This week on PLOS Blog Translational Global Health, a short post from our colleagues in Peru on the role and effects of the retail environment in behaviour change for NCDs.
Everybody knows that eating fresh vegetables and fruits is good for you. At least, let’s assume, the majority of people do. But does this translate into action? We also know that knowledge is not enough. More importantly, does everybody react in the same manner to the same information? Who is more likely to make more concrete moves towards action? All these questions are relevant, because in practice, it will determine “how it works and under what context” for many interventions.
Fruit and vegetable intake is essential in a healthy diet and this has been translated into ‘5 servings per day, 7 days a week’ campaigns worldwide. On the scoping and wider policy side, WCRF’s has developed the NOURISHING framework, a policy framework to promote healthy diets & reduce obesity. But, given our human nature, as behavioural economist Dan Ariely points out, there is certain irrationality in not doing the ‘right thing’.
Despite being an agrarian country, an Andean study in Peru showed that approximately one-third of the population had low fruit and vegetable intake (defined as less than 3 days per week). Insufficient local data at an individual level impedes to monitor the patterns of diet in this population as well as the consumption of healthy and unhealthy food. Moreover, little is known about the personal reasons that lead someone to prefer fruit over an unhealthy snack, and what changes —i.e. an intervention to promote a healthy diet— may be effective in influencing peoples’ decisions.
A research team led by members of the CRONICAS Center of Excellence in Chronic Diseases at Universidad Peruana Cayetano Heredia, based in Lima, Peru, made a quick, on-the-go, hypothesis-driven, unfunded —as usual, fun studies are the unfunded ones— experiment to test if some strategies are more effective to increase fresh fruit purchasing at a university cafeteria.
Here is the experiment.
Three different scenarios were established sequentially, each stage lasted 3 weeks. In a first stage, fruit was positioned over 3 meters away from the point of purchase and price was PEN 1.50 ($US 0.57) per fruit unit with no advertisement. In the second stage, the price remained the same but fruit was positioned next to the point of purchase with an advertisement promoting fruit consumption. The advertisement was displayed in Spanish and showed the unit price and the following message: “Consuming five fruits and vegetables per day prevents many illnesses” as stated by the World Health Organization. Finally, for the third stage, fruit price lowered to PEN 1.00 ($US 0.38) and all the other changes remained as the previous stage. Cafeteria staff participated with daily recording of indicators. A simple approach, using pen, paper and eyes: we needed to know age group (above/under 20), gender and number of fruits sold.
So what was the outcome?
The analyses of the registered information showed an increase in fruit purchasing when comparing fruit sales from the first and the last stage. This is good news, but it is not all. Take home message one: break accessibility barriers for healthier products, and consumption increases. A study, published in Public Health Nutrition journal, showed that simple marketing strategies such as enhancing visibility, adding information and lowering price do also work for increasing fruit consumption. Interestingly, by the third phase, people reacted to it and more fruits were sold.
However, besides the most salient (and significant) results, here is the beauty of being able to disclose your weaknesses, which makes it much more interesting. For context, this cafeteria caters for approximately 200 students per day and most of them have just completed high school and are preparing to enter into university.
Interestingly, the baseline scenario is so challenging: median sales of fruit at the cafeteria are remarkably low, just 1 to 2 fruits per day over each of the 3-week period tested. This is a huge challenge! Second, the human factor is not constant, females do better than males, they buy more fruits, as did the ‘older’-adults —just to be clear, our own research team was banned from buying fruits. Third, as usual — although we would like to claim this, but technically we can’t— we do not know if it was the change of place (availability) or the lowering of price (costs) the biggest driver in increasing sales, because of our ‘bundled’ intervention. Fourth, a further challenge, was that we were not able to explore if fruit sales reduced expenditures in junk-food or if unhealthy sales remained constant.
Last but not least, we were excited to figure out more about the complexities of human nature. We know that this is a small study from “darkest Peru.” Now, when we hear that the target of “5 servings per day” is a simple one to aim for, we will say, it ain’t that simple.
J. Jaime Miranda is Research Professor at the Department of Medicine, School of Medicine and Director of the CRONICAS Center of Excellence in Chronic Diseases, both at Universidad Peruana Cayetano Heredia (UPCH) in Lima, Peru.
Maria Kathia Cárdenas works as health economist at CRONICAS Center of Excellence in Chronic Diseases. She studied a Master in Epidemiological Research at Universidad Peruana Cayetano Heredia (UPCH) through a Fellowship supported by The National Heart, Lung and Blood Institute.