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Health Promotion Practice July 2013 Vol. 14, No. 4 552 –562 DOI: 10.1177/1524839912461792 © 2012 Society for Public Health Education

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The Better Bites program, a hospital cafeteria nutri- tion intervention strategy, was developed by combining evidence-based practices with hospital-specific forma- tive research, including key informant interviews, the Nutrition Environment Measures Study in Restaurants, hospital employee surveys, and nutrition services staff surveys. The primary program components are pricing manipulation and marketing to promote delicious, affordable, and healthy foods to hospital employees and other cafeteria patrons. The pricing manipulation com- ponent includes decreasing the price of the healthy items and increasing the price of the unhealthy items using a 35% price differential. Point-of-purchase marketing highlights taste, cost, and health benefits of the healthy items. The program aims to increase purchases of healthy foods and decrease purchases of unhealthy foods, while maintaining revenue neutrality. This arti- cle addresses the formative research, planning, and development that informed the Better Bites program.

Keywords: nutrition; behavior change; program planning and evaluation; formative eval- uation; health research; community intervention; health promotion; social marketing; health communication

>>IntroductIon

Unhealthy eating habits are associated with greater risk of coronary heart disease, cancer, stroke, diabetes, hypertension, osteoporosis, and obesity (Frazao, 1999), the first three comprising the leading causes of death in the United States (Centers for Disease Control and Prevention, 2011b). Diet and physical inactivity are the second-highest modifiable behavioral risk factors lead- ing to U.S. deaths (Mokdad, Marks, Stroup, & Gerberding, 2004), confirming their significant impact on health,

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1LiveWell Colorado Springs, Colorado Springs, CO, USA 2Public Health Partners, LLC, Colorado Springs, CO, USA 3Applied Research Solutions, Inc., Colorado Springs, CO, USA 4University of Colorado, Colorado Springs, CO, USA 5Penrose Hospital, Colorado Springs, CO, USA 6LiveWell Colorado Springs, Colorado Springs, CO, USA

Planning and Development of the Better Bites Program: A Pricing Manipulation Strategy to Improve Healthy Eating in a Hospital Cafeteria

Mina L. Liebert, MS, MCHES1

Amy J. Patsch, MPH, CHES2

Jennifer Howard Smith, PhD3

Timothy K. Behrens, PhD, CHES, FACSM4

Tami Charles, RD, MA5

Taryn R. Bailey, MS6

Authors’ Note: This work was funded by LiveWell Colorado Springs (LWCS) and Penrose–St. Francis Health Services (PSF). Appreciation goes to Margaret Sabin, CEO of PSF, for her support and commitment to the program. Many thanks goes to other PSF staff and the PSF members of the planning team for their assis- tance with planning and development, particularly Jane Glimco, Sharon Jacobs, Kristine Barrett, Kristine Baldwin, Karen Kovaly, and Michelle Somers. Additional thanks goes to LWCS staff for their assistance with program implementation, specifically Rebekah (Lauersdorf) Wegner and Christina (Swensen) Brandsma. Finally, appreciation goes to North Carolina Prevention Partners for their consultation and resources. Please address correspond- ence to Mina Liebert at [email protected].

Liebert et al. / PLANNING AND DEVELOPMENT OF BETTER BITES PROGRAM 553

quality of life, and longevity (Frazao, 1999). In combi- nation with other factors, poor eating habits have lead to approximately one third of U.S. adults becoming obese (Centers for Disease Control and Prevention, 2011a). Obesity and its comorbid effects make the iden- tification and promotion of healthy eating behaviors of paramount importance.

There are many reasons for hospitals to promote healthy eating, including improving employee health, being a community example, reducing hospital insur- ance costs, and creating a positive corporate image. However, many health care organizations do not encour- age health-promoting eating behaviors; some even allow fast-food restaurants to be located on their premises (Physicians Committee for Responsible Medicine, 2011). A recent survey of nurses demonstrated that 54% were overweight or obese (body mass index ≥27.2 kg/m2; Miller, Alpert, & Cross, 2008), indicating that even health care professionals are not immune to the over- weight and obesity epidemic. Since health profession- als serve as role models and hospitals are institutions of healing, hospital cafeterias are an ideal location to implement a healthy eating intervention (Kolasa, Dial, Gaskins, & Currie, 2010; Miller et al., 2008).

To improve eating habits of hospital employees, LiveWell Colorado Springs (LWCS) is partnering with Penrose–St. Francis Health Services (PSF) to change the hospital eating environment. This article highlights the formative research, planning, and development phases (see Figure 1) that resulted in the Better Bites program, a collaborative nutrition intervention promot- ing delicious, affordable, and healthy food.

>>Background

Part of a Colorado nonprofit committed to reducing obesity, LWCS collaborates with organizations to pro- mote healthy eating and active living. PSF, part of Centura Health’s hospital network, is a hospital system comprising two Colorado Springs hospitals, Penrose Hospital (PH) and St. Francis Medical Center (SFMC). PSF developed an outcomes-based employee wellness initiative in 2011 to align with Centura Health’s 2020 strategic plan, adopting upstream preventive approaches to improve hospital employee health. To support this cultural shift, LWCS is providing the planning, imple- mentation, and evaluation assistance needed to imple- ment the Better Bites program.

Determining the most effective intervention compo- nents is critical when implementing a healthy eating intervention. Studies have indicated that point-of- purchase nutrition information labeling affects change in knowledge; however, there are mixed results regard- ing the label’s influence on purchasing behavior. When

positive behavior change has been demonstrated, the magnitude of the effects has been modest (Freedman & Connors, 2010; Harnack & French, 2008; Seymour, Yaroch, Serdula, Blanck, & Khan, 2004). Subsidizing the price of healthy foods and/or increasing the price of unhealthy foods are potentially more effective behavior change strategies than simply providing nutrition labe- ling (French, 2003; French et al., 2001; Hannan, French, Story, & Fulkerson, 2002; Jeffery, French, Raether, & Baxter, 1994). French et al. (2001) examined various pricing manipulations on sales of lower fat snacks from school vending machines. Price reductions of 10%, 25%, and 50% for healthier snacks resulted in a signifi- cant increase in sales of 9%, 39%, and 93%, respec- tively, compared with usual price conditions. Nontrivial price reductions of 25% and 50% have been found to have the greatest impact on purchasing behavior (French, 2003; French et al., 2001; Jeffery et al., 1994; Powell & Chaloupka, 2009; Thow, Jan, Leeder, & Swinburn, 2010). These findings support the use of financial incentives to encourage behavior change and helped guide the devel- opment of the Better Bites program.

Based on the above findings, PSF and LWCS are working together to test the effectiveness of increasing healthy eating through pricing manipulation and mar- keting strategies. The pricing manipulation component is guided by the theory that reinforcement of positive behaviors through a reward will lead to those behaviors being repeated over time and eventually lead to ongo- ing behavior change even in the absence of the reward (Epstein, Leddy, Temple, & Faith, 2007; Hawkes, 2009). The Better Bites program’s conceptual framework is adapted from the social ecological model (McLeroy, Bibeau, Steckler, & Glanz, 1988; see Figure 2). The Better Bites program, a subset of the comprehensive PSF STRIVE Wellness Program, addresses the organiza- tional and individual levels of influence. The attached model focuses on the specific areas that the Better Bites program targets. By modifying the environment to sup- port healthy food choices and providing financial incentive to encourage those choices, a change in hos- pital employees’ knowledge and behavior is expected. The program components are discussed at greater length below.

>>MetHod

Formative Research

To better understand the current hospital eating environment and viewpoints of hospital employees, qualitative and quantitative data were collected from both hospitals and consisted of key informant inter- views, the Nutrition Environment Measures Study in

554 HEALTH PROMOTION PRACTICE / July 2013

Restaurants (NEMS-R; Saelens, Glanz, Sallis, & Frank, 2007), and hospital and nutrition staff surveys.

Key informant interviews. Three group key informant interviews were conducted with staff from PH (Director of Support Services, Nutrition Services Manager, Head

Chef), SFMC (VP of Operations, Nutrition Services Manager, Clinical Dietitian), and the STRIVE Wellness Program that services both hospitals (Administrative Director, STRIVE Coordinator, and staff person).

The objectives of the interviews were to (a) outline current food service practices, (b) share intervention

FIgure 1 Better Bites Program development Phases

Liebert et al. / PLANNING AND DEVELOPMENT OF BETTER BITES PROGRAM 555

plan options, (c) obtain intervention preferences, and (d) gain staff buy-in. All interviews were audio recorded and transcribed. Findings were summarized into an overview document and shared with the plan- ning team.

NEMS-R. NEMS-R is a 25-item assessment tool that identifies potential factors influencing food choices in restaurants, such as healthy food options, facilitators and barriers to healthful eating, pricing, and marketing (Saelens et al., 2007). LWCS had used this in other pro- grams and believed it would be helpful in analyzing hospital eating environments. The NEMS-R was admin- istered at both cafeterias during the lunch hour, taking approximately 2 hours to complete at each location. Surveys were analyzed using the NEMS Scoring Sheet for Restaurants.

Hospital employee survey. A 17-item survey, taking approximately 2 minutes to complete, was verbally administered one-on-one to hospital employees at both cafeterias during the lunch, dinner, and midnight meal (only at SFMC). Employees with various positions, including: management, medical, and support services, were surveyed. Fifty employees from each hospital were surveyed, representing 4% of total hospital employees (100 out of 2,600). An incentive (free meal or coffee) was provided to encourage participation.

The objectives of the survey were to obtain partici- pants’: (a) work-related demographics, (b) purchasing behaviors, (c) perceptions of healthy food availability, (d) perceived helpfulness of intervention options, and (e) likelihood of modifying their behavior based on intervention options. Data were aggregated and ana- lyzed for the full PSF hospital system and for each hospital individually.

Nutrition services staff survey. A 19-item survey, taking approximately 5 minutes to complete, was dis- tributed for written administration to staff on their lunch break at SFMC and at a staff meeting at PH. Approximately one third (36%) of staff were surveyed at SFMC (13 out of 36), whereas approximately half (51%) of staff were surveyed at PH (38 out of 74). The objectives of the survey were the same as the hospital employee survey, with two additional questions inden- tifying the most popular menu items and the perceived frequency of patrons inquiring about nutritional con- tent. Data were aggregated and analyzed for the full PSF hospital system and for each hospital cafeteria individually.

Intervention Planning and Development

The key to successful program planning and devel- opment was building a strong working relationship

FIgure 2 Better Bites Program conceptual Framework

556 HEALTH PROMOTION PRACTICE / July 2013

with organizational decision makers and identifying established best practices to determine specific pro- gram components.

Executive commitment. The initial, and potentially most important, task of intervention development was obtaining executive-level commitment and program buy-in to improve healthy eating. Identifying a high- level executive who was a proponent of health was the first step. From previous encounters, LWCS knew that the CEO (chief executive officer) of PSF was passionate about health and strongly committed to improving the health of her employees. Additional executive-level staff was also very supportive (VP of Operations and Nutrition Services Manager). The next step was meeting with the CEO, accessible through the STRIVE Coordinator, to present the plan. The final step was obtaining approval and program support, which was acquired in a timely manner thanks to the selection of a committed organi- zation leader. Obtaining high-level support from the beginning allowed for efficient planning, development, and implementation.

Strategic formation of planning team. Selecting appropriate collaborators to participate on the planning team, who could make operational decisions and assist with implementation tasks, was a crucial second element for developing a strong intervention. The core planning team included the Nutrition Services Managers from both hospitals, a clinical dietitian, the STRIVE Coordinator, the Lifestyle Program Manager, and the Administrative Director. It also included the LWCS Director and two contracted LWCS staff, a public health consultant to coordinate the intervention, and a professional program evaluator and statistician. Initiating support from various departments within PSF provided an opportunity to implement a crosscut- ting program that complemented and bolstered other employee wellness efforts.

Literature review and formative research. A litera- ture review was conducted to assess the most effective theoretically based approaches to improving healthy eating among hospital employees. The general search parameters included point-of-purchase labeling, traffic light approach (green, yellow, and red signs correspond- ing to nutritional value), and pricing manipulation to increase healthy food choices in worksite cafeterias. A basic Internet search and a more in-depth PubMed search resulted in more than 30 relevant articles for review. Major findings were summarized, reviewed by the planning team, and used to develop viable interven- tion options that guided formative research efforts (as

described above). Qualitative and quantitative data were systematically gathered to obtain feedback from the pri- ority population (hospital employees) before finalizing the intervention components.

Deciding intervention components. Results from the formative research were compiled and presented to the planning team, who then determined the major pro- gram components. Combining the literature review results with the hospital-specific formative research allowed the planning team to tailor the intervention to best meet the needs of the priority population with a smart and effective use of time and resources. For example, literature results highlighted the effectiveness of using pricing manipulation strategies in vending machines. However, the employee hospital survey revealed that the vast majority of employees (88%) rarely or never use vending machines. Without this combination of inputs, a vending study may have been implemented, which would have been a waste of valu- able resources.

>>results

Formative Research

Key informant interviews. Results showed that all interviewees were generally supportive (many extremely supportive) of the proposed intervention, feeling it aligned well with the strategic plan to improve employ- ees’ health. Some voiced concern over impact on rev- enue, resources needed to label all food items, and potential lack of effectiveness at changing behavior. Despite these concerns, all agreed to an intervention pilot period of 1 year. The planning team considered the interviewees’ concerns when selecting intervention components.

Results revealed important operational similarities and differences between the facilities that would affect implementation. Similarities included the following: managers have full control over modifying prices, facili- ties are self-operated, and more than 75% of the patrons are hospital employees. However, some notable differ- ences also surfaced. Whereas one facility designs the menu far in advance (6-week repeating cycle varying daily), the other designs the menu approximately 1 week in advance (options varying daily; no built-in rotation cycle). One has an electronic recipe database for all hot entrees, whereas the other does not use recipes to make the hot entrees. Because of these findings, the planning team realized that the detailed components of the inter- vention would vary between both facilities.

Liebert et al. / PLANNING AND DEVELOPMENT OF BETTER BITES PROGRAM 557

NEMS-R. The NEMS-R assisted in identifying strengths and areas to improve in the cafeteria environ- ment, although a customized hospital cafeteria survey would have been more helpful. The NEMS-R scorecard was not very useful because the cafeteria setting is dif- ferent from a regular restaurant setting and there was no recommended score or method to interpret scores. Strengths identified in both cafeterias included availa- bility of some current healthy options, absence of sig- nage promoting unhealthy eating, and lack of unhealthy meal deals. Areas to improve included the need for more direct promotion and wider selection of healthy options.

Hospital employee survey. The majority of survey respondents held medical positions (53%). Respondents were surveyed mostly during lunch (67%) and primar- ily worked during the day shift (75%). The majority of respondents purchased food from the cafeteria once a shift (49%; see Table 1).

Several key survey findings guided the direction of the intervention. First, an unexpected finding was that the vast majority of respondents rarely or never used vending machines (88%). Second, most respondents were con- cerned (or extremely concerned) about eating healthy (82%). Third, the majority of respondents were likely (or very likely) to purchase a healthy item if it was less expensive than the less healthy item (83%). Fourth, most respondents were supportive (or very supportive) of caf- eteria staff making a few healthy items less expensive and increasing the price of a few less healthy items to make up for the price difference (73%; see Table 1). These findings confirmed the planning team’s idea to implement a pric- ing manipulation strategy in the cafeterias.

Nutrition services survey. Although less favorable than the hospital employee results, the majority of the nutrition services staffs’ responses revealed overall posi- tive reactions to questions regarding program implemen- tation. Compared with hospital employees, nutrition services staff were less concerned about eating healthy (62.8% vs. 82%), less likely to purchase a less expensive healthy item (56.8% vs. 83%), and less supportive of price-focused interventions (54% vs. 73%; see Table 2). Individuals working in nutrition services may not see value in pricing and promotional marketing because a job benefit is a free meal when working. Additionally, lower results may be attributed to staff perceiving that their workload might increase because of this program.

Intervention Planning and Development

After careful analysis of all formative research find- ings, the Better Bites program was developed with the

goals of increasing purchases of healthy food items and decreasing purchases of unhealthy food items, while staying revenue neutral (or ideally increasing revenue). Hospital employees were selected as the priority popu- lation for two reasons: (a) to support PSF’s STRIVE Worksite Wellness Program and (b) to align with forma- tive findings (more than half of the hospital employee survey respondents eat there once a shift). The second- ary population included all cafeteria patrons (hospital volunteers and visitors).

The results of the literature review and formative research directed efforts to focus on three intervention components: access to healthier foods, marketing, and pricing manipulation. Three new healthy food items were added at both locations with the expectation that more will be added in the future (see Figure 1). To brand the Better Bites program, the PSF marketing department created a logo to assist in marketing the program and tangibly identifying healthy food items. Point-of- purchase marketing was implemented with (a) the Better Bites logo on all food items meeting the Better Bites nutritional criteria and (b) educational signage that high- light taste, cost, and health benefits of the healthy items. Hospital-wide marketing was conducted through a letter from the CEO to all employees, weekly articles in the employee newsletter, and features on the digital infor- mational signage located throughout the hospital.

Three paired items (one existing unhealthy item and a similar but new healthy item) at each hospital were selected for the pricing manipulation component. The price of the healthy items was decreased and the price of the unhealthy items was increased. Figure 1 displays each paired item and their intervention prices. A 35% intervention price differential, between the healthy and unhealthy paired items, was selected based on empiri- cal findings demonstrating optimal purchasing behav- ioral changes when price differentials fall between 30% and 40% (French, 2003; Hannan et al., 2002; J. Knaack, personal communication, June 10, 2011). This differential was also based on favorable projected revenue changes using the pricing strategy calculation from Hannan et al. (2002).

>>dIscussIon

The Better Bites program was developed to modify two hospitals’ eating environments by promoting deli- cious, affordable, and healthy food to staff and other cafeteria patrons. Critical factors contributing to success- ful program development included early executive-level buy-in and a committed planning team representing key departments with relevant areas of expertise. The appropriate individuals to support a systems-level

558 HEALTH PROMOTION PRACTICE / July 2013

taBle 1 Penrose–st. Francis Health services employee survey results

Both Hospitals (n = 100)

St. Francis Medical Center (n = 50)

Penrose Hospital (n = 50)

Survey Items % n % n % n

Time surveyed Lunch 67.0 67 62.0 31 72.0 36 Dinner 24.0 24 20.0 10 28.0 14 Midnight 9.0 9 18.0 9 — — Position/unit Management 18.0 18 14.0 7 22.0 11 Medical 53.0 53 64.0 32 42.0 21 Support 29.0 29 22.0 11 36.0 18 Typical shift Days 75.0 75 76.0 38 74.0 37 Nights 23.0 23 22.0 11 24.0 12 Other/varies 2.0 2 2.0 1 2.0 1 Frequency of purchasing food from the cafeteria Several times a Shift 17.0 17 16.0 8 18.0 9 Once a shift 49.0 49 50.0 25 48.0 24 Several times a week 27.0 27 30.0 15 24.0 12 Once a week 3.0 3 4.0 2 2.0 1 Several times a month 3.0 3 — — 6.0 3 Rarely/never 1.0 1 — — 2.0 1 Frequency of purchasing food from the vending machines

Several times a shift — — — — — — Once a shift 1.0 1 — — 2.0 1 Several times a week 3.0 3 4.0 2 2.0 1 Once a week 4.0 4 6.0 3 2.0 1 Several times a month 4.0 4 4.0 2 4.0 2 Rarely/never 88.0 88 86.0 43 90.0 45 Concern about eating healthy 1 (Not at all) 4.0 4 — — 8.0 4 2 — — — — — — 3 14.0 14 10.0 5 18.0 9 4 26.0 26 30.0 15 22.0 11 5 (Extremely) 56.0 56 60.0 30 52.0 26 Helpfulness of adding nutritional labels on cafeteria food

1 (Not at all) 25.0 25 26.0 13 24.0 12 2 3.0 3 4.0 2 2.0 1 3 8.0 8 4.0 2 12.0 6 4 5.0 5 4.0 2 6.0 3 5 (Extremely) 59.0 59 62.0 31 56.0 28

(continued)

Liebert et al. / PLANNING AND DEVELOPMENT OF BETTER BITES PROGRAM 559

Both Hospitals (n = 100)

St. Francis Medical Center (n = 50)

Penrose Hospital (n = 50)

Survey Items % n % n % n

Likelihood of purchasing healthier items if nutritional labels were provided

1 (Not at all) 22.0 22 22.0 11 22.0 11 2 5.0 5 4.0 2 6.0 3 3 5.0 5 8.0 4 2.0 1 4 19.0 19 6.0 3 32.0 16 5 (Extremely) 49.0 49 60.0 30 38.0 19 Likelihood of purchasing healthy item if less expensive

1 (Not at all) 11.0 11 2.0 1 20.0 10 2 1.0 1 2.0 1 — — 3 4.0 4 4.0 2 4.0 2 4 11.0 11 14.0 7 8.0 4 5 (Extremely) 72.0 72 76.0 38 68.0 34 Missing data 1.0 1 2.0 1 — — Supportiveness of pricing manipulation strategy 1 (Not at all) 8.0 8 2.0 1 14.0 7 2 5.0 5 6.0 3 4.0 2 3 14.0 14 20.0 10 8.0 4 4 17.0 17 10.0 5 24.0 12 5 (Extremely) 56.0 56 62.0 31 50.0 25

taBle 1 (contInued)

change include key decision makers, intervention implementers, and health champions who model posi- tive behaviors for other employees. Key decision mak- ers could consist of the CEO of an organization to be the influencer (voice) of the initiative; the CFO to iden- tify the financial incentive, in terms of revenue increase or decrease in health insurance claims; and/or the COO to implement organizational protocol changes. Key implementers should include nutrition services direc- tors, dietitians, and head chefs who oversee hospital cafeteria operations, including menu development, food procurement, and customer satisfaction. Health champions should include individuals who have expe- rienced program-based positive behavior change or wellness program staff who can align the initiative with overall program goals.

Three primary characteristics are needed to create a successful program to improve the healthy choices in a worksite food environment: (a) organizational financial incentive, (b) positive employee behavior modeling, and (c) employee demand. All three characteristics were addressed in the Better Bites program. Organizations

developing methods to improve employee health should address reduction in overall health care costs to ensure long-term financial benefits. Organizations that are self- insured or pay for a portion of employee insurance can be motivated to reduce the burden of health care costs. Establishing positive role models within an organiza- tion sets a good example and can lead to a health- focused organizational culture. Finally, addressing the demand from “champion” employees to provide healthy eating choices in cafeterias that maintain a majority of their revenue from staff can be an ideal environment conducive to the successful implementa- tion of a similar program.

The inclusion of multiple settings and multiple food choices also strengthened this intervention design. Implementing the program at two hospitals allowed for broader program reach and a larger, more heterogene- ous sample of employees and nutrition staff to assess. Tracking more than one paired food item and having a variety of items between both hospitals required additional evaluation and data analysis, but it allowed for a better understanding of which options were most

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taBle 2 Penrose–st. Francis Health services nutrition services staff survey results

Both Hospitals (n = 51)

St. Francis Medical Center (n = 13)

Penrose Hospital (n = 38)

Survey Items % n % n % n

Interacts with cafeteria patrons Yes 39.2 20 76.9 10 26.3 10 No 56.9 29 7.7 1 73.7 28 Unknown 3.9 2 15.4 2 — — Typical shift Days 62.7 32 38.5 5 71.1 27 Nights 3.9 2 7.7 1 2.6 1 Other/varies 33.3 17 53.8 7 26.3 10 Frequency of eating food from the cafeteriaa

Several times a shift — — 100.0 13 50.0 19 Once a shift — — — — 34.2 13 Several times a week — — — — 7.9 3 Once a week — — — — 2.6 1 Several times a month — — — — — — Rarely/never — — — — 5.3 2 Frequency of purchasing food from the vending machines

Several times a shift 7.8 4 — — 10.5 4 Once a shift — — — — — — Several times a week — — — — — — Once a week — — — — — — Several times a month 2.0 1 — — 2.6 1 Rarely/never 90.2 46 100.0 13 86.8 33 Concern about eating healthy 1 (Not at all) 11.8 6 15.4 2 10.5 4 2 2.0 1 — — 2.6 1 3 23.5 12 23.1 3 23.7 9 4 27.5 14 38.5 5 23.7 9 5 (Extremely) 35.3 18 23.1 3 39.5 15 Helpfulness of adding nutritional labels on cafeteria food

1 (Not at all) 21.6 11 53.8 7 10.5 4 2 3.9 2 — — 5.3 2 3 5.9 3 — — 7.9 3 4 33.3 17 23.1 3 36.8 14 5 (Extremely) 33.3 17 23.1 3 36.8 14 Missing data 2.0 1 — — 2.6 1 Likelihood of purchasing healthier items if nutritional labels were provided

1 (Not at all) 25.5 13 61.5 8 13.2 5 2 9.8 5 7.7 1 10.5 4

(continued)

Liebert et al. / PLANNING AND DEVELOPMENT OF BETTER BITES PROGRAM 561

Both Hospitals (n = 51)

St. Francis Medical Center (n = 13)

Penrose Hospital (n = 38)

Survey Items % n % n % n

3 15.7 8 15.4 2 15.8 6 4 25.5 13 15.4 2 28.9 11 5 (Extremely) 23.5 12 — — 31.6 12 Likelihood of purchasing healthy item if less expensive

1 (Not at all) 9.8 5 15.4 2 7.9 3 2 2.0 1 — — 2.6 1 3 19.6 10 15.4 2 21.1 8 4 17.6 9 15.4 2 18.4 7 5 (Extremely) 39.2 20 15.4 2 47.4 18 Missing data 11.8 6 38.5 5 2.6 1 Supportiveness of pricing manipulation strategy

1 (Not at all) 15.7 8 23.1 3 13.2 5 2 9.8 5 15.4 2 7.9 3 3 19.6 10 7.7 1 23.7 9 4 9.8 5 7.7 1 10.5 4 5 (Extremely) 43.1 22 46.2 6 42.1 16

a. Nutrition services staff receive a free meal when working.

taBle 2 (contInued)

influenced by marketing and pricing manipulation. There are some limitations to the current interven-

tion design. First, the hospital employee survey was administered to only a small number (n = 100) of the total employee population, with a disproportionate percentage of employees surveyed at PH. The survey was administered to 50 employees at both hospitals during various shifts, representing 2.7% of PH employ- ees (50 out of 1,800) and 6.3% of SFMC employees (50 out of 800). Second, the lack of a more appropriate nutrition environmental assessment tool (than NEMS-R) limited the applicability and usefulness of the results.

>>conclusIons

This article serves as an important starting point for health care systems interested in increasing healthy eat- ing through marketing and pricing manipulation. The detailed formative research, planning, and development information outlined in this article provides interested hospital leadership with a road map to initiate a similar program tailored to the needs of their priority population. The intent of the Better Bites program is to change the worksite culture of hospital cafeterias to one that

promotes employee health and wellness. Aligning this program into existing organizational efforts to promote healthy worksite behaviors (employee wellness programs) elevates the Better Bites program to a systemic change toward a comprehensive approach to health. Organizations that house on-site cafeterias, have a financial incentive to improve employee health, and are committed to provid- ing wellness opportunities for their employees would benefit from a program such as Better Bites.

Pricing manipulation strategies affect multiple lev- els of the population, as shown in numerous studies examining positive behavior change through pricing manipulation at the school and worksite level (French, 2003; French et al., 2001; Hannan et al., 2002; Jeffery et al., 1994). Evidence of food subsidies and taxes at the population level is limited, but large-scale, nontrivial price changes have demonstrated positive weight sta- tus outcomes primarily in low-socioeconomic status populations and younger populations (Powell & Chaloupka, 2009). Worksite wellness interventions have shown a modest improvement in employee weight status (Anderson et al., 2009). Additional research is needed to correlate the impact of pricing manipulation strategies with change in weight status.

562 HEALTH PROMOTION PRACTICE / July 2013

The Better Bites program is currently in the imple- mentation phase, and the planning team is in the pro- cess of gathering data to determine the impact of the intervention. Intervention results are planned to be shared in a future publication. The potential impact of the Better Bites program is threefold. First, the pricing differential of 35%, between healthy and unhealthy paired food items, ideally allows for employees to per- ceive value in healthy choices without negatively affecting revenue. Second, providing a variety of pair- ings provides choices so that employees can sample numerous kinds of healthy foods. Third, marketing and continuous exposure to healthier food choices may influence individuals to make healthier choices out- side the hospital setting and incorporate them into their daily behaviors.

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