Choice Architecture Cueing to Healthier Dietary Choices and Physical Activity at the Workplace: Implementation and Feasibility Evaluation

Effect of nutritional guidance on employee work ability, work well-being and quality of life (RAVI trial): Study protocol for a randomized controlled trial

BACKGROUND

The minority of working-age Finns eat according to the national and Nordic nutritional guidelines and increasing numbers of health problems affect the Finnish workforce. Coincidently recruiting new workers in the more rural areas of Finland, such as Satakunta, has been problematic. To optimize the use of the existing workforce, health promotion interventions focusing on nutrition have been suggested to improve the health and well-being of the current working age Finns.

METHODS AND ANALYSIS

The aim of this RCT study is to assess the effectiveness of a 12-month multifactorial nutritional guidance intervention to improve work ability (performance), work well-being, health-related quality of life, work productivity, sickness absence, dietary intake and eating habits. In total, six small or medium-sized companies and their employees (n = 170) from the Satakunta region will be recruited. Companies will be randomized 1:1 to a 12-month multifactorial nutritional guidance intervention group (INT) or a control group (CG). Comprehensive measurements are taken before randomization (baseline) and at the end of the 12-month study period. Primary outcomes (work ability, work well-being and health-related quality of life) are measured with Work Ability Index, Utrecht Work Engagement Scale short questionnaire and EQ-5D. Dietary intake and eating habits are measured with 3-day food records and Food Frequency Questionnaire (FFQ).

DISCUSSION

This study will provide nationally important data on how workplace nutrition guidance affects work-related outcomes, quality of life, and nutritional and overall health status among working age Finns.

Effectiveness of workplace choice architecture modification for healthy eating and daily physical activity

BACKGROUND

Modifying the choice architecture of behavioural contexts can facilitate health behaviour change, but existing evidence builds mostly on small-scale interventions limited in duration, targets, strategies, and settings. We evaluated the effectiveness of a one-year hybrid type 2 implementation-effectiveness trial aimed at promoting healthy eating and daily physical activity with subtle modifications to the choice architecture of heterogeneous worksites. The intervention was contextualised to and integrated into the routine operations of each worksite. Effectiveness was evaluated in a quasi-experimental pre-post design.

METHODS

Intervention sites (n = 21) implemented a median of two (range 1-9) intervention strategies for healthy eating and one (range 1-5) for physical activity. Questionnaires pre (n = 1126) and post (n = 943) intervention surveyed employees' behavioural patterns at work (food consumption: vegetables/roots, fruit/berries, nuts/almonds/seeds, sweet treats, fast food, water; physical activity: restorative movement, exercise equipment use, stair use). The post-intervention questionnaire also measured employees' perception of and response to three intervention strategies: a packed lunch recipe campaign, a fruit crew-strategy, and movement prompts. Multi- and single-level regression models evaluated effectiveness, treating intervention as a continuous predictor formed of the site-specific dose (n intervention strategies employed) and mean quality (three-point rating per strategy halfway and at the end of the intervention) of implementation relevant to each outcome.

RESULTS

Multinomial logistic regression models found the intervention significantly associated with a favourable change in employees' fruit and berry consumption (interaction effect of time and implementation p = 0.006) and with an unfavourable change in sweet treat consumption (p = 0.048). The evidence was strongest for the finding concerning fruit/berry consumption-an outcome that sites with greater dose and quality of implementation targeted by using strategies that reduced the physical effort required to have fruit/berries at work and by covering multiple eating-related contexts at the worksite. The quality of implementation was positively associated with the perception of (p = 0.044) and response to (p = 0.017) the packed lunch recipes, and with response to the fruit crew-strategy (p < 0.001).

CONCLUSIONS

The results suggest that a contextualised, multicomponent choice architecture intervention can positively influence eating behaviour in diverse real-world settings over a one-year period, and that higher implementation quality can enhance intervention perception and response. However, outcomes may depend on the type of intervention strategies used and the extent of their delivery.

Acceptability of workplace choice architecture modification for healthy behaviours

BACKGROUND

Altering the choice architecture of decision contexts can assist behaviour change, but the acceptability of this approach has sparked debate. Considering hypothetical interventions, people generally welcome the approach for promoting health, but little evidence exists on acceptance in the real world. Furthermore, research has yet to explore the implementers' perspective, acknowledging the multidimensionality of the acceptability construct. Addressing these knowledge gaps, this study evaluated the acceptability of a quasi-experimental implementation-effectiveness trial that modified the worksite choice architecture for healthy eating and daily physical activity.

METHODS

Fifty-three worksites participated in the 12-month intervention and implemented altogether 23 choice architecture strategies (Mdn 3/site), including point-of-choice prompts and changes to choice availability or accessibility. Retrospective acceptability evaluation built on deductive qualitative content analysis of implementer interviews (n = 65) and quantitative analysis of an employee questionnaire (n = 1124). Qualitative analysis examined implementers' thoughts and observations of the intervention and its implementation, considering six domains of the Theoretical Framework of Acceptability: ethicality, affective attitude, burden, intervention coherence, opportunity costs, and perceived effectiveness. Quantitative analysis examined employees' acceptance (7-point Likert scale) of eight specific intervention strategies using Friedman test and mixed-effects logistic regression.

RESULTS

Implementers considered the choice architecture approach ethical for workplace health promotion, reported mostly positive affective attitudes to and little burden because of the intervention. Intervention coherence supported acceptance through increased interest in implementation, whereas low perceived utility and high intensity of implementation reduced cost acceptance. Perceived effectiveness was mixed and varied along factors related to the implementer, social/physical work environment, employer, and employee. Employees showed overall high acceptance of evaluated strategies (Mdn 7, IQR 6.4-7), though strategies replacing unhealthy foods with healthier alternatives appeared less supported than providing information or enhancing healthy option availability or accessibility (p-values < 0.02). Greater proportion of male employees per site predicted lower overall acceptance (OR 4.4, 95% CI 1.2-16.5).

CONCLUSIONS

Work communities appear to approve workplace choice architecture interventions for healthy eating and physical activity, but numerous factors influence acceptance and warrant consideration in future interventions. The study contributes with a theory-based, multidimensional evaluation that considered the perspectives of implementers and influenced individuals across heterogeneous real-world settings.

Perception of nudge interventions to mitigate medication errors risk in healthcare service delivery

BACKGROUND

Conventional cognitive interventions to reduce medication errors have been found to be less effective as behavioural change does not always follow intention change. Nudge interventions, which subtly steer one's choices, have recently been introduced.

METHODS

Conducted from February to May 2023, this study aimed to determine the relationships between perceived effectiveness and perceived ease of implementation of six nudge interventions to reduce medication errors, i.e., provider champion, provider's commitment, peer comparison, provider education, patient education and departmental feedback, and the moderating effects of seniority of job positions and clinical experience on nudge acceptability. Partial Least Square Structural Equation Modelling was used for data analysis.

RESULTS AND DISCUSSION

All six nudge strategies had significant positive relationships between perceived effectiveness and acceptability. In three out of six interventions, perceived ease of implementation was shown to have positive relationships with perceived acceptability. Only seniority of job position had a significant moderating effect on perceived ease of implementation in peer comparison intervention. Interventions that personally involve senior doctors appeared to have higher predictive accuracy than those that do not, indicating that high power-distance culture influence intervention acceptability.

CONCLUSION

For successful nudge implementations, both intrinsic properties of the interventions and the broader sociocultural context is necessary.

Creating healthy food environments in recreation and sport settings using choice architecture: a scoping review

Recreation and sport settings (RSS) are ideal for health promotion, however, they often promote unhealthy eating. Choice architecture, a strategy to nudge consumers towards healthier options, has not been comprehensively reviewed in RSS and indicators for setting-based multi-level, multi-component healthy eating interventions in RSS are lacking. This scoping review aimed to generate healthy food environment indicators for RSS by reviewing peer-reviewed and grey literature evidence mapped onto an adapted choice architecture framework. One hundred thirty-two documents were included in a systematic search after screening. Data were extracted and coded, first, according to Canada's dietary guideline key messages, and were, second, mapped onto a choice architecture framework with eight nudging strategies (profile, portion, pricing, promotion, picks, priming, place and proximity) plus two multi-level factors (policy and people). We collated data to identify overarching guiding principles. We identified numerous indicators related to foods, water, sugary beverages, food marketing and sponsorship. There were four cross-cutting guiding principles: (i) healthy food and beverages are available, (ii) the pricing and placement of food and beverages favours healthy options, (iii) promotional messages related to food and beverages supports healthy eating and (iv) RSS are committed to supporting healthy eating and healthy food environments. The findings can be used to design nested, multipronged healthy food environment interventions. Future research is needed to test and systematically review the effectiveness of healthy eating interventions to identify the most promising indicators for setting-based health promotion in RSS.

Nudging Finnish Adults into Replacing Red Meat with Plant-Based Protein via Presenting Foods as Dish of the Day and Altering the Dish Sequence

This study investigated whether Finnish working-aged omnivores (n = 163) could be nudged into replacing red meat with a fava-bean-based protein source via “Dish of the Day” (DoD) and main dish sequence alteration (SA) strategies in a controlled real-world Finnish self-service buffet restaurant with smart scales (Flavoria® Multidisciplinary Research Platform). A further aim was to study whether the effectiveness of the strategies differed by gender, age, and body mass index. The participants were assigned one of four experimental treatments: standard menu (T1), DoD (T2), standard menu + SA (T3), or DoD + SA (T4). The participants could choose any amount or combination of salad components and casseroles with minced meat or fava bean protein. Being subjected to a DoD menu and/or SA had no effect on main dish choice or the share of the meat-based dish in the meal weight. Men were more likely to choose a meat-based main dish and had a higher share of the meat dish in the meal weight compared to women, but no differences were observed between those aged 18–29, 30–44, or 45–65 years or those who were normal weight, overweight, or obese. Future studies should have a larger sample size and investigate food choice motives such as price or environmental awareness.

Sensory Appeal and Routines Beat Health Messages and Visibility Enhancements: Mixed-Methods Analysis of a Choice-Architecture Intervention in a Workplace Cafeteria

Easier recognition and enhanced visibility of healthy options supposedly increase healthy choices, but real-world evidence remains scarce. Addressing this knowledge gap, we promoted nutritionally favourable foods in a workplace cafeteria with three choice-architectural strategies-priming posters, point-of-choice nutrition labels, and improved product placement-and assessed their effects on visual attention, food choices, and food consumption. Additionally, we developed a method for analysing real-world eye-tracking data. The study followed a pretest-posttest design whereby control and intervention condition lasted five days each. We monitored visual attention (i.e., total number and duration of fixations) and food choices with eye tracking, interviewed customers about perceived influences on food choices, and measured cafeteria-level food consumption (g). Individual-level data represents 22 control and 19 intervention participants recruited at the cafeteria entrance. Cafeteria-level data represents food consumption during the trial (556/589 meals sold). Results indicated that the posters and labels captured participants' visual attention (~13% of fixations on defined areas of interest before food choices), but the intervention had insignificant effects on visual attention to foods, on food choices, and on food consumption. Interviews revealed 17 perceived influences on food choices, the most common being sensory appeal, healthiness, and familiarity. To conclude, the intervention appeared capable of attracting visual attention, yet ineffective in increasing healthier eating. The developed method enabled a rigorous analysis of visual attention and food choices in a natural choice setting. We discuss ways to boost the impact of the intervention on behaviour, considering target groups' motives. The work contributes with a unique, mixed-methods approach and a real-world setting that enabled a multi-dimensional effects evaluation with high external validity.