catering organizations, on the contrary, attached considerable importance to their task and role in providing nutrition education. For supermarkets, some respondents acknowledged providing nutrition education as one of the tasks of a supermarket. However, the majority of the respondents did not see providing nutrition education as a task or priority of the supermarket. Making profits is the first priority. Besides, supermarkets are willing to provide some product information.
Experience of organization with educational activities
All companies had some experience with educational activities in the worksite cafeteria. However, not all companies had experience with healthy nutrition activities. Activities are mostly organized in so-called ‘action weeks’ with themes such as ‘nutrition and sports’, ‘bread’, or ‘food from a different country’. During these weeks different materials are used such as posters, leaflets, brochures, displays and articles in the worksite newsletter. Some cafeterias had offered new food products during these action weeks. One catering organization had experience of the labelling of healthy food products. Respondents reported that the employees had always reacted positively towards these actions. All the supermarkets also had some experience with giving information in the supermarket, and most of the supermarkets had experience of giving information about healthy nutrition. Product demonstrations are widely used, often in connection with the introduction of new products. Some supermarkets participated in national campaigns such as the Dutch National Fat Watch Campaign. Elements of this campaign were, for example, supermarket tours guided by a dietician and brochures. One supermarket chain has a sponsored shop magazine in which they regularly pay attention to topics about healthy nutrition.
Decision making process regarding range of products and educational activities
In most worksites, the local catering managers and the representatives of the companies had a shared responsibility towards the range offered in the worksite cafeteria. Most catering managers received guidelines from their head office, while sometimes the representatives of the companies were advised by the company health services and/or a canteen committee. In selecting the cafeteria range, several factors are important. First, cafeterias offer what customers ask for. Besides this, factors like the price, healthiness and (seasonal) availability of the product are important, as well as the variety of the range. In most companies there is no structural policy about giving customers information about (healthy) nutrition. Most catering organizations propose a few ‘action weeks’ during the year with a specific theme. The final decision about these theme weeks, however, is the responsibility of the Service Department of the company. All respondents thought both the catering organization (catering manager) and the representative of the company should be involved in the decision-making process concerning programme participation. A few respondents also indicated that cooks, cafeteria personnel, the works council, the company health services and the canteen committee should be involved in the decision-making process, although these people do not play a key role.
In the case of supermarket chain stores, the head office determines the range of products of the supermarkets. In the case of franchise stores, the owner has the responsibility for the range of the supermarket, although the range has to satisfy certain conditions of the store formula. The selection of the range of the supermarket is based on many different factors, but most important is the profit (margin) of products. Besides this, the number of products sold and unsold, the price of a product, the (local) demand of customers, the range in competing stores, the supply from the wholesale dealer, the size of the package available of the wholesale trade, the ratio between store brands and proprietary articles, the size and location of the store, the kind of customers and the quality of the products are important. The head offices of the chain stores are responsible for the information given to the customers; in the other cases the owner of the supermarket is responsible. This also applies to information about healthy nutrition. People who should be involved in the decision-making process concerning a healthy nutrition intervention in a chain store are, according to the respondents, product managers at the head office, the board of the chain and the branch manager. In the case of franchise stores, the owner of the store and sometimes the executive staff in the supermarket are the ones to be involved in the decision making about a healthy nutrition programme.
Social support
Respondents were asked from which persons they would receive co-operation and social support when conducting a nutrition programme. Besides the company itself and the catering manager, several people in the worksite cafeterias were mentioned by one or more respondents, namely cafeteria personnel, the company health service, the works council, people with responsibility concerning working conditions, the department of public relations, and finally the department of support and services of the head office of the catering organization. The people who should be involved if a supermarket participates in a nutrition education programme were, according to the respondents, the board of the supermarket chain, the store personnel, in the case of a franchise the store owner, in other cases the branch manager, and some departments of the head office (e.g. the department that decides about the range).
Almost all respondents thought that their personnel would react positively to programme participation and would be willing to help to carry out the programme. In order to gain social support from the worksite cafeteria or store personnel, respondents indicated that their personnel should be educated and informed about the programme and healthy nutrition beforehand. Personnel should learn more, for example, about the importance of healthy nutrition and the fat content of food products. Some respondents preferred to inform their personnel during a regular work meeting, others preferred an extra meeting or class. In addition to this, written information about healthy nutrition and the programme should be given to the personnel. An additional way of informing supermarket personnel is through an instruction video; many supermarkets use this already.
Characteristics of the adopting persons
The personal attitude of the respondents towards giving nutrition education in the cafeteria or supermarket was positive, although a major concern was that nutrition education may restrict people's own choices. The majority of the respondents agreed also that the cafeteria setting and the supermarket setting offered good opportunities for influencing eating habits.
|
DISCUSSION |
|---|
|
TOPSUMMARYINTRODUCTIONMETHODSRESULTSDISCUSSIONACKNOWLEDGEMENTSREFERENCES |
|---|
The purpose of the study was to assess conditions for adoption and continued implementation of both educational and environmental programmes, aimed at changing dietary behaviour, to be implemented in worksite cafeterias and supermarkets. The study provided information that can be used for the further development of programmes, as well as the development of implementation strategies.
Concerning programme development for worksite cafeterias, it appeared that the educational programme should not be too obtrusive or dominant, should not consume too much time, and should place an emphasis on positive aspects. Different programme materials seem appropriate for use in the cafeteria (brochures, flyers, handouts, posters, displays, self-help guides, publications in the worksite newsletter). Audio messages and information on receipts are not considered to be workable. For the labelling programme a few features can be added: the labelling programme should only label healthy products, and the labels should be hygienic and highly comprehensible. Labelling a group of products instead of labelling single products is preferred, without including too much information on the labels. Furthermore, labels should be available both as self-adhesive and little cards in bearers. A few features can also be added for the food supply programme. Prices should not increase and only limited changes of the range are desirable. However, respondents could not agree whether these changes should be an extension of the range or rather a replacement of certain products. To link up with the existing way of working, the programmes should be designed with a short action period (a few weeks).
Concerning implementation strategies for worksite cafeterias, some factors can be identified. First, in order to persuade companies to implement a nutrition education programme, the following advantages should be stressed: the concern for employees, the positive influence on company image, and (if we can prove this in further research) possible higher sales for certain products. Furthermore, expected difficulties mentioned by the respondents should be diminished by stressing that the intervention will be delivered ready-made, that the aim of the intervention is not to ban eating unhealthy products, or that only small changes in the range will be necessary. When disseminating the intervention, it is appropriate to approach both the catering organization and the company, because the decision to participate in an intervention programme is a shared decision. Finally, in order to facilitate good implementation of the intervention, the cafeteria personnel should be informed before the start of the intervention.
In general, the same factors regarding programme development and implementation strategy are important for supermarkets. The importance of increasing profit (either directly or indirectly through more customer satisfaction), and the need for programme materials to be professionally and attractively produced, are additional factors requiring consideration in supermarket programmes. Again, several types of materials can be used (brochures, flyers, posters, displays, information in store magazines or advertisements, self-help guides). The possibility of using audio messages and handouts should be studied in individual cases. According to this study, it is not possible to provide nutrition information on receipts. Regarding the labelling programme, a specific feature for the supermarkets is the fact that not too many products can be labelled. Therefore, the labelling should be restricted to the most important product categories, and shelf labelling should be used instead of labelling each single product. Also, the duration of the labelling should be limited and the appearance of the labels should prevent labels moving around in the supermarket. It remains unclear whether (some) product information should be given on the labels in the supermarkets. The results reported in this article are based on interviews with intermediaries. In Glanz et al., results of studies among consumers are described (Glanz et al., 1996). In this review it is concluded that consumers only use nutrition information if it is easily available, clear, perceived as useful and new, and simple to use. Besides programme requirements mentioned by the intermediaries in our study, requirements of consumers should be taken into account.
Regarding implementation strategies, some factors can be added to the factors already described for the worksite cafeterias. Because profit gain is so important for supermarkets, the profit gain of nutrition programmes should be studied, and also the possible indirect profit gains (other than money) should be stressed when persuading supermarkets to start a nutrition education programme. More customer satisfaction or attracting more customers are important for the supermarkets. In the case of franchisers, the franchisers themselves should be approached for participation in a programme. In other cases, the head office of the supermarket chain should be approached since chain stores cannot take the decision whether to take part in a nutrition education programme or not. Because most supermarkets do not see nutrition education as one of their tasks, it is very important to stress the advantages of programme participation for them.
In order to achieve the ideal ‘fit’ between an innovation and its users (and through this consequently enhance its successful implementation), understanding of the environment and context in which a diffusion occurs is important (Orlandi et al., 1997). The results of this study are very useful for the development of nutrition programmes and implementation strategies that have the maximum possible fit between programme and users or environment. Due to the number of respondents in this study, generalization of the results is limited. Due to the consistency of responses from interviewees, it is unlikely the findings would have been substantially different if a greater number of interviews had been conducted.
The study revealed a lot of information that is useful in further development of nutrition programmes.
Glanz et al. reviewed 26 studies on worksite nutrition and cholesterol intervention programmes (Glanz et al., 1992). This review showed that worksite nutrition and cholesterol programmes are feasible in the United States. Moreover, it appeared that strategies that combine both educational and environmental strategies have the greater effect. Based on the results of our study, we concluded that educational and environmental nutrition interventions in worksite cafeterias and supermarkets are feasible in the Netherlands, provided that the conditions identified for adoption and implementation regarding programme development and implementation strategies are taken into account.
One similar study on conditions for adoption and implementation of nutrition programmes was conducted by Peterson and co-workers (Peterson et al., 1986). Seventeen food vendors were interviewed (among them caterers and grocery managers). It showed that the most important reasons for adopting ‘healthy heart marketing practices’ were health concerns of customers and vendors, for example food vendors were sensitive to customer demands. The second most important reason was the food vendors' profit motivation. In this case profit was, for example, free publicity and positive public relations, but also increased business and financial gain. Other factors influencing the adoption of ‘healthy heart marketing practices’ included the fact that a nutrition education programme should entail an opportunity to provide a customer service and that it should show how food vendors could make simple and inexpensive changes. The results of the Dutch study described in this article are consistent with the results of the study conducted in the United States by Peterson et al. (Peterson et al., 1986). Other studies do not report the results of pilot studies separately, but include them briefly within the results of evaluation research in the intervention programme in question. It often concerns meetings with key persons, representatives or steering committees, which are organized to fit the programme to the target population. For the ‘Treatwell programme’ for example, formal and informal interviews were held with employees, including representatives of human resources, food service and health promotion or medical departments (Sorensen et al., 1990). The interviews provided information useful for planning the intervention, such as information about individuals and resources that would enhance programme and policy adoption. Also, existing and potential barriers, and possible ways to eliminate or diminish them, were identified in the interviews. However, no more detailed information is given regarding the methods and results of the interviews. For the ‘Pawtucket Heart Health Program’, 18 interviews with key informants were conducted and reported as part of a case history of nutritional information on menus (Lefebvre, 1986). The respondents represented restaurants, supermarkets, food services, food distributors and food journalists. Based on, among other things, the interviews, several food vending strategies were defined. Examples of these food vending strategies are that programmes have to appeal to the profit motive of the restaurant managers, that labelling has to be simple, and that programmes have to be economical for both the restaurants and their customers to implement them. These food vending strategies are also in accordance with the findings of our study. Furthermore, it is concluded in the Pawtucket study that good taste of healthy products is a critical component of successful food vending strategies (Lefebvre, 1986).
It is regrettable that results of pilot studies in which conditions for adoption and implementation are identified are not published in more detail. Such information may be useful for the development of other programmes. From the present study, it can be concluded that worksite cafeterias and supermarkets are willing to participate in both educational and environmental nutrition programmes, if these programmes satisfy certain demands concerning programme design and programme implementation. Apart from the fact that programmes should be positive and easily practisable for both personnel and customers, programmes must meet a large number of practical demands. In order to ensure these programmes are implemented correctly, implementation strategies should focus on the perceived advantages of nutrition programmes by worksite cafeterias and supermarkets, and on diminishing expected difficulties of conducting nutrition programmes. The results of the present study were used to develop a nutrition education programme, a labelling programme and a food supply programme for use in worksite cafeterias and supermarkets. For a brief description of programme elements see Table 6. The effects of the programmes, as well as factors influencing the implementation of these programmes are now being studied in experiments in cafeterias and supermarkets.
|
|
ACKNOWLEDGEMENTS |
|---|
|
TOPSUMMARYINTRODUCTIONMETHODSRESULTSDISCUSSIONACKNOWLEDGEMENTSREFERENCES |
|---|
The contribution of I. H. M. Steenhuis has been made possible by a grant from the Dutch Cancer Society.
|
REFERENCES |
|---|
|
TOPSUMMARYINTRODUCTIONMETHODSRESULTSDISCUSSIONACKNOWLEDGEMENTSREFERENCES |
|---|
Basch, C. E., Eveland, J. D. and Portnoy, B. (1986) Diffusion systems for education and learning about health. Family and Community Health, 9, 1–26.
Benito, E. (1992) Overview of dietary recommendations on diet and cancer. In Benito, E., Giacosa, A. and Hill, M. J. (eds) Public Education on Diet and Cancer. Kluwer, Dordrecht, pp. 3–13.
Bracht, N. (1990) Health Promotion at the Community Level. Sage, Newbury Park, CA.
De Vries, H. (1993) Determinanten van gedrag (Determinants of behavior). In Damoiseaux, V., Van der Molen, H. T. and Kok, G. J. (eds) Gezondheidsvoorlichting en Gedragsverandering (Health Education and Behavioral Change). Van Gorcum, Assen, pp. 109–132.
Dutch Nutrition Council (Voedingsraad) (1986) Adviesrichtlijnen Goede Voeding (Advice Guidelines Healthy Nutrition). Voedingsraad, ‘s Gravenhage.
Dutch Nutrition Council (Voedingsraad) (1991) Nader advies inzake de richtlijn m.b.t. de vetconsumptie uit het advies Richtlijnen goede voeding 1986 (Further advice regarding the recommendations with relation to the fat consumption in the advice Guidelines Healthy Nutrition 1986). Voedingsraad, ‘s Gravenhage.
Glanz, K. (1993) Environmental and policy approaches to cardiovascular disease prevention through nutrition. Paper presented at the workshop on environmental and policy approaches to cardiovascular disease prevention. Centers for Disease Control, Atlanta, GA.
Glanz, K., Lewis, F. M. and Rimer, B. K. (eds) (1990) Health Behavior and Health Education: Theory, Research and Practice. Jossey-Bass, San Francisco, CA.
Glanz, K., Hewitt, A. M. and Rudd, J. (1992) Consumer behavior and nutrition education: An integrative review. Journal of Nutrition Education, 24, 267–277.
Glanz, K., Sorensen, G. and Farmer, A. (1996) The health impact of worksite nutrition and cholesterol intervention programs. American Journal of Health Promotion, 10, 453–470.[ISI][Medline]
Green, L. W. and Kreuter, M. W. (1991) Health Promotion Planning: An Educational and Environmental Approach. Mayfield, Mountian View, CA.
Lefebvre, C. (1986) A case history of nutritional information on menus. Journal of Foodservice Systems, 4, 153–158.
Netherlands Bureau for Food and Nutrition (Voedingscentrum) (1992) Praktische Voedingsmiddelengids (Practical Food Stuff Guide). ‘s Gravenhage.
Netherlands Bureau for Food and Nutrition (Voedingscentrum) (1998) Zo eet Nederland, Resultaten van de Voedselconsumptiepeiling 1997–1998 (This is how the Netherlands Eats: Results of The Food Consumption Survey 1997–1998). Voedingscentrum, ‘s Gravenhage.
Oldenburg, B., Hardcastle, D. M. and Kok, G. (1997) Diffusion of innovations. In Glanz, G., Lewis, F. M. and Rimer, B. K. (eds) Health Behavior and Health Education; Theory, Research, and Practice (2nd edition). Jossey-Bass Publishers, San Francisco, CA, pp. 270–286.
Orlandi, M. A., Landers C., Weston, R. and Haley, N. (1990) Diffusion of health promotion innovations. In Glanz, G., Lewis, F. M. and Rimer, B. K. (eds) Health Behavior and Health Education; Theory, Research, and Practice. Jossey-Bass Publishers, San Francisco, CA, pp. 288–313.
Peterson, G., Elder, J. P., Knisley, P. M., Colby, J. C., Beaudin, P., DeBlois, D. and Carleton R. A. (1986) Developing strategies for food vendor intervention: The first step. Journal of the American Dietetic Association, 86, 659–661.[ISI][Medline]
Rogers, E. M. (1983) Diffusion of Innovations (3rd edition). The Free Press, New York, NY.
Sorensen, G., Hunt, M. K., Morris, D. H., Donnelly, L. F., Freeman, L., Ratcliffe, B. J., Hsieh, J., Larson, K. and Ockene, J. K. (1990) Promoting healthy eating patterns in the worksite: the Treatwell intervention model. Health Education Research, 5, 505–515.
Steckler, A., Goodman, R. M., McLeroy, K. R., Davis, S. and Koch, G. (1992) Measuring the diffusion of health promotion programs. American Journal of Health Promotion, 6, 214–224.[Medline]
Stewart, D. W. and Shamdasani, P. M. (1990) Focus Groups; Theory and Practice. Applied Social Research Methods Series, 20. Sage Publications, Newbury Park, CA.
US Departments of Agriculture and Health and Human Services (1990) Nutrition and Your Health: Dietary Guidelines for Americans. Home and Garden Bulletin No. 232.
Willet, W. C. (1994) Diet and health: What should we eat? Science, 264, 532–537.
CiteULike 
Connotea 
Del.icio.us What's this?
This article has been cited by other articles:
|
|
 |
|
  M. K. Hunt, E. M. Barbeau, R. Lederman, A. M. Stoddard, C. Chetkovich, R. Goldman, L. Wallace, and G. Sorensen Process Evaluation Results From the Healthy Directions-Small Business Study Health Educ Behav, February 1, 2007; 34(1): 90 - 107. [Abstract] [PDF]
|
|
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||