Assessing a Hospital Retail Cafeterias Opportunities for Engaging Customers in Health Promotion Dianna Sinni Sage College Dietetic

Intern

TITLE: Improving Awareness and Customer Engagement in a Hospitals Retail Cafeteria Healthy Eating Initiative AUTHOR: Dianna Sinni, B.Sc., Dietetic Intern, The Sage Colleges, Troy, NY LEARNING OUTCOME: Facility will understand how to improve awareness of a retail cafeteria health promotion initiative while meeting consumer needs. ABSTRACT: As community-centered pillars of health, healthcare organizations have the opportunity to create positive food environments by offering nutritious food and beverage choices for patients, employees, and visitors. The purpose of this cross-sectional randomized study was to evaluate consumer awareness of a hospital retail cafeteria wellness program, which includes nutrient analysis signage, meal nutrition criteria, and wellness marketing, in order to assess current marketing efficacy. A total of 250 survey data collection tools were distributed to the customer population, which includes both hospital staff and patient visitors during one 3-hour lunch period. Results of the survey revealed 64.7% of consumers to view their healthy eating as moderately and very proactive, while 90% of consumers were unaware of the current healthy eating program. 40& (84 out of 210) participants reported chef recommendations to be how they identify healthy cafeteria options while only 14.2% utilize retail marketing materials. Observations of 60 plated meals during a separate 3-hour lunch period revealed the grill station, also the least healthy, to be the most popular (23 out of 60) as well as minimal wellness marketing efforts. This study revealed consumer interest in healthy eating but lack of awareness of the current retail wellness program. Recommendations for increasing food service employee nutrition knowledge and wellness marketing efforts were provided to the facility to improve consumer utilization of the retail program.

Section II: Introduction and Literature Review The role of hospital food for employees, patients, and guests is strategic in reducing readmissions and encouraging healthy lifestyle behaviors in prevention of chronic diseases. A health care facility that offers a disproportionate ratio of retail food options, specifically limited offerings of nutrient dense foods in comparison to nutrient empty choices, is a contradiction to the facilitys overall mission of improving health. Chronic diseases such as obesity, cardiovascular disease (CVD), stroke, certain types of cancer, and type 2 diabetes mellitus are not only the most common and costly diagnoses today, but also highly preventable, even reversible, through dietary intake and nutrition interventions. 1 The researched facility operates under a contracted food service management company and utilizes their retail wellness platform, entitled FIT. Created in collaboration with the Healthy Hospital Initiative (HHI), the FIT program encompasses product merchandising and firm nutrition guidelines for menu offerings (Appendix A). Within these guideline parameters, total, trans, and saturated fat is limited, along with sodium and sugar content. Caloric content is limited to no more than 600 calories for entrees and 250 calories for side dishes.2 By 2015 100% of cafeteria register offerings must adhere to the FIT guidelines.2 Management of both the facility and food service company were interested in understanding current consumer interest and usage of the FIT program prior to this study. Public health programs such as the HHI and Partnership for a Healthier America seek to leverage hospitals as community leaders in health promotion. However, contrary to mission and popular belief many hospital environments are not health-promoting and even contradict clinician efforts. A study of healthcare facilities whom are part of The California Endowments Healthy Eating, Active Communities Program (HEAC) found many of the public health institutions to have limited policies for reducing unhealthy food choices and a high prevalence of nutrition void, energy dense, sugary food and beverage vending options.3 Another study of McDonalds fast food 3

restaurants in childrens hospitals found that families of patients who visited the cafeteria were twice as likely to think McDonalds was healthy than families at a fast food free hospital.4 In addition, a hospitals financial responsibility should match up with its mission of improving health. For example, a hospital, which profits from unhealthy food, directly conflicts with the institutions overall health driven purpose and can be argued as an ethical issue. In relation to revenue, a Harvard University school cafeteria study involving short-term healthy food subsidizations, 20% price reduction, and healthy eating education materials, revealed an initial 6% sales increase and 17% increase upon return to original prices for healthy choices.5 Researchers at a hospital in Boston found traffic light food labeling to be effective in directing customers to healthy food choices; green represented healthy options, yellow for moderately healthy, and red for unhealthy options.6 These two studies reveal the usefulness of basic wellness marketing and nutrition food labeling for consumer purchases.5, 6 Section III: Materials and Methods Before data was collected, a PERT timeline (Appendix A) was created to outline the tasks and timeline for the entire project. The first step in the project was to complete an in-depth review of the food service FIT program by analyzing the current retail guideline handbook. These guidelines provide the framework for setting up a retail cafeteria in regards to healthy product merchandising, wellness marketing materials, and nutrient guidelines for meals.5 This information was important to understand the current wellness program scope. Additionally, a review of the facilitys retail wellness audit occurred. This audit was completed six months prior to the study by Regional Nutrition Director of the contracted food service company. Requirements and guidelines that were or were not being followed by the facility were noted. Next, a literature review was conducted in correlation with the survey and observational research, and recommendations for facility improvements were concluded based off of the data.

Participants: Survey participants were recruited randomly during lunch hours, 11:00-2:00pm, on one Wednesday. Lunch customers include guests, hospital employees, and some patients. A total of 210 participants completed the survey. This sample population represented approximately 60% of the cafeterias typical lunch service of 350 patrons. As an incentive and thank-you for participants, a 1.5-ounce bag of trail mix was given to those who completed the survey. Using the observational collection tool (Appendix D), a total of 60 random customers were observed in consecutive order either plating or ordering lunch at the available stations. The cafeteria stations include self-serve salad bar, soup bar, made-to-order grill, made-to-order sandwich, and self-serve hot bar. The wellness marketing materials including were observed at each food station and throughout the cafeteria at the utensil station, entrance and exit. Study Design and Data Collection: The study was conducted as a single group, cross-sectional design in order to effectively evaluate customer knowledge of a retail healthy eating program and personal lifestyle choices. Data was collected by survey and observations. Section IV: Results Survey Data: The primary source of data was the 210 completed surveys. This data revealed more detailed information and insight into consumer knowledge, actions, and perceptions of healthy eating. A total for 250 surveys were distributed with 40 returned incomplete or left unreturned and therefore unused in compiling data.

Chart 1: Personal Rating of Healthy Lifestyle 100 80 60 40 20 0

Very Proactive Moderately Proactive

78 56 31
Beginning Awareness

23
Conscious, Not Active

22
Uninterested

Chart 1 reveals 78 participants out of 210 (37%) to find themselves to be moderately proactive in pursuit of a healthy eating lifestyle. 56 out of 210 (26%) find themselves to be very proactive, while 22 out of 210 (10.4%) are uninterested in pursuing a healthy eating lifestyle. The remaining participants are either beginning awareness (14.7%) or conscious but not active (10.9%). Chart 2: Reading Food Labels

17%
YES

83%

NO

Chart 2 reveals how many participants actively read food nutrition labels on a regular basis. 83% (158 out of 210) stated yes, while 17% (33 out of 210) stated no. It is important to note that this data is not specific to only the hospital cafeteria.

Chart 3: Identifying Healthy Options in the Cafeteria

90 80 70 60 50 40 30 20 10 0

84

30 23 15 8

27 12 12

Chart 3 reveals chef recommendations (84 out of 210) to be the most prominent factor in consumer identification of healthy meal choices. Eating a soup or salad for a healthy meal (27 out of 210), utilizing marketing materials (30 out of 210), and personal knowledge (23 out of 210) were also popular identifiers. Chart 4: Customer Awareness of Current Retail Healthy Eating Program

10% Yes 90% No

Only 10% (22 out of 210) participants were aware of the current retail food service healthy eating program in place, while 90% (189 out of 210) were unaware of it.

Observational Results: 38.3% (23 out of 60) participants chose the grill station for their lunch. Nutrition analysis signage was observed for all food items on the soup, hot bar, and grill stations only. The grill station only had nutrient analysis signage for the daily special, and none of the additional side or entre options. Monthly wellness promotion and ingredient spotlight information were only at the cafeteria entrance table and ingredient spotlight information. The seating area and utensil station did not have any wellness marketing. Section V: Recommendations Since 90% of surveyed customers were unaware of the retail FIT program in place and only 14% utilize the current marketing materials to make healthy choices, it is evident that the program is highly underutilized. A wellness program cannot be effective when its recipients who are unaware of its intent or even how to navigate it. However, 63.8% (134 out of 210) of participants reported an active lifestyle and are actively interested in healthy eating for personal wellness. This provides a foundation for the food service department to improve marketing efforts and increase consumer awareness. Recommendations include improvements and increase of current wellness marketing materials and nutrition education for food service employees to better direct customers to healthy choices. According to the observational results, the facility only utilizes wellness marketing at the entrance of the cafeteria and nutrient analysis signage on the hot bar, soup bar, and grill. There are no other marketing materials on the food stations. This creates an opportunity for the facility to increase the visibility of current meal identifiers and nutrient analysis signage. In line with the FIT guidelines (Appendix B), all food items should have nutrient analysis signage. The facility is not adhering to this guideline, which will likely be reflected in future wellness audits. This simple improvement can create seamless aesthetics and continual nutrition guidance throughout the entire cafeteria. 8

Another area for improvement is to increase food service team knowledge of basic nutrition information. 40% (84 out of 210) of customers reported finding healthy options by listening to recommendations from the culinary staff. It is recommended that all food service employees receive education from staff dietitians on the FIT guidelines and nutrition basics. Since chef recommendations are upheld highly in the retail cafeteria, recommendations should correlate with the FIT program and direct customers to healthy options. This type of training could come in the form of quarterly in-services, new hire orientation, or once a week during food service morning meetings. Lastly, creating more prominent and effective marketing materials is recommended. As observed, the facility does not market wellness in the customer seating area or condiment/garbage station. These areas are high traffic and utilized by all those who eat in-house. These customer contact points would likely increase customer awareness more so than having marketing materials only at the cafeteria entrance. Further investigation is needed to determine whether these changes increase customer awareness and engagement in the FIT program. It is also recommended for future facility studies to investigate how healthy combination meals, such as a grill item and healthy side, impact consumer meal choices. Increasing price points on unhealthy foods and lowering prices on healthy foods would also be interesting to research with this facility and its consumers.

Section VI: Appendixes Appendix A PERT Timeline :

B
Review facilitys retail nutrition guidelines

1.5

C
Develop + distribute retail customer survey tool

5 E 2
Analyze data + perform literature review

1.5 D
Observe + record customer lunch purchases

A
Determine process to improve/study

3.5

G
Present research results/recs to Facility Director

F
Results + recommendations

-A-G represents the tasks completed in the chronological order of completion. -The numbers represent the approximate time frame for each task.

10

Appendix B FIT Guidelines: Nutrition Guidelines: Full Meal Calories 600 (400 BF) 25 (20 BF) 5

Entre Only 400 20 5

Side Dish 250 n/a 2

8 Fl. Oz Soup n/a n/a 2

12 Fl. Oz Soup n/a n/a 3

Total Fat (g) Saturated Fat and Trans Fat combined (g) *criteria for artificial trans fat is 0g. Sodium (mg) 600 Key: BF = Breakfast

600

250

500

750

Marketing Guideline Summary: o 1 Monthly Wellness Promotion (ie. February, Heart Health Month focus on whole grain fiber) o Nutrient Analysis Signage on all food items (fat, calories, and sodium only) o Ingredient Spotlight (ie. Quinoa grain of the month) o Display(s) to highlight aforementioned promotions

11

Appendix C Survey Tool: Tell us about your lifestyle. 1. How do you rate yourself in pursuit of a healthy eating lifestyle? (Choose 1 answer) __ Very proactive; I carefully monitor everything I eat and want food that is healthy and provides the best possible support of my healthy lifestyle. __ Moderately proactive; I read labels and primarily make choices that are considered healthy. __ Beginning awareness; I am learning about nutritious choices and am beginning to incorporate them into my dining style. __ Conscious but not active; I know about good nutrition habits but have no adopted them yet. __ Uninterested; I eat whatever I want and am unlikely to change in the near future. 2. Do you read food nutrition labels? __ Yes __ No 3. How do you currently identify the healthier meal choices in the caf? (Choose all that apply) __Signs or marketing materials in the caf that highlight healthy options __Recommendations by the chef or staff __I select what I know is good for me __I count calories and look for this information __I use mobile apps to help me __I have soup or salad when I want a healthy meal __I select the daily special __N/A 4. Are you aware of our cafeterias current healthy eating program? __Yes __No

12

Appendix D Observational Tools: Meal Popularity: Food Station Salad Bar Soup Bar Grill Sandwich Hot Bar # Observed Lunches 14 6 23 10 7 Total: 60 lunches (consecutive)

Marketing Materials: Mark an X for materials observed, leave blank if none. Station Ingredient Spotlight Monthly Wellness Promotion Salad Bar Soup Bar Grill Sandwich Hot Bar Cafeteria Entrance Table Cafeteria Exit Cafeteria Seating Area Utensil/Garbage Area

Nutrient Analysis X X, for daily special only and not for other options X

13

References 1. Academy of Nutrition and Dietetics. Position of AND: The Role of Nutrition in Health Promotion and Chronic Disease Prevention. JAND. 2013. doi: 10.1016/j.jand.2013.05.005 2. Morrison-Compass Group. FIT Retail Wellness Guidelines. Atlanta, GA: 2012. 3. Lawrence S, Boyle M, Craypo L, Samuels S. The food and beverage vending environment in health care facilities participating in the healthy eating, active communities program. Pediatrics 2009;123 Suppl 5:S287-292. 4. Sahud HB, Binns HJ, Meadow WL, Tanz RR. Marketing fast food: impact of fast food restaurants in childrens hospitals. Pediatrics. 2006;118(6):2290-2297. http://pediatrics.aappublications.org/content/118/ 6/2290.long. Accessed March 27th, 2013. 5. Michels KB, Bloom BR, Ricchardi P, Rosner BA, Willett WC. A study of the importance of education and cost incentives on individual food choices at the Harvard School of Public Health cafeteria. JACN. 2008; 27(1):6-11. http://www.ncbi.nlm.nih.gov/pubmed/18460476. Accessed March 27th, 2013. 6. Sonnenberg L, Gelsomin E, Levy DE, Riis J, et al. A traffic light food labeling intervention increases consumer awareness of health and healthy choices at the point-of-purchase. Prev Med. 2014; 59:86. http://www.ncbi.nlm.nih.gov/pubmed/23859926. Accessed March 27th, 2013.

14