Settings-based approaches: healthcare settings

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 healthcare 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 effort 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).

A systematic review of interventions aimed at improving the health of workers in healthcare settings⁵ found that the majority of physical activity and diet interventions led to improvements in at least one health outcome. Multi-component strategies, financial incentives and motivational approaches were particularly effective in driving positive changes. An example of such a strategy in Australia is led by the Western Australian government, which has made efforts to improve food and drink options in public hospitals. The WA policy uses a traffic light system to classify food and drink as red, amber and green. Hospitals required to stock at least 50% green items in each food outlet, with no more than 20% red items, and the rest amber.⁶ The policy also states that green items should be more prominently displayed than others and that only food and drinks with a green classification can 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).

Food service retail in healthcare settings

Efforts to improve healthy food provision in healthcare settings have shown promising outcomes. A review found that educational, labelling, financial and choice architecture interventions can improve the food environment and dietary intake.⁷ In Melbourne, Victoria, healthy options were successfully introduced at a food outlet within a major teaching hospital (the Alfred Hospital).⁸ 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 their own changes to promote healthy food.⁹ 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.¹⁰ 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.¹¹Sales 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.

In mid-2021, Victoria introduced the Healthy choices: policy directive for Victorian public health services (Policy directive) which requires health services to meet food and drink requirements for their in-house managed retail food outlets, all vending machines, all staff/event catering, and items purchased by staff and visitors from patient/resident menus, highlighting a comprehensive approach to improve availability of healthy foods in healthcare services.¹²

Content for this page was updated by Melanie Lum, Research Fellow and Serene Yoong, Associate Professor at the Global Centre for Preventive Health and Nutrition at Deakin University. For more information about the approach to content on the site please see About | Obesity Evidence Hub.