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 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.