Behavioural change box? Applying the COM-B model to understand behavioural triggers that support consumption of fruits and vegetable among subscribers of a fruit and vegetable box scheme.

OBJECTIVE: To understand the key mechanisms that support healthy dietary habits promoted by fruit and vegetable (F&V) box schemes, testing relevant behaviour change triggers identified under the COM-B model in an evaluation research study of a Portuguese F&V box scheme (PROVE). DESIGN: Correlation study with a post-test-only non-equivalent group design based on survey data. The mechanisms underpinning the differences between subscribers and non-subscribers are operationalised as mediation effects. Data availability, theoretical relevance and empirical validation supported the selection and testing of four potential mediators for the effects of subscribing to the box scheme on F&V consumption. These estimations derive from the coefficients of a structural equation model combined with the product coefficient approach and Sobel test. SETTING: The study is part of a wider evaluation study on the impact of the PROVE box scheme on sustainability, health and equity. PARTICIPANTS: A sample of PROVE box subscribers (n 294) was compared with a matched subsample of non-subscribers (n 571) in a nationally representative survey. RESULTS: Subscribing to the PROVE box correlates with an increased probability of eating at least five portions of F&V, irrespective of differences in age, education and perceived economic difficulties. Diet quality perceptions, and more robustly, the strength of meal habits and household availability were identified as relevant mediators. CONCLUSIONS: The subscription to an F&V box scheme is connected with proximal context that enables the consumption of F&V by ensuring more readily available F&V and better situational conditions associated with healthier meal habits.

Explaining inequalities in fruit and vegetable intake in Europe: The role of capabilities, opportunities and motivations.

People who do not eat enough fruit and vegetables (F&V) have incremental health risks. Most Europeans do not comply with health recommendations relating to F&V consumption and this is especially true for those with lower-level education, which reinforces structural inequalities in health and wellbeing among Europeans. This study investigated the role of key behavioural triggers - capabilities, opportunities and motivation (in the COM-B model) - as pathways for educational differentials in F&V intake in Europe. A cross-sectional survey-based study was conducted in five European countries differing widely in their consumption habits, wealth, and climatic conditions. A structural equation model was designed to study how capabilities (diet perceived knowledge, health purchase criteria), opportunities (financial availability, social norms), and motivations (health value, habits strength) affect educational inequalities in the intake of F&V (5 portions a day) as mediators. Multi-group comparisons assessed country differences. People with higher levels of education were more likely to eat the recommended diet, i.e., at least 5 portions of F&V a day. Countries in the sample vary significantly in the percentage of people complying with the recommendation, but not significantly in terms of relative education differentials. The educational gap in the intake of F&V is mainly explained by education differentials in financial availability, diet knowledge, and habits in inserting F&V in main meals. Policies targeting dietary inequalities should address behavioural triggers affecting dietary intake, for example by subsidising F&V, developing targeted dietary awareness campaigns, or by intervening in mass catering contexts to facilitate the implementation of healthy habits.

How to Achieve a Healthier and More Sustainable Europe by 2040 According to the Public? Results of a Five-Country Questionnaire Survey.

The aim of this paper is to understand public preferences for several future scenarios of achieving a healthier, more equitable and sustainable Europe, which differ in the way the society is organized (individualistically vs. collectively) and in the driving sector (public vs. private). To achieve this aim, we conducted a questionnaire survey using representative samples for five European countries in 2018. About three thousand respondents chose among the four scenarios presented within four different contexts (green spaces, active mobility, energy-efficient housing, food consumption) or none of them. A majority of people in the five European countries were ready to accept one of the scenarios. We found significant differences in preferences according to socioeconomic backgrounds and values of respondents. People above 35 years old, those who were less educated, and those in the lowest household income tertile were less supportive of all scenarios. The heterogeneity in preferences associated with differences in socioeconomic backgrounds was larger for the scenario in which society is organized individualistically and driven by the private sector. Smaller distinctions were found in case of the scenario in which society is organized collectively and is driven by the public sector. Departing from social psychological theories, we examine the role of altruistic, biospheric, egoistic, hedonic, and security values. People with stronger biospheric values were more likely to accept scenarios, particularly those which are driven by the public sector and where there is more collective organisation. Those with a more egoistic value orientation were more likely to have higher preferences for scenarios where the private sector had a dominant role. The policy implications, in terms of the selection and framing of policy measures to enhance public support, are discussed.

Equity, Health, and Sustainability with PROVE: The Evaluation of a Portuguese Program for a Short Distance Supply Chain of Fruits and Vegetables.

PROVE is a Portuguese program that empowers small-scale farmers organized into local networks to directly commercialize baskets of locally produced fruits and vegetables to consumers. This study applied a post-test-only non-equivalent group design to evaluate the resulting influence on the social empowerment of farmers and on consumer diets. The method included conducting a survey of PROVE farmers (n = 36) and a survey of PROVE consumers (n = 294) that were compared against matched samples of Portuguese respondents of international surveys (European Social Survey,n = 36 and the INHERIT Five-Country Survey, n = 571, respectively). PROVE farmers reported higher scores for perceived influence on the work environment than the national sample. PROVE consumers were more likely to eat five or more portions of fruits and vegetables a day in comparison to the matched sample of Portuguese citizens (average odds ratio: 3.05, p < 0.05). Being a PROVE consumer also generated an impact on the likelihood of consuming no more than two portions of red meat a week (average odds ratio: 1.56, p < 0.05). The evaluation study suggests that the promotion of short supply chains of fruits and vegetables can make a positive contribution to a healthier, more sustainable, and fairer future in food consumption.

Ten Lessons for Good Practice for the INHERIT Triple Win: Health, Equity, and Environmental Sustainability.

The world's challenges of climate change, damage to ecosystems, and social and health inequalities require changes in human behaviours at every level of organisation, among governments, business, communities, and individuals. An important question is how behaviour change can be enabled and supported at the scale and speed required. The research reported in this paper describes important lessons for good practice in changing contexts to modify behaviours for a triple win for health, equity and environmental sustainability. Authors synthesised learning from qualitative, quantitative and cost benefit evaluations of 15 case studies conducted in 12 countries in Europe. The case studies address ways of living (green spaces and energy efficient housing), moving (active transport) and consuming (healthy and sustainable diets) that support the triple win. Ten lessons for good practice were identified. These include bringing a triple win mindset to policy and practice in planning interventions, with potential to improve environmental sustainability, health and equity at the same time. The lessons for good practice are intended to support governmental and non-governmental actors, practitioners and researchers planning to work across sectors to achieve mutual benefits for health and environmental sustainability and in particular to benefit poorer and more socio-economically disadvantaged groups.

The role of personal social networks on health inequalities across European regions.

The role of personal social networks on health inequalities is little understood. Theoretically, the characteristics of social network features can contribute to, both, increase and attenuate health inequalities. Few empirical studies that focus on the interaction between socioeconomic position and social networks provide little insight on the topic. Using data from the Survey of Health, Ageing and Retirement in Europe, this study analyses the moderation role of personal social networks on health inequalities in later life among northern, central, and southern European regions. Social advantages of higher socioeconomic individuals are re-enforced by the quality of social connections and the provision of social support. In turn, health inequality is attenuated by marital partnership and participation on social activities that benefits more the health of people at lower socioeconomic positions. Furthermore, results suggest that the influence of social network features on health inequalities is shaped by regions' different policy commitments to familiarization/defamilialization pressures.