Preliminary findings of the Drink Less Sugar Project

Transcription

1 Wendy Yan and Polline Leung IN PARTNERSHIP WITH THE EAST GIPPSLAND PRIMARY CARE PARTNERSHIP, BAIRNSDALE REGIONAL HEALTH SERVICE, OMEO DISTRICTHEALTH, EAST GIPPSLAND WATER, GIPPSSPORT, ORBOST REGIONAL HEALTH, EAST GIPPSLAND SHIRE COUNCIL

2 Contents Acronyms and Definitions... 2 Executive summary... 3 Preliminary findings of the drink less sugar project... 7 Background... 7 What is the Drink less sugar project?... 8 Methods Results Participant characteristics Types of SSBs consumed in the workplace Sources of sugary drinks in the workplace Factors that influence drink choices Nutrition knowledge Attitudes towards sugary drinks Qualitative results Process evaluation Discussion Meeting the objectives Implications of this work Discussion of results Strengths and limitations of the project Opportunities for future work/ change Conclusion Acknowledgements Appendix Page 1 of 37

3 Acronyms and Definitions BRHS Bairnsdale Regional Health Service EGPCP East Gippsland Primary Care Partnership PCP- Primary Care Partnership Participating organisations refers to organisations/workplaces that have signed onto implementing the Drink Less Sugar Project VACCHO - Victorian Aboriginal Community Controlled Health Organisation Working Group members from the East Gippsland Primary Care Partnership and partner organisations that have developed the Drink Less Sugar Project SSB sugar sweetened beverage or sugary drinks Page 2 of 37

4 EXECUTIVE SUMMARY Background Rural communities in Australia are known to be at greater risk of obesity and poorer health outcomes. Higher rates of overweight and obesity have been documented in East Gippsland, with 54.7% of the population being overweight or obese compared to 48.9% in the metropolitan population. The consumption of sugar sweetened beverages (SSB) are associated with weight gain and obesity as well as a range of negative health outcomes. In East Gippsland, 19.9% of the population consume SSB daily, with an average consumption of 0.5 litres per person per day. While this is known, there is limited information on current dietary behaviours of the population, settings in which SSB consumption takes place and an incomplete understanding of behavioural processes and factors influencing beverage consumption. Aim Evaluating the Drink Less Sugar Project will allow project objectives to be measured and enrich the intelligence database, namely the rates of SSB consumption and a preliminary understanding of behaviours associated with SSB consumption in workplaces of East Gippsland. The purpose of the report is to present the results from the pre-implementation survey and Healthy Workplace Review. Objectives of the Drink Less Sugar Project To increase the knowledge of participants (workplace staff) about the amount of sugar being consumed from sugar sweetened beverages by June To increase the awareness of participants on the health issues associated with sugary drink consumption by June To increase the motivation and confidence of participants to make improvements/changes to their sugary drink consumption by June To have 50% of participating workplaces register for the achievement program by June 2016 Methods The evaluation of the Drink Less Sugar Project has been planned to occur in three stages. 1. Prior to project implementation by a pre-implementation survey 2. Mid-project evaluation through the Healthy Workplace Review 3. Post-project evaluation by a post-implementation survey ( planning stages) The pre-implementation survey was conducted via SurveyMonkey one week prior to the commencement of the program. The survey was designed to collect data on workplace demographics and to assess nutrition knowledge, motivation and confidence to change before project implementation to measure extent of objectives achieved by the program. The survey link was ed to nominated program coordinators of each 8 participating organisations which was then released to approximately 1700 employees. Page 3 of 37

5 A Healthy Workplace Review was distributed to all participating workplaces to complete independently in May A process evaluation question was incorporated into the workplace review which focussed on the location and visibility of the provided resources. The Healthy Workplace Review and process evaluation was conducted on-site by the researchers for Gippsland Ports (Bairnsdale office), East Gippsland Water (Bairnsdale office) and Omeo Regional Health. Results 311 survey responses were collected, corresponding to a response rate of 18%. In analysis, participants were categorised into groups of consumers (42%) and non-consumers (58%) of SSBs. 2 participants were excluded from analysis as they did not report consumption data. Factors influencing beverage selection Taste was reported most frequently as the top factor when choosing a beverage by 53% of consumers and 41% of non-consumers. Sugar content was reported to be the top factor by more non-consumers (31%) than consumers (14%). Sugary drink consumption The top three SSBs consumed at the workplace were identified as: 1. tea and coffee with added sugar (79%) 2. regular soft drink (16%) and 3. flavoured milk or iced coffee (14%). Predictably, workplaces were the main supplier of SSBs consumed in the workplace (43%). Motivation and readiness to change Most consumers agreed and strongly agreed that their health would improve from a decreased intake of SSBs. Most consumers also reported that they started or made a change to reduce their SSB consumption. Level of nutrition knowledge While similar proportions of consumers and non-consumers correctly identified the sugar content in regular soft drink, only 2% of consumers were able to identify sugar content in sports drinks compared to 21% of non-consumers. Suggestions to decrease sugary drink consumption Strong support for environmental modification was found from survey respondents. 51% of respondents proposed strategies such as increasing alternatives, limiting availability of SSBs and point-of-sale signage to support employees in reducing their SSB consumption. Extent of objectives met by the project Unable to be determined at this stage. Data collected in the pre-evaluation survey allow for baseline measures of knowledge, awareness and motivation to be established. More indicators will be available during post-evaluation. Page 4 of 37

6 Implications of this project The pre-implementation survey and Healthy Workplace Review have successfully collected data on demographics, self-perceived health status, factors influencing beverage preferences, participant s motivation and readiness to change, nutrition knowledge, types of SSBs consumed at work and their sources, information on workplace health and wellbeing and suggestions on decreasing SSB consumption in the workplace. This data forms the baseline measure and will be used for comparison in post-implementation evaluation. Strengths and weaknesses Evaluation was developed concurrently with project development and implementation. Survey and review development was informed by similar work of reputable organisations such as VicHealth and the Cancer Council. Both evaluation tools were reviewed extensively before release. However, limited capacity for other forms of evaluation methods, bias from convenience sampling in the pre-implementation survey, main survey developer s inexperience in survey design and short timeframes for survey development and Healthy Workplace Review are the primary limitations of the evaluation. Opportunities for future work One of the concerns highlighted by the results was that responses from the target population (i.e. regular consumers of sugary drinks) may not be captured by the survey. Future projects can target entire populations in the workplace again, but utilise purposeful sampling methods to selectively study behaviours of an audience that are harder to engage in addition to the collection of voluntary responses from the general population. Education material should target SSBs other than soft drinks as less consumers could correctly identify the amount of sugar in sports drinks opposed to regular soft drink. The target population may already be ready for change so projects should shift from raising awareness to providing support. Environmental modifications such as increasing the supply of healthier alternatives, is one strategy that can be utilised. Conclusion The pre-evaluation survey and workplace review have adequately established a baseline measure for a comparison to take place in post-evaluation. The Drink Less Sugar Project is most effective for populations that are in the pre-contemplation and contemplation stages of change. Majority of survey respondents have reported that they are ready to or have already made a reduction in their SSB consumption. These findings indicate that future interventions may progress beyond raising awareness. Future work may involve supporting employees intent to change and to encourage healthier alternatives through environmental modification. The survey data has provided a glimpse of current behavioural practices in the some workplaces in East Gippsland and is unlikely to be representative of the whole workforce. More refined sampling techniques should be considered to target specific populations in future work. Acknowledgements We would like to express our appreciation to the East Gippsland Primary Care Partnership and the Drink Less Sugar Working Group who invited us to work on this project and have provided assistance, guidance and support. We are particularly grateful to our supervisor, Tiana Page 5 of 37

7 Felmingham, who has provided valuable feedback at every stage, from survey development all the way through to the final report. We would also like to acknowledge Claire Palermo our university supervisor who has supported us on our rural placement. Page 6 of 37

8 PRELIMINARY FINDINGS OF THE DRINK LESS SUGAR PROJECT The Drink Less Sugar Project aims to decrease the percentage of people in East Gippsland who consume sugar sweetened beverages or sugary drinks (SSB) on a daily basis. The purpose of this report is to present the preliminary findings of the Drink Less Sugar Project. Baseline data was collected using a pre-evaluation survey and workplace review. This baseline data will be used for comparison in post-implementation evaluation. Additional findings captured by the evaluation tools are also presented in this report. Overall the report will increase knowledge and understanding of behaviours around SSB consumption and contribute to the knowledge database of rural workplaces. The evaluation for the Drink Less Sugar Project takes place in 3 stages: 1. Pre-evaluation survey was open to participants between 13 th April and 25 th April 2. Process evaluation conducted in three sites via a workplace review between 4 th May and 11 th May 3. A plan to evaluate through post-evaluation surveys to measure program outcomes and process evaluation respectively after June This report presents results of the first two stages of the evaluation to enrich the information database and establish baseline data for the final evaluation stage. BACKGROUND Rising levels of obesity is a global epidemic.(1) Obesity is a risk factor for many health conditions such as cardiovascular disease, type 2 diabetes and depression.(1) Obesity affects individuals and also places great financial burden on the health system.(2) Since 2008, obesity has been a national health priority in Australia.(3) Countless health promotion interventions worldwide, have taken place to combat this epidemic without much success.(4) It is widely recognised that obesity is a complex issue, influenced by a myriad of social, environmental and individual factors and there is no one solution.(5) In particular, rural communities in Australia are known to be at greater risk of obesity and poorer health outcomes.(6) Higher overweight and obese rates have been documented in the East Gippsland region, with 36.8% of the population overweight and 17.9% of the population obese compared to 32.4% and 16.5% in the metropolitan population respectively.(7) Successful, well targeted and cost-effective programs cannot be developed without a comprehensive understanding of socio-determinants of health. i.e. the many social, environmental and personal factors affecting an individual s health.(15) Barriers unique to the rural community and their social-environment include lower levels of education, lower levels of income, poorer access to health services and higher rates of engagement in behaviours that are non-conducive to good health (higher rates of smoking, lower fruit and vegetable consumption, higher rates of physical inactivity and higher rates of soft drink consumption).(8) Page 7 of 37

9 Sugar sweetened beverages (SSB) are the main source of added sugar in the Australian diet.(9) The excessive intake of SSB has been associated with weight gain as well as a range of negative health outcomes.(10) In East Gippsland, 19.9% of the population consume sugar sweetened beverages daily,(11) with an excessive average consumption of 0.5L per day.(7) While this is known, there is a limited understanding of current dietary behaviours of the population with no further data regarding which settings SSB consumption takes place, or an understanding of behavioural processes and factors influencing beverage consumption. What is the Drink less sugar project? Figure 1: Summary of events leading up to the development of the Drink Less Sugar Project Health promotion champions expressed interest in using social marketing techniques to address obesity. Social Marketing Working Group formed Healthy eating selected as a priority health area in line with the EGPCP strategic plan Sugary drink consumption was chosen because there is statistical data on population consumption rates at national, state and regional levels. There were existing resources from reputable organisations that could be utilised. Drink Less Sugar Working Group established and project development begins. In response to the rising rates prevalence of obesity and known statistics on SSB consumption in the East Gippsland region, the Drink Less Sugar Project was developed to decrease SSB consumption. The project uses local social marketing strategies. Selected social marketing campaigns were the Rethink Sugary Drinks campaign by the Cancer Council and VACCHO, LiveLighter, and the H30 Challenge developed by VicHealth. These resources were chosen as they are recent, developed specifically for the Australian and Victorian setting and evaluated for effectiveness. The project distributes these materials to promote their message. The World Health Organisation (WHO) and Ottawa Charter for Health Promotion emphasise that creating supportive environments is critical to supporting health and wellbeing.(12) Recognising that the workplace environment has been identified by the WHO to have strong influences on individual and population health and is a priority setting for health promotion, the working group chose workplaces as their target setting for health promotion.(13) Page 8 of 37

10 The organisations represented in the working group are Bairnsdale Regional Health Service, Omeo District Health, East Gippsland Water, GippsSport, Orbost Regional Health, East Gippsland Shire Council and East Gippsland Primary Care Partnership (EGPCP). Project objectives are: to increase the knowledge of participants about the amount of sugar being consumed from sugar sweetened beverages by June to increase the awareness of participants on the health issues associated with sugary drink consumption by June to increase the motivation and confidence of participants to make improvements and/or changes to their sugary drink consumption by June to have 50% of participating workplaces register for the achievement program by June Detailed project timeline can be found in Appendix 1. The Project was implemented in eight workplaces across East Gippsland on 18 th April 2016 and is expected to finish on 10 th June A number of workplaces across East Gippsland were formally invited to participate. Participation in the project was voluntary. Participating workplaces were Gippsland Ports, East Gippsland Shire Council, Bairnsdale Regional Health Service, Crossco, VicRoads, Omeo District Health, Orbost Regional Health and East Gippsland Water. Each of the participating workplaces nominated a program coordinator, some who are part of the health and wellbeing team. The Drink Less Sugar Project was implemented by forwarding program materials to the program coordinator through s or delivered in person. This person was then responsible for the implementation of the program at their workplace and was the point of contact for the Working Group. The components of implementation were: Resource kit This was sent to the workplace program coordinator one week before the project began. This included instructions, project timelines, the posters to be distributed and other internet resources about SSBs. Posters Four printed posters were distributed to workplaces What are sugary drinks doing to your body Rethink Sugary Drinks Facts about sugary drinks Rethink Sugary Drinks Do you really need that sports drink? Rethink Sugary Drinks You wouldn t eat 16 teaspoons of sugar so why drink it VACCHO. The posters were split into two sets so that a changeover in posters occurred in week 4 of project implementation. Seven weekly ed newsletters Weekly electronic newsletters containing links to external resources such as videos and tips to help reduce SSB consumption were sent out at the beginning of each week starting in week 2. Page 9 of 37

11 Each newsletter had a theme, these were; introduction to the program, H30 program, spot the sugar, jazz up your drink, healthy living, how to progress long term change, healthy lifestyles. An EGPCP developed label reading guide was also distributed in week 4 via ed newsletter. Healthy workplace review This was distributed to all workplaces and required organisations to self-assess the workplace environment in regards to policy, programs, and food and beverage facilities and provisions. H30 Challenge through the month of May The H30 challenge was promoted via posters and the weekly newsletters in week 2 and 3. An East Gippsland link was obtained from VicHealth to release data specific to East Gippsland upon request. Evaluation the Drink Less Sugar Project Identifying what works and why is critical for progress to occur in this area. Impact evaluation enables this to occur by demonstrating the outcomes and effectiveness of programs or interventions.(14) Best practice indicates that the evaluation should be developed concurrently to program development to ensure desired outcomes can be measured.(15) The survey will be a mixture of qualitative and quantitative questions which is a mixed-method evaluation. Mixed-methods evaluation improves the quality of work.(15) Quantitative data is useful for producing statistics while qualitative data can increase the depth of understanding of each participant s experiences and effect of the intervention.(15, 16) In addition to evaluating the impact of the project, process evaluation is planned. Process evaluation asks was the intervention implemented as planned? (15) The questions for process evaluation are found in the Healthy Workplace Review. The purpose of this project was to enrich the intelligence database in regards to region and setting specific data, namely the rates of SSB consumption and a preliminary understanding of behaviours associated with SSB consumption in workplaces of East Gippsland. Evaluation will help the Working Group and participating organisations by: Increasing understanding of employees using baseline data collected in the evaluation. Informing future projects so that they can be more effective and tailored to the target audience. Page 10 of 37

12 METHODS Nutrition and Dietetics students from Monash University, hosted by the East Gippsland Primary Care Partnership for placement, acted as the researchers responsible for baseline data collection and process evaluation of the Drink Less Sugar Project. This ran for eight weeks from April to June Researchers worked with the Drink Less Sugar Working Group to establish potential methods of evaluation. Some proposed methods of evaluation were electronic surveys, focus groups and visual inspections. The group decided that the most appropriate method of evaluation was through electronic surveys where each workplace program coordinator would further distribute to employees via . The plan was to evaluate the program through a pre-program survey, a post-program survey and a healthy workplace audit, with the possibility of a mid-program survey. Pre-evaluation survey development The researchers searched the scientific literature for validated tools for impact and process evaluation, food/beverage frequency questionnaires and validated tools to assess readiness to change, motivation and confidence to change. The researchers also reviewed survey questions from the National Health Survey ,(17) Victoria Population Health Survey ,(7) Rethink Sugary Drinks evaluation survey by the Cancer Council and Victorian Aboriginal Community Controlled Health Organisation (VACCHO)(18) and H30 evaluation survey by VicHealth.(19) Researchers also contacted the Monash Rural School of Health for guidance in survey development. Researchers worked with the Working Group to ensure anonymity of data, alignment with objectives to The Drink Less Sugar program, ease of completion and decrease level of confrontation and length of survey. The survey collected data on demographics (workplace, age, gender), self-perceived health status, type of beverages that were consumed at the workplace, supply source, factors influencing drink preferences, nutrition knowledge in regards to sugar content within SSBs, attitudes towards SSBs, readiness to change, suggestions for the workplace to assist decreasing SSB consumption and general comments. The survey questions and logic plan is found in Appendix 2 of this report. The final survey was ed to the workplace program co-ordinators of each participating organisation for release to all staff in the workplace. The survey was conducted in the week preceding the program to the end of week one. Paper surveys were also requested by some organisations. Workplace review development The aim of the Healthy Workplace Review was to capture the workplace environment and identify areas of improvement to support employee health and wellbeing. This review collected information on health and wellbeing teams, resources allocated to health and wellbeing in the Page 11 of 37

13 workplace, policies, health and wellbeing programs and materials, community engagement and the provision of food and beverage facilities. In addition to the review, one question on the visibility of Drink Less Sugar resources and location addressed process evaluation. The development of the review took place between week one and three of the project. Question development was informed by the ACT Healthy Workplaces Audit(20) and the Healthy Eating Benchmarks from the Achievement Program.(21) The logic plan for each of the questions in the audit is listed in Appendix 3. The review was distributed to all participating workplaces to complete independently as they were asked to self-assess. Researchers and a member of the EGPCP completed reviews with two workplaces on site (Gippsland Ports and Gippsland Water). The rationale was that these two sites were not signed up the Achievement Program and may require some assistance to complete. Results from most of the workplaces will be received by June 2016 and thus not included in this report. Only the process evaluation question that conducted by researchers on site at three workplaces are included in this report. Methods of analysis All quantitative data collected in the survey was analysed in Microsoft Excel and presented as descriptive statistics. Two tailed chi square tests were performed in GraphPad Prism on some data sets to determine statistical significance. Two open ended questions were conducted in the survey that gathered responses on what the workplace could do to help decrease the participants SSB consumption and any additional comments. Text was analysed using a thematic analysis approach to identify common workplace strategies as well as attitudes of participants to interventions in a workplace setting. Responses were categorised by each researcher separately (WY and PL). Final categories and themes were determined together through discussion. Responses which addressed more than one category were acknowledged and categorized in all applicable categories or themes. RESULTS The survey was distributed to approximately 1700 employees of the participating organisations. A total of 311 participants of the Drink Less Sugar Program responded to the pre-program survey This equated to a response rate of 18%. Respondents were categorised as consumers or non-consumers. Consumers were defined as those who drank flavoured milk or ice coffee, ice tea, cordial, sports drinks, energy drinks, regular soft drink, tea or coffee with added sugar, other sugar sweetened drinks at least once a week. Non-consumers were defined as those who reported they did not drink any of the listed drinks. A total of 131 participants (42%) reported to consume sugar sweetened beverages at least once a week and were allocated to the consumer category. 178 participants (58%) reported that they did not drink any of the listed drinks and were labelled as non-consumers. 2 participants were excluded from further analysis as they did not report consumption data. Page 12 of 37

14 Participant characteristics Participant characteristics are described in Table 1. Demographics data for age and gender were found consistent for consumers and non-consumers. Around three quarters of the respondents were female. The most frequently reported age was with age range from 15 to above 65. Almost half the respondents worked at Bairnsdale Regional Health Service (BRHS). This can be expected as BRHS is the largest organisation with most number of participants. A similar percentage of consumers and non-consumers were found to be from each workplace with the exception of BRHS, East Gippsland Shire council and Gippsland Ports and VicRoads. More respondents were found to be non-consumers when they were from BRHS while more respondents from the East Gippsland Shire Council, Gippsland Ports and VicRoads were found to be consumers. When reporting self-perceived health status, almost all (92%) of respondents reported that their health as above good health. A difference in percentage was found between consumers and non-consumers where 95.5% of non-consumers reported their health to be above good compared with 89% of consumers, however this difference was found to be non-significant (p=0.0524). Table 1. Participant characteristics Gender % Total (n=309) % Consumers (n=131) Female Male Would rather not say Age Would rather not say Workplace Bairnsdale Regional Health Service Crossco East Gippsland Shire Council East Gippsland Water Gippsland Ports Omeo District Health Orbost Regional Health VicRoads Would rather not say % Non-consumers (n=178) Page 13 of 37

15 Sugar sweetened beverage Preliminary findings of the Drink Less Sugar Project Self-reported health status % Total (n=309) % Consumers (n=131) Excellent health Very good Good Fair Poor Incomplete answers Types of SSBs consumed in the workplace The top three SSBs consumed at the workplace were identified as: 1) tea and coffee with added sugar (79%) 2) regular soft drink (16%) and 3) flavoured milk or iced coffee (14%). 4% of participants reported drinking other SSBs such as milo, chai latte and soy milk. % Non-consumers (n=178) Figure 2: Types of sugary drinks consumed in the workplace reported by consumers. Which of the following drinks do you drink at least once a week at work? Tea or coffee with added sugar Regular soft drinks Flavoured milk or iced coffee Cordial Other Iced tea Sports drinks Energy drinks 0% 20% 40% 60% 80% 100% Response ratio *Response ratio was used as participants could select more than 1 answer Sources of sugary drinks in the workplace The top four suppliers of SSBs were identified as: 1) workplaces (55%) 2) takeaway/restaurant/café (24%) 3) supermarket (19%) 4) and canteen (14%). Only 3% of participants reported to consume SSBs brought in from home and family members while working. Page 14 of 37

16 % of all respondents Where sugary drinks are obtained Preliminary findings of the Drink Less Sugar Project Figure 3: Where consumers obtained the sugary drinks they consume in the workplace. When you drink sugary drinks at work, where do you get them? Supplied by the workplace Takeaway/restaurant/cafe Supermarket Canteen Service station or convenience store Vending machine at work Other Incomplete answer 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Response ratio Factors that influence drink choices Four factors that influence the individual s choice of beverage were listed. These were taste, cost, ease of access and sugar content. Participants were asked to rank the factors in order of 1 being the most important, to 4 being the least important. As shown in figure 4, taste was reported as the most important factor for consideration when deciding on drink choices for both consumers and non-consumers. While 14% of consumers reported sugar content as a leading factor when selecting a drink, more non-consumers (31%) reported this as their leading consideration and was found to be of statistical significance (p=0.0006). Figure 4: A comparison the frequency of each factor reported to be the most important by consumers and non-consumers 60% 40% The most important factor when choosing a beverage 20% 0% Taste Sugar content Cost Easily available Factor Consumers Non-consumers Nutrition knowledge When assessing nutrition knowledge, consumers and non-consumers were found to have a similar level of knowledge in knowing the amount of sugar in regular soft drink om selecting the correct response of 7 teaspoons as shown in Figure 5 (21% non-consumers vs 18% consumers). However, significantly more non-consumers knew the sugar content in sports drinks (21% nonconsumers vs 2% consumers) (p=<000.1). Interestingly, 75% of consumers selected I don t Page 15 of 37

17 % respondents % respondents Preliminary findings of the Drink Less Sugar Project know as a response to this question. This could indicate that consumers had better nutrition knowledge of the sugar content in different types of SSBs. Figure 5: Comparison of the number of consumers and non-consumers that correctly identified the sugar content in regular soft drink with 7 teaspoons as the correct answer. 40% 30% 20% 10% How many teaspoons of sugar do you think there are in 1 can of regular soft drink? 0% 4 teaspoons 7 teaspoons 10 teaspoons 13 teaspoons I don't know Incomplete response Selected responses Consumers Non-consumers Figure 6: Comparison of the number of consumers and non-consumers that correctly identified the sugar content in sports drinks with 9 teaspoons as the correct answer. 80% 70% 60% 50% 40% 30% 20% 10% 0% How many teaspoons of sugar do you think there are in 1 bottle (600mL) of sports drink (Gatorade, Powerade etc)? 5 teaspoons 9 teaspoons 12 teaspoons 15 teaspoons I don't know Incomplete response Selected responses Consumers Non-consumers Attitudes towards sugary drinks If I drink less sugary drinks, my health will improve This question links self-perceived health status to current behaviour and personal health beliefs. The responses from the participants are heavily skewed to the right as seen in Figure 6. 69% of consumers agree and strongly agree to the belief that cessation of consumption of SSBs will improve their health. Page 16 of 37

18 Percetnage of respondents (%) Preliminary findings of the Drink Less Sugar Project I want to drink less sugary drinks A participant s readiness to change is measured in this question. Similar to the previous statement, most respondents agreed with the statement as seen in Figure 7. 34% and 23% of consumers agree or strongly agree to the statement respectively; indicating that more than half of the consumers may have considered changing current behaviours. Figure 7: Proportion of consumer responses in regards to statements relating to their attitudes on sugary drinks. Consumer's attitudes towards sugary drinks 45% 40% 35% 30% 25% 20% 15% 10% 5% 0% Strongly disagree Disagree Neither agree nor disagree Agree Strongly agree If I drink less sugary drinks, my health will improve I want to drink less sugary drinks Response In assessing a participant s readiness to change in question 11, a steady increase was observed in the number of consumers that reported a readiness to change from stages 1 to 4 with most consumers reporting themselves to have made a change to decrease the amount of SSBs they drink and have been following the change for at least six months. As non-consumers do not drink SSBs, an analysis was unnecessary for the questions assessing readiness to change. Overall, most consumers believe that a lower intake of sugar sweetened beverage can improve health. Over a half of consumers have considered reducing current SSB intake with more than one third of consumers that have taken action to make this change. Table 2. Readiness to change assessed by the stages of change cycle Question 11 Statements Consumers Stage 1 precontemplation Stage 2 Contemplation Stage 3 Action Stage 4 Maintenance I have not thought about decreasing the amount of sugary drinks that I drink. 15% I have thought about decreasing the amount of sugary drinks that I drink, but I have not yet taken any action to make this change. 18% I have thought about decreasing the amount of sugary drinks that I drink and am currently beginning to take action to make this change for less than 6 months. 21% I have made a change to decrease the amount of sugary drinks that I drink and I have been following this change for at least six months 34% Blank response 11% Page 17 of 37

19 Qualitative analysis Open ended responses were received from 145 participants. 33 were excluded from further analysis as they stated that they do not drink SSBs or that they question was not applicable to them and 2 were excluded as they reported consumption data which was irrelevant to the research question. Analysis of the data (n=110, consumer=65, non-consumer=45) identified four themes and a number of subthemes about reducing SSB consumption in the workplace. The length of each response was between 1-3 sentences. Most participants only addressed one theme or subtheme. Theme 1: It s not a problem One third of respondents, from both consumer and non-consumer groups, reported SSB consumption in the workplace not to be a concern. Consumers reported this more frequently than non-consumers. Subtheme 1a: No desire to reduce consumption Around a fifth of participants expressed that their SSB consumption at work is too low to be a concern. Participants reported their consumption data alongside their statement to qualify their opinion. Most participants reported drinking from one sugar in tea or coffee once or twice a day to only consuming SSBs infrequently. Only one response was from a non-consumer as they only consume SSBs at home. All participants in this category expressed no intention to change their current behaviour. In particular, three respondents expressed that regardless of intake, they did not want to change their behaviour. I only have one flavoured milk per week so I don't see this having a huge effect [sic] on my health Subtheme 1b: Workplace does not need to change A group indicated that they felt the workplace adequately supports healthier choices. Two reasons that the workplace does not need to change were noted.. 1. Workplaces were reported to not have SSBs available and provide adequate beverage choices. Participants felt that there are sufficient alternatives such as tea, coffee and artificial sweeteners in the workplace to allow individuals to make healthy choices. Not really, artificial sweeteners already available and filtered tap water available they only supply coffee/tea/milo 2. It is not the workplace s role to manage individual behaviour. Participants expressed that the decision to drink SSBs lies with the individual so the workplace does not need to change to support healthier decisions. No it is up to the person to take responsibility No they only supply us with tea, coffee and water its [sic] our choice to add sugar Subtheme 1c: Other solutions A small portion of respondents suggested the problem lies elsewhere and that reducing the supply of SSBs in the workplace is not the solution. This included adequate staffing levels to Page 18 of 37

20 reduce fatigue (therefore the need to drink them) and a more active workplace (stand-up desks, etc.) might help offset the impact of sugary drinks. Theme 2: Increase alternatives to sugary drinks A third of participants expressed that increasing the availability of healthier alternatives could decrease SSB consumption. Beverages that participants would like to see in their workplace were juices, diet soft drink, herbal tea, different types of milk and flavoured mineral water. Three participants felt that their food and beverage choices were limited at work and would like to see an increase in operating hours for the onsite food outlet. Subtheme 2a: Sugar alternatives Participants also felt that having sugar alternatives such as stevia would enable them to drink less sugar at work. Subtheme 2b: Availability/accessibility/appeal of water Participants want increased accessibility to water, bottled water and filtered water. Participants mentioned that they would like water fountains at convenient locations, free bottled water and filtered water. Bring back filtered water in staff kitchen There should be water fountains in each ward and office area to encourage people to drink more water. If its easily accessible people would use it more. Aside from increasing the availability or accessibility, for some, it was increasing the appeal of water that was important. People indicated that while water was available, three participants expressed a preference for filtered water and two participants for chilled water. Four participants suggested making water more appealing by providing citrus fruits to add to water or free water bottles for every staff member. provide items that make water more appealing ie [sic] provide water bottles, or install filtered water taps in the staff room Theme 3: Decreasing the availability of sugary drinks Responses here were clearly divided into two kinds of reduction; reducing the supply and removing it completely. Subtheme 3a: Reducing sugary drinks Only non-consumers suggested that reducing the supply of SSBs and sugar at work would be beneficial. They felt that while SSBs or sugar should still be available, the amount and visibility should be reduced. Not have cans of soft drink so cheap and readily available. I don t drink or buy them at work but it has crossed my mind to do so now and again because they are so cheap and there are heaps of them sitting in the kitchen Page 19 of 37

21 Subtheme 3b: Banning sugary drinks Significantly more non-consumers suggested removing SSBs from the workplace was an appropriate strategy. In particular, two respondents felt strongly that SSBs should not be available in hospitals. I find it ironic that a Hospital would allow the sale of such drinks when we are facing an obesity epidemic. DO NOT HAVE THEM AVAILABLE Theme 4: Education Both groups mentioned that education would be beneficial. Three strategies were specifically mentioned: 1. Education on health effects, types of sugar, sugar content in food 2. Promoting healthy alternatives and reminders on the sugar jar 3. Placing educational materials on the fridge door and at the point of sale. Process evaluation Program fidelity was assessed through the Healthy Workplace Review. At the three workplaces assessed (Gippsland Ports, East Gippsland Water and Orbost Regional Health), researchers were able to visually confirm that posters were posted in accessible areas. Posters were found: Gippsland Ports in the office hallway East Gippsland Water tea room notice board, tea room table, fridge door Orbost Regional Health Patient waiting room, reception, dietitian s office and community notice board Multiple posters were displayed at East Gippsland Water Bairnsdale office and Orbost Regional Health. Two posters were found pinned to the office partitions in the hallway at Gippsland Ports. The resource kit was also found pinned to the tearoom notice board at Gippsland Water Bairnsdale office. Researchers had planned to visit the VicRoad s Bairnsdale office however were unable to visit due to time constraints. Page 20 of 37

22 DISCUSSION Meeting the objectives Project objectives remain unresolved as it is unclear at this preliminary stage of the evaluation to determine if the project has met its objectives. Data collected in the pre-evaluation survey allow for baseline measures of knowledge, awareness and motivation to be established. The number of workplaces registered for the achievement program will be determined in post evaluation. Implications of this work The pre-evaluation survey and workplace review have collected information that adds to the intelligence database for SSB practices and behaviour. In addition, this data provides baseline measures to allow for a comparison for increase in awareness, knowledge and motivation to change to be demonstrated with a follow-up survey at the end of the program. Confidence levels were not measured in the pre-evaluation survey. The survey has provided participants an opportunity to provide suggestions on how their workplace could enable employees to make a reduction of SSBs. The suggestions and analysis will be communicated to workplaces at the end of the program and can be used when planning future workplace programs. Discussion of results Survey participants representativeness, delivery and sampling method It is known that self-selected survey methods produce biased results. This is because researchers have little control over who completes the survey.(22) The direct limitation is that survey respondents cannot be assumed to represent the population.(15) As the demographics of all participants of the project could not be obtained from workplaces, there is no method to determine if the survey respondents are representative of the participating organisations. The data collected in this project about SSB consumption in the workplace may not be reflective of the most common practices in participating workplaces. Furthermore, practices observed in participating workplaces may not be representative of the entire workforce in East Gippsland. From the existing data collected from national health surveys, it is known that men aged are the most frequent consumers of SSBs.(7) This population is not well represented in the sample (3%). It is also likely that the intended target audience of the project were not captured by the survey. The demographics of survey respondents were skewed towards female (73%), of age over 46 years (57%)and employed in health services (58%). Previous studies have found lower SSB consumption in female participants, older participants and those with higher education.(23) Employees of health services can be assumed to be of higher health literacy compared to the average person. This presents a strong bias that influences the findings. The Drink Less Sugar Project aimed to raise awareness of the health effects associated with excessive intake of SSBs and increase motivation to change is most effective for those in the precontemplation stages of change.(24) Literature has found those in the pre-contemplation stages of change are less likely to be engaged in health programs and to voluntarily respond to program surveys.(25) Aside from engagement, there were other barriers in extending the reach of the survey. The survey was distributed electronically, usually via the staff ing system. Employees that do not have office roles may have decreased access to the survey. While paper Page 21 of 37

23 surveys were distributed, this was not consistent across all sites. Issues with engagement and reach can be overcome by a mixed-methods approach. The combination of purposeful and probability sampling methods can improve the representation of all groups within a workplace.(15) Education Results from the survey have clearly showed a significant difference in the level of nutrition knowledge possess by consumers and non-consumers. A knowledge gap in the nutritional content of SSBs is evident in consumers where 75% of consumers reported not to know the amount of sugar present in sports drinks. The difference in level of nutrition knowledge may be one of the contributing factors leading to a higher intake of SSBs in consumers. Another contributing factor could be that consumers, as indicated by the results, place less consideration on sugar content of SSBs in the process of beverage selection compared to non-consumers. Previous studies have shown health literacy and health related knowledge to be predictors of SSB consumption.(26, 27) Workers in healthcare organisations are likely to have a higher level of health literacy and health related knowledge therefore may explain for the higher ratio of nonconsumers reported in the three healthcare organisations (BRHS, Omeo District Health, Orbost Regional Health) compared to other participating organisations. Since the results strongly suggest that consumers are less informed about nutrition in a variety of SSBs and that there is an association of increased health literacy and improved health knowledge with decreased SSB consumption, educating workers about sugar content in less obvious sources of sugar such as sports drinks, flavoured milk and ice teas may be an effective strategy in reducing SSB consumption. Indeed many participants recommended education as a strategy to decrease SSB consumption in the workplace. In particular, participants suggested educating colleagues about the different types of sugar and sugar content in a variety of drinks where hidden sugars could be found. Workplace interventions The workplaces is a valuable setting for health promotion to occur and is recognised by the Drink Less Sugar Project.(13) Healthy Together Victoria and the Achievement Program prioritises a settings approach with advice to promote health at places where Victorians live, work, learn and play. Education on health messages is a key strategy of health promotion but health promotion in workplaces should move beyond individual education and aim to intervene at multiple levels of the worksite environment. (28) A multifaceted approach to health promotion is recommended by leading health organisations such as the WHO. High level scientific research have shown that multilevel intervention in the workplace can improve dietary intake.(28-30) Multi-faceted approaches in the workplace have proven to be the most effective but standalone trials have also demonstrated that environment modification strategies (31-33) have the potential to influence dietary behaviours albeit small effect sizes.(28, 29) Most respondents expressed an awareness of excessive SSB consumption having an adverse effect on their health and the desire to drink less. Two thirds of respondents reported having already reduced their SSB intake. These results suggest that most respondents are ready for change or have already reduced their intake. The respondents of the survey, if representative of Page 22 of 37

24 the workforce, directs future work to focus on strategies tailored towards action and maintenance stages of behavioural change. Workplace interventions supportive of behavioural change would be an appropriate intervention. Of those that completed the open ended responses, 51% of respondents expressed a support for environmental modification as a workplace intervention. Environmental modification have been recorded in literature to include strategies such as food labelling, promotional materials, expanding availability of healthy products and efficient food placement.(29) All of these strategies were mentioned by participants in the open ended responses of the survey. The specific breakdown of participant responses were as followed; 30% mentioned increasing alternatives, 17% mentioned reducing availability of SSBs through cost, location and number and 4% mentioned point-of-purchase signage such as putting reminders on the sugar jar and signage and reminders and the point of sale. The emphasis of these approaches is increasing options, not removing SSBs completely. Participants expressed that they wanted increased beverage choices at work as well as increased access to water. This may be attributed to the emphasis on taste as the primary factor of consideration when choosing a beverage. Taste continues to be a primary factor of consideration even when the alternative provides additional benefits to health.(34)workplaces should consider providing healthier alternatives which are favoured by workers in terms of taste as the alternative to SSBs. Decreasing SSB visibility and availability was another approach suggested by participants, but it is important not to restrict individual choice completely. Eight participants (6%) expressed concern regarding individual choice and responsibility. Choosing strategies that do not restrict individual choice is important to respect individual decisions. With strong evidence for workplace interventions, particularly environmental modification that is echoed by participants, these strategies should be highly considered for future projects. Process evaluation The strategic positioning of promotional materials is an element of social marketing and has shown to effectively promote the product.(35) During the visual inspection, researchers found it easy to locate the posters at Gippsland Water and Orbost regional health. Posters are most effective when people can see it and read it. Tearooms and waiting rooms are ideal environments for this to occur. A recommendation could be made to the placement of promotional materials to be in locations where people are most likely have time to stop and read. Strengths and limitations of the project Validated tools and questionnaires about beverage consumption and motivation to change, example questions from national health surveys and state-wide surveys from leading nutrition research organisations were sourced in creating the survey to compensate for the inexperience in survey design by researchers WY and PL. The survey was tested by multiple members of the working group who had expertise in health promotion and public health as well as a layperson. Page 23 of 37

25 Improvements to the survey were made from the feedback obtained. A similar approach was used in the development of the Healthy Workplace Review. A limitation in the data collection process was the project s capacity to use other forms of research methods beyond an electronic survey. Voluntary responses received through convenience sampling will attract a certain type of bias, as reflected in the survey demographics. (36) The electronic mode of delivery limited the reach of the program to possibly exclude field workers. Two main criticisms were made to the survey from participant s feedback: 1. Unclear wording in question 5 Question 5 of the survey asked participants to order factors that influenced their beverage preference. Unusable responses were received in the paper survey where a number of respondents misinterpreted these instructions. An was also received to clarify the instruction. 2. Inadequate recognition of respondents who did not drink SSBs Many participants stated in the open questions that they did not drink SSBs possibly because they felt the need to clarify their position. In particular, paper survey respondents felt a strong need to add their own response boxes to the attitudes question about how they did not drink SSBs. An extensive search of the literature has found no consistent definition for the term sugar sweetened beverage.(37) The Drink Less Sugar Project refers to SSBs as sugary drinks. Differing definitions of a sugary drink in literature raised much discussion of who the target audience of the project is. Participants who have 1-2 teaspoons of sugar in their tea or coffee may not perceive that they are subjected to the same health risk to those who consume soft drinks and other SSBs as shown in the qualitative analysis. OPPORTUNITIES FOR FUTURE WORK/ CHANGE 1. Participant selection Non-random sampling or convenience sampling was used for the pre-evaluation survey but as respondents cannot be said to be reflective of the entire target population, results cannot be generalised to the population and recommendations may not be applicable to all East Gippsland workplaces. One of the concerns highlighted previously was that responses from the target population (i.e. regular consumers of sugary drinks) may not be captured by the survey. Purposeful sampling specifically selects participants for their knowledge or experience in the area of interest.(16) This sampling method allows researchers to set criterion to determine participant eligibility.(16) Purposeful sampling is commonly used in the recruitment of survey respondents and combining this with random sampling strategies could increase the generalisability of results.(16) Future projects can target entire populations in the workplace again, but utilise purposeful sampling methods to selectively study behaviours of an audience that weren t captured by this project and are harder to engage in addition to the collection of voluntary responses from the general population. Page 24 of 37

26 2. Education The results have shown that there are still workplace staff who are unaware of the sugar content in SSBs. Education on the energy content of SSB, potential health risk associated with SSB consumption (such as weight gain) and improving health literacy and general nutrition knowledge are strategies that have been trialled in studies in attempt to lower SSB intake and improve diet quality. To date, most findings are inconsistent and there has not been a study to compare the strategies.(27) As the results show that most consumers have limited knowledge on the amount of sugar in SSBs, especially sports drinks, future education can shift focus from educating on soft drinks to other forms of SSBs including sports drinks, flavoured milk, iced coffee, iced tea and energy drinks. Studies that have shown the most effectiveness are interventions that combine education and environmental modification (28-30), therefore, future projects should consider a combination of education and environmental strategies where possible. 3. Increasing the supply of healthy alternatives The Drink Less Sugar Project utilises posters and promotional materials to raise awareness of SSB consumption. While further research in this area needs to occur to determine the suitability of environmental modification for the population, if most of the population is indeed in the action and maintenance stages of change, shifting the focus on environmental modification may be more appropriate. The findings of this project have found a strong support of healthier alternatives by workers. Future projects can consider environmental modifications such as increasing healthy alternatives to support employees making a reduction in their SSB consumption. Low cost strategies that are easy to implement are the supply of alternatives such as sugar alternatives, stevia, herbal tea, lemon slices in water, provision of bottled water or water bottles. Interventions in infrastructure such as installing water filters and increasing the number of water fountains may require more planning. CONCLUSION The pre-evaluation survey and workplace review have adequately established a baseline measure for a comparison to take place in post-evaluation. The survey data has allowed insight into behavioural practices in some workplaces of East Gippsland. More refined sampling techniques can be considered to study specific populations in the future. The Drink Less Sugar Project is most effective for populations that are in the pre-contemplation and contemplation stages of change. Majority of survey respondents have reported that they are ready to or have already made a reduction in their SSB consumption. These findings indicate that future interventions may need to progress beyond education. Future work could involve supporting employees intent to change and to encourage healthier alternatives through environmental modification. ACKNOWLEDGEMENTS We would like to express our appreciation to the East Gippsland Primary Care Partnership and the Drink Less Sugar Working Group who invited us to work on this project and have provided Page 25 of 37

27 assistance, guidance and support. We are particularly grateful to our supervisor, Tiana Felmingham, who has provided valuable feedback at every stage, from survey development all the way through to the final report. We would also like to acknowledge Claire Palermo our university supervisor who has supported us on our rural placement. Page 26 of 37

28 Appendix Appendix 1: Detailed project timeline Page 27 of 37