An audit of vending machines and food outlets in HNELHD sites found that healthier (green/amber) food and beverage choices were not readily available. Only 29% of beverages available in vending machines were healthier choices and almost none of the foods (1%). Moreover, foods and beverages were poorly labelled in spite of strong support from parents for the provision and labelling of healthy food and drink choices in health facilities. The intervention significantly improved the availability and labelling of healthier drink choices in vending machines. However, it did not improve the availability of healthier foods in vending machines and it did not have a major influence on the availability of healthy choices in food outlets.
We are aware of one other Australian study that has measured the impact of a healthier choices strategy in health care facilities. The Queensland Government introduced the ‘A Better Choice Healthy Food and Drink Supply Strategy’ for Queensland Health Facilities in September 2007. The aim was to increase the supply of healthy food and drink to Queensland Health staff, visitors and the general public in Queensland Health facilities. The strategy became mandatory on 1 September 2008 and it was evaluated in 2009 . Most of the 278 facilities surveyed (78 percent) reported implementation of more than half of the requirements of the strategy, and 25 percent reported full strategy implementation. Reports from a majority of facilities indicated that 82% of food outlets had restricted the supply of red category foods and drinks to <20% of items on display. Also, almost three-quarters (74 per cent) of facilities reported that red category food and drinks had been completely removed from vending machines. However, consistent with our finding that changes to food/snack items stocked in machines proved harder than changing drinks, the Queensland study reported that changing snack vending machines was difficult . This may be because it is easier to source healthier drink alternatives, such as bottled water and low fat milks, than source appropriate healthier food alternatives that have a long shelf-life, are of appropriate size and shape (i.e. fit in the vending machine slots) and are comparatively priced.
Several factors may have contributed to the intensity and reach of our intervention being less than desired for both vending machines and food outlets. Intensity was limited by delays in finalising the vending contract and, once the contract was in place, there were additional delays on many sites related to machine installation and confusion over whether or not machines had to comply with the policy directive. The exemption for fundraising and existing contracts clearly limited the reach of the intervention. There were also logistical challenges reaching outlets. Distance and non-use of email made contact, training and follow-up support hard, particularly given that managers of these outlets were often volunteers and part-time. Also, performance monitoring and feedback may not have been sufficient to encourage compliance. More strategic use of the information on parent (customer) perceptions may have encouraged managers to supply foods and beverages more in line with demand and ideas for healthier fundraising alternatives may have led to better compliance from the fundraising outlets. For example, NSW schools have identified creative ways of making money that promote health and wellbeing such as selling fruit and vegetable boxes . Being purposeful about promoting fruit and vegetables in health services may also be beneficial. In the US, regular farmer’s markets in Kaiser Permanente’s health facilities have led to improvements in the fruit and vegetable consumption of patrons .
Another barrier to increasing healthier choices may have been concerns about loss of profits. Indeed, this was the reason fundraising volunteer groups lobbied against the original policy directive at state level, leading to the exemption. In a survey of Canadian and US Paediatric hospitals, McDonald and colleagues found that revenue from food outlets, or the presence of more internally-operated cafeterias, was positively associated with availability of less nutritious foods and inversely associated with availability of healthful food and beverage alternatives . This suggests that a reliance on or drive for revenue may promote the sale of less nutritious food. Thus, it may have been helpful if we had provided information and examples on how vending machines and food outlets can sell mostly healthy food and still turn a profit. Also, given the improvements in labelling and that 65% of outlet managers agreed that food outlets on health service sites should have signs clearly showing healthy choices, an easier first step may have been the introduction of shelf labels.
The strengths of this study include the use of audits rather than self-report for collecting data on food availability and working with dietitians to determine food and drink classifications against previously developed criteria. Also, we were able to quantify the level of parental support for making healthier choices available in health facilities. The main limitation was the absence of a comparison group, restricting our ability to attribute changes to the intervention. Small sample sizes precluded meaningful statistical analysis in some cases. Also, a one-off audit may not be representative of items typically offered for sale although, for vending, interim reports from the contractor were consistent with the audit findings.
Efforts to improve the health of foods available in health care facilities are not new in Australia. The New South Wales Health Department developed a nutrition strategy in 1995 to promote better nutrition for people in NSW , and in line with this strategy, a number of area health services, including Hunter, adopted food and nutrition policies . These initiatives may have improved the nutritional quality of foods for patients [16, 17], but it is evident from renewed efforts to introduce policy and the high prevalence of unhealthy ‘red’ foods found in this study that there is also a need to improve the nutritional quality of food available for sale to staff, visitors and outpatients.