Health Promotion International, Vol. 17, No. 3, 255-262,
September 2002
© Oxford University Press 2002
Health promotion practices of restaurants and cafés in Australia: changes from 1997 to 2000 using an annual telemarketing intervention
Hunter Centre for Health Advancement, Newcastle, Australia
Address for correspondence: Karen Gillham The Hunter Centre for Health Advancement Locked Bag 10 Wallsend NSW 2287 Australia E-mail: Karen.Gillham{at}hunter.health.nsw.gov.au
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SUMMARY |
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 TOP SUMMARY INTRODUCTIONMETHODSRESULTSDISCUSSIONACKNOWLEDGEMENTSREFERENCES |
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This study looked at whether rates of health promotion practices among restaurants and cafés in the Hunter Region of New South Wales (NSW), Australia, increased between 1997 and 2000. During the project period all restaurants and cafés in the region were offered an annual direct marketing telephone interview (1997, 1998 and 1999), during which resources were offered to assist in the adoption of health promotion practices. Owners or managers of restaurants and cafés completed phone interviews that assessed 18 health promotion practices relating to: environmental tobacco smoke (two practices); responsible service of alcohol (five practices); healthy food choices (one practice); food safety (four practices); occupational health and safety (three practices); and the prevention of infectious diseases (three practices). Changes in practices were examined by comparing data from cross-sectional samples in 1997 (before any offers of resources) and 2000 (after up to three annual telemarketing calls), and among a cohort interviewed in both 1997 and 2000. Ninety-one per cent of restaurants and cafés (321) participated in the 1997 survey and 239 (81%) participated in the 2000 survey. A cohort of 122 restaurants and cafés participated in both surveys. Significant increases were present for 14 of the 18 health promotion initiatives in the cross-sectional sample and for 10 of the 18 health promotion initiatives in the cohort. For both cross-sectional and cohort samples, a change in at least one practice in each area was evident, with the exception of nutrition. The proportion of restaurants and cafés in the project region that undertake health promotion initiatives is increasing. A telephone-based intervention may contribute to such an increase. The suggestion that the prevalence of health promotion initiatives in restaurants and cafés can be increased highlights the potential for health promotion to be more actively involved in this setting.
Key words: alcohol; health promotion; restaurants; smoking
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INTRODUCTION |
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TOPSUMMARYINTRODUCTIONMETHODSRESULTSDISCUSSIONACKNOWLEDGEMENTSREFERENCES |
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Restaurants and cafés offer considerable potential for the delivery of health promotion initiatives to the community. Eating out is a common recreational activity, with Australians spending just under $1000 per head on eating out each year (Restaurant and Catering Australia Website, 2000
). Restaurants and cafés offer a setting with the potential to address a number of health risks for both clients and staff, including smoking (Siegel, 1993), alcohol consumption (Kjaerheim et al., 1995), consumption of healthy food (Fitzpatrick et al., 1997), food safety (Tebbutt, 1991), occupational health and safety (Hendricks and Layne, 1999), and the prevention of infectious diseases.
A range of health promotion practices has the potential to reduce such risks. The introduction of smoke-free dining has been shown to reduce exposure to environmental tobacco smoke and associated respiratory symptoms among staff (Brauer and Mennetje, 1998), whilst the introduction of responsible service of alcohol initiatives has been shown to modify drinking and driving behaviours of clients of licensed premises (Boots, 1994; Haworth and Bowland, 1995). The implementation and monitoring of food handling procedures in restaurants and cafés has been shown to be effective in reducing food-borne diseases. Occupational health and safety measures among staff have also been shown to be effective in the restaurant and café industry (Hendricks and Layne, 1999).
Despite the potential for restaurants and cafés as a community setting for the implementation of health promotion initiatives, little data exist concerning the current health promotion practices of them. One study reports on the frequency of the provision of some smoke-free dining in a sample of 365 restaurants in New South Wales (NSW), Australia (Schofield et al., 1993). This study found that 2% of restaurants were totally smoke free and that 22% of restaurants reported having some smoke-free areas. No data on the prevalence of practices in other health promotion areas could be found.
Similarly, limited data are available regarding the effectiveness of health promotion interventions in restaurants and cafés. A number of studies have reported outcomes in minimizing alcohol-related harm within the restaurant industry. In a study by Howard-Pitney et al., a responsible service of alcohol training programme delivered in a sample of restaurants and bars in Utah (USA) was shown to impact significantly upon changing beliefs and knowledge of both servers and managers, but showed no effects on server behaviour (Howard-Pitney et al., 1991). Interventions relating to nutrition have been evaluated for the effects of ‘point of purchase’ information in restaurants (Mayer et al., 1986; Colby et al., 1987). These studies have demonstrated increases in nutrition knowledge or improvements in attitudes concerning healthy foods among clients, and results from Albright et al.’s study revealed that a point of purchase menu labelling intervention was associated with an increase in the purchase of low-fat/low-cholesterol foods (Albright et al., 1990). In regard to improving food safety in restaurants and cafés, Campbell et al. reported that routine inspections of food service premises is effective in reducing the risk of food-borne illness, and that food handler training can improve the knowledge and practices of food handlers (Campbell et al., 1998).
An important criterion for the success of health promotion initiatives in community settings is support from relevant stakeholders. A number of studies have revealed community support for restaurant smoking bans. Mullins and Borland reported a strong community desire for smoke-free dining in Australia (Mullins and Borland, 1995), and a study by Schofield and Edwards revealed that 90% of surveyed customers thought that restaurants should provide either separate smoke-free areas or a total smoking ban (Schofield and Edwards, 1995). Similarly, community support exists for the provision of healthy food choices in restaurants. Fitzpatrick et al. showed that a sample of restaurant customers in Canada were significantly more satisfied with lower fat than with regular menu items (Fitzpatrick et al., 1997).
Typically, health promotion interventions implemented in restaurants and cafés have targeted a single health area, and have involved face-to-face contact visits. Given the large number of restaurants there may be in any geographical area, there would seem to be value in exploring interventions that may not be as resource intensive and that have the capacity to target multiple health promotion practices.
This study sought to assess the potential effectiveness of a telephone-based dissemination strategy to increase the rates of health promotion practices in the areas of smoking restriction, prevention of alcohol-related harm, provision of healthy food choices, food safety behaviours, occupational health and safety, and the prevention of infectious disease transmission, between 1997 and 2000 for restaurants and cafés in the Hunter Region of NSW, Australia. Within this period, health promotion staff attempted to support restaurants and cafés in the introduction and implementation of health promotion practices in these areas through a project involving an annual direct marketing telephone interview and the offer of resources. This intervention was designed to reinforce and assist restaurants and cafés with the implementation of legal requirements and to encourage them to adopt relevant health promotion practices in other topic areas.
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METHODS |
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TOPSUMMARYINTRODUCTIONMETHODSRESULTSDISCUSSIONACKNOWLEDGEMENTSREFERENCES |
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Sample and procedure
The study was conducted in the Hunter Region of NSW, Australia. The outcome data reported are from surveys undertaken with owners or managers of restaurants and cafés in 1997 and 2000. Between 1997 and 2000, restaurants and cafés had the opportunity to receive between one and three telemarketing calls and associated resources (1997, 1998, 1999). The 1997 outcome data are from the first telemarketing call, in which data on practices were collected prior to premises being offered any resources. All restaurants and cafés listed in the regional telephone directory at the time of each survey were selected to participate. Hereafter, the term ‘restaurants’ will include restaurants and cafés. A letter was sent to the owner or manager of the restaurant, followed by up to six attempts at conducting a telephone interview. Restaurants that had closed down (indicated by disconnected number or returned mail) and for which it was not possible to speak to the owner or manager after six phone contacts were excluded. Restaurants that were reported to provide seating, to not be located within a hotel or club, and whose owners or managers were English speaking were eligible to participate.
Intervention: annual telemarketing intervention
An advisory group, consisting of restaurant and café representatives, a food surveillance staff member, a hospitality educator and health promotion staff, was responsible for the direction of the project, including the selection of health areas, health promotion initiatives and resources offered to restaurants. A range of health areas were selected based on their contribution to mortality and morbidity in Australia, the relevance of risk factors to restaurants, and the capacity of restaurants to undertake risk reduction initiatives (see Table 1).
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Health promotion initiatives
For each health area, health promotion initiatives were chosen that focused on either modifying the service and organizational environment of restaurants, or the provision of information to staff or customers, and were considered for inclusion in this project on advisory group advice. The health promotion initiatives were derived from appropriate sections of legislative documents, recommendations from peak bodies including the Department of Gaming and Racing, the Licensing Court of New South Wales, Work Cover and the New South Wales Cancer Council, and literature on practices likely to be effective in reducing harm associated with environmental tobacco smoke (National Health and Medical Research Council, 1996
). The selected health promotion initiatives are shown in Table 1
.
Resource development
A resource or service was developed for each health promotion initiative. Owners and managers who were not practising the health promotion initiatives at the time of contact were asked if they would like resources or services for that initiative. These were provided within 1 month of contacting restaurants. For example, owners of those restaurants that did not provide any smoke-free areas were offered a written resource on why restaurants should provide smoke-free areas and tips on how to do this, and those that did not have a written responsible service of alcohol policy were offered a sample written policy. Further detail on the resources offered is provided in Table 1.
Measures
During each telemarketing occasion, restaurants were interviewed to assess the practice of health promotion initiatives relating to each health promotion area: smoking, responsible service of alcohol, nutrition, food safety, occupational health and safety, and the prevention of infectious diseases. Telephone interviewers completed the interview by asking restaurant owners or managers if each of the practices listed in Table 1 were undertaken in the restaurant at the time of each contact.
Statistical analysis
Analysis was undertaken using SAS statistical software. The differences in prevalence of health promotion practices between 1997 and 2000 for the cross-sectional samples were assessed by calculating proportions with 95% confidence intervals. For the cohort, differences were examined using McNemar’s test. A significance level of 0.01 was used given the large number of tests performed.
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RESULTS |
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TOPSUMMARYINTRODUCTIONMETHODSRESULTSDISCUSSIONACKNOWLEDGEMENTSREFERENCES |
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Participation rates
Cross-sectional samples
In 1997, 500 restaurants were listed in the telephone directory. Of these, 21 (4%) were no longer open or were not contactable after six telephone attempts. Of the 479 remaining restaurants, 127 (25%) were ineligible (39 did not provide seating, 28 were located in a hotel or club, and 60 had owners or managers that could not speak English). Of the eligible restaurants (n = 352), 321 (91%) participated.
In 2000, a total of 460 restaurants were listed in the telephone directory. Of these, 45 (10%) were no longer open or were not contactable after six telephone attempts. Of the 415 remaining restaurants, 121 (26%) were ineligible (36 did not provide seating, 38 were located in a hotel or club, and 47 had owners or managers that could not speak English). Of the eligible restaurants (n = 294), 239 (81%) participated.
Cohort
A total of 122 restaurants participated in both surveys.
Exposure to the intervention
Cross-sectional samples
Of those restaurants that participated in the survey in 2000 (n = 239), 85 (35%) had been exposed to one direct telephone marketing call and offered the associated resources, 88 (37%) had been exposed to two calls and 66 (28%) had been exposed to three calls.
Cohort
Of the 122 restaurants in the cohort, 87 (71%) of these had been exposed to two direct telephone marketing calls, and 35 (29%) of these had been exposed to three calls.
Health promotion practices
Cross-sectional samples
Table 2 shows the number and proportion of restaurants undertaking each of the 18 health promotion practices in 1997 and 2000. The proportion of restaurants undertaking practices in 1997 ranged from 9 to 83% compared with 2000, where the proportion of restaurants undertaking practices ranged from 26 to 92%. Significant increases were present for 14 of the 18 items, and for at least one health promotion item for all health areas except for nutrition.
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Cohort
Table 3
shows the number and proportion of restaurants in the cohort undertaking each of the 18 health promotion practices in 1997 and 2000. The proportion of restaurants undertaking practices in 1997 ranged from 9 to 86% compared with 2000, where the proportion of restaurants undertaking practices ranged from 34 to 93%. Significant increases were found for 10 of the 18 health promotion initiatives at p = 0.01, and for at least one item in all health areas except for nutrition.
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DISCUSSION |
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TOPSUMMARYINTRODUCTIONMETHODSRESULTSDISCUSSIONACKNOWLEDGEMENTSREFERENCES |
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The project has provided previously unavailable data on the prevalence of a number of health promotion practices in restaurants, and an insight into whether practices are increasing in an area in which health promotion practitioners have conducted interventions to attempt to increase rates of health promotion initiatives. Restaurants are a business enterprise, with their focus directed towards the sale and consumption of food and alcohol. Therefore, working with restaurants in an attempt to decrease health risks can represent a challenge to health promotion practitioners. The results show that a large proportion of restaurants adopt health promotion practices, with 70% or more of restaurants in the cross-sectional sample undertaking 13 of the 18 practices in 2000, compared with five practices in 1997. Similarly, 70% or more of restaurants in the cohort sample reported undertaking 15 of the 18 practices in 2000, compared with eight practices in 1997.
The results suggest that the adoption of health promotion initiatives by restaurants can be increased. The following practices relating to smoking and alcohol were shown to increase by 30% or more over the period of the study in both the cross-sectional and cohort samples: provision of at least some smoke-free dining areas, promotion of non-/low-alcoholic drinks and having a written responsible service of alcohol policy. Other practices that were increased by 
30% over time for the cohort relate to occupational health and safety: restaurants with a hazards checklist and a hazards report. Significant increases were present for most initiatives in both the cross-sectional sample and the cohort. For both cross-sectional and cohort samples, a change in at least one practice in each area was evident, with the exception of the nutrition area.
The health promotion practices most likely to be undertaken by restaurants in 2000 in both cross-sectional and cohort samples were the provision of hygiene information, food storage information and food handling information for staff. The health promotion practices least likely to be undertaken by restaurants in 2000 in both cross-sectional and cohort samples were the provision for staff of written information about HIV and hepatitis and having a written HIV/ hepatitis policy. This could be as a result of restaurant owners or managers perceiving food safety behaviours to be closely related to their core business, but the prevention of infectious disease as irrelevant in their main role.
The positive results indicate that there may be a place for health promotion practitioners to become more actively involved in the facilitation of health promotion initiatives with restaurants. A direct marketing telephone interview and the subsequent provision of resources may be one such initiative that is successful in contributing to increased health promotion practice in restaurants.
Some other limitations of the project should be noted. The inability of non-English speaking owners and managers to participate in the study imposes some limit on the generalizability of the results. Also, as the survey relies on self-reporting to determine the prevalence of health promotion practices, the results may overestimate the actual levels.
An increased willingness to provide smoking information to staff and to implement smoke-free areas was evident. This willingness may indicate a response among restaurants to either the growing community awareness of the risks of exposure to environmental tobacco smoke (Mullins and Borland, 1995; Schofield and Edwards, 1995), to the effects of the intervention, or to other factors such as the introduction of legislation requiring NSW restaurants to be totally smoke free from September 2000, which was 7 months after the 2000 project telemarketing call.
Over the period of the project, licensed restaurants were more likely to adopt alcohol-related initiatives. Prior to the collection of baseline data, an amended Liquor Act was introduced in NSW in 1996. The new Act included a number of strategies that were being targeted by the study. The introduction of these changes may have contributed to the increase in adoption of such alcohol-related practices during the study period. It is difficult to estimate the extent to which the increases can be attributed to the study, to the new laws, or to a combination of such factors.
Furthermore, over the period of the study, restaurants were subject to regular inspections of food handling procedures by local government inspectors in addition to resource provision by the current project. The offer of resources and services via this study in conjunction with the regular monitoring of food handling pro-cedures in restaurants may have provided a strong incentive for the adoption of food safety initiatives.
Increases in the adoption of initiatives concerning occupational health and safety and HIV/AIDS and hepatitis were evident. At the time of the study, no activities designed to facilitate the adoption of such initiatives were known to have been occurring. The low initial prevalence of occupational health and safety, HIV/AIDS and hepatitis activity at baseline demonstrates the uniqueness of these forms of health promotion activity in restaurants. The subsequent observed increases in prevalence of these initiatives suggest that restaurants are willing to consider initiatives that address a range of community health issues that are not directly related to the provision of food services. Further support of this willingness represents an opportunity for health promotion practitioners.
To the research team’s knowledge this is the first study of its kind to investigate capacity to change the health promotion practices in numerous health areas by restaurants. The findings provide a basis for future research and evaluation of similar health promotion initiatives in this setting. The telemarketing approach represents a feasible and sustainable method for reaching a large number of restaurants over a large geographical area in an efficient manner. There remains a challenge of whether the impact of adoption of health promotion practices impacts on improvements to consumer health and changes in knowledge of restaurant staff. There also remains a challenge of how to develop further the telemarketing intervention in order to further increase health promotion initiatives among restaurants in a cost-effective manner.
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ACKNOWLEDGEMENTS |
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TOPSUMMARYINTRODUCTIONMETHODSRESULTSDISCUSSIONACKNOWLEDGEMENTSREFERENCES |
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The authors would like to thank participating restaurants and cafés, the Hunter Restaurant and Catering Association, Newcastle City Council and the Hunter Institute of Technology. The authors would also like to thank Julie-Anne Kenworthy, Tham Vo and Megan Williams for their assistance with the project, Andrew Hampson, Sally Burrows, Adrian Flanagan and Ian Clare for their statistical assistance, and Jan Burns for her programming assistance.
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REFERENCES |
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