Health Promotion International, Vol. 19, No. 2, 197-204, June 2004
HEALTH PROMOTION INTERNATIONAL Vol. 19. No. 2 © Oxford University Press 2004. All rights reserved
Does the Heartbeat Award scheme in England result in change in dietary behaviour in the workplace?
1Unité 106 Nutrition, Alimentation et Sociétés, Institut de recherche pour le développement, Montpellier, France, 2Division of Health in the Community, Warwick Medical School, University of Warwick, Coventry, UK and 3Institute of Work, Health and Organisations, University of Nottingham, Nottingham, UK
Address for correspondence: Michelle Holdsworth, Chargée de Recherche, U106 Nutrition, Alimentation et Sociétés, WHO Nutrition Collaborating Centre, IRD, 911 Avenue Agropolis, BP 5045, Montpellier, France, E-mail: holdswor{at}mpl.ird.fr
SUMMARY
The Heartbeat Award (HBA) scheme is a national nutrition labelling scheme that operates throughout England. The aim of this study was to assess whether the implementation of the HBA scheme in the workplace results in an improvement in eating habits at work. A longitudinal survey of employees using a structured questionnaire pre- and post-HBA intervention in six workplaces in Leicestershire, England, was conducted. A qualitative food frequency questionnaire was used to assess dietary behaviour 6 months before the scheme was implemented and 6 months afterwards. Four HBA workplaces (n = 453 employees) were compared with two comparison workplaces (n = 124 employees). The outcome measures for dietary change were consumption of 20 food items, i.e. 16 food-frequency and four food-type items. Changes in pre-intervention data compared with post-intervention data evaluated the impact of the HBA on eating habits. Differences were considered statistically different at the p < 0.05 level. Crude and adjusted odds ratios were used to assess differences in change in dietary behaviour between the intervention and comparison workplaces. The results showed that there was significantly more positive change in intervention workplaces only (i.e. the changes were not detected in the comparison workplaces) for four of the 20 food items tested: increase in consumption of fruit (p = 0.029); reduction in consumption of fried foods (p = 0.044) and sweet puddings (p = 0.042); and change to lower fat milks (p = 0.034). In conclusion, the HBA had a modest impact on dietary intake, resulting in a significant positive change in four out of 20 foods consumed by employees in HBA-holding premises.
Key words: dietary change; healthy eating intervention; Heartbeat Award; workplace
INTRODUCTION
The Health Education Authority (HEA) launched the Heartbeat Award (HBA) scheme in England in 1990 (Department of Health and Social Security/Health Education Council, 1986
). The HBA scheme evolved from the Heartbeat Wales project, initiated in 1985 (Parish et al., 1987). Heartbeat New Zealand also modelled itself on the Heartbeat Wales project (Peach et al., 1996). The scheme is an environmental strategy that increases opportunities for behaviour change by providing customers with information, reminders and reinforcement to guide them towards healthier choices. The HBA scheme aims to provide a supportive environment rather than focusing solely on individual responsibility (Vaandrager et al., 1993). During the period of data collection in this study, the criteria for the HBA scheme were set nationally by the HEA and the HBA was awarded to catering establishments fulfilling the following criteria: at least one-third of the dishes on the menu were ‘healthy choices’; at least one-third of the eating area was non-smoking; at least 30% of food handling staff had received training on hygiene; and the premises complied with food hygiene regulations (HEA, 1992). The HBA scheme is unique among nutrition labelling schemes in combining these elements (Holdsworth and Haslam, 1998). The replacement of the HEA with the Health Development Agency has meant that at present there is no organization officially responsible for national coordination of the HBA in England. However, the scheme continues to operate throughout England based on national criteria set in 1996 (HEA, 1996).
As food eaten outside the home is making an increasingly important contribution to food intake, the potential role of the HBA scheme in influencing dietary change is evident. The workplace is a particularly good opportunity to expose individuals to healthier food choices. Nationally, the scheme has been promoted in a range of settings, and 28% of awards are held by workplaces (Baxter, 1993). The overall aim of the HBA scheme is to encourage caterers to take an active role in reducing levels of coronary heart disease (Seymour, 1990). The nutrition goals of the scheme are to reduce total fat, sugar and salt, and increase the availability of fibre-rich, starchy foods (HEA, 1992). The scheme has been described elsewhere (HEA, 1992; Holdsworth et al., 1997; Warm et al., 1997; Holdsworth and Haslam, 1998).
The political changes within the National Health Service from the early 1990s led to increasing requests from health purchasers to demonstrate the validity of health promotion programmes in the UK (Catford, 1993). In Leicestershire, the evaluation of the HBA scheme was prioritized because of the scale of resources invested by the purchasing health authority and the high level of support it was given within the county (Holdsworth and Spalding, 1997).
The impact of the scheme on dietary behaviour has never been evaluated, although the need for an evaluation of the scheme in changing behaviour has been highlighted (Pope et al., 1994; Pope and Cooney, 1995; Warm et al., 1997). Other studies have assessed the impact of the scheme on dietary attitudes and knowledge (Holdsworth et al., 2000), practitioners' views of the scheme (Murphy et al., 1993; MacAuslan, 1995; Snowden, 1998; Holdsworth et al., 1999), and its impact on catering practice (Pope and Cooney, 1995; Warm et al., 1997; Holdsworth et al., 1998). Evaluations of similar nutrition labelling schemes in North America and Europe have yielded mixed results, but most demonstrate some positive short-term impact on eating behaviour; however, their effectiveness in changing long-term dietary behaviour is difficult to ascertain due to a lack of follow-up studies (Holdsworth and Haslam, 1998; Janer et al., 2002).
The specific objectives of this paper were to evaluate changes in employee eating habits following implementation of the HBA scheme and to determine whether observed change could be attributed to the scheme.
METHODS
A longitudinal survey of employees was carried out using a structured, self-administered questionnaire (available from M.H.) 6 months before the intervention and 6 months after the HBA had been awarded. As the difference in time between administration of pre- and post-test questionnaires was one calendar year, this controlled for any seasonal variations in food consumption.
A detailed description of workplace selection and administration of the questionnaire has been reported previously (Holdsworth et al., 2000). Two premises applying for the HBA were unsuccessful in receiving it, and were used as a comparison group for the study. The pre-intervention questionnaire was administered to employees as described above. The post-intervention questionnaire was distributed 6 months after the HBA application was withdrawn. The purpose of the comparison group was to assess if changes detected in HBA workplaces also occurred in comparison premises, possibly reflecting a secular change.
The questionnaire investigated: meal type eaten at work and home, food intake at work and home; attitudes to dietary change, influences on food choice and general attitudes to healthier eating; knowledge about healthier eating; and socio-demographic characteristics. This paper focuses on changes in dietary behaviour at work as a result of the HBA scheme. Findings on changes in dietary attitudes and knowledge have been published elsewhere (Holdsworth et al., 2000).
Data collected concentrated on the frequency of consumption of key food items. This method is most suited to assessing dietary intake in large populations, and particularly in the workplace (Hunt et al., 1993; Glasgow et al., 1996). Foods were listed that contributed the major sources of fat, dietary fibre and sugar using data from the UK National Food Survey (Ministry of Agriculture, Fisheries and Food, 1992). Asian foods were incorporated to reflect the cultural diversity of the survey population. Sixteen food items/groupings were listed and respondents were asked to record how often they ate the foods (at work and at home), responding on a 6-point scale of: ‘never’, ‘less than once a week’, ‘1–3 times a week’, ‘4–6 times a week’, ‘once a day’ and ‘more than once a day’. In addition, four questions were included to ask about the ‘type’ of food chosen for milk, bread, spreading fat and the addition of sugar to drinks. The Food Frequency Questionnaire (FFQ) developed was thus defined as ‘qualitative’ in that it did not investigate portion size [e.g. (Semphos, 1992)].
Demographic variables were measured, including age, gender, ethnicity and body mass index [BMI; weight (kg)/height (m)2]. BMI was assessed from self-reported weight/height and two groups were defined for cross tabulation purposes: BMI 20–25 (ideal weight) and BMI >25 (overweight/obese). Age was reclassified into two age groups, 19–45 years and 45–65 years. Social class was coded from respondents' self-reported occupation using the UK Standard Occupation Classification (OPCS, 1990) and arranged into two bands. These comprised non-manual (I professional, II managerial and III non-manual) and manual (III manual, IV semi-skilled and V unskilled).
Validity and reliability
The questionnaire items were deemed to have face validity and content validity by the team of State Registered Dietitians implementing the scheme. Additionally, the questionnaire was pre-tested and piloted twice in a population similar to the main sample to ensure that questions were properly understood. Analysis of the food consumption data in relation to socio-demographic variation produced the results one would expect from previous studies, indicating a measure of construct validity. Validity with a quantitative dietary assessment technique was deemed unnecessary as the data were not being used to estimate nutrient intake (van Assema et al., 1992), and internal validity was ensured as comparative individual change was restricted to within the study.
Statistical analyses
Data from the questionnaires were coded, input and verified by two different operators. Data were analysed using SPSS (Statistical Package for the Social Sciences, 1998). Data analyses were performed using only the subset of employees who responded at both time points (pre-and post-intervention). Analyses are therefore based on individual change and paired comparisons are made. Changes in pre-intervention data compared with post-intervention data evaluated the impact of the HBA on eating habits. Change variables were constructed from the difference between the frequency of consumption of food items pre- and post-intervention. Direction of change was recoded so that ‘positive change’ respondents were compared with ‘negative change/no change’ respondents, as it is positive behaviour change that indicates a positive outcome of the intervention. Odds ratios were used to assess differences in change in dietary behaviour between the intervention and comparison workplaces. Multiple logistic regression methods were used to estimate odds ratios adjusted for potentially confounding variables. In all cases, odds ratios were adjusted for age, gender, ethnicity, social class and BMI. Differences were considered statistically different at the p < 0.05 level.
RESULTS
Response rates
Of eight eligible workplaces, six agreed and two refused to participate. Data were analysed for the four HBA workplaces (one service industry, one psychiatric hospital, one community hospital and one head office of a food manufacturer) and two comparison workplaces (one shoe manufacturer and one retailer/department store). All current employees in all six workplaces at baseline were eligible for inclusion in the study. At follow-up, only employees included in the baseline assessment were eligible. Changes in staff employed and individual refusal to be included at baseline affected the numbers of employees available for follow-up and ultimately for comparative analyses.
For workplaces with the HBA, the overall response rate was 62.6% (n = 888) pre-intervention and 73.2% (n = 453) of possible employees post-intervention. For comparison workplaces, the overall response rates were 50.3% (n = 265) pre-intervention and 62.6% (n = 124) of possible employees post-intervention.
Socio-demographic characteristics
Socio-demographic characteristics of the sample who responded to both surveys are summarized in Table 1. There were 453 adults in HBA-holding premises, two-thirds of whom were aged <45 years. Nearly three-quarters were female and the vast majority was white. Social class distribution indicated that 88.8% of the sample was from social classes I, II and III non-manual, with only 11.2% in social classes III manual, IV and V. The comparison workplaces contained significantly more men (p < 0.001) and more respondents in lower social class groups (III manual, IV and V employees) (p < 0.005). Around two-thirds of the sample was in the ideal BMI range.
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Changes in food type chosen
There was no difference in the extent of positive change between intervention and comparison workplaces in the consumption of bread or spreading fat, or the addition of sugar to hot drinks (Table 2). However, significantly more positive change in type of milk chosen was observed in intervention workplaces (p = 0.034).
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Frequency of consumption of individual food items
The distribution of change in frequency of consumption of 16 food items was compared (Table 3).
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The results showed that there was significantly more positive change solely in intervention workplaces (i.e. the changes were not detected in the comparison workplaces) for four of the food items tested: increase in consumption of fruit (p = 0.029); reduction in consumption of fried foods (p = 0.044) and sweet puddings (p = 0.042); and more change to using lower fat milks (p = 0.034). Adjusted odds ratios estimated in the logistic regression indicated that the change in fruit consumption was independent of the observed gender and social class differences between the intervention and comparison groups.
DISCUSSION
The main purpose of the survey was to evaluate changes in employee eating habits following implementation of the HBA scheme and to determine whether changes were attributable to the scheme. Overall the intervention had a positive impact on consumption of four of the 20 foods assessed, resulting in a significant increase in fruit consumption and use of lower fat milks, and a significant reduction in consumption of sweet puddings and fried foods. The positive increase in fruit consumption may be explained as this is a food item easy to ‘add in’ to the diet. It may have replaced other items, especially as there was an apparent reduction in consumption of sweet puddings. The same explanation could be applied to the increased use of lower fat milks which, when available, are relatively straightforward to substitute for higher fat varieties.
The level of input as the HBA scheme operates in practice appears to be insufficient to enable substantial change in other components of dietary behaviour. The scheme has been shown to be successful in raising awareness of healthy eating in the workplace (Holdsworth et al., 2000), but this study suggests that this awareness translates into modest behaviour change for four of 20 food items measured. The HBA scheme does provide some key elements of a model of effective dietary interventions (Winett et al., 1993): persuasion, prompts, reminders, environmental support and providing guidelines to eat healthily. The key elements of advising individuals how to overcome barriers to change and enhancing motivation by providing feedback on performance with specific goals are missing. These elements could be provided if the HBA scheme became part of a wider nutrition programme at work, acknowledging the fact that individual support in addition to environmental change maybe necessary to facilitate greater change in dietary behaviour. Indeed, multi-faceted workplace programmes have been demonstrated to be most effective (American Dietetic Association/US Public Health Service, 1993; Dugdill and Springett, 1994; Contento et al., 1995; Pellmar et al., 2002).
Small changes are used to indicate success in health promotion, and one could argue that it is unrealistic to expect more change from such a low intensity programme as the HBA scheme, meaning that any impact is diluted. Other evaluations have suggested that the use of incentives are particularly effective, such as price reduction of healthier options, which appear to be more successful in increasing food purchase than healthy labelling (French et al., 2001; Horgen and Brownell, 2002; French, 2003). Some authors (Horgen and Brownell, 2002; Smith et al., 2002) have suggested that food labelling with healthy messages can have a negative impact on consumption, as customers may perceive that labelled food will be less tasty, or they may misinterpret the meaning of logos. This could be one explanation for the poor impact of the HBA scheme.
There are a number of limitations to this study. One of the difficulties in measuring changes in employee behaviour is that any instrument used needs to be sensitive enough to measure change and be simple enough to be used in the workplace. Hence there may have been changes in dietary behaviour that could have been detected by more rigorous dietary assessment techniques, such as food diaries or weighed intake. Neither of these methods was appropriate for use in the workplace, with samples comprising hundreds of employees.
Self-selection of intervention status by workplaces was inevitable in this study, and it was not possible to determine the participation of employees. This could have introduced a bias as more motivated employees could have been over-represented in the final study population. The difficulty in randomizing within health education programmes has been discussed before (Nutbeam et al., 1990). The overall response rates in the workplace study were lower than anticipated pre-intervention (HBA premises, 62.6%; comparison workplaces, 50.3%), but improved at post-intervention (HBA premises, 73.2%; comparison workplaces, 62.6% of possible employees). However, these compare favourably with response rates in other workplace nutrition surveys [e.g. (Sorenson et al., 1992)]. Adjusting for age, gender, ethnicity, BMI and social class meant that socio-demographic profile differences between intervention and comparison workplaces were accounted for.
CONCLUSION
Overall, the HBA had a modest impact on dietary intake, resulting in a significant positive change in four of 20 foods consumed by employees in HBA-holding workplaces. Four areas of significant change were observed: an increase in fruit intake and use of lower fat milks; and a reduction in consumption of sweet puddings and fried foods. The difference in change between intervention and comparison workplaces means that the changes are likely to result from the HBA scheme. However, no significant change was found in the other 16 foods investigated. The HBA scheme may be more effective if it is part of a wider multi-faceted intervention, incorporates price incentives and is better funded locally to facilitate more intensive input and monitoring. Effectiveness reviews under the responsibility of the Health Development Agency could contribute to developing evidence to improve the effectiveness of the current scheme.
ACKNOWLEDGEMENTS
We are grateful to all the workplaces and employees who agreed to participate in this study. We are equally grateful to Blossom Keppie, Lisa Sinfield, Diane Spalding and Helen Storer of the Leicestershire Nutrition and Dietetic Service for their professional support. Funding for this project was provided by Leicestershire Health Authority from Health of the Nation monies.
FOOTNOTES
All authors were based at the Department of Epidemiology and Public Health, University of Leicester, UK, at the time of data collection.
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