More than the worksite cafeteria: the workplace food environment of small and medium-sized enterprises in the Netherlands.

OBJECTIVE: To characterise the food environment of Dutch small and medium-sized enterprises (SMEs), encompassing physical, sociocultural, economic and policy features and to explore variations within SMEs according to company characteristics (number of employees, location of work and presence of worksite cafeteria). DESIGN: Online cross-sectional survey study of a representative Dutch SME sample by a panel agency. SETTING: Dutch SMEs. PARTICIPANTS: Three hundred and fifteen employees of Dutch SMEs responsible for food and drink in their company. RESULTS: Most SMEs did not have a worksite cafeteria, no provision of fruits or vegetables, and did not offer discounts on food or drinks. The food environment of these SMEs varied significantly based on company characteristics. For example, SMEs with a worksite cafeteria were significantly more likely to have fruits (OR = 8·76, 95 % CI (4·50, 17·06)), vegetables (OR = 10·29, 95 % CI (5·49, 19·31)) and company food policies (OR = 5·04, 95 % CI (2·08, 12·20)) than SMEs without. Additionally, SMEs with ≥ 50 employees were more likely to have fruits (OR = 2·39, 95 % CI (1·42, 4·03)), vegetables (OR = 1·89, 95 % CI (1·04, 3·46)) and company food policies (OR = 2·82, 95 % CI (1·09, 7·29) than SMEs with < 50 employees. Moreover, having a worksite cafeteria (B = 0·23, 95 % CI (0·08, 0·38)) and employees working mostly on-site (B = 0·14, 95 % CI (0·01, 0·28)) were associated with stronger social norms of healthy and sustainable eating at work compared to SMEs without a worksite cafeteria and working mostly off-site. CONCLUSIONS: In SMEs, an overall comprehensive picture of the food environment points to its limited active encouragement of healthy food choices, particularly so in small SMEs without a worksite cafeteria. Company characteristics strongly influence SME food environments and should be considered when developing interventions improving SME workplace food environments.

Transitioning towards more plant-based diets: sharing expert knowledge through a system lens.

Transitioning towards more plant-based protein diets is essential for public and planetary health. Current research about consumption practices of protein sources provides limited insight in the multidisciplinary nature and interconnectivity of the food environment. This study aimed to collect mental models of review authors by synthesizing both their implicit and explicit system views into an overarching system view. Published reviews were used to select participants and identify variables that explain the protein transition in relation to the food environment. To overcome differences in disciplines and scale levels (e.g. individual, interpersonal, environmental), variables were organized according to the Determinants of Nutrition and Eating Framework. Eight review authors shared their mental models in an interview. Participants were asked to construct a causal loop diagram (CLD), a tool proven valuable in making one's ontology explicit to others. Implicit system views in narrative were converted into CLDs using a coding framework. The overarching system view suggests that a multitude of feedback loops sustain current consumption patterns of protein sources, for example by reinforcement through habit, availability and peer support. Several aspects require further research, such as variable relationships that were subject to disagreement and the lack of reciprocity between the physical and social elements of the food environment. In addition, knowledge gaps were exposed, including long-term behaviour and interaction of multiple variables. As a boundary object, the overarching system view can facilitate the direction of future research. The findings underscore the interconnected nature of many disparate elements within the food environment, stressing the need for holistic methods like systems thinking. These are essential in developing a systemic understanding and facilitating the transition towards more plant-based diets.

How perceptions of meat consumption norms differ across contexts and meat consumer groups.

Social norm perceptions are implicit standards describing what is typically done or seen as acceptable and have shown to be important both in sustaining meat consumption as well as facilitating meat reduction. Norm perceptions depend on individual differences and the contexts (e.g., supermarket, restaurant). Yet, evidence how norm perceptions differ within and across individuals is scarce. The primary aim of this study was to investigate how descriptive, injunctive, and personal norms perceptions favouring meat consumption differ across contexts and meat consumer groups. The second aim was to investigate how generic dynamic norm perceptions vary across meat consumer groups. British meat eaters (n = 1205, 25-65 years) participated in an online cross-sectional survey. Weekly meat, fish and meat substitute consumption was measured with the adapted Oxford Meat Frequency Questionnaire. All but dynamic norm perceptions were measured for the supermarket, restaurant and worksite cafeteria context. Dynamic norms were measured without a specified context. A two-step cluster analysis was conducted to identify meat consumer groups. Descriptive norm perceptions favouring meat consumption were strongest in supermarket and restaurant contexts, compared to the worksite cafeteria. Injunctive and personal norms favouring meat consumption were both perceived strongest in the supermarket, followed by the restaurant, and least in the worksite cafeteria context. Four meat consumer groups were identified and those with higher meat intake (i.e., Meat lovers and Exceeders) perceived norms favouring meat consumption stronger and norms favouring meat avoidance weaker than the groups with lower meat intake (i.e., Flexitarians and Moderates). While norm perceptions differed between meat consumer groups, the pattern of contextual differences is similar for these meat consumer groups. Our findings underscore the importance of considering contexts and meat consumer groups in efforts to reduce meat consumption.

Characterizing food environments of hospitals and long-term care facilities in the Netherlands: a mixed methods approach.

BACKGROUND: Hospitals and long-term care facilities, which are key institutions to serve health and well-being, have an important exemplary role in providing supportive food environments to encourage healthy and sustainable food choices. The objective of this study is to characterize the physical, socio-cultural, political and economic dimensions of the food environment for health care receivers, health workforce and visitors in healthcare settings, and make comparisons between the food environment of hospitals and long-term care facilities. METHODS: To characterize the food environment in healthcare settings, two sub-studies were conducted. In sub-study 1, semi-structured interviews were held with staff members (n = 46) representing 11 hospitals and 26 long-term care facilities (rehabilitation centres, nursing homes, institutions for people with intellectual disabilities and mental healthcare institutions). In sub-study 2, staff members audited the food environment in hospitals (n = 28) and long-term care facilities (n = 36) using a predefined checklist. RESULTS: The food environment in Dutch healthcare settings varies substantially between locations although noticeable differences between hospitals and long-term care facilities were identified. Hospitals and larger long-term care facilities featured more often restaurants and utilized central spaces for preparation of meals, while smaller long-term care facilities often operated as household-like settings. Type of healthcare shaped the socio-cultural food environment, with hospitals primarily emphasizing nutrition for fast recovery, while long-term care facilities more often as an instrument (i.e., to structure the day). Participants highlighted the importance of food policies and broad organizational support for realizing and regulating improvement of the food environment. Yet, long-term care facilities were less familiar with national guidelines for food environments compared to hospitals. Several economical aspects, like profit motives, strict budgets and contracts with external parties affected and shaped the food available within all healthcare settings. CONCLUSIONS: This study characterized the food environment in Dutch healthcare settings. Disclosed differences between hospitals and long-term care facilities should be incorporated in strategies for a transition of the food environment. Future research should investigate the underlying mechanisms of the healthcare food environment attaining all healthcare stakeholders - health care receivers, staff and visitors - while prioritizing sustainability alongside healthiness.

Enhancing interprofessional teamwork between youth care professionals using an electronic health record; a mixed methods intervention study.

We aimed to investigate whether using a shared electronic patient record (EPR-Youth) strengthened interprofessional teamwork among professionals in youth care and child healthcare. Using a mixed-methods design, we compared two partly overlapping samples of professionals, who completed questionnaires before the introduction of EPR-Youth (n = 117) and 24 months thereafter (n = 127). Five components of interprofessional teamwork (interdependence, newly created professional activities, flexibility, collective ownership of goals, and reflection on processes) were assessed for this study. Midway through the study period, focus groups were held with 12 professionals to examine how EPR-Youth contributed to interprofessional teamwork. Professionals reported significantly more flexibility after the introduction of EPR-Youth than before. Professionals scored slightly -but not significantly- more positively on the other components of teamwork. Focus group participants reported that using EPR-Youth strengthened their sense of interdependence and collective ownership of goals, and contributed to newly created professional activities. At baseline, levels of interprofessional teamwork differed between organizations. Focus group participants confirmed these differences and attributed them to differences in facilitation of interprofessional teamwork. Our findings suggest that using EPR-Youth can foster interprofessional teamwork. Organizational differences underline that implementing an EPR alone is inadequate: shared definitions of teamwork and organizational facilities are needed to strengthen interprofessional teamwork.

Socioeconomic inequalities in self-assessed health and food consumption: the mediating roles of daily hassles and the perceived importance of health.

BACKGROUND: Urgent daily hassles, which are more common among people with a lower socioeconomic position (SEP), might limit one's ability to address less pressing goals, such as goals related to health promotion. Consequently, health goals may be viewed as less focal, which could jeopardize one's health. This study examined an understudied pathway: whether a higher severity of daily hassles resulted in a lower perceived importance of health and whether these two factors sequentially mediate socioeconomic inequalities in self-assessed health (SAH) and food consumption. METHODS: A cross-sectional survey among 1,330 Dutch adults was conducted in 2019. Participants self-reported SEP (household income, educational level), the severity of eleven daily hassles (e.g., financial hassles, legal hassles), the perceived importance of health (not being ill, living a long life), SAH, and food consumption. Structural equation modeling was used to examine whether daily hassles and the perceived importance of health sequentially mediated income and educational inequalities in SAH, fruit and vegetable consumption (FVC) and snack consumption. RESULTS: No evidence of sequential mediation through daily hassles and the perceived importance of health was found. Daily hassles individually mediated income inequalities in SAH (indirect effect: 0.04, total effect: 0.06) and in FVC (indirect effect: 0.02, total effect: 0.09). The perceived importance of not being ill and living a long life both individually mediated educational inequalities in SAH (indirect effects: 0.01 and -0.01, respectively, total effect: 0.07). CONCLUSIONS: Income inequalities in SAH and FVC were explained by daily hassles, and educational inequalities in SAH were explained by the perceived importance of health. Socioeconomic inequalities may not be sequentially explained by a more severe experience of daily hassles and a lower perceived importance of health. Interventions and policies addressing challenging circumstances associated with a low income may improve SAH and healthy food consumption among lower-income groups.

Process evaluation of workplace health promotion in a sheltered workplace: a care ethics perspective.

Despite the potential health benefits of workplace health promotion for employees in sheltered workplaces, participation is often limited. The aim of this study was (i) to understand this limited participation, and (ii) to find opportunities for adapting workplace health promotion, such that it better meets the needs of the target population. A responsive process evaluation of an extensive multi-component workplace health promotion program targeting lifestyle behaviors, financial behaviors, literacy and citizenship, was performed in a large, sheltered workplace in the Netherlands (>3500 employees). To understand the limited participation, interviews with employees (n = 8), supervisors (n = 7) and managers (n = 2), and 10 participant observations were performed. To find opportunities for improving workplace health promotion in the sheltered workplace, 7 dialogs with employees were performed (n = 30). The interview data on the barriers for participation were evaluated through the lens of care ethics, as this allowed to understand the role of various stakeholders in the limited participation, as well as the indirect role of the institutional context. Findings showed that participation in workplace health promotion could increase if it is organized in a way that it encourages employees to work on health together, allow to tailor activities to different needs and capabilities of employees, and connects activities to employees' daily lives. A strength of this study is that the responsive process evaluation focused both on barriers for participation, as well as on opportunities to increase participation.

People who cannot participate in work without adaptations, for example, due to disability, can work in sheltered workplaces. These employees face various health risks, which are prompted by, for example, low income or low (health) literacy. More and more sheltered workplaces provide health promotion programs to improve health of their employees, such as educational workshops about physical exercise and healthy nutrition. However, participation of employees in such programs is limited. In this study, we investigated why participation is limited, and what are possible ways to make workplace health promotion programs that aim to improve health more attractive to employees in a sheltered workplace. We used different methods, such as interviews, group dialogs and participant observations. We concluded that workplace health promotion programs seem to rely too much on the individual employee, who prefers to work on health together with peers. Employees also value that activities in the health program are useful for their daily lives. This increases the relevance of the program for them and makes employees more inclined to participate.

Human spatial memory is biased towards high-calorie foods: a cross-cultural online experiment.

BACKGROUND: Human memory appears to prioritise locations of high-calorie foods, likely as an adaptation for foraging within fluctuating ancestral food environments. Importantly, this "high-calorie bias" in human spatial memory seems to yield consequences for individual eating behaviour in modern food-abundant settings. However, as studies have mainly been conducted in European (Dutch) populations to date, we investigated whether the existence of the cognitive bias can be reasonably generalised across countries that vary on culturally-relevant domains, such as that of the USA and Japan. Furthermore, we investigated whether sociodemographic factors moderate the expression of the high-calorie spatial memory bias in different populations. METHODS: In a cross-cultural online experiment, we measured the food location memory of diverse participants from the USA (N = 72; 44.4% Male; 54 ± 15.99 years) and Japan (N = 74; 56.8% Male; 50.85 ± 17.32 years), using a validated computer-based spatial memory task with standardised images of high-calorie and low-calorie foods. To directly compare the magnitude of the high-calorie spatial memory bias in a broader cultural scope, we also included data from a previous online experiment that identically tested the food spatial memory of a Dutch sample (N = 405; 56.7% Male; 47.57 ± 17.48 years). RESULTS: In the US sample, individuals more accurately recalled (i.e. had lower pointing errors for) locations of high-calorie foods versus that of low-calorie alternatives (Mean difference = -99.23 pixels, 95% CI = [-197.19, -1.28]) - regardless of one's hedonic preferences, familiarity with foods, and encoding times. Likewise, individuals in the Japanese sample displayed an enhanced memory for locations of high-calorie (savoury-tasting) foods (Mean difference = -40.41 pixels, 95% CI = [-76.14, -4.68]), while controlling for the same set of potential confounders. The magnitude of the high-calorie bias in spatial memory was similar across populations (i.e. the USA, Japan, and the Netherlands), as well as across diverse sociodemographic groups within a population. CONCLUSIONS: Our results demonstrate that the high-calorie bias in spatial memory transcends sociocultural boundaries. Since the cognitive bias may negatively impact on our dietary decisions, it would be wise to invest in strategies that intervene on our seemingly universal ability to efficiently locate calorie-rich foods.

Stakeholder dialogue on dilemmas at work as a workplace health promotion intervention including employees with a low SEP: a Responsive Evaluation.

BACKGROUND: The aim of this study was to evaluate the perceived changes of an innovative workplace health promotion intervention and evaluation. In this study, a bottom-up approach was taken to define the central themes and relevant outcomes of an intervention. These central themes and relevant outcomes of the intervention were defined together with stakeholders, including employees with a low socioeconomic position. METHODS: The intervention consisted of a series of structured stakeholder dialogues in which dilemmas around the - by employees defined -health themes were discussed. The intervention was implemented in a harbor service provider with approximately 400 employees. Over a two-year period, 57 participants engaged in eight dialogues of one hour. 15 interviews and six participant observations took place for the evaluation of the intervention. RESULTS: Together with the stakeholders, high workload and mental health were defined as central themes for the dialogue intervention in the male-dominated workplace. The dialogue intervention contributed to changes, on different levels: individual, team, and organization. Overall, the stakeholder dialogues advanced the understanding of factors contributing to high workload and mental health. In reply to this, several actions were taken on a organizational level. CONCLUSIONS: Taking a bottom-up approach in WHP allows to understand the health issues that are important in the daily reality of employees with a low socioeconomic position. Through this understanding, workplace health promotion can become more suitable and relevant for employees with a low socioeconomic position. TRIAL REGISTRATION: Netherlands Trial Register (NRT): NL8051. Registration date: 28/09/2019, Retrospectively registered https://www.trialregister.nl.

What's important to you? Socioeconomic inequalities in the perceived importance of health compared to other life domains.

BACKGROUND: Pressing issues, like financial concerns, may outweigh the importance people attach to health. This study tested whether health, compared to other life domains, was considered more important by people in high versus low socioeconomic positions, with future focus and financial strain as potential explanatory factors. METHODS: A cross-sectional survey was conducted in 2019 among N=1,330 Dutch adults. Participants rated the importance of two health-related domains (not being ill, living a long life) and seven other life domains (e.g., work, family) on a five-point scale. A latent class analysis grouped participants in classes with similar patterns of importance ratings. Differences in class membership according to socioeconomic position (indicated by income and education) were examined using structural equation modelling, with future focus and financial strain as mediators. RESULTS: Three classes were identified, which were defined as: neutralists, who found all domains neutral or unimportant (3.5% of the sample); hedonists, who found most domains important except living a long life, work, and religion (36.2%); and maximalists, who found nearly all domains important, including both health domains (60.3%). Of the neutralists, 38% considered not being ill important, and 30% considered living a long life important. For hedonists, this was 92% and 39%, respectively, and for maximalists this was 99% and 87%, respectively. Compared to belonging to the maximalists class, a low income predicted belonging to the neutralists, and a higher educational level and unemployment predicted belonging to the hedonists. No mediation pathways via future focus or financial strain were found. CONCLUSIONS: Lower income groups were less likely to consider not being ill important. Those without paid employment and those with a higher educational level were less likely to consider living a long life important. Neither future focus nor financial strain explained these inequalities. Future research should investigate socioeconomic differences in conceptualisations of health, and if inequalities in the perceived importance of health are associated with inequalities in health. To support individuals dealing with challenging circumstances in daily life, health-promoting interventions could align to the life domains perceived important to reach their target group and to prevent widening socioeconomic health inequalities.

Internally regulated eating style: a comprehensive theoretical framework.

Internally regulated eating style, the eating style that is driven by internal bodily sensations of hunger and satiation, is a concept that has received increasing attention in the literature and health practice over the last decades. The various attempts that have been made so far to conceptualise internally regulated eating have taken place independently of one another, and each sheds light on only parts of the total picture of what defines internally regulated eating. This has resulted in a literature that is rather fragmented. More importantly, it is not yet clear which are the characteristics that comprise this eating style. In this paper, we identify and describe the full spectrum of these characteristics, namely, sensitivity to internal hunger and satiation signals, self-efficacy in using internal hunger and satiation signals, self-trusting attitude for the regulation of eating, relaxed relationship with food and tendency to savour the food while eating. With this research, we introduce a common language to the field and we present a new theoretical framework that does justice not just to the full breadth of characteristics that are necessary for the internally regulated eating style but also to the associations between them and the potential mechanisms by which they contribute to this eating style.

Nudging healthy eating in Dutch sports canteens: a multi-method case study.

OBJECTIVE: To provide a micro-investigation into the long-term effects and process of implementation of a nudge intervention on food choice in sports canteens. DESIGN: Multi-method case study. SETTING: Eight products were added to the range of foods and drinks in two football canteens in the Netherlands for 3 and 15 weeks, serving as a baseline period. In the intervention period, these products were promoted with the use of salience, scarcity, availability and default nudges, for 26 and 16 weeks, respectively. Aside from the collection of sales and revenue data, reach, acceptability, adherence and applicability were measured using observations, questionnaires and interviews. PARTICIPANTS: Questionnaires were filled in by seventy and fifty-nine visitors of the canteens. Four interviews were held with board members and canteen personnel. RESULTS: Mixed results were obtained regarding the suitability of nudges to be used to promote healthy eating in sports clubs. Sales and revenue data did show positive trends, the intervention was seen as acceptable by all stakeholders and the intervention had a large reach. However, adherence to the intervention in both canteens and the effects of the nudges on the total consumption pattern were low. Factors were identified that promoted or hindered the intervention at an individual, interventional and organisational level. CONCLUSIONS: Nudges seem to be a valuable addition to other efforts to combat unhealthy eating. However, the extent of their impact as a single intervention tool is limited in the current food-abundant environment.

The effect of a brief mindfulness intervention on perception of bodily signals of satiation and hunger.

An increasing number of studies investigate the effects of mindfulness on food intake and weight outcomes, while the underlying mechanisms by which mindfulness exerts its effects have received less attention. We conducted two pre-registered studies to shed light on the frequently proposed yet largely understudied hypothesis that mindfulness improves awareness of bodily signals of satiation and hunger. We assessed the ability to perceive the onset of bodily signals of satiation with the two-step water load test (Study 1) and the ability to perceive the onset of bodily signals of hunger with the preload test (Study 2). A brief mindfulness exercise (body scan) did not impact the perception of satiation but improved the ability to perceive bodily signals of hunger. After the consumption of a standardized preload, participants in the two experimental conditions felt equally satiated; nevertheless, those in the mindfulness condition perceived the onset of hunger 18min earlier than those in the control condition and this effect persisted also in the presence of control variables. These findings together suggest that even a single and short mindfulness exercise can improve perception of hunger signals substantially, while more intensive mindfulness training may be needed to impact perception of satiation signals.

Eating behavior and food purchases during the COVID-19 lockdown: A cross-sectional study among adults in the Netherlands.

On March 15, 2020, the Dutch Government implemented COVID-19 lockdown measures. Although self-quarantine and social-distancing measures were implemented, restrictions were less severe compared to several other countries. The aim of this study was to assess changes in eating behavior and food purchases among a representative adult sample in the Netherlands (n = 1030), five weeks into lockdown. The results show that most participants did not change their eating behaviors (83.0%) or food purchases (73.3%). However, socio-demographic differences were observed among those that reported changes during lockdown. For example, participants with overweight (OR = 2.26, 95%CI = 1.24-4.11) and obesity (OR = 4.21, 95%CI = 2.13-8.32) were more likely to indicate to eat unhealthier during lockdown compared to participants with a healthy weight. Those with a high educational level (OR = 2.25, 95%-CI = 1.03-4.93) were also more likely to indicate to eat unhealthier during lockdown compared to those with a low educational level. Older participants were more likely to indicate to experience no differences in their eating behaviors compared to those of younger age, who were more likely to indicate that they ate healthier (OR = 1.03, 95%CI = 1.01-1.04) as well as unhealthier (OR = 1.04, 95%CI = 1.02-1.06) during lockdown. Participants with obesity were more likely to indicate to purchase more chips/snacks (OR = 2.79, 95%CI = 1.43-5.45) and more nonalcoholic beverages (OR = 2.74, 95%CI = 1.36-5.50) during lockdown in comparison with those with a healthy weight. Of those that used meal delivery services before, 174 (29.5%) indicated to use meal delivery services more frequently during lockdown. Although the results confirm the persistence of dietary routines, profound socio-demographic differences were observed for those that did report changes. Especially for individuals with overweight and obesity, the lockdown has taken its toll on healthy dietary choices. Further research should unravel underlying mechanisms for these observations.

How the Use of a Patient-Accessible Health Record Contributes to Patient-Centered Care: Scoping Review.

BACKGROUND: Worldwide, patient-centered care is becoming a widely used concept in medical practice, getting more and more attention because of its proven ability to improve quality of care and reduce costs. Although several studies show that patient-accessible electronic health records (PAEHRs) influence certain aspects of patient-centered care, the possible contribution of PAEHR implementation to patient-centered care as a comprehensive concept has not, to our knowledge, been structurally evaluated to date. OBJECTIVE: The objective of this study is to review whether and how the use of PAEHRs contributes to patient-centered care both in general and among specific population groups. METHODS: We followed PRISMA Extension for Scoping Reviews reporting guidelines. We identified literature in 5 databases, using the terms "patient-accessible medical records," "patient experiences," and "professional experiences" as key concepts. A total of 49 articles were included and analyzed with a charting code list containing 10 elements of patient-centered care. RESULTS: Studies were diverse in design, country of origin, functionalities of the investigated PAEHR, and target population. Participants in all studies were adults. Most studies reported positive influence of PAEHR use on patient-centered care; patient accessible health records were appreciated for their opportunity to empower patients, inform patients about their health, and involve patients in their own care. There were mixed results for the extent to which PAEHRs affected the relation between patients and clinicians. Professionals and patients in mental health care held opposing views concerning the impact of transparency, where professionals appeared more worried about potential negative impact of PAEHRs on the patient-clinician relationship. Their worries seemed to be influenced by a reluctant attitude toward patient-centered care. Disadvantaged groups appeared to have less access to and make less use of patient-accessible records than the average population but experienced more benefits than the average population when they actually used PAEHRs. CONCLUSIONS: The review indicates that PAEHRs bear the potential to positively contribute to patient-centered care. However, concerns from professionals about the impact of transparency on the patient-clinician relationship as well as the importance of a patient-centered attitude need to be addressed. Potentially significant benefits for disadvantaged groups will be achieved only through easily accessible and user-friendly PAEHRs.

Neighbourhood fast food exposure and consumption: the mediating role of neighbourhood social norms.

BACKGROUND: The association between the residential fast food environment and diet has gained growing attention. However, why the food environment affects food consumption is under-examined. This study aimed to investigate neighbourhood social norms with respect to fast food consumption as a potential mediating pathway between residential fast food outlet exposure and residents' fast food consumption. METHODS: A correlational study was conducted in which a nationwide sample of 1038 respondents living across The Netherlands completed a survey. Respondents reported their fast food consumption (amount/week) as well as perceived descriptive and injunctive norms regarding fast food consumption in their neighbourhood. Fast food outlet exposure was measured by the average count of fast food outlets within a 400 m walking distance buffer around the zip-codes of the respondents, using a retail outlet database. Regression models were used to assess associations between residential fast food outlet exposure, fast food consumption, and social norm perceptions, and a bootstrapping procedure was used to test the indirect -mediation- effect. Separate analyses were performed for descriptive norms and injunctive norms. RESULTS: There was no overall or direct association between residential fast food outlet exposure and residents' fast food consumption. However, fast food outlet exposure was positively associated with neighbourhood social norms (descriptive and injunctive) regarding fast food consumption, which in turn were positively associated with the odds of consuming fast food. Moreover, results of the bootstrapped analysis provided evidence of indirect effects of fast food outlet exposure on fast food consumption, via descriptive norms and injunctive norms. CONCLUSIONS: In neighbourhoods with more fast food outlets, residents were more likely to perceive fast food consumption in the neighbourhood as more common and appropriate. In turn, stronger neighbourhood social norms were associated with higher fast food consumption. Acknowledging the correlational design, this study is the first that implies that neighbourhood social norms may be a mediating pathway in the relation between the residential fast food environment and fast food consumption. Future research may examine the role of neighbourhood social norms in other contexts and explore how the changing food environment may shift our consumption norms.

Foraging minds in modern environments: High-calorie and savory-taste biases in human food spatial memory.

Human memory may show sensitivity to content that carried fitness-relevance throughout evolutionary history. We investigated whether biases in human food spatial memory exist and influence the eating behavior of individuals within the modern food environment. In two lab studies with distinct samples of 88 participants, individuals had to re-locate foods on a map in a computer-based spatial memory task using visual (Study 1) or olfactory (Study 2) cues that signaled sweet and savory high- and low-calorie foods. Individuals consistently displayed an enhanced memory for locations of high-calorie and savory-tasting foods - regardless of hedonic evaluations, personal experiences with foods, or the time taken to encode food locations. However, we did not find any clear effects of the high-calorie or savory-taste bias in food spatial memory on eating behavior. Findings highlight that content matters deeply for the faculty of human food spatial memory and indicate an implicit cognitive system presumably attuned to ancestral priorities of optimal foraging.

Responsive evaluation of stakeholder dialogue as a worksite health promotion intervention to contribute to the reduction of SEP related health inequalities: a study protocol.

BACKGROUND: Large health inequalities exist in the Netherlands among individuals with a high compared to a low socioeconomic position. Worksite health promotion interventions are considered promising to reduce these inequalities, however, current interventions seem not to have the desired effects. This study proposes 'moral case deliberation', a form of stakeholder dialogue on moral dilemmas, as an integrated and inclusive intervention for worksite health promotion. This intervention takes into account three factors that are considered possible underlying causes of low effectiveness of current interventions, namely the lack of deliberate attention to: 1) the diverging values and interests of stakeholders in worksite health promotion, 2) the ethical issues of worksite health promotion, and 3) the connection with the lived experience (lifeworld) of lower SEP employees. Moral case deliberation will help to gain insight in the conflicting values in worksite health promotion, which contributes to the development of a vision for worksite health promotion that is supported by all parties. METHODS: The intervention will be evaluated through Responsive Evaluation, a form of participatory research. Key to Responsive Evaluation is that stakeholders are consulted to determine relevant changes as a result of the intervention. The intervention will be evaluated yearly at both fixed moments (baseline and annual evaluation(s)) and continuously. Mixed methods will be used, including interviews, participatory observations, analyses of HRM-data and short questionnaires. In addition, the intervention will be evaluated economically, on both monetary and non-monetary outcomes. DISCUSSION: This protocol proposes an innovative intervention and a novel participatory evaluation in the context of worksite health promotion. The study aims to gain understanding in how dialogue on moral dilemmas on health and health promotion can contribute to heightened personal and mutual understanding among stakeholders and practice improvements in the work context. By evaluating the intervention in more than one setting, findings of this study will provide knowledge about how MCD can be adapted to specific work settings and what changes it may lead to in these settings. TRIAL REGISTRATION: Netherlands Trial Register (NRT): NL8051. Registration date: 28/09/2019, retrospectively registered. https://www.trialregister.nl/.

Developing Embodied Conversational Agents for Coaching People in a Healthy Lifestyle: Scoping Review.

BACKGROUND: Embodied conversational agents (ECAs) are animated computer characters that simulate face-to-face counseling. Owing to their capacity to establish and maintain an empathic relationship, they are deemed to be a promising tool for starting and maintaining a healthy lifestyle. OBJECTIVE: This review aimed to identify the current practices in designing and evaluating ECAs for coaching people in a healthy lifestyle and provide an overview of their efficacy (on behavioral, knowledge, and motivational parameters) and use (on usability, usage, and user satisfaction parameters). METHODS: We used the Arksey and O'Malley framework to conduct a scoping review. PsycINFO, Medical Literature Analysis and Retrieval System Online, and Scopus were searched with a combination of terms related to ECA and lifestyle. Initially, 1789 unique studies were identified; 20 studies were included. RESULTS: Most often, ECAs targeted physical activity (n=16) and had the appearance of a middle-aged African American woman (n=13). Multiple behavior change techniques (median=3) and theories or principles (median=3) were applied, but their interpretation and application were usually not reported. ECAs seemed to be designed for the end user rather than with the end user. Stakeholders were usually not involved. A total of 7 out of 15 studies reported better efficacy outcomes for the intervention group, and 5 out of 8 studies reported better use-related outcomes, as compared with the control group. CONCLUSIONS: ECAs are a promising tool for persuasive communication in the health domain. This review provided valuable insights into the current developmental processes, and it recommends the use of human-centered, stakeholder-inclusive design approaches, along with reporting on the design activities in a systematic and comprehensive manner. The gaps in knowledge were identified on the working mechanisms of intervention components and the right timing and frequency of coaching.

Identifying social norms in physical aspects of food environments: A photo study.

It is widely accepted that physical food environments can contribute to unhealthy eating, but less is known about how physical cues in these environments actually stimulate eating. Our study starts from the assumption that social norms are embedded in physical cues and aims to make an inventory of physical cues that communicate what is socially accepted as normal and/or appropriate to eat in a Dutch outside-the-home food context. In Study 1, we conducted a qualitative study in which photographs taken in self-service food environments were analyzed using strategies from photo documentation and semiology. Grounded theory was applied to identify a wide variety of specific physical cues that were ultimately grouped into 18 higher level categories of physical cues (e.g. consumption traces, product availability). Most cue categories were associated with either descriptive or injunctive social norms, but some were associated with both types. In Study 2, we aimed to quantitatively cross-validate the social norm interpretations among laypeople (N = 173) by focusing on two selected photographs. More than half of the physical cues that participants identified in these photographs as being influential had been identified in Study 1 as cues bearing a normative message. The results further indicated that other people's behavior is easier to recognize in physical food environments than signals about what ought to be done. Given the great variety of identified physical cues associated with social norms, we posit that social norms are widely embedded in food environments and might guide eating behavior. Further research should study the effects of these cues on behavior and test whether the underlying process can be attributed to social norm interpretations.