Participant characteristics
Thirty-three nominated participants were invited to take part in the interviews, of whom six declined to participate due to Covid-19, lack of time or staff shortages, seven indicated willingness to participate but did not respond after two follow-ups, and eight provided no response after three invitation attempts. The study sample comprised eight food providers and four Network members. Two food providers from the same company asked to participate in a joint interview. Three participants were from small ( 300,000 people) health districts. The interviews took on average 71 min (range 58–94 min) to complete. Three food providers and one Network member participated via email. The majority of participants had been in their roles between two and five years (range 1-14.5 years), although many were not in their current roles when the Policy was first adopted.
Reflexive thematic analysis
Three themes were generated encompassing the experiences of the Policy implementers (food providers, FP, and Network members, NM). Tools and resources identified by the participants that could assist with the Policy implementation are described within the themes as appropriate.
Theme 1: Complexities of operating food outlets under a healthy food and drink policy in public health sector settings
In general, food providers were described as having “good intentions” (NM#3) to implement the Policy, and they spoke about being “100% behind in making things healthy” (FP#2). However, the implementers described several complexities of operating food outlets in a hospital compared to operating cafes or restaurants in other settings.
Subtheme: Operating under several different food-related policies and contracts while catering to many distinct customer groups is challenging
Food providers operated simultaneously according to several food-related policies and contracts and often worked in different hospitals across the region within their DHBs. Food providers, especially in smaller DHBs, were often simultaneously responsible for running the inpatient meal service, providing Meals on Wheels in the community, providing meals in the staff cafeteria, operating public cafes and vending machines, and providing catering on hospital premises. The contrasts between the specific and strict nutritional, food safety and allergen regulations for inpatient and Meals on Wheels services, and the Policy nutritional criteria, were sometimes challenging to manage when preparing patient and staff café meals in the same kitchen. Food service personnel were able to adapt to the Policy requirements but needed time and training to make adjustments.
“There’s lots of restrictions to [patient meals]. (…) we make it easy for ourselves, and we make kind of this ‘one pot wonder’ that then gets little things added to it [to be sold in cafeteria]. (…) It takes them [cooks] out of their comfort zone of what they’ve always been used to. But, they’ll get there, they’ve got there, that’s fine.” (FP#6)
The implementers spoke about the differences between DHBs with respect to their population profiles [40], the variation in adopted healthy food and drink policy [28], the number of food outlets within the organisation, and whether the food outlets were operated internally or by external providers. From an organisational perspective, working in a large DHB with several external and commercial food providers, including franchised outlets expected to provide their usual core offerings, was challenging due to “different businesses who have really different ways of working – or you know – different priorities around them” (NM#3). In a smaller DHB, an operating model for the Policy implementation could have fewer food providers or only outlets operating internally. DHBs with a potential commercial interest in selling less healthy items, where the percentage of revenue was used to contribute to running other DHB services, was seen as conflicting for the Policy implementation.
An important contract with a bearing on the Policy implementation was the Multi-Employer Collective Agreement, which states that unionised resident medical officers are entitled to free meal(s) during their working hours at the expense of the DHBs [41]. As one participant noted, “We talked quite a bit [about] becoming a sugar-free DHB. But some initial conversations with the doctors’ unions, made us realise that would be much more difficult than what we anticipated.” (NM#2) The difficulty was mainly due to legal clauses that guarantee provision of certain items under the collective agreement that could not be restricted by the Policy.
Hospitals also catered to multiple distinct customer groups. Medical staff, including shift workers, often face challenges with long working hours in a highly demanding environment [13, 14]. High levels of stress are also experienced by visitors of unwell and sick patients (although the Policy is not aimed at them, they may eat at hospital food outlets). Implementers noted that “a lot of the time especially when staff and visitors are busy, or stressed, they tell us they just want some comfort food” (FP#7) and the “requests for comfort foods including chocolate and sugar-sweetened beverages” (NM#4) were barriers to the Policy implementation. Customer survey results align with our findings in that the second most common reason staff opposed the Policy (n = 221, 48%) was the removal of foods that provide energy or comfort [39]. Additionally, approximately one-fifth of visitors (n = 44, 23%) reported that the comfort feeling provided by foods/drinks influenced their product choice [39].
Participants saw that the Policy served as a guideline to follow and implement regardless of personal opinions. “At the end of the day we are a contracted service – my client (the [DHB]) decided to implement the policy – we are just here to follow their directive.” (FP#3) There was also appreciation that “we got to look at this thing [the Policy] across the whole board, you know. We can’t just put a nutrition lens on it, we’ve got to be looking at it from the equity and accessibility lens as well and thinking what’s the right thing to do here.” (NM#3) The introduction of healthier options was often associated with the perception that they were more expensive, less tasty, and unsuitable for sale in hospitals located in socio-economically disadvantaged areas.
Subtheme: Lack of a level playing field threatens food providers’ profits
Implementers noted there was an uneven playing field between food providers, particularly with respect to profitability. There were no consequences or incentives specified in contracts if food providers complied or did not comply with the Policy, even where contracts contained a Policy clause. For food providers implementing the Policy, business disadvantages were perceived as outweighing any possible benefits from being compliant, because customers could easily access and purchase ‘not permitted’ Red items (fried food, confectionery, and SSBs) nearby, e.g., just outside the hospital, and Network members had no authority to enforce compliance.
“The reality is almost every hospital has a bakery or dairy within sight of the front door and to them the food policy is an absolute God send – because staff and visitors spend a fortune with them buying what we can’t sell (…) if I had the money I would buy a dairy as close to the hospital as I could get because I am afraid the healthy food policy just drives customers to their business.” (FP#3)
The Policy was perceived as too restrictive to ensure the long-term profitability and sustainability of a commercial operation. The number of customers seeking healthier options was unlikely to ensure sustained profit margins for food providers adhering to the Policy. “Well we obviously can’t sell what we want to sell – which reduces our takings. So everything that we do sell – the cost of goods is going to be spot on, because otherwise you’re losing money.” (FP#4) A drop in profits was observed after the initial adoption and implementation of the Policy, and sales did not recover over time. Lesser profits from drinks were seen where the adopted policy only permitted plain water and milk, even more so when water was freely available from water fountains in the hospitals.
“It definitely hurts the pocket financially. We have to work a lot harder than the average café to make our money. We can’t rely on the easy sale of a bottle of orange juice etc. We know from our non-DHB café sites that the drink sales, non-water are easy wins.” (FP#7)
The decrease in profits in one food or drink category was predicted to have a ripple effect on sales of items in other categories, potentially decreasing the likelihood of retaining customers, impacting commercial viability, and threatening survival in a highly competitive market.
“It is not just the juice that you [are] losing. Because that customer, potentially, would have (…) bought something else with that juice as a meal. So now, (…) you’ve taken not just the juice, you’ve taken the meal away as well.” (FP#2)
Additional complexities were reflected in a mismatch between items permitted under the Policy and the current NZ food supply. Changing and adjusting recipes and mixed meals cooked on-site was perceived as feasible, although healthier ingredients were often not available in sufficient quantities and were more expensive, increasing the price of compliant menu items, sometimes already priced higher to make up for lost profits elsewhere. Preliminary audit results of food and drink availability in NZ hospitals confirm the higher price point for compliant Green items, which cost significantly more on average per item (NZ$6.00) than either Amber (NZ$4.70) or Red (NZ$4.00) foods/drinks (Ni Mhurchu et al., submitted for publication).
“Commercial quantities of wholemeal pasta is a nightmare (…) there’s a limit to what I can do with 3 pasta shapes to keep the menu viable. So we do use non-wholemeal pasta as well. I suspect there just isn’t the market for a wide range of wholemeal pasta in commercial quantities and a dozen hospitals nationally asking for it isn’t likely to generate it either.” (FP#3)
Food providers agreed that a tool to help assess recipe compliance was unlikely to be helpful or practical because it would be time-consuming to type in all ingredients and because recipes changed frequently. “I don’t know if anyone’s going to have the time or the inclination to type in a recipe and see whether that recipe is compliant, or what parts are or aren’t.” (FP#6) However, a tool to indicate if individual ingredients were policy-compliant or providing ready-to-use recipes could be useful.
It was perceived that some suppliers and manufacturers were unaware that the Policy existed, although many interviewees had a positive relationship with food suppliers and conveyed the requirements of the Policy to them. Small manufacturers with compliant products often struggled to keep up with the demand. Finding healthier and affordable packaged foods and snacks was problematic, even though some compliant products were available in the market (e.g., those produced to comply with school policy criteria). There was a need for a good understanding of the Policy criteria and time was required to search online or attend food shows to identify compliant products.
Implementers suggested creating a centralised database of packaged products with their traffic light classification to reduce the workload of individual food providers when searching for products, and to create an information-sharing platform for suppliers interested in offering their healthier items to hospital food providers.
“Food providers and Policy monitors would benefit from having access to a living (continually updated) national database of commercial food/drink products with their Policy classification (Green/Amber/Red). This database would support consistent Policy implementation and monitoring across DHBs. It could also be used to promote a wider range of Green/Amber products to food providers (an incentive for food manufacturers to supply data, and for wholesalers to include Green/Amber products in food procurement systems).” (NM#4)
Network members previously created a limited list of available packaged products, although this database became quickly outdated due to the continuously changing food supply.
Theme 2: Adoption, implementation and monitoring of the Policy as a series of incoherent ad-hoc actions
This theme focused on various components of a healthy food policy cycle that were often incoherent and not well-coordinated, leading to inefficient and inconsistent actions. There were differences in experiences between the DHBs. Although participants expressed some uncertainties surrounding the new health reform and healthcare structure, several hoped it would bring more coordinated and nationally-led implementation.
Subtheme: The policy has not been sufficiently prioritised
In some DHBs, management was perceived as reluctant to sign off and officially approve the Policy or its adapted version. This hesitancy prevented implementation actions, as there was no official policy document in place. “I don’t understand what the difficulty, what the delay in approving this is? (..) I think that’s a big support – just being able to, you got a piece of paper, and saying this is what we’re doing.” (NM#1) Having management endorsement simplified matters when addressing customer enquiries about changes in food and drink availability. “It’s nice for me to have that endorsement, because then it’s not just coming from me and it’s not my decision, and that was a lot of it.” (FP#6) However, frequently no clear roles or responsibilities were assigned to individuals to oversee implementation or carry out monitoring, regardless of policy adopted by the DHB.
The Network was perceived by members as an important peer support group and its monthly meetings provided a platform to share individual successes, challenges, and feedback from food providers, and to learn from the experiences of other DHBs. Some DHBs allocated a proportion of the work hours of Network members or other public health staff to support the Policy implementation. In most cases, DHB employees who were ‘passionate’ about public health voluntarily took on the additional Policy-related work. Often, the amount of work was overwhelming for one person or a small unit to manage on top of other duties.
“We don’t have a nutrition programme within our public health unit. And it has been no mandate or no real clear expectations from our DHB that [we] would be responsible for the Healthy Food and Drink Policy. (…) it would require some, you know, FTE [full-time equivalent] being dedicated to it.” (NM#2)
One suggestion was to specify in employee workplans and contracts the responsibilities and number of hours that should be dedicated to implementation and monitoring the Policy regionally and nationally, and provide an online monitoring tool and associated training that would allow systematic, regular and feasible auditing of hospital food availability. Building public health nutrition capacity in each region was considered a priority so that policy-related work continued despite staff turnover and other work often prioritised in the DHBs, such as inpatient meal service, environmental sustainability initiatives, and time-critical issues (e.g., Covid–19 pandemic).
“I’m one of the very few people on the Network, who has any capacity to work in this space. And I think it’s, you know, it’s one of the biggest downfalls of the National Policy, is that nobody’s actually got the capacity to work with it.” (NM#3)
Clear and consistent regional capacity and streamlined implementation appeared more likely if a single policy was mandated and endorsed at the national level. Food providers would also welcome a nationally-led and consistent policy to create a more level playing field and demonstrate that the Policy is a priority for the government and DHB management. A consistent policy could also incentivise manufacturers to increase the number of policy-compliant products they offer because of increased demand in the market.
Subtheme: Engagement and collaboration between decision makers, implementers, and customers lacks transparency
Several interviewees alluded to a general lack of engagement and collaboration between implementers and decision makers during the adoption and implementation stages, which was sometimes linked to the Policy being voluntary and not officially endorsed by the Ministry of Health. Some perceived the adoption as a directive by the DHB management. “The way it was communicated to our catering supervisor was pretty much: (…) this is the policy, and you have to follow it. Yeah, so quite a directive approach.” (NM#2) At the same time, food providers’ concerns regarding profitability and implementation were dismissed. “We wanted to ask questions about (…) how it was gonna be implemented, and the response was (…) “There is no discussion about this, you will take it or you will leave it, this is it”.” (FP#2).
General lack of funding for implementation, and no financial incentives for complying with the Policy, meant Network members “had to work really hard on the relationship aspect of implementing the Policy.” (NM#3) Good working relationships were built with food providers in some DHBs but often undermined when Network members or workplace management demanded compliance and focused on minor non-compliance issues (which was perceived as a waste of time) rather than focusing on elements that had potential to impact on customers’ healthy eating habits more broadly.
Some DHBs had implementation plans in place, but often these were out of date, with some original implementation goals set years earlier still not achieved. A stepwise approach would likely support smooth implementation, as shown by one DHB that received help from a local public health unit in identifying healthier and compliant options.
“So we went through the policy and had a look at it and thought, what can we do straight away, what’s going to take time, how are we going to communicate to our staff and our public? Because I knew it was going to meet some resistance, which it did. So we tried to work out the easy things first – and then put plans in place, where we could say ‘okay you’ve got three months to wean them off the 200 gram pies and put them onto, you know, smaller ones’.” (FP#6)
There was also little consultation with hospital staff during the development and adoption of the Policy and, subsequently, insufficient, sporadic and reluctant communication about the changes during implementation from the DHB management. One participant noted, “the DHB handle that side as it is their policy and their staff café – I don’t see that very much is done at all” (FP#4). Some participants thought that “it needs to be a national rollout and it needs to be talked, spoken about nationally. So if there is a national policy make it a national drive. So that people are aware of it.” (FP#2) This led to discontent among the food providers, who felt the burden of communication, which they saw as the DHB’s responsibility, was pushed onto them and often involved dealing with customer complaints, verbal abuse and blame directed at food providers and their staff.
“I can’t and I don’t expect all my staff to explain all this [the unavailability of some food and drinks] to customers. (…) the message should pass on to the visitors by putting a sign on the entrance promoting [the Policy] (…) so the customer will have that expectation that they won’t get a coke in the hospital.” (FP#1)
“I believe it has affected staff attitudes as we are the ones who receive the disgruntled feedback and complaints about no longer being able to purchase certain items.” (FP#8)
Some DHBs had basic customer communication plans, often not (fully) enacted. One interviewee described a very successful, active and engaging communication effort driven by a local public health unit when the DHB changed to offering only healthy beverages. Although customer survey results indicated a high proportion of staff (n = 1986, 79%) and just over half of visitors (n = 142, 56%) were aware of the Policy, free text responses highlighted the need for improved communication with customers about the specific changes to hospital food environments to ensure their buy-in and engagement, and to promote healthier options [39]. In line with customer survey findings, interview participants also recommended improving communication with staff and visitors by using simple messages in the form of videos, posters, and flyers to communicate changes in food and drink availability, and explain the purpose and reasoning behind focusing on food environments rather than individual responsibility for healthier eating.
Theme 3: Policy is (currently) not achieving the desired impact
In general, the implementers believed that DHBs should provide healthy options for staff and visitors and be role models for healthy eating for the wider community, and accepted the Policy, at least in principle, as a path to achieving this goal. “I totally understand and applaud this policy. In its essence it is a wonderful concept and as a hospital we should be encouraging healthy eating habits.” (FP#7). Customer survey results indicated that both staff (n = 1635, 66%) and visitors (n = 190, 76%) supported having a healthy food and drink policy in NZ hospitals. Among staff, the main reason for support was role modelling, as indicated by 82% (n = 1338) of respondents [39]. However, there was some doubt in our study whether the current Policy criteria accurately reflected the principles of healthy eating. This scepticism often stemmed from personal beliefs, variable knowledge and understanding of nutrition, and the many factors influencing individual food choices apart from healthiness.
There was a belief that if the Policy was implemented fully, it could have a positive and tangible impact on staff and visitors. “I personally think it’s something really worthwhile, but it’s, hasn’t really flown and it has not been seen a priority within our organisation.” (NM#2) Some interviewees acknowledged that they “worked with quite a few different food and drink policies over the years, and none of them are perfect by any means.” (NM#3) Overall, participants noted that the challenges outlined in themes 1 and 2 would need to be addressed for the Policy to have its desired positive impact, but also highlighted the importance of the factors mentioned in the following subtheme that play a role in healthy eating choices.
Subtheme: Unhealthy options remain highly accessible and attractive to hospital staff and visitors
Participants had conflicting views about consumer demand for healthier options. Some thought there was a demand for healthier options, which may have increased in recent years. “I think so, yeah. People do like healthy food, I like healthy food myself.” (FP#4) and “I think people are always looking to eat healthily.” (FP#5), but customers seeking healthier options were perceived as only a relatively small proportion of the current market.
“From my experience, I think that there is a small portion [of people] that are really looking for some healthier alternatives. Most of the time, I get asked for less healthy food. Some people [are] asking, do you have this, do you have that, but most of the time, it’s less healthy food.” (FP#1)
In some cases, customers who indicated they would like healthier options were considered unreliable when it came to purchasing food that aligned with their stated demand. Food providers were reluctant to continue to supply healthier options in the future if they did not sell well, especially when considering wastage and loss of profits from unsold healthier options.
“When we put out the different healthy options we can get great feedback, but this is not reflected in the purchase. Too many say ‘oh this is nice’ or ‘what a great idea’ but do not buy. We were putting out a great range of salad boxes freshly prepared each day. We have had to stop because they didn’t sell; but were nice to look at! (…) We have a small core group of people who want the healthier options, but this is not always regular buying.” (FP#7)
Some food providers also felt uncomfortable ‘pushing’ healthier options onto their customers and thought they should be free to sell a broader range of items than the Policy allowed and customers should be free to choose what they want to eat.
“But when you’re talking, oh it can’t be over 120 grams this or it can’t be that, and I’m thinking, you know, who are you kidding? I mean, you’re telling grown people either what they can eat and what they can’t, you know. They’re not allowed a choice, and I think that’s wrong.” (FP#4)
Generally, individual choice was a key argument against the Policy, often also voiced by customers. Customer survey results also showed that among staff who opposed the Policy (n = 465, 18%), the most common reason was the desire for the freedom to eat what they wanted (n = 313, 67%). However, only 15% (n = 71) agreed with the statement that the Policy will be ineffective in positively influencing food and drink choices in NZ hospitals [39]. Some food providers thought that instead of ‘policing’ what the customers could eat, “there should be more education provided and better informed decisions made by customers rather than just removing their choices.” (FP#8) Some food providers succeeded by making subtle changes to their menus and products but hesitated to promote these changes in case customers perceived healthier foods as less tasty. “I don’t think people actually realise the changes that we have made, because we’ve made them kind of under the radar a little bit. And they haven’t had to miss out on anything.” (FP#6) Another DHB successfully achieved a higher proportion of healthy items because they “adopted a ‘quality improvement’ model (increase % of Green items, rather than strict Policy compliance), which food providers appreciated. However, a stricter approach was used to observe compliance with the subsequent soft drink ban.” (NM#4) More collaboration and communication with food providers (and customers) could increase their understanding and buy-in of the Policy as a worthwhile food environment intervention.
“It’s a challenge at times to simply explain to people why we want to influence the environment (…) It’s just sort of understanding that, you know, a lot of people seem to think it’s about individual choice, and so it’s moving people beyond that individual choice paradigm, I guess, and some want to hear that, and some don’t want to bother about that.” (NM#3)
There was also a view that customers would not make healthier choices outside the DHB premises. Efforts of food providers to offer healthier options may have a limited impact on the health of staff and visitors because unhealthy options were readily available close to hospitals or through online food delivery platforms. “I don’t think that’s going to make one iota’s difference in the bigger picture of things.” (FP#2) Some commented that a significant change in the entire food supply would be required to see a positive difference in the customers’ health outcomes.
“I’m too small. Doesn’t matter how hard I push. Doesn’t matter, what I do, I will not change one person’s eating habit. (…) If New Zealand really want to make the whole country compliant, (…) go to supermarkets, take out all the sugar in drinks. There will be much more useful than my little store.” (FP#1)
Customers (sometimes even the health-conscious customers) who wanted confectionery, SSBs and deep-fried foods were perceived as willing to go and seek them elsewhere. Customer survey results indicated that although more than half of staff (52%) purchased food or drinks regularly (at least once a week) from food outlets within the healthcare facilities, a significant proportion of staff (42%) also bought items from food outlets outside the hospital at least once a week [39].
Some interview participants noticed an increase in purchases of unhealthy items that were subsequently brought onto the DHB premises, which could contribute to mixed messages to customers about the options available in hospitals. However, the changes in food and drink within the hospital might positively influence customers’ choices ‘by default’ because unhealthy options were no longer available.
“So it’s about sending those messages. And it’s nice now when you’re down there, and a little kiddie wants a drink, and their options are milk and water. So you at least know, they’re going to have that healthy options.” (FP#6)
The key to customer buy-in and increasing their demand for healthier options offered by DHB food providers was believed to be ensuring that tasty, familiar, and well-presented food was available.
