The settings approach to promotion of healthy eating has been growing in importance ever since the Ottawa charter for health promotion was adopted in 1986 (https://www.who.int/healthpromotion/conferences/previous/ottawa/en/). In settings, a large number of individuals can be reached including many unlikely to engage in preventive health behaviors. Since, for many companies, the concern for the long term health and well-being of its employees is of strategic concern health promoters and companies in a growing number of cases have joined efforts to develop and test healthy eating interventions. Common to settings approaches is that in all cases intermediaries play an important role in delivering the intervention. Traditionally our understanding of how individuals adopt a healthy eating pattern has relied on insights from behavioural health theories that traditionally put the individual in the centre. However, to make interventions work in complex social settings, we need theoretical insights from organizational sociology. This is due to the fact that the sustainability of such interventions is a central challenge in public health nutrition interventions¹.

Sustainability of a healthy eating intervention is about how the healthy eating project keeps up its momentum after the researchers have left.

This paper reports on key elements in sustaining increased F&V consumption in a canteen environment intervention that has been followed in the 5 years after the intervention was started. The full report from the study including detailed accounts of the daily employee F&V intake in the 5 Danish workplaces will be available in Thorsen et al².

Traditionally, it has been assumed that interventions can be regarded as one size fits all. However the current study shows that worksite interventions need to be tailored to the needs of the particular worksite environment in which they are implemented. Furthermore this tailoring needs to be done in close partnership with the local stakeholders. Intermediaries that seem to play a special role in food and nutrition issues are canteen staff and managers.

An intervention in Danish canteens

The current intervention project started in 2000 as a partnered dialogue research design where the Danish 6-a-day partnership along with local worksites and the research partner developed the intervention. The point of entry to the worksite was the canteen. The specific choice of intervention components was done in cooperation with the local food service team and the research partner. The canteen staff initiated a mapping of the F&V consumption in the different canteen workstations in order to increase the F&V availability throughout the whole menu range. The strategies for embedding F&V in meals were directed towards the four main menu types in Danish canteens: hot dishes, cold dishes, salads and snacks.

In order to monitor quantitatively the F&V consumption, an assessment scheme was developed. The quantitative monitoring played a role in the local setting to keep up momentum but also to raise external awareness of the ability of worksite intervention to raise F&V intake. The monitoring was performed routinely by the staff, and data was collected at baseline, 1 year after intervention and 5 years after intervention. Besides the quantitative evaluation, the intervention was followed using a qualitative methodology. The qualitative evaluation helped develop a better understanding of how healthy eating interventions seemed to become shaped through the interaction of different stakeholders and how this interaction might contribute to the sustainability of the intervention.

Results of the intervention

The status of the project in 2008 is that 4 out of 5 of the involved cases have been successful in terms of their ability to increase the consumption of F&V, but it also shows that some sites have been more successful than others. The insight gained from the qualitative evaluation suggests that fruit and vegetable interventions seem to be shaped and translated in slightly different directions depending on the local context. Healthier eating interventions will and should be shaped and controlled by the involved local actors’ ideas of health and nutrition, and also by their conceptions of how these facts interrelate with the worksite’s working conditions and working performance. This also means that not only can interventions be expected to do something for stakeholders; stakeholders at the same time do something for the intervention. This “doing” is dependant on the nature, the history, and the internal power relations of the particular workplace – coined by Hildebrandt and Seltz³ as the social constitution of the company. All in all, it is important to understand any kind of interaction – and lack of interaction – between the workplace and the healthier eating activity.

Recipe for an effective intervention?

Results also indicate that there is no single best recipe for an intervention, but that interventions should be developed to suit the local needs depending on the social constitution of the worksite. As a consequence, interventions cannot be delivered, but only be rolled out in partnerships. Results also indicate that worksite food service is an important intermediary for developing intervention components, but that increasingly human resource staff and top management participate in shaping healthy eating strategies.