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A qualitative study of independent fast food vendors near secondary schools in disadvantaged Scottish neighbourhoods

A qualitative study of independent fast food vendors near secondary schools in disadvantaged... Background: Preventing and reducing childhood and adolescent obesity is a growing priority in many countries. Recent UK data suggest that children in more deprived areas have higher rates of obesity and poorer diet quality than those in less deprived areas. As adolescents spend a large proportion of time in school, interventions to improve the food environment in and around schools are being considered. Nutrient standards for school meals are mandatory in the UK, but many secondary pupils purchase foods outside schools at break or lunchtime that may not meet these standards. Methods: Qualitative interviews were conducted with fast food shop managers to explore barriers to offering healthier menu options. Recruitment targeted independently-owned shops near secondary schools (pupils aged c.12-17) in low-income areas of three Scottish cities. Ten interviews were completed, recorded, and transcribed for analysis. An inductive qualitative approach was used to analyse the data in NVivo 10. Results: Five themes emerged from the data: pride in what is sold; individual autonomy and responsibility; customer demand; profit margin; and neighbourhood context. Interviewees consistently expressed pride in the foods they sold, most of which were homemade. They felt that healthy eating and general wellbeing are the responsibility of the individual and that offering what customers want to eat, not necessarily what they should eat, was the only way to stay in business. Most vendors felt they were struggling to maintain a profit, and that many aspects of the low-income neighbourhood context would make change difficult or impossible. Conclusions: Independent food shops in low-income areas face barriers to offering healthy food choices, and interventions and policies that target the food environment around schools should take the neighbourhood context into consideration. Keywords: Fast food, Diet, Nutrition, Food policy, Adolescence, School meals, Neighbourhood, Food vendors Background stronger in northern European countries [4]. The study Adolescence has been identified as a critical period in also found that nutrition knowledge among European the formation of dietary habits and the development of adolescents was “modest” at best and concluded that in- long-term patterns in body weight [1,2]. Obesity in child- terventions targeting lower-income groups are needed [5]. hood is a particular concern because it is linked to a range Family environment plays an important role in shaping of poorer health outcomes tracking through to adulthood diet and lifestyle, but many children spend a considerable [3]. Data pooled from a nine-country study in Europe proportion of time away from home in, and beyond, the revealed that socioeconomic status (SES) is related to school environment. It is in such settings that the ability adolescent diet quality, and the association becomes to make autonomous choices is developed and exercised. Numerous countries have school meal nutrient standards * Correspondence: [email protected] that are statutory and well-defined [6] but may not reach University of Aberdeen, Aberdeen, Scotland 3 children who bring food from home or purchase lunch Scottish Collaboration for Public Health Research & Policy, Edinburgh, Scotland outside of school. In Scotland, 63% of secondary school Full list of author information is available at the end of the article © 2014 Estrade et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Estrade et al. BMC Public Health 2014, 14:793 Page 2 of 8 http://www.biomedcentral.com/1471-2458/14/793 students report purchasing food and beverages outside of on the proportion of pupils entitled to free school meals school at lunchtime at least occasionally [7]. An observa- [15], which is based on household income. Schools were tional study in Glasgow noted that food outlets catered spe- classified by this measure of household poverty rather cifically to pupils by offering them special lunchtime meal than using area-level deprivation index, as a school’s deals and promotions [8]. Subsequent analysis of the foods location may not necessarily coincide with the socio- offered revealed that many exceeded recommended levels demographic profile of its pupils, given that secondary of energy, fat, and saturated fat, and salt. Further afield, a school pupils come from a wider catchment area than Brazilian study found that shops with more processed foods the area immediately surrounding the school. Geographic were closer to schools than those selling minimally- Information System [GIS] maps, built on those created for processed foods [9], and data from the Health Behaviour of a previous study geocoding food retailers’ proximity to School Children (HBSC) surveys in Canada showed a sig- schools [16], were used to identify takeaway shops within nificant association between food retailer density within easy walking distance (~1 km via road network, around a walking distance of schools and the probability of pupils 10 minute walk) of schools where the proportion of pupils eating lunch from those nearby retailers [10]. entitled to free school meals was above the national Policy efforts in a number of countries have been average. On-the-ground observations were carried out aimed at addressing obesity in a public health context, to confirm that locales meeting these inclusion criteria for example though mandatory calorie labelling on menus, were also open for business during school lunch hours. restrictions on advertising of unhealthy foods to children, taxes on sugar-sweetened beverages or high-fat foods, Sampling and recruitment limitations on serving sizes, and a ban on trans fats [11]. A purposive sample of independent establishments sell- In May 2013 the Scottish Government issued a draft ing foods prepared on site for take-away consumption framework, entitled Supporting Healthy Choices [SHC] during the school lunch period were selected. Chain res- [12], encouraging food vendors in Scotland to offer taurants and shops (those with multiple locales, in which healthier options, particularly to children and young site managers did not have executive decision-making people. The document details a wide range of recom- power) were excluded as managers at those sites were mended changes in cooking practices, promotional ac- expected to have limited control over menus and pri- tivities, portion sizes, as well as types and portion sizes cing: this was confirmed by speaking with on-site man- of foods offered. If implemented, it is envisaged that agers of two popular chains while recruiting. A total of such changes could have a potentially beneficial impact fourteen shops were excluded for this reason. Recruit- on the nutritional quality of food bought by pupils who ment materials were delivered to every shop meeting the eat outside of school at lunchtime. While a similar ef- inclusion criteria (total of 35) within the defined recruit- fort, known as the Responsibility Deal [13], has been ment areas by a member of the research team (ME). tried in England, it has consisted almost exclusively of In total, 35 invitations were distributed. Recruitment larger franchises signing on. Little is known about the packs contained a user-friendly expression of interest way in which smaller, independent food businesses view form, along with a pre-stamped, addressed envelope. these kinds of public health nutrition guidelines, nor Only one response was received, which was from a the reasons they might have for not signing on to such vendor who did not want to participate. In-person follow- initiatives. up visits to each shop, typically three or four visits per This aim of this study was to identify the challenges shop, were then made in order to obtain interviews. The that owners of small (independent) food businesses most common reason given by food vendors for declining might face in making changes to improve the nutritional participation was a lack of time or extra personnel to quality of their menu options. Given that interventions cover the duties of the manager/owner while s/he was targeting lower-income groups are needed [5], we focused being interviewed. Though we initially planned for 15–20 our data collection in less-affluent areas around Scotland. interviews, data saturation was reached quickly, such that no new codes were derived from the final two inter- Methods views, and further efforts to recruit were halted after 10 The research team ensured that this study was conducted interviews. and reported in accordance with the RATS guidelines for qualitative research [14]. Data collection Ethical approval for the study was obtained from the Setting College of Life Sciences and Medicine Ethics Review Lower-income areas around two secondary schools (pupils Board at the University of Aberdeen prior to commen- aged c.12-17) were selected in each of three Scottish cities: cing recruitment. Informed consent was obtained in Aberdeen, Edinburgh, and Glasgow. Schools were selected writing from each vendor prior to being interviewed. All Estrade et al. BMC Public Health 2014, 14:793 Page 3 of 8 http://www.biomedcentral.com/1471-2458/14/793 interviews took place on the premises of the takeaway Themes shops and lasted approximately ½ hour. Those who com- Five overarching themes emerged throughout the inter- pleted the interview received a £15 grocery gift card in ac- views. These were: pride in what is sold; the concept of knowledgement of their time sacrifice. Interviews followed individual responsibility for one's health; customer de- a semi-structured topic guide to explore food vendor ex- mand; profit margins; and the unique underpinnings of periences and views on making healthy changes to menus. the neighbourhood context. Words in brackets have Recommendations within the SHC framework formed the been added to some quoted material in order to clarify basis for many of the questions. Examples of the topics meaning. For differentiation, a unique code assigned to covered included: factors affecting decisions about what to the individual vendor appears before each quote. offer on the menu and what price to ask; the meaning of “healthy eating” and its role in a takeaway environment; the potential role of NHS Health Scotland’sHealthy Living Pride in what is sold Award [17]; and the feasibility of specific recommenda- The independent food vendors interviewed in this study tions within the SHC framework. During the interviews, consistently took pride in the food they sold, most of further probing questions were asked within each discus- which they made themselves. They used words like trad- sion topic to elicit deeper responses about the habits and itional, proper,and fresh to describe their menus, and preferences of schoolchildren as customers. viewed themselves proudly as an integral part of the fabric and identity of the neighbourhoods in which they did Analysis business. Belief that they were preparing food the “proper” Interviews were audio-recorded and transcribed verbatim, way was one important factor affecting their willingness to and transcripts were loaded in to NVivo 10 [18] for coding make changes to cooking methods. and analysis. Given the emergent nature of the data and [v1] Beef dripping is what we cook in and it’s… I mean the importance of letting participant voices be heard, a how can we say we’re traditional if we’re cooking in data-driven inductive thematic analysis method was used, palm oil? Palm oil is a new thing, or rapeseed oil, it’sa allowing themes to develop directly from the data in the new one, and that’s not the taste. It does affect the taste. absence of any pre-existing model or framework. A total While vendors recognised that diet quality and healthy of 39 codes were identified and then grouped together by eating were public health concerns, they tended to be- conceptual similarity. A theme was developed for each lieve that they were selling healthier foods than their group of codes, chosen as a word of phrase that would competitors, and that other shops in the neighbourhood best describe and encompass the essence of the codes in were the ones in need of making changes. that group. Constant comparison was used to ensure rep- [v1] …they’ve proven like a fish & chips is healthier resentation of all perspectives, and negative cases as well than, well it’s got less calories and stuff in it than your as unanticipated themes were sought [19,20]. Interviews, kebabs or your pizzas. transcription, and coding were all undertaken by a single [v2] …well actually this kebab shop is more healthy researcher (ME), ensuring the highest possible level of than chippie shops. Fried things, you know they cook it acquaintance with the data. A second researcher (SD) in the fat, full fat oil and everything, and this is like, un- independently coded a random selection of interviews for healthy, you know? We cook mostly pizzas and kebabs comparison, in order to confirm coding validity. Initial and grill, and it's very healthy, you know… [fat] going coding agreement was over 87%, and the remaining codes down with pure meat left, and salad. It’s very healthy. were settled upon with input by a third researcher (RJ). th Table 1 Recruitment statistics Data saturation was reached by the 8 interview. Establishment type Invited Interviews attained Ninety-two per cent of the codes had been established after seven interviews, and no new codes emerged from Café/sandwich/snack shop 16 5 the final two interviews. Kebab 7 2 Fish & Chipper 6 2 Results Chinese 3 0 Nine of the interviews were conducted with managers or Indian 2 1 owners of the participating businesses, and one was con- Mobile van 1 0 ducted with a senior employee familiar with the workings of the business. Although more of the invitees were male, Total 35 10 a greater number of female interviews were obtained. Invitee Gender Forty per cent of all female invitees agreed to an inter- Male 20 4 view, while only twenty per cent of male invitees did so Female 15 6 (Table 1). Estrade et al. BMC Public Health 2014, 14:793 Page 4 of 8 http://www.biomedcentral.com/1471-2458/14/793 Personal autonomy and responsibility Several managers with school-aged children or Belief in individual and personal responsibility was a grandchildren expressed their frustration at the pref- broad and cross-cutting theme, coming out in every erences and purchasing habits of school children interview across a range of general questions about the who entered their shops at lunchtime. Many also felt meaning of healthy eating, as well as specific questions that offering healthier options to school children about the SHC framework. would not be enough to produce any real change in Most vendors felt they already provided opportunities behaviour. for healthy eating, but that customers who purchase the [v6] School kids eat chips. And baguettes. That's it. less healthy options would not be persuaded to change They dinnae [don’t] want anything else but chips and their food preferences, especially school children. The curry sauce or chips and cheese, and a baguette. vendors consistently saw themselves as external to cus- [interviewer] What about offering a healthy meal deal tomers’ preferences and felt they had very little influence or discount? in a customer’s decision-making process. [v6] I would like to do that with the kids, because we [v3] …if somebody wants to eat fried chicken, you do salad boxes. I'd like to do that. But it's just, they can’t convince him, no: go for grilled… cannae [can’t] see past chips. I'd like to do an offer on Several were keenly aware of the negative press directed the salad boxes, but it's just they want chips. at takeaways in relation to obesity and conveyed a sense of [interviewer] Do you do special offers for the kids? antipathy to that notion. [v7] Yeah we do, but it’s a healthy option, it’s a sugar- [v1] Obesity starts from… you've got to get into values. free juice, baked crisps, and a tuna roll. I mean, I’m an overweight woman. I know why I’m over- [interviewer] Do they go for that? weight. It’s because I eat too much. It’s not rocket sci- [v7] No! …we’re lucky if we sell one a month! ence. Everybody knows that. You just can't blame a A sense of niche was an important part of why vendors company or whatever, because it's what I choose to eat. perceived that their customers would not be receptive to [v5] I usually like to give enough food for the cus- more healthy options from their outlet. tomer, so it's up to them to make up their own mind [v4] …certainly if there was anything like a deal with a about how much they eat… I mean when you reach healthier option, people prefer to go to a sandwich shop 18 years old, even before that, you're responsible for for sandwiches and come to a chipper for chipper food… what you put in your stomach… If you want to eat well, As I say, people are coming to the chip shop and they’re you will eat well. coming because they want… they’re not coming because [v8] Is it not [enough] just reducing their portion sizes they want fruit. when they’re home? One vendor described the problem as one that is influ- enced by more upstream factors. [interviewer] If you have a meal deal and in place of Customer demand crisps you give fruit, and in place of fizzy drink you offer Vendors were keenly aware of customer preferences and water, would people go for that? felt they needed to offer what customers perceived as [v10] No! Ha! No! I think you have to get the kids “good food” and in order to keep their business. They when they’re young to build it up. And I think, because conveyed a strong belief that simply offering healthier there’s quite a lot of poverty, they just go for the cheap- options wouldn’t create a shift in customer demand, est and the most filling. And that’s what the problem viewing themselves as relatively powerless to change is… it’s instilled in them… what people want. Some also felt that offering too many options could [v4] No. I don’t think we have the influence [on what put customers off. customers eat]. I think people have got their favourite [v8] I think the customers might start getting confused kind of food…and if you’re a good business, then yes, because there’s just too much choice. I think that can be your reputation will bring people back. So, I think that off-putting as well. I think we’ve kinda discovered that, would be the influence. Good food. even after all these years, that too much choice people [v3] …the people who are health conscious, they only don’t like. They like a limited [choice] so that it’seasy think about that. The people who are not, they don't for them to pick. bother you even with 100 different options, they're gonna pick the Coke out of it. You know, so this is not Being profitable actually the question, what is available, what is not Cost and profitability were major concerns among food available. …if somebody wants something, they come vendors, especially in regards to introducing healthier here to buy that thing. They don't come here to [say] options. Price was seen as playing a central role in cus- “okay, don't give me this, you can give me that”. tomers’ decisions about which menu items to choose, Estrade et al. BMC Public Health 2014, 14:793 Page 5 of 8 http://www.biomedcentral.com/1471-2458/14/793 and most vendors cited it as the key factor in their own neighbourhood were viewed as an added burden in the decisions about which products to purchase for their struggletomakeaprofit. shop and from which suppliers. They described a constant [v2] we are still selling the same things, you know, struggle to cope with the economic pressure of rising food same prices… if you put it too high… oh! Customers say costs and tightening profit margins. Many vendors also it's too expensive. It's too expensive….in this area. In cited difficulty in finding the right balance between in- some rich areas people don't complain… creasing menu prices and keeping their customers. [v3] it's very hard. A takeaway business is very hard. [v4] Prices have gone up. Even like potatoes. I mean at To get a customer and keep it, it's very hard… There's this time last year… we're getting three times the price already so much struggling in this, particularly in this of potatoes to what we were last year because of all the area, you have to survive very hard…the business is floods in England and that, so, and the fish is scarce, so struggling… There are like four takeaways just on this that's gone up considerably. So that's your two main street which are empty. things you use in this kind of business, so yeah, it's kinda [v1] the prices have gone up so much where our profit costly… And I think just with the recession and that margin… we're just barely making a profit just now. If people are kind like choosing something a bit cheaper we were probably anywhere else in Aberdeen or in the because they can't really afford these expensive meals. city centre we'd be able to charge more, but in [this Healthier options were viewed as unfeasible in many neighbourhood], most of our customers are on a limited cases, because vendors perceived that they wouldn’tbe budget. We just can't, we're just pared right down to able to charge enough to make a profit. the bone. [interviewer] Do you think there’s any way they could Most vendors were not keen to seek out publicity for be enticed to buy [healthier options]? healthy menu options. They did not believe that a [v10] I don’t know, you’d probably have to give them Healthy Living Award [17] would have any positive im- away for nothing… pact on their business or customers’ perceptions, and [v6] I don't allow my [own] kids to have fizzy juice that it might even send mixed messages. [carbonated soft drinks], so I dinnae [don’t] really like [v1] I think that would be a bit of a joke… people having it. I'd like to buy fresh juice, but it's the prices… would be laughing at that in a chip shop. it's so expensive, and you wouldn't make any money. [v3] If you're sitting on Princes Street [centre of Edinburgh], With the price you would have to charge, they would posh people walking in, they see this [HLA] sticker in nae [not] want to buy it. So you've got to think of that as the window, yes, they pick like that. Yes, it does matter. well… A case of Coke for seven pound, you would never Because their sort of perception, you know… they want buy juice for that price; no way… If the government to seethose sort of things.But theareawelivein… they wants you to buy all this fresh stuff, they should bring don'tcarewhatyou display. down the price. However, one vendor commented that it could be a Because vendors were struggling to turn a profit in good way to attract couples or groups who want to eat order to stay in business, a culture of competition was together but have varying priorities and preferences also evident in many of the neighbourhoods, including when it comes to healthy eating. rivalry for pupils’ lunchtime business. [v6] They just want chips… they go about looking for the deals; they'll have a look and then go along have a Regulatory levers look at their deals and then come back and they'll An alternative approach being implemented in various order… they like the value for money. The competition countries is use of regulatory levers involving health- here is unbelievable. related food taxes, although with the exception of sugar sweetened beverages [21] there is little evidence based Neighbourhood context on rigorous evaluation [22,23]. During interviews in the In all three cities, interviews were conducted in neigh- current study, we discussed food taxes with the vendors. bourhoods that were comparatively less well-off than They tended to be strongly opposed to this approach be- many others in their city. Though shops were chosen for cause they felt that it would be an unfair burden on small their proximity to schools in which a higher than na- business. In particular, because of the neighbourhood tional average proportion of children were receiving free context and their hesitancy to ask higher prices of their school meals, the Scottish Index of Multiple Deprivation customers, vendors believed that they would have to score confirmed the status of each neighbourhood as bear the cost of taxes targeting specific foods. more deprived. Food vendors sensed this, and though [v1] Supermarkets can absorb it. We can't. We can't the economy in general was implicated as a negative absorb that kind of tax. It’s crazy. I can't see how that factor, the unique and enduring characteristics of each would influence obesity. Estrade et al. BMC Public Health 2014, 14:793 Page 6 of 8 http://www.biomedcentral.com/1471-2458/14/793 Vendors also felt that any increase in price might In their study on features of convenience stores sur- drive customers to purchase the more expensive foods rounding schools in Minnesota, USA, Gebauer et al. [28] elsewhere. identified the following as barriers to stocking healthy [v8] I don’t think that is gonna do anything [for obes- foods: challenge to switch over stock, lack of infrastruc- ity]. It’s just gonna affect our business. You know, be- ture, and fear of losing business. All of these have been cause they’ll maybe not buy it from here, but they’ll get expressed as concerns in the current study by the food it cheaper at the supermarkets. vendors interviewed. In addition, the vendors we inter- viewed cited lack of technical knowledge that would be Discussion needed to implement the SHC guidelines, for example in The aim of this study was to identify potential barriers order to offer calorie information to customers. Several that independent fast food vendors near lower-income UK cities have had success offering this type of training to secondary schools might face in offering healthier menu fast food vendors as part of local healthier food awards options. The food vendors in this study were proud of schemes [29,30]. However, because vendors in our study the foods they made and sold, and viewed their offerings mentioned that healthy food awards were not important as healthier than their competitors’. While they recognised to their customers, alternate incentives may be needed to that obesity is a major public health problem, vendors felt reach vendors in deprived areas. As an example, a scheme that both the cause and resolution are rooted in individual implemented in Northern Ireland offered a £200 grant to responsibility for one’s diet and lifestyle choices. They ex- businesses who took part in the Healthier Takeaways Pro- plained that, as with non-food businesses, responding to ject [31]. The program was successful in helping fast food customer demand is a priority, and that customers in their vendors to make small, sustainable changes, like replacing area, especially school children, would not be persuaded 17-hole salt shakers with 5-hole shakers in order to reduce to purchase healthier foods. Vendors in these relatively levels of added salt. low-income neighbourhoods expressed concerns about of- Although the idea of regulation was opposed by most fering menu items that wouldn’t sell well, because they vendors in our study, it could be a useful tool to “level were already struggling to maintain a profit and stay in the playing field” and ease the pressure on vendors to business. When explaining why it would be unfeasible for compete. One current approach being discussed is the them to offer healthier options or change their customers’ possibility of policies to limit targeting and promotional behaviours, they cited characteristics rooted in culture and strategies that vendors utilise to attract school pupils as the neighbourhood context. lunch-time customers [32]. The views expressed by food vendors in this study are In addition to targeting food vendors, interventions similar to those from a London study that examined in- that target consumer behaviour may be necessary to in- dependent food vendors’ views on implementing better fluence customer demand to which vendors respond. sustainability practices. The vendors felt unable to make Further research is needed to identify the factors that changes to their business practices because profit mar- most influence the food choices of pupils in deprived gins were too tight to risk a drop in customer demand areas. It is worth noting, however, that school children [24]. In our study, vendors’ views about individual re- make up only a fraction of the clientele for the food ven- sponsibility for eating habits, body weight, and health in dors we interviewed. Vendors must take the preferences general were also consistent with current cultural norms. of the wider community that they serve into account, When members of a large restaurant association were and therefore targeting pupil behaviour may not be surveyed, health and nutrition issues were reported by enough. less than 1% of restaurant owners and managers as Examining the situation through an economic lens can topics of concern [25], and a recent survey of British also help explain the positions taken by food vendors in this study. Chell and Pittaway [33] explored the ways in adults found that nearly two thirds believed that being overweight was an individual’s own fault, attributable to which restaurant and café entrepreneurs talked about a lack of willpower [26]. their businesses and found large differences in the actions taken by expanding businesses compared to declining The vendors we interviewed felt they occupied a spe- cial niche in their neighbourhoods with the type of foods businesses. Expanding businesses described measures that they offered and were reluctant to change those offer- characterised proactive behaviours, such as making menu changes. Declining businesses described measures indica- ings. They were also reluctant to add healthier options (as an alternative to replacing current menu items) be- tive of reactive behaviour, such as making changes based cause they felt that too much choice would put customers on an Environmental Health officer’s recommendations. Given that the businesses we interviewed described them- off. Current literature in this area indeed supports the idea that too much choice can have negative psychological selves as struggling to survive, it is logical to question effects for customers [27]. whether or not these businesses can be expected to Estrade et al. BMC Public Health 2014, 14:793 Page 7 of 8 http://www.biomedcentral.com/1471-2458/14/793 implement proactive changes without clear evidence of guidelines may inadvertently exclude shops in disadvan- potential economic benefit. taged neighbourhoods from feasible participation, thereby Time has been cited in a number of studies as an im- potentially widening current inequalities. If voluntary portant factor of influence on food choice [34], and it frameworks are to be implemented in economically dis- has been described by schoolchildren as a concern of advantaged areas, independent food vendors may need higher importance than cost [35]. Therefore, we ex- substantial financial and technical assistance to ensure pected time to come out as a strong theme that vendors that their customers don’t miss out on potential benefits. recognised as important in attracting customers, particu- Competing interests larly at school lunch time, but it was only mentioned The authors declare that they have no competing interests. briefly in two out of the ten interviews. It became clear through our own observations, as well as from the com- Authors’ contributions All authors contributed to designing the study. ME carried out data ments of the food vendors, that the schoolchildren in collection and analysis. ME, SD, and RJ validated the coding framework. All these neighbourhoods are willing to spend their lunch authors were involved in editing the manuscript, and all authors approved time in longer queues to get the best deal on the foods the final manuscript. they want. One possible explanation is that within the Acknowledgements deprived neighbourhood context, time may become a We are very grateful to the food vendors who took time to participate in less important aspect than price, since previous research this study. This study was funded by the Scottish School of Public Health Research. AE is supported by the Medical Research Council (Neighbourhoods in low-income communities has found that cost is a and Health Programme MC_UU_12017/8). major barrier to healthy food choices [36]. When chil- dren from a deprived London neighbourhood were Author details 1 2 University of Aberdeen, Aberdeen, Scotland. Glasgow Centre for Population asked what would motivate them to make healthier Health, Glasgow, Scotland. Scottish Collaboration for Public Health Research choices at takeaways, they cited cheaper prices and a & Policy, Edinburgh, Scotland. MRC/CSO SPHSU, University of Glasgow, better choice of foods, including fruits and vegetables Glasgow, Scotland. [37], and a study in Glasgow produced similar findings Received: 18 March 2014 Accepted: 29 July 2014 [32]. To inform the planning of targeted interventions, Published: 4 August 2014 further in-depth follow-up among schoolchildren in dis- advantaged neighbourhoods will be useful. References 1. Alberga AS, Sigal RJ, Goldfield G, Prud’homme D, Kenny GP: Overweight The hard-to-reach population represented in this study and obese teenagers: why is adolescence a critical period? Pediatr Obes makes it unique. Because independent food vendors in 2012, 7:261–273. low-income areas are a very difficult group to recruit, this 2. Jeffery RW, Linde J: Popoulation approaches to obesity prevention. In Obesity Prevention and Public Health. Edited by Crawford D, Jeffery RW. New is one of few studies that has involved them directly and York: Oxford University Press; 2005. brought their opinions and concerns to light. However, 3. 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Gostin L: Law as a tool to facilitate healthier lifestyles and prevent fering healthy food choices, and implementing voluntary obesity. JAMA 2007, 297:87–90. Estrade et al. BMC Public Health 2014, 14:793 Page 8 of 8 http://www.biomedcentral.com/1471-2458/14/793 12. Supporting Healthy Choices: A draft framework for voluntary action. Scottish 37. Patterson R, Risby A, Chan MY: Consumption of takeaway and fast food in Government. May 2013: http://www.scotland.gov.uk/Resource/0042/ a deprived inner London Borough: are they associated with childhood 00422516.pdf. obesity? BMJ 2012, 2:e000402. 13. Public Health Responsibility Deal: England Department of Health. 2014. 38. Economos C, Folta S, Goldberg J, Hudson D, Collins J, Baker Z, Lawson E, https://responsibilitydeal.dh.gov.uk/. Nelson M: A community-based restaurant initiative to increase availability 14. Clark J: How to peer review a qualitative manuscript. London: BMJ Books; of healthy menu options in Somerville. Massachusetts: Shape Up 2003. Somerville. Preventing Chronic Disease 2009, 6:A102. 15. Education Scotland: Scottish Schools: Free school meal statistics by school. 2012. http://www.educationscotland.gov.uk/scottishschoolsonline/. doi:10.1186/1471-2458-14-793 Cite this article as: Estrade et al.: A qualitative study of independent fast 16. Ellaway A, Macdonald L, Lamb K, Thornton L, Day P, Pearce J: Do obesity- food vendors near secondary schools in disadvantaged Scottish promoting food environments cluster around socially disadvantaged neighbourhoods. BMC Public Health 2014 14:793. schools in Glasgow, Scotland? Health Place 2012, 18:1335–1340. 17. Healthy Living Award. NHS Health Scotland. http://www.healthylivingaward. co.uk/. 18. NVivo 10 Qualitative analysis software. QSR International; 2013. 19. Pope C, Ziebland S, Mays N: Qualitative research in health care. Analysing qualitative data. BMJ 2000, 320:114–116. 20. 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Dar-Nimrod I, Rawn C, Lehman D, Schwartz B: The maximization paradox: The costs of seeking alternatives. Pers Indiv Differ 2009, 46:631–635. 28. Gebauer H, Laska MN: Convenience stores surrounding urban schools: an assessment of healthy food availability, advertising, and product placement. J Urban Health 2011, 88:616–622. 29. McIntyre A: Award scheme in healthy food appeal to takeaways. Wharfedale Observer: http://www.wharfedaleobserver.co.uk/news/10545063. Award_scheme_in_healthy_food_appeal_to_takeaways/; 16 July 2013. 30. Healthier chips award scheme: Healthier chips award scheme. Rochdale Borough Council. http://www.rochdale.gov.uk/campaigns/healthier_chips. aspx; 2013. 31. Evaluation of the Healthier Takeaways Project. Antrim Borough Council Environmental Health Department; 2009. www.foodvision.cieh.org/ document/view/243. 32. The ‘Big Eat In’ follow up study; Final report. Glasgow Centre for Population Health: Scottish Centre for Social Research; 2011. 33. 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Withall J, Jago R, Cross J: Families’ and health professionals’ perceptions • Convenient online submission of influences on diet, activity and obesity in a low-income community. • Thorough peer review Health Place 2009, 15:1078–1085. • No space constraints or color figure charges • Immediate publication on acceptance • Inclusion in PubMed, CAS, Scopus and Google Scholar • Research which is freely available for redistribution Submit your manuscript at www.biomedcentral.com/submit http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png BMC Public Health Springer Journals

A qualitative study of independent fast food vendors near secondary schools in disadvantaged Scottish neighbourhoods

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Springer Journals
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2014 Estrade et al.; licensee BioMed Central Ltd.
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1471-2458
DOI
10.1186/1471-2458-14-793
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Abstract

Background: Preventing and reducing childhood and adolescent obesity is a growing priority in many countries. Recent UK data suggest that children in more deprived areas have higher rates of obesity and poorer diet quality than those in less deprived areas. As adolescents spend a large proportion of time in school, interventions to improve the food environment in and around schools are being considered. Nutrient standards for school meals are mandatory in the UK, but many secondary pupils purchase foods outside schools at break or lunchtime that may not meet these standards. Methods: Qualitative interviews were conducted with fast food shop managers to explore barriers to offering healthier menu options. Recruitment targeted independently-owned shops near secondary schools (pupils aged c.12-17) in low-income areas of three Scottish cities. Ten interviews were completed, recorded, and transcribed for analysis. An inductive qualitative approach was used to analyse the data in NVivo 10. Results: Five themes emerged from the data: pride in what is sold; individual autonomy and responsibility; customer demand; profit margin; and neighbourhood context. Interviewees consistently expressed pride in the foods they sold, most of which were homemade. They felt that healthy eating and general wellbeing are the responsibility of the individual and that offering what customers want to eat, not necessarily what they should eat, was the only way to stay in business. Most vendors felt they were struggling to maintain a profit, and that many aspects of the low-income neighbourhood context would make change difficult or impossible. Conclusions: Independent food shops in low-income areas face barriers to offering healthy food choices, and interventions and policies that target the food environment around schools should take the neighbourhood context into consideration. Keywords: Fast food, Diet, Nutrition, Food policy, Adolescence, School meals, Neighbourhood, Food vendors Background stronger in northern European countries [4]. The study Adolescence has been identified as a critical period in also found that nutrition knowledge among European the formation of dietary habits and the development of adolescents was “modest” at best and concluded that in- long-term patterns in body weight [1,2]. Obesity in child- terventions targeting lower-income groups are needed [5]. hood is a particular concern because it is linked to a range Family environment plays an important role in shaping of poorer health outcomes tracking through to adulthood diet and lifestyle, but many children spend a considerable [3]. Data pooled from a nine-country study in Europe proportion of time away from home in, and beyond, the revealed that socioeconomic status (SES) is related to school environment. It is in such settings that the ability adolescent diet quality, and the association becomes to make autonomous choices is developed and exercised. Numerous countries have school meal nutrient standards * Correspondence: [email protected] that are statutory and well-defined [6] but may not reach University of Aberdeen, Aberdeen, Scotland 3 children who bring food from home or purchase lunch Scottish Collaboration for Public Health Research & Policy, Edinburgh, Scotland outside of school. In Scotland, 63% of secondary school Full list of author information is available at the end of the article © 2014 Estrade et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Estrade et al. BMC Public Health 2014, 14:793 Page 2 of 8 http://www.biomedcentral.com/1471-2458/14/793 students report purchasing food and beverages outside of on the proportion of pupils entitled to free school meals school at lunchtime at least occasionally [7]. An observa- [15], which is based on household income. Schools were tional study in Glasgow noted that food outlets catered spe- classified by this measure of household poverty rather cifically to pupils by offering them special lunchtime meal than using area-level deprivation index, as a school’s deals and promotions [8]. Subsequent analysis of the foods location may not necessarily coincide with the socio- offered revealed that many exceeded recommended levels demographic profile of its pupils, given that secondary of energy, fat, and saturated fat, and salt. Further afield, a school pupils come from a wider catchment area than Brazilian study found that shops with more processed foods the area immediately surrounding the school. Geographic were closer to schools than those selling minimally- Information System [GIS] maps, built on those created for processed foods [9], and data from the Health Behaviour of a previous study geocoding food retailers’ proximity to School Children (HBSC) surveys in Canada showed a sig- schools [16], were used to identify takeaway shops within nificant association between food retailer density within easy walking distance (~1 km via road network, around a walking distance of schools and the probability of pupils 10 minute walk) of schools where the proportion of pupils eating lunch from those nearby retailers [10]. entitled to free school meals was above the national Policy efforts in a number of countries have been average. On-the-ground observations were carried out aimed at addressing obesity in a public health context, to confirm that locales meeting these inclusion criteria for example though mandatory calorie labelling on menus, were also open for business during school lunch hours. restrictions on advertising of unhealthy foods to children, taxes on sugar-sweetened beverages or high-fat foods, Sampling and recruitment limitations on serving sizes, and a ban on trans fats [11]. A purposive sample of independent establishments sell- In May 2013 the Scottish Government issued a draft ing foods prepared on site for take-away consumption framework, entitled Supporting Healthy Choices [SHC] during the school lunch period were selected. Chain res- [12], encouraging food vendors in Scotland to offer taurants and shops (those with multiple locales, in which healthier options, particularly to children and young site managers did not have executive decision-making people. The document details a wide range of recom- power) were excluded as managers at those sites were mended changes in cooking practices, promotional ac- expected to have limited control over menus and pri- tivities, portion sizes, as well as types and portion sizes cing: this was confirmed by speaking with on-site man- of foods offered. If implemented, it is envisaged that agers of two popular chains while recruiting. A total of such changes could have a potentially beneficial impact fourteen shops were excluded for this reason. Recruit- on the nutritional quality of food bought by pupils who ment materials were delivered to every shop meeting the eat outside of school at lunchtime. While a similar ef- inclusion criteria (total of 35) within the defined recruit- fort, known as the Responsibility Deal [13], has been ment areas by a member of the research team (ME). tried in England, it has consisted almost exclusively of In total, 35 invitations were distributed. Recruitment larger franchises signing on. Little is known about the packs contained a user-friendly expression of interest way in which smaller, independent food businesses view form, along with a pre-stamped, addressed envelope. these kinds of public health nutrition guidelines, nor Only one response was received, which was from a the reasons they might have for not signing on to such vendor who did not want to participate. In-person follow- initiatives. up visits to each shop, typically three or four visits per This aim of this study was to identify the challenges shop, were then made in order to obtain interviews. The that owners of small (independent) food businesses most common reason given by food vendors for declining might face in making changes to improve the nutritional participation was a lack of time or extra personnel to quality of their menu options. Given that interventions cover the duties of the manager/owner while s/he was targeting lower-income groups are needed [5], we focused being interviewed. Though we initially planned for 15–20 our data collection in less-affluent areas around Scotland. interviews, data saturation was reached quickly, such that no new codes were derived from the final two inter- Methods views, and further efforts to recruit were halted after 10 The research team ensured that this study was conducted interviews. and reported in accordance with the RATS guidelines for qualitative research [14]. Data collection Ethical approval for the study was obtained from the Setting College of Life Sciences and Medicine Ethics Review Lower-income areas around two secondary schools (pupils Board at the University of Aberdeen prior to commen- aged c.12-17) were selected in each of three Scottish cities: cing recruitment. Informed consent was obtained in Aberdeen, Edinburgh, and Glasgow. Schools were selected writing from each vendor prior to being interviewed. All Estrade et al. BMC Public Health 2014, 14:793 Page 3 of 8 http://www.biomedcentral.com/1471-2458/14/793 interviews took place on the premises of the takeaway Themes shops and lasted approximately ½ hour. Those who com- Five overarching themes emerged throughout the inter- pleted the interview received a £15 grocery gift card in ac- views. These were: pride in what is sold; the concept of knowledgement of their time sacrifice. Interviews followed individual responsibility for one's health; customer de- a semi-structured topic guide to explore food vendor ex- mand; profit margins; and the unique underpinnings of periences and views on making healthy changes to menus. the neighbourhood context. Words in brackets have Recommendations within the SHC framework formed the been added to some quoted material in order to clarify basis for many of the questions. Examples of the topics meaning. For differentiation, a unique code assigned to covered included: factors affecting decisions about what to the individual vendor appears before each quote. offer on the menu and what price to ask; the meaning of “healthy eating” and its role in a takeaway environment; the potential role of NHS Health Scotland’sHealthy Living Pride in what is sold Award [17]; and the feasibility of specific recommenda- The independent food vendors interviewed in this study tions within the SHC framework. During the interviews, consistently took pride in the food they sold, most of further probing questions were asked within each discus- which they made themselves. They used words like trad- sion topic to elicit deeper responses about the habits and itional, proper,and fresh to describe their menus, and preferences of schoolchildren as customers. viewed themselves proudly as an integral part of the fabric and identity of the neighbourhoods in which they did Analysis business. Belief that they were preparing food the “proper” Interviews were audio-recorded and transcribed verbatim, way was one important factor affecting their willingness to and transcripts were loaded in to NVivo 10 [18] for coding make changes to cooking methods. and analysis. Given the emergent nature of the data and [v1] Beef dripping is what we cook in and it’s… I mean the importance of letting participant voices be heard, a how can we say we’re traditional if we’re cooking in data-driven inductive thematic analysis method was used, palm oil? Palm oil is a new thing, or rapeseed oil, it’sa allowing themes to develop directly from the data in the new one, and that’s not the taste. It does affect the taste. absence of any pre-existing model or framework. A total While vendors recognised that diet quality and healthy of 39 codes were identified and then grouped together by eating were public health concerns, they tended to be- conceptual similarity. A theme was developed for each lieve that they were selling healthier foods than their group of codes, chosen as a word of phrase that would competitors, and that other shops in the neighbourhood best describe and encompass the essence of the codes in were the ones in need of making changes. that group. Constant comparison was used to ensure rep- [v1] …they’ve proven like a fish & chips is healthier resentation of all perspectives, and negative cases as well than, well it’s got less calories and stuff in it than your as unanticipated themes were sought [19,20]. Interviews, kebabs or your pizzas. transcription, and coding were all undertaken by a single [v2] …well actually this kebab shop is more healthy researcher (ME), ensuring the highest possible level of than chippie shops. Fried things, you know they cook it acquaintance with the data. A second researcher (SD) in the fat, full fat oil and everything, and this is like, un- independently coded a random selection of interviews for healthy, you know? We cook mostly pizzas and kebabs comparison, in order to confirm coding validity. Initial and grill, and it's very healthy, you know… [fat] going coding agreement was over 87%, and the remaining codes down with pure meat left, and salad. It’s very healthy. were settled upon with input by a third researcher (RJ). th Table 1 Recruitment statistics Data saturation was reached by the 8 interview. Establishment type Invited Interviews attained Ninety-two per cent of the codes had been established after seven interviews, and no new codes emerged from Café/sandwich/snack shop 16 5 the final two interviews. Kebab 7 2 Fish & Chipper 6 2 Results Chinese 3 0 Nine of the interviews were conducted with managers or Indian 2 1 owners of the participating businesses, and one was con- Mobile van 1 0 ducted with a senior employee familiar with the workings of the business. Although more of the invitees were male, Total 35 10 a greater number of female interviews were obtained. Invitee Gender Forty per cent of all female invitees agreed to an inter- Male 20 4 view, while only twenty per cent of male invitees did so Female 15 6 (Table 1). Estrade et al. BMC Public Health 2014, 14:793 Page 4 of 8 http://www.biomedcentral.com/1471-2458/14/793 Personal autonomy and responsibility Several managers with school-aged children or Belief in individual and personal responsibility was a grandchildren expressed their frustration at the pref- broad and cross-cutting theme, coming out in every erences and purchasing habits of school children interview across a range of general questions about the who entered their shops at lunchtime. Many also felt meaning of healthy eating, as well as specific questions that offering healthier options to school children about the SHC framework. would not be enough to produce any real change in Most vendors felt they already provided opportunities behaviour. for healthy eating, but that customers who purchase the [v6] School kids eat chips. And baguettes. That's it. less healthy options would not be persuaded to change They dinnae [don’t] want anything else but chips and their food preferences, especially school children. The curry sauce or chips and cheese, and a baguette. vendors consistently saw themselves as external to cus- [interviewer] What about offering a healthy meal deal tomers’ preferences and felt they had very little influence or discount? in a customer’s decision-making process. [v6] I would like to do that with the kids, because we [v3] …if somebody wants to eat fried chicken, you do salad boxes. I'd like to do that. But it's just, they can’t convince him, no: go for grilled… cannae [can’t] see past chips. I'd like to do an offer on Several were keenly aware of the negative press directed the salad boxes, but it's just they want chips. at takeaways in relation to obesity and conveyed a sense of [interviewer] Do you do special offers for the kids? antipathy to that notion. [v7] Yeah we do, but it’s a healthy option, it’s a sugar- [v1] Obesity starts from… you've got to get into values. free juice, baked crisps, and a tuna roll. I mean, I’m an overweight woman. I know why I’m over- [interviewer] Do they go for that? weight. It’s because I eat too much. It’s not rocket sci- [v7] No! …we’re lucky if we sell one a month! ence. Everybody knows that. You just can't blame a A sense of niche was an important part of why vendors company or whatever, because it's what I choose to eat. perceived that their customers would not be receptive to [v5] I usually like to give enough food for the cus- more healthy options from their outlet. tomer, so it's up to them to make up their own mind [v4] …certainly if there was anything like a deal with a about how much they eat… I mean when you reach healthier option, people prefer to go to a sandwich shop 18 years old, even before that, you're responsible for for sandwiches and come to a chipper for chipper food… what you put in your stomach… If you want to eat well, As I say, people are coming to the chip shop and they’re you will eat well. coming because they want… they’re not coming because [v8] Is it not [enough] just reducing their portion sizes they want fruit. when they’re home? One vendor described the problem as one that is influ- enced by more upstream factors. [interviewer] If you have a meal deal and in place of Customer demand crisps you give fruit, and in place of fizzy drink you offer Vendors were keenly aware of customer preferences and water, would people go for that? felt they needed to offer what customers perceived as [v10] No! Ha! No! I think you have to get the kids “good food” and in order to keep their business. They when they’re young to build it up. And I think, because conveyed a strong belief that simply offering healthier there’s quite a lot of poverty, they just go for the cheap- options wouldn’t create a shift in customer demand, est and the most filling. And that’s what the problem viewing themselves as relatively powerless to change is… it’s instilled in them… what people want. Some also felt that offering too many options could [v4] No. I don’t think we have the influence [on what put customers off. customers eat]. I think people have got their favourite [v8] I think the customers might start getting confused kind of food…and if you’re a good business, then yes, because there’s just too much choice. I think that can be your reputation will bring people back. So, I think that off-putting as well. I think we’ve kinda discovered that, would be the influence. Good food. even after all these years, that too much choice people [v3] …the people who are health conscious, they only don’t like. They like a limited [choice] so that it’seasy think about that. The people who are not, they don't for them to pick. bother you even with 100 different options, they're gonna pick the Coke out of it. You know, so this is not Being profitable actually the question, what is available, what is not Cost and profitability were major concerns among food available. …if somebody wants something, they come vendors, especially in regards to introducing healthier here to buy that thing. They don't come here to [say] options. Price was seen as playing a central role in cus- “okay, don't give me this, you can give me that”. tomers’ decisions about which menu items to choose, Estrade et al. BMC Public Health 2014, 14:793 Page 5 of 8 http://www.biomedcentral.com/1471-2458/14/793 and most vendors cited it as the key factor in their own neighbourhood were viewed as an added burden in the decisions about which products to purchase for their struggletomakeaprofit. shop and from which suppliers. They described a constant [v2] we are still selling the same things, you know, struggle to cope with the economic pressure of rising food same prices… if you put it too high… oh! Customers say costs and tightening profit margins. Many vendors also it's too expensive. It's too expensive….in this area. In cited difficulty in finding the right balance between in- some rich areas people don't complain… creasing menu prices and keeping their customers. [v3] it's very hard. A takeaway business is very hard. [v4] Prices have gone up. Even like potatoes. I mean at To get a customer and keep it, it's very hard… There's this time last year… we're getting three times the price already so much struggling in this, particularly in this of potatoes to what we were last year because of all the area, you have to survive very hard…the business is floods in England and that, so, and the fish is scarce, so struggling… There are like four takeaways just on this that's gone up considerably. So that's your two main street which are empty. things you use in this kind of business, so yeah, it's kinda [v1] the prices have gone up so much where our profit costly… And I think just with the recession and that margin… we're just barely making a profit just now. If people are kind like choosing something a bit cheaper we were probably anywhere else in Aberdeen or in the because they can't really afford these expensive meals. city centre we'd be able to charge more, but in [this Healthier options were viewed as unfeasible in many neighbourhood], most of our customers are on a limited cases, because vendors perceived that they wouldn’tbe budget. We just can't, we're just pared right down to able to charge enough to make a profit. the bone. [interviewer] Do you think there’s any way they could Most vendors were not keen to seek out publicity for be enticed to buy [healthier options]? healthy menu options. They did not believe that a [v10] I don’t know, you’d probably have to give them Healthy Living Award [17] would have any positive im- away for nothing… pact on their business or customers’ perceptions, and [v6] I don't allow my [own] kids to have fizzy juice that it might even send mixed messages. [carbonated soft drinks], so I dinnae [don’t] really like [v1] I think that would be a bit of a joke… people having it. I'd like to buy fresh juice, but it's the prices… would be laughing at that in a chip shop. it's so expensive, and you wouldn't make any money. [v3] If you're sitting on Princes Street [centre of Edinburgh], With the price you would have to charge, they would posh people walking in, they see this [HLA] sticker in nae [not] want to buy it. So you've got to think of that as the window, yes, they pick like that. Yes, it does matter. well… A case of Coke for seven pound, you would never Because their sort of perception, you know… they want buy juice for that price; no way… If the government to seethose sort of things.But theareawelivein… they wants you to buy all this fresh stuff, they should bring don'tcarewhatyou display. down the price. However, one vendor commented that it could be a Because vendors were struggling to turn a profit in good way to attract couples or groups who want to eat order to stay in business, a culture of competition was together but have varying priorities and preferences also evident in many of the neighbourhoods, including when it comes to healthy eating. rivalry for pupils’ lunchtime business. [v6] They just want chips… they go about looking for the deals; they'll have a look and then go along have a Regulatory levers look at their deals and then come back and they'll An alternative approach being implemented in various order… they like the value for money. The competition countries is use of regulatory levers involving health- here is unbelievable. related food taxes, although with the exception of sugar sweetened beverages [21] there is little evidence based Neighbourhood context on rigorous evaluation [22,23]. During interviews in the In all three cities, interviews were conducted in neigh- current study, we discussed food taxes with the vendors. bourhoods that were comparatively less well-off than They tended to be strongly opposed to this approach be- many others in their city. Though shops were chosen for cause they felt that it would be an unfair burden on small their proximity to schools in which a higher than na- business. In particular, because of the neighbourhood tional average proportion of children were receiving free context and their hesitancy to ask higher prices of their school meals, the Scottish Index of Multiple Deprivation customers, vendors believed that they would have to score confirmed the status of each neighbourhood as bear the cost of taxes targeting specific foods. more deprived. Food vendors sensed this, and though [v1] Supermarkets can absorb it. We can't. We can't the economy in general was implicated as a negative absorb that kind of tax. It’s crazy. I can't see how that factor, the unique and enduring characteristics of each would influence obesity. Estrade et al. BMC Public Health 2014, 14:793 Page 6 of 8 http://www.biomedcentral.com/1471-2458/14/793 Vendors also felt that any increase in price might In their study on features of convenience stores sur- drive customers to purchase the more expensive foods rounding schools in Minnesota, USA, Gebauer et al. [28] elsewhere. identified the following as barriers to stocking healthy [v8] I don’t think that is gonna do anything [for obes- foods: challenge to switch over stock, lack of infrastruc- ity]. It’s just gonna affect our business. You know, be- ture, and fear of losing business. All of these have been cause they’ll maybe not buy it from here, but they’ll get expressed as concerns in the current study by the food it cheaper at the supermarkets. vendors interviewed. In addition, the vendors we inter- viewed cited lack of technical knowledge that would be Discussion needed to implement the SHC guidelines, for example in The aim of this study was to identify potential barriers order to offer calorie information to customers. Several that independent fast food vendors near lower-income UK cities have had success offering this type of training to secondary schools might face in offering healthier menu fast food vendors as part of local healthier food awards options. The food vendors in this study were proud of schemes [29,30]. However, because vendors in our study the foods they made and sold, and viewed their offerings mentioned that healthy food awards were not important as healthier than their competitors’. While they recognised to their customers, alternate incentives may be needed to that obesity is a major public health problem, vendors felt reach vendors in deprived areas. As an example, a scheme that both the cause and resolution are rooted in individual implemented in Northern Ireland offered a £200 grant to responsibility for one’s diet and lifestyle choices. They ex- businesses who took part in the Healthier Takeaways Pro- plained that, as with non-food businesses, responding to ject [31]. The program was successful in helping fast food customer demand is a priority, and that customers in their vendors to make small, sustainable changes, like replacing area, especially school children, would not be persuaded 17-hole salt shakers with 5-hole shakers in order to reduce to purchase healthier foods. Vendors in these relatively levels of added salt. low-income neighbourhoods expressed concerns about of- Although the idea of regulation was opposed by most fering menu items that wouldn’t sell well, because they vendors in our study, it could be a useful tool to “level were already struggling to maintain a profit and stay in the playing field” and ease the pressure on vendors to business. When explaining why it would be unfeasible for compete. One current approach being discussed is the them to offer healthier options or change their customers’ possibility of policies to limit targeting and promotional behaviours, they cited characteristics rooted in culture and strategies that vendors utilise to attract school pupils as the neighbourhood context. lunch-time customers [32]. The views expressed by food vendors in this study are In addition to targeting food vendors, interventions similar to those from a London study that examined in- that target consumer behaviour may be necessary to in- dependent food vendors’ views on implementing better fluence customer demand to which vendors respond. sustainability practices. The vendors felt unable to make Further research is needed to identify the factors that changes to their business practices because profit mar- most influence the food choices of pupils in deprived gins were too tight to risk a drop in customer demand areas. It is worth noting, however, that school children [24]. In our study, vendors’ views about individual re- make up only a fraction of the clientele for the food ven- sponsibility for eating habits, body weight, and health in dors we interviewed. Vendors must take the preferences general were also consistent with current cultural norms. of the wider community that they serve into account, When members of a large restaurant association were and therefore targeting pupil behaviour may not be surveyed, health and nutrition issues were reported by enough. less than 1% of restaurant owners and managers as Examining the situation through an economic lens can topics of concern [25], and a recent survey of British also help explain the positions taken by food vendors in this study. Chell and Pittaway [33] explored the ways in adults found that nearly two thirds believed that being overweight was an individual’s own fault, attributable to which restaurant and café entrepreneurs talked about a lack of willpower [26]. their businesses and found large differences in the actions taken by expanding businesses compared to declining The vendors we interviewed felt they occupied a spe- cial niche in their neighbourhoods with the type of foods businesses. Expanding businesses described measures that they offered and were reluctant to change those offer- characterised proactive behaviours, such as making menu changes. Declining businesses described measures indica- ings. They were also reluctant to add healthier options (as an alternative to replacing current menu items) be- tive of reactive behaviour, such as making changes based cause they felt that too much choice would put customers on an Environmental Health officer’s recommendations. Given that the businesses we interviewed described them- off. Current literature in this area indeed supports the idea that too much choice can have negative psychological selves as struggling to survive, it is logical to question effects for customers [27]. whether or not these businesses can be expected to Estrade et al. BMC Public Health 2014, 14:793 Page 7 of 8 http://www.biomedcentral.com/1471-2458/14/793 implement proactive changes without clear evidence of guidelines may inadvertently exclude shops in disadvan- potential economic benefit. taged neighbourhoods from feasible participation, thereby Time has been cited in a number of studies as an im- potentially widening current inequalities. If voluntary portant factor of influence on food choice [34], and it frameworks are to be implemented in economically dis- has been described by schoolchildren as a concern of advantaged areas, independent food vendors may need higher importance than cost [35]. Therefore, we ex- substantial financial and technical assistance to ensure pected time to come out as a strong theme that vendors that their customers don’t miss out on potential benefits. recognised as important in attracting customers, particu- Competing interests larly at school lunch time, but it was only mentioned The authors declare that they have no competing interests. briefly in two out of the ten interviews. It became clear through our own observations, as well as from the com- Authors’ contributions All authors contributed to designing the study. ME carried out data ments of the food vendors, that the schoolchildren in collection and analysis. ME, SD, and RJ validated the coding framework. All these neighbourhoods are willing to spend their lunch authors were involved in editing the manuscript, and all authors approved time in longer queues to get the best deal on the foods the final manuscript. they want. One possible explanation is that within the Acknowledgements deprived neighbourhood context, time may become a We are very grateful to the food vendors who took time to participate in less important aspect than price, since previous research this study. This study was funded by the Scottish School of Public Health Research. AE is supported by the Medical Research Council (Neighbourhoods in low-income communities has found that cost is a and Health Programme MC_UU_12017/8). major barrier to healthy food choices [36]. When chil- dren from a deprived London neighbourhood were Author details 1 2 University of Aberdeen, Aberdeen, Scotland. Glasgow Centre for Population asked what would motivate them to make healthier Health, Glasgow, Scotland. Scottish Collaboration for Public Health Research choices at takeaways, they cited cheaper prices and a & Policy, Edinburgh, Scotland. MRC/CSO SPHSU, University of Glasgow, better choice of foods, including fruits and vegetables Glasgow, Scotland. 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Withall J, Jago R, Cross J: Families’ and health professionals’ perceptions • Convenient online submission of influences on diet, activity and obesity in a low-income community. • Thorough peer review Health Place 2009, 15:1078–1085. • No space constraints or color figure charges • Immediate publication on acceptance • Inclusion in PubMed, CAS, Scopus and Google Scholar • Research which is freely available for redistribution Submit your manuscript at www.biomedcentral.com/submit

Journal

BMC Public HealthSpringer Journals

Published: Dec 1, 2014

Keywords: public health; medicine/public health, general; epidemiology; environmental health; biostatistics; vaccine

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