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Environmental: Healthy influences

Settings-based approaches: healthcare settings

Last updated 24-04-2020

Settings-based interventions can create supportive environments for obesity prevention and management. Outlined below is the rationale for policy and practice changes in healthcare settings, together with a summary of evidence on strategies shown to be effective and a discussion of some notable trials.

Key Evidence

01

Healthcare settings can model a healthy food environment for staff, patients and visitors

02

WA Health conducts audits to monitor compliance with its Healthy Options policy

The World Health Organization recommends strategies in community settings to tackle modifiable risk factors for chronic disease including poor diet and physical inactivity.1 Strategies may draw on existing infrastructure in settings such as workplaces, healthcare settings, sports clubs and grocery stores to reach large numbers of people.

Public hospitals are large employers2 and, given links between poor diet and chronic disease,3 it is important to model a healthy food environment for staff, patients and visitors in this setting. The availability of healthy food and drink options in hospital food outlets and vending machines can be limited despite most Australian state health departments having policies aimed at improving hospital food environments. A systematic review of interventions aimed at improving dietary outcomes in health care settings found evidence that the following strategies were effective at promoting behaviour change:4

  • Reducing the effort required to select healthy options and/or increasing the effect to select unhealthy options (e.g. increasing prominence of fruit and water within a canteen, and reducing prominence of chips and confectionery)
  • Increasing availability of healthy options (e.g. requiring that at least 75% of snacks provided in a canteen are healthy)
  • Offering smaller portions (e.g. offering two size options for the main meal offered in a canteen).

Within the Australian context, the Western Australia government has led efforts to improve food and drink options in public hospitals. The WA policy relies on a traffic light system to classify food and drink as red, amber and green, with hospitals required to stock at least 50% green food and drinks in each food outlet, no more than 20% red and the rest amber.5 Its policy states that green items should be more prominently displayed than other categories and only food and drinks with a green classification are to be included in sales promotions.

Importantly, WA Health conducts audits to monitor compliance with its Healthy Options policy. In 2018–19:

  • 29% of audited cafés, kiosks and canteens were fully compliant with the policy (up from 7% in 2016)
  • 55% of vending machines were fully compliant (up from 24%)
  • 14% of ward trolleys were fully compliant (up from none).

Following the latest audit, WA Health Minister Roger Cook said he expected hospital boards to do more to improve healthy food offerings, including making compliance with the healthy options policy a condition of contracts with external food suppliers.6 “It’s so important that while we have a department that does a great job at talking about healthy food, healthy living, making sure people stay healthy, that they provide those opportunities and become real exemplars for those values themselves,” he told ABC news. Other states have opted to ban sugary drinks in hospitals as part of their healthy food and drink policies, including NSW7 and Queensland.8

In Melbourne, Victoria, healthy options were successfully introduced at a food outlet within a major teaching hospital (the Alfred Hospital).9 Hospital leadership worked with the food retailer on strategies which included decreasing portion sizes; increasing the range of salads, sushi and yoghurt; reducing fried food; moving sugar-sweetened beverages out of sight; and favourable pricing for healthy foods. Key to the program’s success was a phased approach, input from hospital dietitians, and consistent communication throughout the organisation about the importance of ensuring a healthy food environment.

Short-term trials were co-developed between the food retail owner and hospital staff, giving the food outlet owner the confidence to suggest and initiate his own changes to promote healthy food.10 The food outlet owner came to view the shift to healthier food options as innovative and essential to remaining a viable business.

In a convenience store at the same hospital, a separate 17-week trial tested the effect of a 20% price increase in ‘red’ beverages (e.g. non-diet soft drinks, energy drinks), while prices of ‘amber’ (e.g. diet soft drinks, small pure fruit juices) and ‘green’ beverages (e.g. water) were unchanged.11 The change was associated with a decrease in sales of red and amber beverages while sales of green beverages increased. The store manager and staff considered the intervention business-neutral, despite a small reduction in beverage revenue overall.

The hospital also made changes to its vending machines to reduce the proportion of unhealthy food and beverages and increase the availability of healthier options.12Sales of the unhealthiest food and drinks (‘red’) significantly decreased and this was not fully offset by an increase in ‘green’ and ‘amber’ products, however a renegotiation of higher commission rates during tendering for the vending contract meant there was no change in revenue for the hospital.

References

1. World Health Organization (2014). Global status report on noncommunicable diseases. Available from: https://www.who.int/nmh/publications/
2. Australian Institute of Health and Welfare (2019). Hospital resources 2017–18: Australian hospital statistics. Available from: https://www.aihw.gov.au/reports/hospitals/
3. Australian Institute of Health and Welfare. 2019. Australian Burden of Disease Study: impact and causes of illness and death in Australia 2015. Canberra, Australia.
4. Al-Khudairy L, Uthman OA, Walmsley R, Johnson S & Oyebode O. (2019). Choice architecture interventions to improve diet and/or dietary behaviour by healthcare staff in high-income countries: a systematic review. BMJ Open, 9(1), e023687
5. WA Health (2015). Healthy Options WA: Food and Nutrition Policy for WA Health Services and Facilities. Available from: https://ww2.health.wa.gov.au/About-us/
6. O'Flaherty A. (2019). WA hospitals are failing healthy food standards, with Fiona Stanley Hospital among the worst. ABC News. Available from: https://www.abc.net.au/news/
7. Boys C. (2017). NSW Health announces plans to remove sugary drinks from all hospitals. Sydney Morning Herald. Available from: https://www.goodfood.com.au/
8. Bavas J. Queensland hospitals to ban junk food and sugary drinks. ABC News, 2018. Available from: http://www.abc.net.au/news/201...
9. VicHealth (2016). Introduction of Healthy Choices at Alfred Health food outlets - Evaluation summary. Available from: https://www.vichealth.vic.gov.au/
10. Boelsen-Robinson T, Blake MR, Backholer K, Hettiarachchi J, Palermo C and Peeters A (2019). Implementing healthy food policies in health services: A qualitative study. Nutr Diet 76(3): 336-43.
11. Blake MR, Peeters A, Lancsar E, Boelsen-Robinson T, Corben K, Stevenson CE, Palermo C and Backholer K (2018). Retailer-Led Sugar-Sweetened Beverage Price Increase Reduces Purchases in a Hospital Convenience Store in Melbourne, Australia: A Mixed Methods Evaluation. Journal of the Academy of Nutrition and Dietetics 118(6): 1027-1036.e1028.
12. Boelsen-Robinson T, Backholer K, Corben K, Blake MR, Palermo C and Peeters A (2017). The effect of a change to healthy vending in a major Australian health service on sales of healthy and unhealthy food and beverages. Appetite 114: 73-81.