Learning from each other: benchmarking the ‘nutrition sensitivity’ of New Zealand DHB food and beverage policies

Background: Policy is increasingly being promoted as an important public health tool for tackling obesity. Pressures are mounting for healthy food policy in New Zealand public hospitals as a means of role-modelling healthy eating. Food policy can be used in the hospital setting to ensure the nutrition quality of food and foodservices. Currently, there is no government policy directing the quality of food in NZ hospitals, possibly because there is no research on food policy in the twenty NZ District Health Boards (DHBs). Balanced Score Cards are known to be an effective means of assessing policy and health system performance, however there are no Balanced Score Cards for assessing the ‘nutrition sensitivity’ of DHB food policy. Objective: The aim of this project was to develop and apply a Balanced Score Card of ‘nutrition sensitivity’ indicators to New Zealand DHB food and beverage policy. Secondly, the study aims to explore the barriers to, and facilitators of, food and beverage related policy in New Zealand DHBs. Methods: A single case study design was used to assess the nutrition sensitivity of DHB food and beverage policies and the DHB policymaking processes. Both quantitative and qualitative research methods were used. A Balanced Score Card created from best practice nutrition policy guidelines was used to assess the nutrition sensitivity of documented DHB policies, resulting in each DHB’s policy receiving a nutrition sensitive score. The score card had three components (development, implementation and monitoring, and nutrition quality indicators). Semi-structured interviews were conducted with policy advocates from each DHB. The interviews explored the experiences of policy advocates involved in food and beverage policy, with a focus on the barriers to, and facilitators of, policy processes. Interview transcripts were analysed thematically using a general inductive approach. Results: Healthy food environment policies for staff and visitors are prevalent across DHBs, with thirteen DHBs having active policy and five DHBs with policy under development. Only three DHBs had food and beverage policy for inpatients. There was a wide variation in the nutrition sensitivity scores across DHB policies. The most nutrition sensitive policies had the largest amount of detail, were the most recent, and were written by Dietitians. In general policies received a low score for their level of detail on implementation and monitoring. Analysis of interview transcripts produced six overarching themes for the factors which influence the DHB policy development and implementation process. These are; the presence of a ‘Policy Champion’, DHB senior management support, internal staff culture, external political environment, food contractors, and the evidence base for policy development. The main finding was that the elected Board and senior management have the strongest influence on food policy. Support from senior management for food policy resulted in a smoother implementation and more nutrition sensitive policy for the DHB. Conclusion: In New Zealand DHBs hospitals are role modelling healthy eating environments with the use of nutrition sensitive food and beverage policy for their staff and visitors. However these hospitals are unlikely to have Board approved food policy for their inpatients. This is concerning considering Dietitians, the traditional ‘gate-keepers’ of NZ hospital food quality, are moving away from foodservice into clinical roles. The development of nutrition sensitive policy should be a focus for DHBs and the Balanced Score Card developed in this study is a tool to guide food policy development and evaluation. Senior management have a strong influence on the quality of food policy and should support evidence based policy development to create a health promoting environment alongside patient treatment goals