National Social Marketing Centre

The project takes a two-pronged approach to increase fruit and vegetable consumption. It uses a local fruit and vegetable provider to increase the supply of fruit and vegetables within the neighbourhood, while also delivering educational sessions for parents, students and the wider community to increase demand.

A dedicated brand, ‘Bostin Value', was created to promote the school fruit and vegetable stall. It was used on promotional material including vouchers, price lists and a leaflet sent to parents. Some ‘5-A-Day' materials were also distributed. The stall is promoted through practical taster sessions with children and adults and at school events, such as parents' evening and health week.

Supply side

Phase 1
Improving the availability of fruit and vegetables locally addresses the physical access issues reported by some residents in the area. In particular, those without access to a vehicle; less physically mobile older people; and those who do their shopping on a weekly basis, who may run out of fruit and vegetables mid-week and could therefore use the school stall to ‘top-up' their supply.

A local greengrocer was commissioned to set up a stall at Hawbush Primary School to sell fresh produce to parents and local residents. The fruit and vegetable stall operates in the school playground twice a week, on Tuesdays and Thursdays, around school finishing time (2:45pm to 3:30pm) to capture the ‘pick-up' market.

The stall offers fruit and vegetables at competitive prices compared with the favoured supermarkets (Tesco, Asda, Aldi and Lidl), and provides special offers, such as ‘buy-one-get-one-free' and half-price promotions. This addresses affordability and caters for those who seek bargains that large supermarkets frequently offer. Other special promotions include ready-prepared chopped vegetables; one-person vegetable packs and recipe packs (e.g. stew packs, stir-fry packs, salad ingredients and recipe cards). This addresses some of the cost and waste issues associated with buying fresh fruit and vegetables. Also, the hassle of shopping and food preparation is eased by having all the necessary ingredients and meal ideas included in the packs. Vouchers worth £1 were given to children to encourage them to choose products and visit the stall, thus creating familiarity with fruit and vegetables. Parents have also received money-off coupons to encourage them to use the stall.

A trial run of the fruit and vegetable stall took place in the week commencing 23 March 2009. The stall began regularly operating in late April 2009 (after the Easter break) and will continue until November 2010.

Phase 2 (July 2010 onwards)
Supply will be further strengthened by supporting and including the two most local convenience stores. This will deliver the best results in improving access to and consumption of fresh produce locally, in a sustainable way. The greengrocer from the Bostin Value stall will deliver fruit and vegetables to the local convenience shops to sell throughout the school summer holidays. Sales at these shops will be monitored and compared to baseline sales prior to their receiving the fruit and vegetable deliveries.

The exit strategy for the project will be determined by the results collected from evaluations throughout the project. Below are the three possible outcomes, and the response to each of the findings:

1. Outcome: Data from parent questionnaires show that fruit and vegetable consumption among the target population has significantly increased. Sales data from the stall shows an increase in sales.

Response: The stall will continue to sell produce at the school, or the greengrocer will supply fruit and vegetables to local convenience shops to meet the increased demand.

2. Outcome: Consumption of fruit and vegetables has not changed since the start of the project and sales data shows that fruit and vegetable purchase from the Bostin Value stall is insignificant.

Response: An investigation will be undertaken into why fruit and vegetable consumption has failed to increase, and the reasons for parents not purchasing from the stall. 

3. Outcome: Consumption has increased, but sales from the Bostin Value stall are insignificant.

Response: Since parents are consuming more fruit and vegetables but prefer to purchase fruit and vegetables from alternative sources, food access was not the barrier to increasing fruit and vegetable consumption.

Demand side
A Food for Health Advisor was employed from April 2009 to:

• plan and deliver skills sessions and awareness raising activities
• liaise with the local fruit and vegetable provider to organise purchasing opportunities and provide additional support for the stall
• monitor and evaluate the outcomes of the project, including sending progress reports to the steering group, partners and funding body

Free practical cooking and tasting sessions lasting between 30 minutes and 1.5 hours are held. They provide the same seasonal fruit and vegetables sold by the stall.

The aim of the sessions is to increase fruit and vegetable consumption by:

• Increasing knowledge about fruit and vegetables, including health benefits and seasonality of different produce
• Raising awareness of healthy eating
• Improving food preparation and cooking skills
• Addressing the barriers to eating more fruit and vegetables, such as cost, wastage and preparation time

Educational sessions for pupils are held during class time, either as part of classroom activities or as separate small groups in the community room.

Sessions for parents and the wider community are available once a week at the school using the community room. These practical sessions, lasting 1.5 hours, focus on preparing and cooking cheap meals using seasonal fruit and vegetables and leftovers, tasting new foods, and budgeting for food shopping.

Family cooking sessions ran successfully in December 2009 with parents and children cooking together after school. They were well attended, but it was difficult for parents to concentrate solely on cooking due to distractions from the children. It was decided that for parents to focus more on cooking and developing their cooking skills, it would be better to deliver sessions when the children were at school.

Food retail mapping
From September 2007 to April 2008, initial research took place to identify areas within the borough that were likely to experience food access problems. A list of registered food and drink outlets was obtained from the local Trading Standards and Environmental Health departments. Using MapInfo software, the Public Health Intelligence team mapped small local food retail outlets within the 20 per cent most deprived areas nationally and located away from other food shops. Outlets likely to sell a range of foods were included, while outlets like newsagents and off-licences were disregarded.

Food for Health Advisors from NHS Dudley visited the food retail outlets to explore the availability and quality of fresh fruit and vegetables. The selected areas included Dudley, Halesowen, Brierley Hill and Netherton. Of the food retail outlets visited, the following three were involved in the initial scoping research:

• M & A Stores, Hawbush, Brierley Hill (Ward – Brierley Hill)
• Best News, Gads Green, Dudley (Ward - St Thomas)
• Saul’s News, Fatherless Barn, Halesowen (Ward - Hayley Green)

Population mapping
Once the three areas and stores had been selected, the Transport Planning Team at Dudley Council used Accession software to identify the population (based on 2001 Census data) within 200m, 400m and 600m distance of each shop. The Public Health Intelligence Team used MOSAIC software to supplement the demographic data and help develop a picture of the type of people who live in the three areas.

Review of local data
The project team used data from the Dudley Health Survey 2004 and Health Behaviour Survey 2006 (conducted with school children) to estimate fruit and vegetable consumption for the identified populations in the three areas. Findings from the Dudley Health and Lifestyle Survey helped provide more information on the motivations behind fruit and vegetable consumption.

Focus groups
To better understand the target audience and provide information for segmenting the group, the NSMC carried out qualitative research. Six focus groups were conducted in December 2007 and February 2008 with just under 60 residents in Fatherless Barn, Gad’s Green and Hawbush.

The focus groups aimed to explore:

• Residents’ daily routines
• Influences at meal times
• Food purchasing culture
• Perceptions of and barriers to eating fruit and vegetables
• Ways of increasing consumption

Stakeholder research
In addition to qualitative research with the target audience, Food for Health Advisors conducted stakeholder interviews in Fatherless Barn, Gad’s Green and Hawbush. Stakeholders interviewed included:

• a head teacher
• school health advisors
• learning link/family workers
• parent governors
• local retailers
• supermarkets
• local churches
• neighbourhood managers
• local primary care staff

The interviews aimed to explore the views of professionals who worked in the neighbourhoods and gather ideas on increasing fruit and vegetable consumption among local residents.

Concept testing
Based on the scoping research, the project team developed a number of different intervention models and tested these with members of the target audience.

In July 2008, an independent researcher was commissioned to undertake interviews with nine residents recruited by a recruitment consultant. All participants were female, White British, aged between 27 and 42 years, with children, and lived in the Hawbush estate. Four out of nine residents were single parents, three worked part-time and five did not have access to a car.

Attitudes to the following intervention ideas were explored with the residents:

• Mobile shop
• School fruit and vegetable stall
• Get Cooking! healthy eating sessions linked in with vouchers
• Supermarket scheme, including transport service and voucher scheme
• Increasing quality and quantity of fruit and vegetables in local shops

All respondents felt that the mobile shop and school produce stall would be most suitable in reducing barriers to increasing fruit and vegetable consumption. Further discussions with industry experts and the steering group identified feasibility issues with the mobile fruit and vegetable shop (specifically sustainability, cost and staff implications). The project team therefore decided to proceed with the school-based intervention.

Influence of parent-child dynamic

• Focus groups with the target audience highlighted that children exert a high level of influence over what they eat through ‘pester power’ tactics. Corresponding with some of the stress that mothers reported in their daily routines, such as getting their children ready for school, pressure is also exerted at meal times. Some mothers felt that children criticise the food they cook and in some cases will refuse to eat a particular meal.
• Some parents’ desire for their children to eat something often meant that they would serve whatever their children wanted, rather than what would be good for them. Quarrels at meal times left some parents feeling that getting their children to eat healthily was a ‘battle’.
• The cost of fruit and vegetables and the amount of waste produced when they are not consumed are major concerns for parents, particularly those with low income.
• A common view held by parents was that children would be more likely to pick the unhealthy option if given the choice: ‘If it’s biscuit or fruit, most children go for biscuits.’ Providing increased choice to children meant that some parents had to cook a number of different meals to cater for different tastes.
• Some parents felt that what you eat depends on what mood you’re in. For example, many cited the desire for warm food in cold weather. Therefore, some parents felt it was unfair to make children eat something they may not be in the mood for and meals should be determined by what you want, rather than what you might need.

Any interventions therefore needed to help parents provide a desirable offer to children and stimulate demand from children for fruit and vegetables.

Addressing demand and supply
The scoping research underlined the importance of a two-pronged approach to fruit and vegetable consumption: focusing on making it easier to buy fruit and vegetables (through availability, price and preparation) and increasing demand for them (increasing skills and confidence, using children’s ‘pester’ power and reducing waste).

The link between improved fruit and vegetable consumption and the location of food retail outlets in deprived areas, as well as between healthy eating and food retailing, requires further research. Analysis so far has failed to show that price and availability in shops plays a significant role in predicting fruit and vegetable consumption. This is a primary motivation for this pilot project.

Focus groups with the target audience shed light on people’s day-to-day food shopping. Findings suggested that people tend to buy groceries on a weekly basis at supermarkets, which were viewed as being cost-effective, good for discounts, convenient, and offered a wide variety of quality products. Local shops were only used for top-ups and out of necessity for ‘emergency’ food items, such as bread and milk, rather than out of choice. Fruit and vegetables sold in local shops were seen as being expensive and poor quality.

Findings from the Dudley Health and Lifestyle Survey confirmed that driving factors behind fruit and vegetable consumption are both supply and demand related:

• Among those who eat less than five portions of fruit and vegetables a day, the most common reason for doing so was, ‘I just don’t think about it.’ This indicated that a purely supply-side intervention would be insufficient
• Only two per cent of the Dudley population indicated that they didn’t eat enough fruit and vegetables because they couldn’t buy them from their local shop
• The more deprived the area, the more likely respondents were to say that they couldn’t afford more fruit and vegetables. While 3 per cent of those living in the least deprived parts of Dudley stated this as a reason for not eating the recommended portions, this proportion rose to 11 per cent of residents in the most deprived areas

The project aims to encourage parents of young children to:

• consume more fruit and vegetables
• consume a wider variety of fruit and vegetables
• try different kinds of fruit and vegetables more frequently
• purchase more fruit and vegetables
• reduce reported levels of wastage

The above aims are being monitored and evaluated throughout the project every six months, through:

• Lifestyle questionnaires sent to parents
• Food recognition quizzes for students
• Likes and dislikes surveys
• Three-day food diary
• A sales database to monitor stall sales

Data from Hawbush primary school are being compared with a control school that didn’t receive any interventions.

The segmentation process built on the different stages of research to better understand the customer group. The project team started by looking at Dudley as a whole, then narrowed down the scope to three areas (Hawbush, Gads Green and Fatherless Barn). These were selected because there was perceived poor physical access to fruit and vegetables; they were deprived areas; and there was low fruit and vegetable consumption.

Research with stakeholders and the target group identified the role parenting plays in healthy eating. Parents believed that their children’s eating behaviours were very difficult to change once poor eating habits were established. The project therefore focuses on parents of young children, to try and target behaviours before they become habitual.

The qualitative research revealed that some parents were worried about wasting fruit and vegetables, because children didn’t eat them. This had an impact on their finances and discouraged them from trying new foods. This group were also likely to have low food preparation skills, which was a key barrier to eating more fruit and vegetables. This group of parents was therefore considered ‘at risk’ and chosen as the target audience for the project.

The project team then selected the geographic area in which to implement the interventions. Looking at existing data for Dudley, the parameters considered were:

1. A high proportion of children under 16
2. A proportion of households with no car
3. A high proportion with low fruit and vegetable intake

Hawbush was selected as the pilot area for the Healthy Retail project. This was due to the following factors:

• It has the highest proportion of overweight and obese year six pupils
• It has the highest proportion of year five and year six pupils who don’t eat at least the recommended portions of fruit and vegetables
• It has the highest proportion of year five and year six pupils who only eat one portion (or less) of fruit and vegetables a day
• It is within the Brierley Hill ward, which has one of the highest concentrations of fast food and takeaway outlets
• It has the highest proportion of children aged 0 to 15 years (2001 census)
• It has the highest proportion of lone parent households
• It has a relatively high proportion of households with no access to a vehicle
• Stakeholder knowledge of the area
• Existing links with the school and wider community

There are approximately 2,704 residents within 600 metres distance of Hawbush Primary School (2001 census). There are around 235 pupils at the school, of which 176 are in years 1 to 6. Hawbush Primary School was identified as the target school due to its high obesity rates; high proportion of low income families; lack of car owners; and poor access to local fruit and vegetables.

The primary target audience for the project are parents with children aged 4 to 11. School staff and the wider community were chosen as secondary audiences.

Benefits
The perceived benefits and costs of consuming fruit and vegetables were explored in the focus groups. Overall, participants felt that the positives outweighed the negatives. The main perceived benefits of consuming fruit and vegetables included:

• They’re good for your ‘health’ (especially in old age) – improve digestion, keep colds away, helps you lose weight
• They help you look and feel better – good for your skin and hair, gives you more energy
• They help improve children’s behaviour – contain natural sugars, unlike sweets and chocolate, which can make children hyperactive

Barriers

• Fear of wastage - Participants gave a number of examples of when fruit and vegetables were wasted, because they weren’t eaten in time before they rotted Many of the participants, particularly single parents, stuck to a strict financial budget and had a keen eye for prices and bargains. Food wasted was therefore a huge financial misuse, discouraging people from buying fruit and vegetables and experimenting with different foods.
• Local access to fruit and vegetables - Some participants reported that local shops stocked certain fruit and vegetables, usually potatoes and onions, but there wasn’t enough choice, the quality was low and they were generally too expensive. Lack of access to a car or time to travel to buy fresh fruit and vegetables was cited as another barrier.
• Preparation time – Generally, participants felt that preparing fruit and vegetables took too much time, especially since one of the tactics used to encourage children to eat more fruit and vegetables was to cut them up or arrange them in an appealing manner.
• Skills and education - There was a concern that children didn’t have good food skills, and had little idea of how to cook and what foods are good or bad for them. Some felt that parents needed to improve their food preparation skills, so they could better educate and encourage their children to eat more fruit and vegetables.
• Price – Some participants felt that fruit and vegetables were expensive, and since price was important in their purchasing decisions (particularly those with a large family), they were less likely to buy them.
• Habits - Some participants felt that it was difficult to get children to eat new foods as they get older, so it is important to ensure that fruit and vegetables are incorporated into their eating routine as early as possible.
• Uncertainty over the benefits of fruit and vegetable consumption – Some participants felt the positives associated with ‘health’ are not always dependent on fruit and vegetable consumption: for example, that someone could be thin without eating healthily.

Solutions
To overcome the perceived barriers, the project takes a two-pronged approach to increasing fruit and vegetable consumption through increasing the supply and demand of fruit and vegetables.

Supply has been addressed by setting up a fruit and vegetable stall at a local school to improve the availability of fruit and vegetables. The produce is offered at competitive pricing compared with the favoured supermarkets, and includes chopped vegetables and single portion vegetable packs. Recipe packs are handed out and taster sessions held, to provide opportunities for people to try new foods without worrying about waste or family members’ preferences.

To increase demand, educational sessions are being held at the school with children and parents. The sessions aim to raise awareness of healthy eating and the health benefits of fruit and vegetables. They also aim to improve skills in preparing and cooking seasonal fruit and vegetables and provide suggestions on avoiding waste.

Unhealthy snacks, such as crisps and chocolate, are a major source of competition to fruit and vegetable consumption, and are seen as convenient, cheap and tasty. By partnering with a local produce supplier to provide fresh food regularly on the school grounds, and running educational cooking sessions, the project demonstrates that fruit and vegetables can be affordable, accessible and appealing.

Peer pressure from other family members and peers also has a big influence on the types of food children eat, which can have positive or negative outcomes. By basing the healthy eating interventions at a school and targeting parents, students and staff, the project aims to shift norms by allowing adults and children to buy and try out different kinds of fresh fruit and vegetables together.

The Theory of Reasoned Action proposes that behaviour is determined by a person’s intention to perform a certain behaviour. Intention is determined by attitudes towards the behaviour and wider social norms.

In this context, social norms can be how individuals think their significant others will feel about them undertaking a certain behaviour (such as how peers, children and relatives will feel about a parent giving healthy snacks). Attitudes are defined as the way individuals view or evaluate the given behaviour (for example, what do parents think and feel about fruit and vegetables, and is this a positive or negative attitude?). Finally, intention is the individual’s readiness to perform the behaviour (in this case, to be willing to try giving their child fruit and vegetables).

According to this theory, if an individual thinks a behaviour is positive (their attitude towards it) and feels that others will be accepting of them undertaking it (the social norm), their intention to adopt the behaviour will increase.

This project aims to create a positive attitude to healthy eating (both in parents/carers and children) and to shift the social norm so that it becomes a socially acceptable behaviour to eat fruit and vegetables.

Taste Acquisition Theory suggests that repeated tasting of foods allows children to discover the intrinsically rewarding properties of fruits and vegetables - that they come to like the taste. As children come to like fruit and vegetables more, they’ll become more likely to eat these foods simply for their flavour, rather than for any external reward.