The Fruit Shop - NHSGGC Public Health Resource Unit

The Royal Alexandra Hospital, Paisley
Evaluative report on the impact of a fruit and vegetable retail
shop in a hospital foyer
Angela Coll, Alasdair Gilmore and Rona Dougall
2006

We would like to take this opportunity to thank all the staff, visitors and
outpatients at the Royal Alexandra Hospital who took the time to
complete and return the questionnaire.
If you require any further information regarding this report please contact
Rona Dougall, Public Health Resource Unit, NHS Greater Glasgow &
Clyde, Dalian house, Glasgow, G3 8YZ Tel: 0141 201 4779 Email:
rona.dougall@ggc.scot.nhs.uk
iii

Table of Contents
Introduction 1
Surveys
Aims & objectives 15
Research questions 16
Methodology 16
Survey 1 17
Survey 2 20
Survey 3 21
Characteristics of
respondents
23
Results
Awareness of fruit &
vegetables
Page
Impact of shop 32
Barriers to use 47
Discussion 60
Conclusion &
recommendations
References
Appendix 1: Survey 1
Questionnaire result tables
25
71
74
83
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Abstract
The fruit shop in the Royal Alexandra Hospital was established in 2002
with initial outlay provided by Have a Heart Paisley (HAHP) to help
improve access to fruit and vegetables for the local community. The
venture had a successful first year but had placed considerable demands
on the hospital staff responsible for it on a daily basis. In order to ensure
a constant stock of good quality, fresh produce the management of the
shop was given over to a wholesale fruit and vegetable supplier in 2003.
In 2004-5 a series of three separate evaluative surveys was undertaken
looking at the impact of the shop as a healthy eating resource for all
hospital staff and users. Questionnaires were given to staff, out-patients
and visitors. Brief interviews with a small sample of staff were also
carried out.
The results reveal that there has been a significant positive change in
fruit and vegetable consumption by staff members since the fruit shop had
opened. While out-patients and visitors used the shop less there was
general support for the shop amongst these groups. Potential barriers to
using the shop were reported, including shift patterns, location of the
shop, hours of opening, and poor quality at times. Suggestions to help
overcome these barriers include extended opening hours to cover weekend
visiting times, a mobile trolley, ordering and/or delivery service and
refrigeration of products.
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Introduction
Background
The Royal Alexandra Hospital
Fruit Shop
International Perspective on fruit and vegetable consumption
The Global Burden of Disease Study (Lock et al 2002) identified that
fruit and vegetable consumption was the sixth most important
contributor to the burden of disease in developed countries. In
addition, The World Health Organisation (WHO) 2002 reported that
that low intakes of fruit and vegetables causes approximately 2.7
million (or 4.9%) deaths globally. Furthermore, the WHO report 2002
concluded that 7.5% of loss of Disability Adjusted Life Years
(DALYS) could be attributed to inadequate fruit and vegetable
consumption, estimating that between 25-49% of CHD in developed
countries is due to fruit and vegetable consumption levels below 600g
per day. From an international perspective the WHO advocates that
at least 400g of fruit and vegetables daily should be consumed,
equivalent to five 80g portions, per day. This 400g goal is based on
apparently healthy fruit and vegetable intakes of populations with
low rates of CHD on the Northern Coast of the Mediterranean. A
recent report of the joint WHO/FAO Expert Consultation on Diet,
Nutrition and the prevention of Chronic Disease (2003) provided
updated evidence and confirmed the relevance of dietary targets.
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Furthermore, The WHO Global Strategy on Diet, Physical Activity
and Health (2004) encourages countries, such as Scotland, to take
action around food and health issues, by implementing national
strategies on diet.
Diet and Coronary Heart Disease
There are many dietary factors that have been linked to CHD, which
may help explain the relatively high risks of the disease among lower
socio-economic groups (National Heart Forum 1998). Epidemiological
data suggest that the incidence of CHD is inversely related to the
plasma levels of vitamin E, and to a lesser extent to vitamin C. Fruit
and vegetables are the main source of antioxidant vitamins in the
diet; however, these are also rich in other potentially protective
substances such as flavoids and fibre, which makes it more difficult
to know exactly what is having the beneficial effect. The exact
mechanism by which antioxidants may protect against the
development of CHD remains uncertain. Low-density lipoprotein
(LDL) cholesterol is the primary lipoprotein found in atherosclerotic
plaque. Specific antioxidants, such as vitamin E can inhibit LDL
oxidation, in turn, vitamin C significantly improves arterial
vasoreactivity and vitamin E regeneration (Adams et al 1999).
Evidence that low intake of antioxidants may be relevant to CHD
comes from several sources; epidemiological studies, case control
studies, observational studies and controlled trials.
A 14-year follow-up observational study in Finland (Knekt et al
1994) concluded that antioxidant vitamins protected against CHD, in
particular, vitamins E, C and the caratenoids. Elsewhere, the Iowa
Woman’s Health Study (Kushi et al 1996), which had a seven year
follow up, found that only vitamin E consumption was inversely
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associated with deaths rates from CHD. In a pooled analysis of nine
prospective studies Knekt et al (2004) found that a lower CHD risk
was associated with higher intake of dietary vitamin E.
Countries with a very high incidence of CHD, such as Scotland have
significantly lower plasma levels of vitamin E, whereas countries
with a lower incidence have a relatively higher consumption of
antioxidant vitamins (Riemersma et al 1990).
Scotland
Scotland has higher death rates from cancer, heart disease and
strokes than almost any other westernised industrial country. Over
2600 people aged under 65 die each year from coronary heart disease
(CHD), over 4000 from cancers and around 700 from strokes. Poor
eating habits are a significant factor in many of these premature
deaths (The Scottish Office 1996). The average Scottish diet is
deficient in certain vitamins and fibre and contains too much
saturated fat, salt and sugar (The Scottish Office 1996).
Consequently, there is a broad consensus of opinion that a healthy
eating pattern can help to reduce the risk of cardiovascular disease,
cancer and obesity. Primary prevention to reduce the incidence of
CHD is therefore a high priority in Scotland.
CHD and stroke are major causes of death and ill health in Scotland
and were identified as a national priority in the 1990’s. According to
recent figures from the UK Government Actuary’s Department, life
expectancy in Scotland is lower than the rest of the UK (Leon et al
2003). CHD accounts for over 13,000 deaths each year in Scotland
(Blamey et al 2002). There is a complex interaction of physical
environment, social environment, individual response and behaviour,
genetic endowment and the provision of services interacting with
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economic and other influences from which the health status of a
nation emerges (Wood et al 2001). One of the key reasons for
Scotland’s poor health is deprivation. Those in the most deprived
areas have a 2.5 times greater risk of dying from CHD than those in
the least deprived areas. This association is most obvious in those
aged under 65 (Scottish Executive 2000). Life expectancy in
Scotland, for women, is the lowest in Europe and for men, the second
lowest after Portugal (Leon et al 2003).
The population of Scotland also has a notably low vegetable and fruit
intake. The National Diet and Nutrition Survey (2003) showed that
on average men and women consumed fewer than three portions of
fruit and vegetables. This was significantly lower for those living in
households in receipt of state benefits. Within such households men
consumed on average 2.1 portions compared with 2.8 in other
households, whereas women consumed only 1.9 compared with 3.1.
Moreover, variations in fruit and vegetable intake within Scotland
relate to regional differences in CHD (National Heart Forum1998).
The Scottish Heart Health Study (Bolton-Smith et al 1991), an
epidemiological study of 10,359 men and women aged between 40-59
years, found that the highest CHD mortality amongst men (SMR136)
contrasted with the lowest (SMR 61) in fruit and vegetable
consumption. In the former group 17% ate no green vegetables and
30% no fruit compared to the latter where only 6% ate no green
vegetables and 13% ate no fruit. However, it could be argued that
those people who eat more fruit and vegetables tend also to be those
who smoke less and exercise more, thus have healthier lifestyles.
The Diet and Nutrition Survey (1998) suggested that strategies to
increase consumption in lower socio-economic groups need to focus
on how often people eat fruit and vegetables, as well as how much is
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consumed. In some areas it would take an increase in consumption
of 100% to reach 400g a day.
National Strategies
In a 1991 policy statement, Health Education in Scotland, the
government acknowledged the decisive influence of diet on our
health. Here, for the first time, national priorities and health targets
were set to tackle the main causes of premature death in Scotland. It
emphasised the importance of healthy lifestyles and identified the
achievement of a better diet as a priority for action. A further
Government policy statement Scotland’s Health – A Challenge To Us
All followed in 1992. To develop a strategy to achieve targets, a
National Nutrition Task Force was set up from 1992 to 1995, which
produced a wide-ranging Action Plan for achieving the Scottish
Healthy Eating Targets by 2005. The strategy on improving
Scotland’s diet is set out in Eating for Health – A Diet Action Plan
for Scotland (SDAP), which was published in 1996. The SDAP
identified four main barriers to healthy eating:
• Availability – limited availability of healthy foods at an
acceptable cost and quality
• Affordability – difficulty and expense of travelling on public
transport to ‘out-of-town’ shopping centres
• Skills – Lack of basic cooking skills and equipment
• Culture – long established dietary habits and reluctance to
experiment with new foods
This plan for action over a ten-year period provided a coherent
framework for tackling dietary shortcomings in Scotland. It
examined the changes required in the diet of deprived communities
for whom a low income and unavailability of healthy food choices
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present particular barriers to achieving a healthy diet. A number of
recommendations within this plan relate to fruit and vegetables,
with the target of doubling fruit and vegetable intake by 2005 being
described as the single most important dietary target. A healthier
diet has also been identified as one of the national priorities in
Towards a Healthier Scotland (1999), which endorsed the targets set
out in the SDAP. The SDAP has recently been updated by Eating for
Health, Meeting the Challenge (2004), which calls for a more co-
ordinated approach to the implement the SDAP, both nationally and
locally at strategic and policy levels, building upon key actions in
Improving Health in Scotland: The Challenge (2003), commonly
known as the National Challenge Plan.
The National Challenge Plan (2003) provides a strategic framework
to support the processes required to deliver a more rapid rate of
health improvement in Scotland. It builds on the foundation of
Towards a Healthier Scotland (1999), and is focussed on
implementing the next phase of the SDAP to the extent that it has a
measurable, incremental impact each year to 2010.
The key conceptual stages are to: -
• Increase the demand for healthy food
• Supply the demand for healthy food
• Provide support, education and skill development to allow
people to act on this information to make healthy choices
Both the SDAP and The National Challenge Plan (2003) emphasise
the importance of removing attitudinal and practical barriers
perceived as preventing the population from having full access to a
healthy diet. Implementation will take a multi-setting approach to
provide opportunities for and access to healthy food choices. This
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will include settings such as workplaces, schools and communities.
The National Challenge Plan has set the target of a 50% reduction in
death from CHD in people under 75 between 1995 and 2010. Various
initiatives are in place to help deliver these targets include the
National Scotland’s Health at Work Programme (SHAW) and
National Demonstration Projects, such as Have a Heart Paisley
(HaHP).
The National Scotland’s Health At Work Programme (SHAW) is an
award scheme designed to raise the profile of health promotion in the
workplace. SHAW was established in 1996 as accreditation
initiative to encourage businesses in Scotland to participate in a
voluntary award scheme, which would stimulate employers to
provide healthy workplaces. The working environment has been
identified as an important setting for health promotion which
provides an ideal opportunity for shaping healthy eating patterns in
occupational groups for whom inequalities have been identified
(Poulter & Torrance 1993). Worksites are a key channel for delivery
of interventions designed to reduce chronic disease amongst adult
populations. As adults spend up to one third of their time at work,
the workplace can be seen as both a possible factor in affecting
health and as a convenient context for promoting health (HEA 1997).
From an International perspective, the World Health Organisation
supports and endorses health promotion in the workplace setting
and in Scotland many government white papers acknowledge the
importance of the workplace in relation to health promotion,
including, Scotland’s Health – A Challenge To Us All (1992);
Towards a Healthier Scotland (1999); Securing Health Together
(2000) and Improving Health in Scotland – The Challenge (2003).
The National Challenge Plan (2003) introduces a new focused
approach to Health Improvement initiatives with the workplace
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eing named as one of the four major themes. Special focus
programmes include further implementation of the Eating for Health
– Diet Action Plan (1996). Here, the workplace has been identified as
a setting to provide opportunities for, and access to, healthy food
choices and to ensure that individuals who have motivation and
skills to make healthier food choices have these choices made
available to them.
This ‘settings’ approach to health promotion also informs the
internationally acknowledged concept of Health Promoting Hospitals
and Scotland’s Health Promoting Health Service (HPHS) framework.
The HPHS applies the principles of health at work to the hospital
setting as a workplace. Building on the HPH concept it also
recognises the hospital as both a public institution and a workplace
‘in which people engage in daily activities in which environmental,
organisational and personal factors interact to affect health and well-
being’ (Paton et al., 2005).
Food Access
Many disadvantaged consumers’ still face significant barriers to
accessing a healthier diet, contributing to high rates of diet-related
diseases and lower life expectancy in low-income communities
(O’Neill 2005). Therefore, implementing strategies to improve food
access in low-income areas could in theory improve the opportunities
of residents of poor neighbourhoods to make healthier choices, reduce
social exclusion and improve general health (Cummins & Macintyre
2004). However, food access is much wider than just being able to
purchase foods.
The term ‘food access’ has been defined in several different ways. It
can be used to define an area where there are no shops, or shops sell
a poor range of healthy foods or where healthy food is unaffordable to
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those on low incomes. (Reisig 2000; Cummins & Macintyre 2002). As
well as the location of supermarkets and small shops, physical and
socio-economic factors, such as the bus route, car ownership and age
of the population can combine to create barriers to accessing a
healthier diet (O’Neill 2005).
Where there is a lack of availability of affordable healthy food in
communities, this is sometimes referred to as a ‘food desert’. There is
conflicting evidence on the prevalence of food deserts (White et al
2004; Cummins & Macintyre 2002; Morland 2002; Cummins &
Macintyre 1999). Several studies have attempted to explore the
existence of food deserts in urban areas (Cummins & Macintyre
2002; Whelan 2002; Reisig 2000; Cummins & Macintyre 1999), but
as yet no studies have provided clear evidence concerning their
existence or defining characteristics (White et al 2004).
Some other studies have looked at the impact of new large
supermarkets being opened in deprived areas (Wrigely 2003; White
2004; Cummins et al 2005). Wrigley (2003) found that more than
two thirds of the local population with poor diets increased their
consumption of fruit and vegetables, following the opening of a new
large supermarket (Wrigely 2003). However, Cummins et al (2005)
argue that Wrigley (2003) used an uncontrolled before/after study
design. In contrast, White (2004) failed to demonstrate a relationship
between diet and supermarket access and similarly Cummins et al --
(2005) found little evidence for a positive intervention effect at
community level on fruit and vegetable consumption after adjusting
for confounding variables.
The findings of the White et al (2004) suggest that the key predictors
of healthy eating are primarily dietary knowledge and a ‘healthy
lifestyle’, so we must question whether those whose diet is ‘less
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healthy’ than desirable would eat more healthily if supplied with
improved retail provision. Similarly, O’Neill (2005) concluded that
factors such as choice, affordability and life-skills were important,
rather than just the geographical location of shops.
It is now widely recognised that the capacity and opportunities for
individuals to bring about change to their health can be significantly
affected by the competence of the community in which they live to
address issues beyond the control of any one individual (Nutbeam
2004). If an environment is conducive to a healthier lifestyle, people
have greater freedom to choose the’ healthier’ alternatives and
change their behaviour (Ewles & Simnett 2001).
Paisley
Paisley is the largest town in Scotland with a population of around
85000. About a quarter of the population live in areas of deprivation
(until recently referred to as Social Inclusion Partnerships (SIP)
areas) and this is where the highest levels of heart disease are found
(HaHP 2001). Paisley has one of the worst CHD records in Scotland
with the overall CHD death rate 8% higher than the Scottish
average. In some parts of the town the CHD death rate is up to 50%
higher than Scotland as a whole (HaHP 2001). If the Standardised
Mortality Rate (SMR) for Scotland is set at 100 as a reference, the
SMR of Paisley is 115, however, some SIP areas, such as Ferguslie
Park, have an SMR of 152 (HaHP 2001). Heart disease accounts for
one third of all deaths in Paisley (HaHP 2001). The relationship
between deprivation and SMR is demonstrated and suggests that
there are serious health inequalities in Paisley (Renfrewshire Food
Federation 2001). Some peripheral housing schemes in the area
have very poor access not only to basic accommodation but also to
good quality fresh produce. The results of the Renfrewshire Food
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Federation (2001) community mapping exercise revealed that there
were some stark differences in food access issues between areas
within Paisley. Some of the more highly deprived areas had very
little choice and could not access fresh fruit and vegetables. In
addition, certain areas had poor public transport provision further
confounding the situation.
Only 28-38% of Paisley residents eat the five recommended portions
of fruit and vegetables a day (Public Health Institute Scotland 2000).
Local Strategies in Paisley
In response to Improving Health in Scotland:The Challenge (2003), a
local action plan was produced in Argyll & Clyde entitled Improving
Health , Meeting the Challenge in Argyll & Clyde (2004). This Local
Challenge Plan identified local priorities, one of which was to
increase access to affordable healthier choices in communities, with
particular attention to fruit and vegetables.
There are many barriers, which inhibit an increase in fruit and
vegetable intakes and various strategies have been designed to
address them. Some interventions have sought to improve access to
fruit and vegetables by tackling barriers such as cost and
availability; others aim to change attitudes. Such interventions
include Have a Heart Paisley (HaHP), which is a National
Demonstration Project addressing coronary heart disease funded by
the Health Improvement Strategy Division of the Scottish Executive
Health Department.
HaHP is one of a set of National Health Demonstration Projects
created as a result of the White Paper on Health, Towards a
Healthier Scotland, each focusing on a health priority area. It is an
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area based, multi-component, multi-agency project with a strong
community focus that aims to prevent CHD, to promote good health
and to reduce health inequalities in Paisley. HaHP pulls together
action on the lifestyle factors that affects a person’s risk of suffering
from CHD and in doing so pays attention to people’s life
circumstances.
Although it will be some time before the effect of this project will be
seen in Paisley’s rate of heart disease, HaHP is already believed to
be making an impact on health. HaHP has helped to develop Paisley-
wide strategies to help make healthier choices in relation to eating,
tobacco and physical activity more acceptable and easier to make.
HaHP has a Healthy Eating Strategy, which addresses two key
stands: -
• The need for a greater choice of healthier food
• The levels of knowledge and skills of individuals and
communities have in relation to health eating
HaHP provided initial start-up funding to the fruit shop in the Royal
Alexandra Hospital in 2002 as part of its commitment to community
initiatives.
The hospital fruit shop
The hospital fruit shop is a commercial venture located in a busy
urban hospital setting to serve all staff, visitors and patients. It was
conceived in response to growing rates of cardiovascular disease in
an area of low socio-economic status. The hospital in question, the
Royal Alexandria Hospital (RAH), Paisley, is a large District General
Hospital serving a population of over 200,000 people. It employs
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around 3000 staff operating 600 beds, day cases and outpatients. The
idea of having a fruit and vegetable retail shop in the hospital foyer
was first mooted by a Cardiologist at the RAH in 2002, who
presented the idea for a six month pilot scheme to Have a Heart
Paisley (HaHP) .
In discussion with HaHP it was agreed that patients, staff and
visitors to the hospital could all benefit from increased access and
availability of fruit and vegetables on the hospital site. The proposed
shop would provide access to good quality fresh fruit and vegetables
at reasonable prices to staff and the local community.
The shop was opened in 2002, funded by HaHP for the pilot period. It
was staffed by the hospital’s Hotel Services department, and ran as
an in-house venture with all profits being transferred to the
hospital’s Health at Heart Project, a programme to increase access to
cardiac rehabilitation at the RAH. However, with no experience in
retailing fruit and vegetables, the management of the shop proved an
onerous task for hospital staff in addition to regular duties. In 2003,
the overall running of the shop was given over to the fruit and
vegetable retailer who had supplied the shop since it opened with the
agreement that a percentage of the profits would be given to the
hospital’s general funds. This decision enabled the shop to keep a
much fresher stock with more variety.
The concept of a retail fruit and vegetable shop located in a hospital
or a workplace is novel and could provide a model for further
exploration in terms of its contribution to staff health, local
community facilities, and the wider agenda around health
improvement.
13

This study will investigate the use of the fruit and vegetable shop by
staff and other hospital users and consider any impact on healthy
eating attitudes and behaviours.
14

Surveys
15
The Fruit Shop
The RAH Health Promotion Group, commissioned a questionnaire
survey of hospital staff to find out how the shop was being used and
to determine whether it was having any impact on healthy eating
amongst staff.
Aims & objectives
Aim
The aim of the study is to assess the impact of having a fruit and
vegetable retail shop in a hospital foyer on staff.
Objectives
• Assess awareness of the healthy eating message amongst
RAH staff and users in relation to fruit and vegetable
consumption.
• Determine the influence of the fruit and vegetable retail
shop on hospital staff and users.
• Identify any perceived barriers, which stop people from
using the fruit shop.

Research Questions
1. What is the general level of awareness among staff, out-
patients and visitors with regard to the health benefits of fruit
and vegetables?
2. To what extent has the fruit and vegetable retail shop
influenced staff and users?
3. What impact if any has the shop had on amount of fruit
reaching and being consumed in the wards.
4. What barriers have been identified as preventing staff from
using the fruit and vegetable retail shop?
Methodology
A questionnaire survey of staff was commissioned in 2004. This was
followed later by two smaller questionnaire surveys of out-patients
and visitors, and series of interviews with a small selection of staff.
The three surveys used similar but not identical question schedules
i.e participants were not all asked the same range of questions.
However, three key themes were addressed at some point in each
survey. These can be summarised as follows:
� awareness of the benefits of fruit & vegetable consumption
� impact of shop on fruit & vegetable purchase and consumption
(including patients)
� barriers to use of the shop
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In addition, the first two surveys reported on the kinds of produce
bought from the shop. Questions relating to these themes will be
discussed in this report. Only significant results will be discussed,
although reference will be made to any non-significant findings of
particular interest. [See Appendices for responses to all questions].
The first staff survey involved considerably more participants than
subsequent surveys and so forms the core of this report.
Survey 1: staff postal survey
A questionnaire was selected as the tool for investigation. A range of
optional answers were available for most questions but some Open-
ended questions were also included so that respondents could qualify
their answers.
Survey 1: questionnaire Preparation
The format of the questionnaire was simple to ensure that it was
fully comprehensive to all staff. Tick boxes were used for answering
most questions. The wording of the questions was short with
familiar words and phrases to help respondents understand and
conceptualise in the same way (Bowling 2003). Questions were
grouped into sections to achieve a logical progression with
qualitative questions left until the end to encourage completion. The
questionnaire was pre-coded for easier analysis.
Survey 1: piloting
The questionnaire was first piloted by giving 30 questionnaires to a
dedicated person to distribute in three departments within the
hospital, one ward, catering and the Health at Heart Centre.
However, these were not handed out to the staff in two of the
17

departments and only the Health at Heart Centre staff returned the
questionnaires. Eleven questionnaires were returned and some
changes were made taking into consideration various comments.
The questionnaire was then re-piloted two weeks later. This time the
researcher handed out the questionnaires personally to staff in the
canteen selecting a random sample from various departments by
selecting tables with different staff groups sitting there. A piloting
questionnaire tool was developed to ensure that respondents fully
understood what was required with regards to pre-testing the
evaluation questionnaire. Staff were asked only to take the pilot
questionnaire if they had time to complete and return it within the
next few days.
This approach was more successful and as a result a mixed sample of
around 30 RAH staff were successfully recruited to pilot the
questionnaire to check that its instructions, content, wording,
sequence were adequate (Edwards & Talbot 1994). Twenty-three of
the piloted questionnaires were returned and the results revealed
that 91% (n=21) found the questionnaire easy to read. The
questionnaire was then adjusted in accordance with any relevant
comments.
Survey 1: distribution
The questionnaire was distributed with an accompanying letter
signed by a Cardiac Consultant at the RAH. It was decided that a
letter signed by a known figure of authority within the hospital could
possibly increase the response rate. A systematic random selection,
of 370 hospital staff were issued the questionnaire attached to their
payslip with a return envelope. The questionnaire was attached to
every tenth payslip within each departmental grouping of salary
slips, to ensure that the sample was random. The questionnaires
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were numbered and the names of recipients recorded beside each
number on a sheet. This was both to enable the researcher to
identify non-responders for the second and third distributions and
also to randomly select the winners of the prize draw. Three fruit
baskets were offered as prizes to encourage the return of the
questionnaires.
The first distribution resulted in a 34% response rate. The second
distribution by internal mail, to non-responders, using payroll codes
to identify departments brought the response rate up to 49%.
However, many of the questionnaires were returned undelivered, as
the payroll code did not necessarily mean that the person was based
in that department. For the third issue the correct hospital address
was obtained from payroll and this time the questionnaire was
accompanied by a personally addressed letter rather than a ‘dear
colleague’ as previously sent. The third issue was more successful
resulting in a 65% response rate. This included 56 male returns and
182 female with two not stating their gender.
Survey 1: validity and reliability
A systematic random sample was selected to ensure external validity
of this study.
Survey 1: data analysis/impact
Data from the questionnaires was stored in an Excel file and the
data was initially analysed by a member of the Research Team at
NHS Argyll & Clyde using chi-square as specified in the original
proposal. However, Excel tables were later converted into a Microsoft
Word document and chi-square cross tabulations undertaken.
The questionnaire was analysed using chi-square, a non-parametric
statistical test. The chi-square test was considered suitable in
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assessing for an awareness of healthy eating campaign amongst
different groups of workers as it allows the study of
relationships/differences between data; it is relatively easy to code
for subsequent analysis and can highlight good ideas for further
exploration (Edwards & Talbot 1994). The McNemar-Bowker test
was used to establish differences over time for both fruit and
vegetable consumption prior to the fruit shop opening to current
intake. In order to ensure generalisability in establishing that the
sample was representative of the population a chi-square percentage
overall test was performed. This was significant for all questions
expressing that there was an equal population proportion answering
each possible response to the question.
Survey 1: ethics
Confidentiality was assured and the questionnaires did not include
names. A general designation was asked for to help make
comparisons between occupational status and postcodes were used to
determine deprivation categories.
A Consultant Cardiologist at the Royal Alexandra Hospital
commissioned the study. NHS ethical approval of Phase 1 of Have a
Heart Paisley (HaHP) covered the study with an amendment letter
being submitted. The study is an amendment to a previous study,
which contained questionnaires on healthy eating and physical
activity. NHS Ethics Committee approved the final amendment to
the questionnaire following piloting on 4 th August 2004.
Survey 2: other hospital users (out-patients & visitors)
To capture the views of out-patients and visitors to the hospital a
second survey was carried out in July 2005 using a structured
questionnaire. Two new questionnaires were drawn up based on that
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used in the staff postal survey and were designed to provide
quantitative and qualitative data. Draft questionnaires were piloted
on July 2005 and the relevant changes made thereafter. Out-patients
were sampled while sitting in the waiting areas of the hospital and
visitors were initially sampled while entering and exiting through
the main door. However, this was found to be inconvenient and
consequently visitors were sampled while waiting to enter the wards
at visiting periods. To reduce possible bias, the questionnaire was
delivered on a face-to-face basis with both groups. Over the month of
August 2005, 100 out-patients and 100 visitors completed the
questionnaire.
Survey 3: staff interviews
A third survey was carried out in July/August 2005 to collect further
views of staff. Of approximately sixteen interviews carried out twelve
were documented. These were with staff from six different wards
covering four hospital departments: cardiology; geriatric; surgical;
and medicine. Staff interviewed included: nurses (including
auxiliary nurses) (5); ward managers (1); technical staff (1); domestic
assistants (1); care assistants (1); administrators (1); and medical
staff (2).
The interview was semi-structured and focussed on four areas of
interest: impact of the shop awareness of health benefits of eating
fruit & vegetables/increased consumption; impact on snacking
behaviour; functioning of shop (opening hours, prices, etc); impact on
amount of fruit available in the wards/increased consumption by
patients. Questions were open-ended allowing for comment from
participants.
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Limitations of Methodology
The aim of these surveys was to evaluate the health impact of the
fruit and vegetable retail shop in the RAH foyer. Results may have
been limited by low sample sizes: Survey 1 sampled approximately
10% of staff and sample sizes in Surveys 2 & 3 were considerably
lower. In Survey 1 a random systematic approach was taken to
sampling. There was a low uptake from DepCap 7 (8%), males (24%)
and a high uptake from those in a Professional Occupation (52%),
which may have skewed results.
Information gathered was not consistent throughout the surveys.
Details relating to deprivation, transport, individual age and gender
were collected in Survey 1 only.
Evaluation was not planned in initial discussions around the fruit
shop. The surveys reported here were undertaken eighteen months
after the shop opened without any baseline baseline of staff’s
knowledge, awareness and consumption of fruit and vegetables being
gathered prior to the introduction of the shop. Tones and Tilford
(2001) believe that when an evaluation is being introduced into a
programme at some point after implementation has begun certain
forms of evaluation design are precluded and the capacity to
generate particular results will, as a consequence, be reduced. With
no robust means of comparing pre and post intervention responses
the value of these surveys is somewhat diminished. However, they
do provide a detailed snapshot of response to the shop from a variety
of perspectives.
22

Characteristics of respondents
Survey 1
The overall response rate of the questionnaires was 65%. Initially,
370 questionnaires (97 to males and 271 to females) were distributed
and 240 were returned following three issues. Staff respondents
were predominantly female. A total of 77% of responders were
female compared to 69% of non-responders. Details of age group and
occupation category responses are detailed in Figures 1 & 2
A chi-square percentage overall test was significant for all questions
expressing that there was an equal population proportion answering
each possible response to the question.
The four categories that were assessed for every question using the
chi-square test were gender, age group, deprivation categories (using
postcodes) and occupation. No significant difference was found
within any of these categories regarding transport methods to work
with the majority of staff (77%) travelling to work by car.
Fig.1 Fig.2
Survey 1 - Staff: respondents by
age group
32%
11%
10%
27%
20%
16-25 years 26-35 years
36-45 years 46-55 years
56+ years
Survey 1- Staff: respondents
by occupation
17%
11%
3%
9%
7%
professional
scientific & Technical
ancillary
admin & clerical
maintenance & estates
other
53%
23

Survey 2
Out–patients respondents were also predominantly female (58.3%)
with the majority being aged 56 or older (67.4%). 23% of out-patient
respondents had been an in-patient in the hospital for at least one
night in the past year. Visitor respondents were predominantly
female (73.3%) and over 56 years of age (68.7%) [Figures 3 & 4].
Fig.3 Fig.4
Out-patients: respondents by
age group
67%
Survey 3
1% 7%
14%
11%
16-25 years 26-35 years
36-45 years 46-55 years
56+ years
69%
Visitors: respondents by age
group
3%
3%
10%
15%
16-25 years 26-35 years
36-45 years 46-55 years
56+ years
Staff who were interviewed had been employees of the hospital for
anything less than 1 year to 20 years. Age and gender were not
recorded for this group.
24

Awareness of fruit and vegetables
Awareness of recommendations
Results
Steptoe et al (2003) reported that the factor that emerged as the most
consistent psychological correlate of outcome was awareness of
recommendations concerning fruit and vegetable consumption. Similarly,
Wardle et al (2000) found strong evidence for an association between
nutrition knowledge and intake of fruit and vegetables, with those in the
highest knowledge quintile 25 times more likely to meet current
recommendations than those in the lowest quintile. These studies appear
to support the role played by nutritional knowledge in determining a
healthy diet and suggest that awareness of official recommendations is
important.
RAH Surveys
Awareness among staff respondents in Survey 1 exceeded the national
average by around 20% (86% of staff selected five-a-day as the daily
recommendation). This figure was higher than the findings of the Health
Education Population Survey 2005 (HEPS) and the Food Standards
Agency Survey (2002) where only around half of those surveyed were
aware of the five-a-day recommendation.
Each survey addressed awareness of healthy eating in at least one
question. Survey 1 asked a range of questions around this issue.
25

Table 1
% Staff : how many portions of a combination of fruit and
vegetables do you think that health experts recommend eating
every day?
%
Response
rate:
240/240
=100%
Total
1
0
2
1
3
2
4
4
5
86
6
6
Don't
know
0
Total
100
P
Value

more aware of the 5-a-day message compared to 73% (n=19) of those in
the over 56 years age group.
Fig.6
% respondents
80
70
60
50
40
30
20
10
0
% 0ut-patients & visitors: awareness of
recommended portions per day
1 2 3 4 5 6 or
portion level
over
don't
know
outpatients
visitors
Awareness was lower in out-patients and visitors with 51.7% (n=46) out-
patients and 68.8% (n=66) of visitors selecting the five-a-day option. [Fig
6]
Table 2 illustrates how many staff felt that fruit and vegetables have an
important part to play in the prevention of disease.
Table 2
%
% Staff : fruit and vegetables have an important part to play in the
prevention of disease.
Response rate:
240/240 =100%
Total
Strongly
agree
Agree
Neither
Disagree
Don't
know
Total
P
Value
54 43 1 1 1 100

All subjects answered this question with 97% of responders agreeing or
strongly agreeing with this statement. The results were significant in
both occupation (p

of specific diseases, namely heart disease (Table 3), cancer (Table 4) or a
stroke (Table 5).
Table 3
% Staff : by eating more fruit and vegetables, people can reduce their chances of
getting heart disease.
Response rate:
239/240 =100%
Strongly agree
Agree
Neither
Disagree
Don't know
Total
P Value
Total 51 47 1 0 1 100

Table 4
% Staff : by eating more fruit and vegetables, people can reduce their chances
of getting cancer.
Response rate:
229/240 =100%
Total
Strongly
agree
45
Agree
45
Neither
5
Disagree
1
Strongly
disagree
1
Don't
know
3
Total
100
30
P
Value

Table 5
% Staff : by eating more fruit and vegetables, people can reduce their
chances of getting a stroke.
Response rate
226/240=100%
Total
Strongly
agree
43
Agree
48
Neither
4
Disagree
1
Strongly
disagree
0
Don’t
know
4
Total
100
31
P
Value

Impact of shop
Influence
Each survey asked about the influence of the fruit shop on awareness of
the benefits of fruit and vegetable consumption. With reference to
Question 11a (Survey 1) occupation was found to be significant (p

It has made the awareness that everyone knows that you have to have five
pieces of fruit and veg a day.
Results expressed significance for occupation where the occupation group
found to have the least knowledge of the recommended daily intake (RDI)
were those who felt least influenced by the fruit shop regarding the RDI
for fruit and vegetables.
Asked whether the shop had influenced consumption of fruit and
vegetables a majority of staff in Survey 1 reported a positive influence of
the shop.
Fig 10
Staff : % who feel the shop influenced them to
consume more fruit and vegetables
46%
Yes No
Responses to this question were significant for age group [Table 6].
54%
33

Table 6: Survey 1 (Qu.13)
% Staff : do you feel that having the fruit shop in
the RAH foyer has helped you to eat more fruit and vegetables daily?
Response rate:
231/240 =100%
Yes No Total P Value
Total 54 46 100 0.24
Age group 0.031
16-25 39 61 10
26-35 74 26 20
36-45 49 51 27
46-55 53 47 32
56+ 46 54 11
Total 100
Notes:
Question 13 applied to all 240 survey respondents and, of these, 9 (3.8%) did not answer the question
Information on gender, age group, deprivation category and occupation was missing for some respondents
These respondents were excluded from the analysis of responses by these particular groups
P values are based on the chi-square test of association. P values less than 5% indicate
that the differences in responses across groups are statistically significant. n.s indicates differences are not
statistically significant.
For out-patients and visitors who are more sporadic users of the hospital,
the question asked was more speculative. Even so, results were
encouraging: asked if the presence of the fruit shop ‘would help you to eat
more fruit and vegetables daily’ both groups answered positively (out-
patients 79.2% (n=76); visitors 78.8% (n=78)). Despite this, and the fact
that almost two thirds of visitors reported being aware of the 5-a-day
message, less than half of them reported eating more than two portions of
fruit and/or vegetables daily.
34

Fig.11
% respondents
90
80
70
60
50
40
30
20
10
0
Out-patients & visitors: % reporting positive influence of
shop on consumption of fruit and vegetables
out patients visitors
Yes
No
Don't know
A comparison of responses to Question 7 and Question 12 of Survey
1(staff) indicates the reported levels of fruit and vegetable consumption
before and after the opening of the shop [Table 7]. Using the McNemar-
Bowker test, significance for both fruit and vegetables (p

• 9% (n=12) who previously ate 1-2 portions reported eating 3-4
portions after the shop opened
• 4% (n=2) who previously ate 2-4 portions reported eating 5-6
portions after the shop
Table 7: Survey 1 (Qu. 7 & 12)
Question 7a & 12a - fruit consumption before and after the opening of the fruit shop
AFTER N (%)
None 1-2 3-4 5-6 >6 Total
None 15 (52) 13 (45) 1 (3) 0 (0) 0 (0) 29
1-2 3 (2) 94 (74) 27 (21) 3 (2) 0 (0) 127
BEFORE 3-4 0 (0) 1 (2) 51 (84) 9 (15) 0 (0) 61
N (%) 5-6 1 (9) 0 (0) 1 (9) 9 (82) 0 (0) 11
>6 0 (0) 0 (0) 0 (0) 0 (0) 3 (100) 3
Total 19 108 80 21 3 231
McNemar-Bowker test p6 Total
None 4 (57) 3 (43) 0 (0) 0 (0) 0 (0) 7
1-2 0 (0) 115 (88) 12 (9) 2 (2) 1 (1) 130
BEFORE 3-4 0 (0) 0 (0) 54 (96) 2 (4) 0 (0) 56
N (%) 5-6 0 (0) 0 (0) 0 (0) 2 (100) 0 (0) 2
>6 0 (0) 0 (0) 0 (0) 0 (0) 2 (100) 2
Total 4 118 66 6 3 197
McNemar-Bowker test p=0.001
= subject eats less = subject eats the same = subject eats more
No significance was found within categories with regards to whether staff
were more likely to choose fruit as a snack after the opening of the fruit
shop. However, in all categories but one (deprivation category six) the ‘yes’
responses were most prominent.
Product Preferences
In order to further determine the impact of the shop, Surveys 1 and 2
asked a range of questions looking at the kinds of products bought by
staff, out-patients and visitors. Although not all results were significant,
36

some interesting patterns were revealed amongst age group, gender and
deprivation categories.
Table 8 relates to the purchase of weighed fruit by staff. A significant
difference was found within age groups (p

etween age groups it was clear that the 16-25 year old age group were
less likely to purchase vegetables, which will be discussed later.
Table 9: survey 1 (Qu.15 b)
% Staff : how often do you buy weighed vegetables from the fruit shop?
Response rate:
191/240 =100%
Total
Daily
2
2-3 days a
week
15
Once a
week
21
Rarely Never Total P
Value
24
38
100

Table 11 relates to whether the staff bought fruit juices from the shop.
The purchase of fruit juices was found to differ significantly amongst
deprivation categories (p

Fig 12
% reporting a purchase
Fig 13
% respondents
Out-patients and visitors: types of items purchased most
frequently
100
90
80
70
60
50
40
30
20
10
0
weighed fruit
weighed vegetables
100
80
60
40
20
0
single fruit
cut fruit packs
vegetable packs
salad vegetables
pasta salads
dried fruit
pulses
nuts
yoghurts
fruit juices
water
flowers
Produce bought by respondents - by type
put-patients who
use shop
visitors who use
shop
staff respondents
weighed fruit
outpatients
visitors
weighed vegetables
cut fruit packs
vegetable packs
dried fruit
pulses
nuts
fruit juices
flowers
40

Table 12 shows how many staff had tried new vegetables since the
opening of the fruit shop. A significant difference in gender (p

Table 13: Survey 1 (Qu.16 c)
% Staff : has the fruit shop influenced you to try
any new kinds of fruit and vegetables that you hadn't eaten
before - 5 pack of fruit?
Response rate:
171/240 =100%
Yes
No
Total
P Value
Total 21 79 100

Table 14: Survey 1 (Qu.16d)
% Staff : has the fruit shop influenced you to try
any new kinds of fruit and vegetables that you hadn't eaten
before - cut fruit packs?
Response rate:
184/240 =100%
Yes No Total P Value
Total 35 65 100

There was no significant difference within any categories regarding trying
any new kinds of weighed fruit, vegetable packs, soup packs, dried fruit,
nuts and pulses.
Buying to take home
Table 1 relates to whether staff bought fruit and vegetables to take home.
The results were significant for both gender (p

Out-patients and visitors were also asked whether they made fruit shop
purchases to take home [Fig 14].
Fig 14
% respondents
80
70
60
50
40
30
20
10
0
Vending/WRVS shop
Out-patients, visitors and staff who buy fruit &
vegetables to take home
Yes No
out-patients
visitors
Survey 1 staff
Although not significant, around one quarter of the staff reported using
the WRVS shop less and there had been a reduction in usage of vending
machines [Figure 15].
Fig.15
Staff: use of WRVS shop for snacks since fruit
shop open
29%
47%
22%
2%
Less More About the same Did not use
45

This pattern of change was reinforced in comments gathered in staff
interviews (Survey 3).
While a number of comments were critical in terms of satisfaction (re
product quality, opening hours, etc.) all comments on this topic suggested
the shop had either no negative impact or a positive impact on purchase
and consumption of fruit and vegetables in the hospital.
The fruit is much nicer in the shop. Sometimes I get an apple from the
WRVS but the apples from the fruit shop are much nicer. I tend to go in
there and get peaches and apples. I would be more inclined to get
something out of the shop rather than a bit of chocolate.
I think in the afternoon you tend to go down and buy some fruit for the
afternoon break and so. Yes.
I don’t usually use it for snacks and things. I don’t really bother. I
really use it for the fruit so I couldn’t really say that I use if for juices
and things like that. Fruit. I don’t really bother with chocolate bars.
Yes, it has. I don’t tend to eat at lunch-time but when I do buy, I buy
from there [fruit shop].
46

Barriers to use
Questions in all surveys addressed the factors that prevented people using
the shop. These were posed in two ways:
• what stops you from using the shop
• what would help you to use the shop more
Key themes were selected as prompts for comment. In terms of aspects
that prevent use these included
• Location
• Time restraints
• Opening hours
• Quality
• Shop elsewhere/bring in own
Although not a key theme, money available to spend on food was also
identified as an issue for those in lower paid employment and living in the
more deprived areas.
Suggested improvements to promote use included:
• Mobile trolley
47

• Ordering service
• Extended opening hours
• Improved quality/refrigeration of stock
• Promotions
Questions were largely open-ended and attracted considerable additional
comment. Some comments highlighted links between one aspect and
another. For example, restricted use of the shop due to location within the
hospital and working hours/break times influenced support for a mobile
trolley and ordering service and/or extended opening hours.
Results are reported here with reference to additional comments made by
respondents. They are grouped under four headings:
� Location/time restraints
� Opening hours
� Quality
� Marketing
Location/time restraints
Figure 16 indicates that staff felt that the most common single restraints
on use of the shop reported were working hours and location of shop.
Many staff also commented that the location of the shop was a problem
not only because of its distance from their department but also due to
time restraints placed on them by working hours.
48

Fig 16
% of respondents
Staff : What prevents you from using the shop
more?
50
45
40
35
30
25
20
15
10
5
0
Location of shop
Knowledge of how to cook
Money available to spend
likes/dislikes of family
Working hours
knowledge of how to prepare
transport home
cost
don't eat fruit/veg
Areas that identified the location of the shop as a barrier included
maternity, pharmacy, theatres and catering. Staff who worked some
distance away from the shop in a separate hospital building commented
on the inconvenience :
“Bring things into work, I do not have time to come from
maternity to main building”
“Work in maternity – bring my own food- not able to leave our
area”
These comments also address time constraints placed on staff by virtue of
working a distance away:
“No time to queue”
Other
49

The inconvenient location of the shop could be resolved to some extent by
the introduction of a trolley service but this idea was supported by only
49% of staff. The location of the shop was of less concern to out-patients
and visitors. However, a number from each group referred to the shop as
‘handy’ suggesting a degree of satisfaction with its location.
Participants were given a range of suggestions that might help them used
the shop more. Figure 17 demonstrates responses to these suggestions..
There seemed to be a general consensus that a mobile trolley, ordering
service with delivery, price promotions and extended opening hours would
help staff to use the shop more.
Fig 17
% of respondents
90
80
70
60
50
40
30
20
10
0
Mobile Trolley
What would help you use the shop more?
Different Opening hours
Recipe/cooking suggestions
Price promotions/offers
Broader product range
Other
Visitors
Out-patients
Furthermore, three staff members also commented on the advantages of a
mobile trolley service:
“Mobile trolley would be a great advantage as we are limited to
time for breaks”
“Mobile trolley also excellent for maternity and visitors”
Staff
50

“Mobile trolley would probably be helpful for patients”
An ordering service with hospital delivery was also identified as being
beneficial to helping staff using the shop more by 33 (24%) females and
nine (23%) males. Staff also expressed an interest in an ordering service
with customer pick up but this was not as popular as the delivery service
with only 25 (18%) females and three (8%) males favouring this idea. In
fact, one member of staff commented that she is already taking orders and
delivering herself:
“I often take ‘orders’ of fruit and vegetables to the other clinics
I work in”
Opening Hours
Figure 18 relates to whether the shop opening hours suited users’ needs.
Survey 1 results for this question were significant for gender (p

Fig.18
% of respondents
90
80
70
60
50
40
30
20
10
0
Do you feel that the fruit shop opening hours suit your
needs?
Visitors Out-patients Staff
Seventy-six (50%) female staff and fifteen (37%) male staff stated that
their working hours prevented them from using the fruit shop more.
Although, in contrast, less than half of those sited the shop opening hours
as a barrier preventing them from using the shop: only 36 (20%) females
and 2 (4%) males stated that the shop hours did not meet their needs.
With regards to the shop opening hours significance was expressed within
gender (p

“May be useful to have fridge and ‘honest box’ so that night
shift can have access to fruit and vegetables.”
Comments from staff, out-patients and visitors stressed a preference for
extended opening hours to cover weekends.
“It is a good shop. I just wish it would open at weekends”
“ I think more people would buy if it was opened Saturday and
Sunday near visiting time”
Four members of staff reported that shop staff had refused to serve them
within opening hours as the shop was being set up. The comments
included:
“ I have been at the fruit shop at 8.45 a.m. and told that they
are not open”
“Sometimes I have passed the shop at 8.30 a.m. and been told
that it was not open yet, so I was unable to purchase fruit for
my lunch and was not able to come back to the shop later”
Another reported not being served at 7 p.m.
“On occasion have arrived at 7 p.m. only to be told it is already
closed”
This would suggest the need for consistent opening hours so that being
turned away does not put off staff.
53

Quality
Four aspects of customer satisfaction were assessed, these were, service
(a), quality (b), prices (c) and choice (d). With regard to satisfaction of the
service (a), the results were significant within deprivation categories
(p

Fig.20
% of respondents
120
100
80
60
40
20
0
quality
Rating for quality, prices and choice.
prices
choice
quality
prices
choice
quality
prices
Staff Out-patients Visitors
choice
Don't use shop
Poor
OK
Good
Very good
Although no significant difference was found within categories regarding
the quality of produce at the fruit shop, several people commented that at
times the quality of the fruit and vegetables could be poor. Five people
reported that the quality at times had stopped them from choosing fruit
as a snack with examples of such comments below:
“I feel the fruit is over-ripe and does not taste as good as it
might”
“I feel much of the fruit is not of a high standard”
“Fruit at present does not have any taste”
In addition, ten staff felt that the quality of the fruit and vegetables
prevented them from using the shop more, reporting that the fruit and
vegetables do not last:
55

“ This week grapes purchased on Monday lunchtime found to
have fur on them”
“Fruit does not last when taken home”
“Sometimes fruit is overripe, on rare occasions”
“Quality of fruit not always the best (apples)”
“Produce does not always stay fresh for long, cannot buy in
bulk”
Some staff members have even made some suggestions to help improve
the quality of the fruit and vegetables. These include refrigeration of the
stock, sell-by dates and checking stock regularly for deterioration. Such
comments included:
“Quality/ripeness as week goes on? – Lack of refrigeration”
“Check on fruit going soft and take out of boxes”
“Quality of fruit and vegetables generally very good. Better
than supermarkets and cheaper too. Only problem is that the
produce does not have a ‘use-by’ date and sometimes it can be
past its best”
“Keep vegetables cool. Sometimes buy vegetables/potatoes and
they are old. Strawberries have been old”
In general, hospitals can be quite warm environments, which may
contribute to the quick deterioration of the produce. However, not all the
comments were negative with some staff members feeling that the quality
56

has improved since the retailer took over the running of the shop. These
comments included:
“Since the last ‘take-over’ the quality and range of products has
improved beyond recognition”
“Has much improved since it was opened at first”
“May use shop more in future as quality seems much better”
Furthermore, other members of staff reported that an improvement in
and consistency of the quality would encourage them to use the shop
more:
“Quality has to be consistent”
“Improvement of quality”
“Better quality”
This highlights the need for action to be taken to preserve the quality of
the stock and to provide a consistently high standard product.
Marketing
Thirty-five (25%) female staff and fifteen (38%) male staff identified that
price promotions/offers would help them to use the shop more.
Suggestions included fruit smoothies, small pieces of fruit to taste, recipes
and price promotions. In addition, one member of staff would like to see
organic produce, another diced carrot and turnip and someone else
suggested that:
57

“ It would be good to have a selection of beans, chick peas etc.
Greater selection of unsalted nuts along with
pumpkin/sunflower seeds etc.”
Another staff member recommended providing:
“A guide on how to select the freshest produce, what you
should look for when purchasing vegetables and fruit, little tip
cards on how to prepare and cook”
Someone else suggested a health promotion drive may be beneficial:
“It might be useful to explain if eating a wide range of fruit and
vegetables has a greater impact on healthy living as opposed to
eating a select few which you know and like. I might be
persuaded to try new things if I knew my general health would
improve by doing so”
Thirty-six staff members reported that they did not use the shop as they
bring in their own food from home. Some preferred to buy their fruit and
vegetables with the weekly supermarket shop whilst others commented
that they were not the main food shopper for the family.
58

Awareness
Discussion
It would be gratifying to claim that the relatively high level of
awareness found amongst staff (86%) and users (52% out-patients;
69% visitors) of the RAH hospital was directly influenced by the
presence of the shop but such a claim cannot be upheld with
certainty. The five-a-day message, although promoted primarily in
England, received wide publicity nationwide and was complemented
by a variety of healthy eating initiatives throughout the country.
Furthermore, as a health promotion message, five-a-day is simple,
clear, positive, quantified and food-based (Kelly & Stanner 2003)
making it easy for people to remember. The past five years has seen
a trend towards more widely held knowledge of the five-a-day
recommendation among the general public rising from 43% able to
quote it in 2000, to 67% in 2005 (FSA, 2006), undermining any direct
claim for the shop in this regard.
Bearing in mind the wide dissemination of five-a-day, comments
suggest that the shop’s presence in the hospital foyer does act as a
concrete reinforcement of the message and an accessible means to
act upon it:
60

I think it has influenced everyone because they are
coming through the front door and it is the first
thing they see.
I would not say the presence of the shop has
increased my awareness of five-a-day, but it has
certainly made it more accessible for me to buy it.
Although Barrett (2001) claimed that health professionals are little
different to the general public in their diet related knowledge, beliefs
and actions, results here suggest that awareness amongst RAH staff
was higher than average. The role of fruit and vegetable
consumption in disease prevention was also generally well
understood with 97% of staff agreeing that there was a benefit to be
gained, particularly in relation to cancer, heart disease and stroke.
Awareness of disease prevention was reported less frequently
amongst the younger age group (16-25years). However, awareness
does not necessarily translate into consumption. HEPS (2005) found
that while knowledge of the recommended consumption of fruit and
vegetables has continued its upward trend, there has not been a
similar rise in motivation to increase consumption since the launch
of the ‘five-a-day’ programme in 2001. This is borne out amongst
staff, out-patients and visitors of the RAH where, although
awareness of recommendations was recorded as generally high, daily
portion consumption remained relatively low. However, there was a
trend towards increasing the number of portions consumed. While
the majority of all respondents reported eating only between one and
two portions of fruit and the same for vegetables per day, this
represented an increase in consumption towards the recommended
intake.
61

Belief in the benefits to health has been related to consumption in a
number of cross sectional studies (Anderson et al 2000; Wardle et al
1997; Steptoe et al 2003). Baker & Wardle (2003) found that
nutritional knowledge explains around half of the variation
associated with gender, indicating that men eat less fruit and
vegetables than women, in part because of their low awareness of the
health recommendations or health benefits. In the current study this
association was not significant.
Paramenter (2002) observed that people have little motivation to
change their diets even when they have the intention to do so
suggesting that for any intervention to be effective it must be robust.
The fruit shop is perhaps not best described as a ‘robust’ intervention
but it does show a degree of effectiveness. Contributing to this is its
prominent location within the hospital setting. The shop combines a
reminder of the healthy eating message with an easy and convenient
opportunity to act upon it.
Influence
General
Around half of the staff claimed that they did not feel influenced by
the shop in relation to the health benefits of fruit and vegetables.
Results were more positive regarding its impact on actual
consumption: over one-third reported making purchases from the
shop at least two to three times per week; over half reported buying
fruit to take home; and almost a quarter reported choosing fruit as a
snack in preference to WRVS shop or vending machine options.
Similarly, out-patients and visitors reported that the shop had
influenced them to consume more fruit and vegetables. These results
suggest that the convenience of the shop has had a positive impact
on healthy eating.
62

Generally, the shop tended to be used more by females than males
and those in the younger age group tended to use it least. These
results confirm findings of previous studies which claim that being
young or male are important determinants of low fruit and vegetable
consumption (Thompson et al 1999; Brug et al 1995; Laforge 1994;
Smith & Smith 1994). An explanation for the age factor may be a
shift away from cooking meals from basic ingredients and a reliance
on ready-made and convenience foods (Kelly & Stanner 2003) that
has reduced knowledge and skill in the young. Earlier studies
confirmed a link between confidence in cooking and healthy eating
(McGlone 1999; Lawrence et al 2000) suggesting that lack of
confidence and low basic food skills may contribute to a limited
intake of fruit and vegetables (McGlone 1999). Taste, preparation
time, lack of cooking skills, motivation and acceptability have all
been identified as barriers to increasing vegetable intake. In order to
address this issue, various community initiatives, such as the
Scottish Community Diet Project, now support training to improve
and develop confidence in cooking skills and shopping. In terms of
the hospital fruit shop it may be worth considering different
marketing approaches aimed at these specific groups.
Age groups
Fruit and vegetable consumption is usually higher in older people
rather than younger age groups (Wardle 1995; Thompson 1999). The
Health Education Population Surveys (HEPS) from 1996 to 2003
have shown a significant increase in daily fruit and vegetable
consumption for most age groups since 1996, with the exception of
those aged 16-24years. Furthermore, the National Diet and
Nutrition Survey (NDNS) 2004 found that both men and women
aged 19-24 years consumed fewer portions of fruit and vegetables
than those aged 50-64 years old. The lower consumption of the
63

younger age group has also been highlighted in other studies
(Mainland 1998; Thompson et al 1999).
Amongst RAH staff, those in the two younger age groups (16-25years
and 25-35years) made purchases from the shop less frequently.
Fewer of the 16-25 year old age group felt influenced by the presence
of the shop to eat more fruit and vegetables and those in both
younger age groups tended not to buy from the shop compared to
those from the 36-55 year age group who reported using the fruit
shop on a frequent basis. It also appeared that those in the 36-45
years age group tried more new products than those in the 16-25
year old group. Soup and vegetable packs were more likely to be
purchased by females over 26 years old.
Gender
Results in this survey concur with findings of previous studies
indicating distinct gender differences in healthy eating behaviour,
specifically related to fruit and vegetable consumption (Wardle et al
2000; Thompson 1999; Wardle et al 1997; Smith & Smith 1994). Men
appear to be less concerned about healthy eating and less positive
about fruit and vegetables (Wardle 1997). Wardle et al (1997)
suggest that this gender difference may be attributed to a greater
concern over weight control amongst women. Subsequent research
suggests a slightly different picture. Ashfield-Watt et al (2003) found
that women eat considerably more fruit than men but that men tend
to eat more vegetables than women, and that total combined intakes
were approximately equal.
In this survey a significantly greater proportion of females purchased
weighed vegetables, bought more cut fruit, and were more likely to
try new products. Of those who bought fruit and vegetables to take
home 80% were female, possibly because they were the main food
64

shopper in the household. In contrast, nuts appeared to be more
popular with males than females.
Deprivation
Fruit and vegetable intake is greater among people of higher socio-
economic status indicating that the raising of consumption in lower
economic groups might help reduce socio-economic inequalities in
health (Li et al 2000). The established view is that low income men
eat an inappropriate diet, posses inadequate nutritional knowledge
and are not interested in changing their dietary habits (Daborn et al
2005; Baker & Wardle 2003; Lobstein 1999). Shohaimi et al (2004)
found that men who live in the most deprived areas were estimated
to consume 27g less fruit and vegetables per day compared to those
in less deprived areas (EPIC-Norfolk Study). However, the
persuasiveness of healthy eating messages is influenced by
experience: Blaxter (1996) has argued that because people in the
lower social classes have greater personal experience of chronic
disease and premature mortality than more affluent groups, they
will also have greater experience both of survival despite the
presence of risk factors, and of illness despite healthy lifestyles.
Experience of this kind challenges the efficacy of healthy eating
campaigns.
Although the positive impact of knowledge has been questioned,
awareness remains an aim of health promotion and is still reported
in relation to social status. In 2005 HEPS found that those in the
most deprived areas were less likely to be aware of the five-a-day
recommendations. On the contrary, in this study awareness of the
benefits of healthy eating was high amongst staff from the most
deprived areas with the majority of those in deprivation category
seven able to quote five-a-day and agreeing that eating more fruit
and vegetables could reduce the risk of heart disease, stroke and
65

cancer. While a similarly high percentage of people in this category
did not feel that their awareness had been influenced directly by the
shop, they reported higher portion consumption since the shop
opened suggesting that the shop served to make healthy choices
easier to implement.
Shepherd et al (1997) found that value for money was a significant
predictor for the two lowest income groups. Results amongst RAH
shop users in relation to product choices supported this idea. Those
in the most affluent deprivation category one (most affluent) were
more likely to buy the cut fruit packs in comparison with those in
deprivation category seven (most deprived). This could be due to
price as cut fruit packs are more expensive. Furthermore, a higher
percentage of those in deprivation category one (most affluent) were
more likely to try new products in comparison to those in deprivation
category seven (most deprived), which again could reflect spending
power and attitudes to cost/risk benefits.
Less people from deprivation category six bought products to take
home, however, more from this group used public transport,
suggesting that difficulties involved in carrying heavy shopping
might have been a factor. In support of this theory, half of the staff
in deprivation category seven (most deprived) reported taking fruit
and vegetables home, where, interestingly enough, all but one
travelled to work by car.
HEPS 1996-2003 surveys reported that daily consumption increased
for both men and women for all social classes with the exception of
those in the most deprived areas. However, in 2004 particular
improvements were seen for men and lower social grades (HEPS
2005). Consistent with these findings, the fruit shop survey shows
an increase in consumption within the most deprived areas.
66

Changes over time
The McNemar-Bowker test was used for detecting differences over
time. The results confirmed that there had been a positive change in
eating habits by staff members since the fruit shop had opened with
nearly half of staff who previously ate no fruit or vegetables now
eating one to two portions of each. These results are promising as
they show a reported increase in both fruit and vegetable
consumption since the fruit shop has opened. HEPS 1996-2003 has
shown a significant increase over time in the percentage eating five
portions of fruit and vegetables daily with a mean consumption of
approximately three portions a day.
Barriers
Several potential barriers to shop use were identified in this survey
including: opening hours, shift patterns, location/time restraints,
money available to spend on food and poor quality at times.
Opening hours
Originally, it was assumed that having a fruit and vegetable shop on
site in the hospital would increase access to everyone. However, the
results suggest that the opening hours of the shop did not meet the
needs of all potential users, particularly staff working shift patterns
including evenings and weekends.
Significance was expressed for gender, deprivation category and
occupation with regards to the shop opening hours suiting staff
needs. Many staff operate on a shift basis, including night shift or
weekends, when the shop is not open, whilst others are based in
areas which, are not readily accessible to the fruit shop. Previous
research indicates that 32% of respondents from the nursing
profession cited shift patterns and 23% cited lack of breaks as
67

preventing them from eating healthily (Faugier et al 2001 part 1).
Kearney et al (1998) also established that irregular working hours,
busy lifestyle and time were perceived barriers to healthy eating.
There seemed to be a general consensus that a mobile trolley,
ordering service with delivery and extended opening hours would
help staff to use the shop more.
Opening hours were also of concern to out-patients and visitors.
While the majority reported satisfaction with opening hours when
asked to give a yes/no answer, a large proportion of the many
additional comments provided expressed a desire for extended hours
to cover evening visiting times and weekends.
The prominent and central position of the shop is undoubtedly a
positive feature. Placed in the main hospital foyer it is both eye-
catching and attractive. However, its location was also raised as a
barrier to use for some sections of the staff. Respondents from
several departments stated that the shop was quite a distance from
their particular site, thereby restricting their opportunities to use it.
This concurs with research by Faugier et al (2001 part 2) where the
four main themes identified by the nursing profession as barriers to
healthy eating emerged as: availability; variety; distance from
catering facilities; and breaks/staffing levels/workload issues. It was
suggested that a mobile trolley service, ordering service with delivery
or extended opening hours would help to make the shop produce
more accessible.
With regards to accessibility, it was reported that on occasion shop
staff had been turned away as the shop was being set up. Some were
then unable to return to the shop during their working day due to
the distance from their place of work, not enough time at breaks or
68

staffing issues. This highlights missed opportunities to help staff eat
more healthily and also damages the reputation of the shop.
In addition, lack of consistent availability of quality produce was
identified as a potential barrier, with some stating that at times the
quality of the produce was poor. Inconsistent quality, cost, problems
with shelf life and storage, taste and availability have all previously
been identified as barriers by consumers, particularly with regard to
fresh food (Baghurst 2003). Given the warm hospital environment
which can cause products to deteriorate, refrigerated display stands
were proposed as a solution to increase the shelf life of the fresh
produce. Although this can be costly, further investment of this kind
may be worth considering. Another, less expensive suggestion to
help increase sales was to put use-by dates on pre-packed produce.
The issue of affordability must be viewed in the context not only of
the price of the products but on income. Although the shop was
considered to be reasonably priced by most staff, a higher percentage
of those in the lower deprivation categories and those working in
Ancillary Services cited that money available to spend on food
prevented them from using the shop more. Furthermore, a higher
percentage of those in Ancillary Services felt that cost was an issue.
Disdall (2003) found that eating more fruit and vegetables will
automatically be viewed as an additional expense in terms of cost,
physical and psychological effort and time. He suggests that
campaigns to promote eating more fruit and vegetables need to be
accompanied by education on ways to exchange habitually bought
food items for fruit and vegetables, such that no further expense, in
money or effort, is incurred.
In this study, more people from the more affluent deprivation
categories were buying products to take home. If the shop is to help
69

educe inequalities then people from within the lower deprivation
categories need to be encouraged to increase their fruit and vegetable
intake. One suggestion would be the ‘quick sale’ of any excess
produce with a limited shelf life at the end of each day. Pricing
strategies have been shown to be effective in promoting purchases of
foods such as fruits, vegetables and salads (French et al 1997; Jeffrey
et al 1994). Strategies to make prices more attractive may be worth
considering for the fruit shop and suggestions included price
promotions and selling basic products at a low cost, subsidised by
higher priced more exotic or prepared products. Cost and access to
food can affect the practical ability to change. Whereas the extent of
change is more effectively addressed through strategies linked to
food preferences, acceptability, life skills (e.g. cooking), health and
attitudes to health, knowledge and understanding of the ‘healthy
eating messages’ and the ability to translate these messages into
food based advice (Kelly & Stanner 2003).
70

71
Conclusion &
recommendations
Various studies have highlighted the importance of motivation
(Disdall et al 2003; Stockley et al 1993; Cox et al 1996) and this been
reiterated here. While there is considerable support for the shop,the
need to motivate staff towards eating more fruit and vegetables has
been indicated in the results. Lessons may be learned from St
Vincent’s University Hospital in Dublin, which participated in a
public awareness campaign on healthy eating by running a ‘Focus on
Fruit’ week in June 2003 and ‘Focus on Vegetables’ week in
September 2003 (Magoche et al 2004). The ‘Focus on Fruit’ week
included literature, displays, a quiz issued over lunchtime, and
increased fruit choices on the service counters in the canteen. A
follow-up article was then put in the hospitals’ newsletter
emphasising the health benefits of an increased fruit intake.
The health benefits of fruit and vegetables could be promoted
throughout the RAH hospital by use of posters and leaflets. In
addition, it may be beneficial to identify marketing opportunities
such as price promotions, taster sessions, recipes or cooking tips to
encourage staff to use the shop more. Peer education, cartoons, taste
testing, setting personal goals and discount coupons were some of the

strategies used in successful fruit and vegetable programs for low-
income adults in the US (Anderson et al 2001; Buller et al 1999;
Havas et al 1998). A strategy that has proved successful in
increasing vegetable consumption in an adult low-income group in
the UK was the development of recipes (Kilcast et al 1996).
Emmons et al (1999) found that multiple intervention programs and
activities were associated with significant improvements in
motivation for dietary change in the Working Healthy Project.
Furthermore, The Working Well Trial demonstrated that longer,
interactive intervention efforts (e.g. contests, nutrition education
classes) were more effective in increasing fruit and vegetable intake
than one-off activities or more passive efforts (e.g. printed materials)
(Paterson et al 1997).
Strategies for increasing fruit and vegetable consumption could
concentrate on increasing the number of consumers, the frequency of
consumption and the amount consumed at each eating occasion.
Such strategies may focus on ways to structure eating opportunities
for fruit and vegetables into daily eating patterns. These could
include promoting fruit with breakfast, fruit as a snack or as a
dessert, salad with lunch, vegetables or salad with main meals,
homemade soup or fruit juice.
The results of this survey suggest that the hospital fruit shop can
play a part in increasing the awareness of the health benefits of fruit
and vegetables and in motivating hospital staff and users to
introduce more fruit and vegetables into their daily diet.
72

The following recommendations may contribute to this aim:
• improve the availability of fruit and vegetables to those
working shifts
• consider widening shop opening hours to cover all visiting
times and weekends
• consider ways to maintain the quality of produce for longer
• address the affordability issue of fruit and vegetables to people
on low income by considering price promotions/pricing
strategy
• consider a mobile system (e.g. trolley service) to operate within
the hospital to improve accessibility for staff departments at a
distance from the shop and for patients
• consider promotional programmes including price promotions,
product promotion and recipe promotions
73

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World Health Organisation. (2004). Global Strategy on Diet, Physical Activity and
Health report by the Secretariat. World Health Organisation.
Wrigley, N., Warm, D.L. and Margetts, B. M. (2003). Deprivation, diet and food retail
access: findings from the Leeds ‘food deserts’ study. Environment and Planning, 35,
151-88
82

Appendix 1
Survey 1 questionnaire: result tables
Question 5 - How do you make the main part of your journey to work?
Response rate:
239/240 =100%
Number (%)
Walk Public Transport Car Motorbike Bicycle Total P Value
Total 23 (10) 27 (11) 186 (78) 1 (0) 2 (1) 239 (100)

Question 7a - On average how many portions of fruit do you eat in a day?
Number (%)
Response rate:
237/240 =100%
None 1-2 3-4 5-6 More Total P Value
Total 19 (8) 110 (46) 83 (35) 22 (9) 3 (1) 237 (100)

Question 7b - On average how many portions of vegetables do you eat in a day?
Number (%)
Response rate:
207/240 =100%
None 1-2 3-4 5-6 More Total P Value
Total 6 (3) 126(61) 66(32) 6 (3) 3 (1) 207 (100 )

Question 8 - How many portions of a combination of fruit and vegetables do you think that
health experts recommend eating every day?
No (%)
Response rate:
240/240 =100%
1 2 3 4 5 6 Don't know Total P Value
Total 1 (0) 3 (1) 5 (2) 9 (4) 207 (86) 14 (6) 1 (0) 240 (100)

Question 9 - Fruit and vegetables have an important part to play in the prevention of disease.
Response rate:
240/240 =100%
Number (%)
Strongly agree Agree Neither Disagree Don't know Total P Value
Total 129 (54) 104 (43) 3 (1) 2 (1) 2 (1) 240 (100)

Question 10a - By eating more fruit and vegetables, people can reduce their
chances of getting heart disease.
Number (%)
Response rate:
239/240 =100%
Strongly agree Agree Neither Disagree Don't know Total P Value
Total 120 (51) 112 (47) 3 (1) 1 (0) 3 (1) 239 (100)

Question 10b - By eating more fruit and vegetables, people can reduce their chances of getting back pain.
Response rate:
197/240 =100%
Number (%)
Strongly
agree
Agree Neither Disagree Strongly
disagree
Don't
know
89
Total P Value
Total 16 (8) 31 (16) 48 (24) 49 (25) 9 (5) 44 (22) 197 (100)

Question 10c - By eating more fruit and vegetables, people can reduce their chances of getting cancer.
Response rate:
229/240 =100%
Number (%)
Strongly
agree
Agree Neither Disagree Strongly
disagree
Don't
know
90
Total P Value
Total 103 (45) 103 (45) 11 (5) 3 (1) 2 (1) 7 (3) 229 (100)

Question 10d - By eating more fruit and vegetables, people can reduce their chances of getting a stroke.
Response rate:
226/240 =100%
Number (%)
Strongly
agree
Agree Neither Disagree Strongly
disagree
Don't
know
91
Total P Value
Total 96 (43) 109 (48) 8 (4) 2 (1) 1 (0) 10 (4) 226 (100)

Question 10e - By eating more fruit and vegetables, people can reduce their chances of getting hearing problems.
Response rate:
199/240 =100%
Number (%)
Strongly
agree
Agree Neither Disagree Strongly
disagree
Don't
know
92
Total P Value
Total 9 (5) 20 (10) 45 (23) 56 (28) 18 (9) 51 (26) 199 (100)

Question 11a - Do you feel that the HaHP fruit shop in the RAH
foyer has influenced your awareness of:- Recommended daily
intake of fruit and vegetables?
Number (%)
Response rate:
227/240 =100%
Yes No Total P Value
Total 94 (41) 133 (59) 227 (100) 0.011
Gender 0.107
Male 17 (32) 37 (69) 54 (24)
Female 75 (44) 96 (56) 171 (76)
Total 225 (99)
Age group 0.423
16-25 8 (36) 14 (64) 22 (10)
26-35 16 (35) 30 (65) 46 (20)
36-45 23 (38) 38 (62) 61 (27)
46-55 32 (44) 40 (56) 72 (32)
56+ 14 (56) 11 (44) 25 (11)
Total 226 (100)
Deprivation Category 0.419
1 (Most affluent) 8 (44) 10 (56) 18 (8)
2 14 (44) 18 (56) 32 (15)
3 14 (39) 22 (61) 36 (17)
4 16 (39) 25 (61) 41 (19)
5 30 (50) 30 (50) 60 (28)
6 6 (33) 12 (67) 18 (8)
7 (Most deprived) 1 (11) 8 (89) 9 (4)
Total 214 (94)
Occupation 0.018
Professional 39 (33) 78 (67) 117 (53)
Scientific & Technical 5 (29) 12 (71) 17 (8)
Ancillary (Hotel Services) 6 (35) 11 (65) 17 (8)
Admin & Clerical 23 (59) 16 (41) 39 (18)
Maintenance/Estates 4 (57) 3 (43) 7 (3)
Other 14 (61) 9 (39) 23 (10)
Total
Notes:
220 (97)
Question 11a applied to all 240 survey respondents and, of these, 13 (5.4%) did not answer the question
Information on gender, age group, deprivation category and occupation was missing for some respondents
These respondents were excluded from the analysis of responses by these particular groups.
P values are based on the chi-square test of association. P values less than 5% (marked with *sig)
indicate that the differences in responses across groups are statistically significant. n.s. indicates
differences are not statistically significant.
rce: HaHP Fruit Shop Evaluation 2004
93

Question 11b - Do you feel that the HaHP fruit shop in the RAH
foyer has influenced your awareness of:- Health benefits of
intake of fruit and vegetables?
Number (%)
Response rate:
221/240 =100%
Yes No Total P Value
Total 94 (43) 127 (58) 221 (100) 0.031
Gender 0.173
Male 18 (34) 35 (66) 53 (24)
Female 74 (45) 92 (55) 166 (76)
Total 219 (99)
Age group 0.539
16-25 7 (30) 16 (70) 23 (10)
26-35 21 (46) 25 (54) 46 (21)
36-45 25 (42) 34 (58) 59 (27)
46-55 27 (40) 41 (60) 68 (31)
56+ 13 (54) 11 (46) 24 (11)
Total 220 (100)
Deprivation Category 0.753
1 (Most affluent) 8 (44) 10 (56) 18 (9)
2 15 (47) 17 (53) 32 (15)
3 12 (35) 22 (65) 34 (16)
4 16 (42) 22 (58) 38 (18)
5 26 (45) 32 (55) 58 (28)
6 10 (53) 9 (47) 19 (9)
7 (Most deprived) 2 (22) 7 (78) 9 (4)
Total 208 (94)
Occupation 0.111
Professional 43 (37) 73 (63) 116 (100)
Scientific & Technical 4 (24) 13 (77) 17 (100)
Ancillary (Hotel Services) 7 (41) 10 (59) 17 (100)
Admin & Clerical 21 (55) 17 (45) 38 (100)
Maintenance/Estates 3 (43) 4 (57) 7 (100)
Other 12 (60) 8 (40) 20 (100)
Total
Notes:
215
Question 11b applied to all 240 survey respondents and, of these, 19 (7.9%) did not answer the question
Information on gender, age group, deprivation category and occupation was missing for some respondents. These
respondents were excluded from the analysis of responses by these particular groups.
P values are based on the chi-square test of association. P values less than 5% (marked with *sig) indicate that the
differences in responses across groups are statistically significant. n.s indicates differences are not statistically
significant.
Source: HaHP Fruit Shop Evaluation 2004
94

Question 11c - Do you feel that the HaHP fruit shop in the RAH
foyer has influenced your awareness of:- Need to eat more fruit
and vegetables?
Number (%)
Response rate:
225/240 =100%
Yes No Total P Value
Total 125 (56) 100 (44) 225 (100) 0.109
Gender 0.152
Male 26 (47) 29 (53) 55 (25)
Female 98 (58) 70 (42) 168 (75)
Total 223 (99)
Age group 0.109
16-25 7 (33) 14 (67) 21 (9)
26-35 31 (67) 15 (33) 46 (21)
36-45 36 (59) 25 (41) 61 (27)
46-55 37 (52) 34 (48) 71 (32)
56+ 13 (52) 12 (48) 25 (11)
Total 224 (100)
Deprivation Category 0.972
1 (Most affluent) 10 (56) 8 (44) 18 (9)
2 16 (50) 16 (50) 32 (15)
3 21 (62) 13 (38) 34 (16)
4 20 (51) 19 (49) 39 (18)
5 35 (57) 26 (43) 61 (29)
6 10 (56) 8 (44) 18 (9)
7 (Most deprived) 5 (56) 4 (44) 9 (4)
Total 211 (94)
Occupation 0.207
Professional 58 (50) 58 (50) 116 (53)
Scientific & Technical 8 (47) 9 (53) 17 (8)
Ancillary (Hotel Services) 12 (67) 6 (33) 18 (8)
Admin & Clerical 27 (69) 12 (31) 39 (18)
Maintenance/Estates 3 (38) 5 (63) 8 (4)
Other 13 (62) 8 (38) 21 (10)
Total
Notes:
219 (97)
Question 11c applied to all 240 survey respondents and, of these, 15 (6.2%) did not answer the question
Information on gender, age group, deprivation category and occupation was missing for some respondents
gender, age group, deprivation category and occupation was missing for some respondents.
These respondents were excluded from the analysis of responses by these particular groups.
P values are based on the chi-square test of association. P values less than 5% (marked with *sig)
indicate that the differences in responses across groups are statistically significant. n.s. indicates differences
are not statistically significant.
Source: HaHP Fruit Shop Evaluation 2004
95

Question 12a - How many portions of fruit did you eat per day prior to the HaHP
fruit shop being opened in the RAH?
Number (%)
Response rate:
233/240 =100%
None 1-2 3-4 5-6 More Total P Value
Total 30 (13) 127 (55) 62 (27) 11 (5) 3 (1) 233 (100)

Question 12b - How many portions of vegetables did you eat per day prior to the
HaHP fruit shop being opened in the RAH?
Number (%)
Response rate:
220/240 =100%
None 1-2 3-4 5-6 More Total P Value
Total 11 (5) 139 (63) 65 (30) 3 (1) 2 (1) 220 (100)

Question 13 - Do you feel that having the HaHP fruit shop in
The RAH foyer has helped you to eat more fruit and
vegetables daily?
Number (%)
Response rate:
231/240 =100%
Yes No Total P Value
Total 125 (54) 106 (46) 231 (100) 0.24
Gender 0.499
Male 28 (50) 28 (50) 56 (24)
Female 96 (55) 78 (45) 174 (76)
Total 230 (100)
Age group 0.031
16-25 9 (39) 14 (61) 23 (10)
26-35 34 (74) 12 (26) 46 (20)
36-45 30 (49) 31 (51) 61 (27)
46-55 39 (53) 35 (47) 74 (32)
56+ 12 (46) 14 (54) 26 (11)
Total 230 (100)
Deprivation Category 0.688
1 (Most affluent) 10 (56) 8 (44) 18 (8)
2 20 (63) 12 (38) 32 (15)
3 18 (53) 16 (47) 34 (16)
4 23 (52) 21 (48) 44 (20)
5 34 (56) 27 (44) 61 (28)
6 7 (37) 12 (63) 19 (9)
7 (Most deprived) 6 (67) 3 (33) 9 (4)
Total 217 (94)
Occupation 0.558
Professional 63 (53) 56 (47) 119 (53)
Scientific & Technical 9 (53) 8 (47) 17 (8)
Ancillary (Hotel Services) 9 (50) 9 (50) 18 (8)
Admin & Clerical 26 (67) 13 (33) 39 (17)
Maintenance/Estates 5 (63) 3 (38) 8 (4)
Other 10 (44) 13 (57) 23 (10)
Total
Notes:
224 (97)
Question 13 applied to all 240 survey respondents and, of these, 9 (3.8%) did not answer the question
Information on gender, age group, deprivation category and occupation was missing for some respondents
These respondents were excluded from the analysis of responses by these particular groups
P values are based on the chi-square test of association. P values less than 5% (marked with *sig) indicate
that the differences in responses across groups are statistically significant. n.s indicates differences are not
statistically significant.
Source: HaHP Fruit Shop Evaluation 2004
98

Question 14 - How often do you use the HaHP fruit shop in the RAH foyer?
Response rate:
232/240 =100%
Number (%)
Daily 2-3 times
a week
Once a
week
2-3 times a
month
Less than
once a
month
99
Never Total P Value
Total 19 (8) 77 (33) 38 (16) 32 (14) 23 (10) 43 (19) 232 (100)

Question 15a - How often do you buy weighed fruit from the HaHP fruit shop in the RAH foyer?
Response rate:
211/240 =100%
Number (%)
Daily 2-3 days a week Once a week Rarely Never Total P Value
Total 8 (4) 51 (24) 55 (26) 43 (20) 54 (26) 211 (100)

Question 15b - How often do you buy weighed vegetables from the HaHP fruit shop in the RAH foyer?
Response rate:
191/240 =100%
Number (%)
Daily 2-3 days a week Once a week Rarely Never Total P Value
Total 3 (2) 29 (15) 40 (21) 46 (24) 73 (38) 191 (100)

Question 15c - How often do you buy 5 pack of fruit from the HaHP fruit shop in the RAH foyer?
Response rate:
184/240 =100%
Number (%)
Daily 2-3 days a week Once a week Rarely Never Total P Value
Total 3 (1) 14 (8) 31 (17) 56 (30) 80 (44) 184 (100)

Question 15d - How often do you buy cut fruit packs from the HaHP fruit shop in the RAH foyer?
Response rate:
199/240 =100%
Number (%)
Daily 2-3 days a week Once a week Rarely Never Total P Value
Total 10 (5) 28 (14) 50 (25) 46 (23) 65 (32) 199 (100)

Question 15e - How often do you buy cut vegetable packs from the HaHP fruit shop in the RAH foyer?
Response rate:
176/240 =100%
Number (%)
Daily 2-3 days a week Once a week Rarely Never Total P Value
Total 0 (0) 10 (6) 17 (10) 51 (29) 98 (56) 176 (100)

Question 15f - How often do you buy soup packs from the HaHP fruit shop in the RAH foyer?
Response rate:
173/240 =100%
Number (%)
Daily 2-3 days a week Once a week Rarely Never Total P Value
Total 0 (0) 1 (1) 6 (4) 38 (22) 128 (74) 173 (100)

Question 15f - How often do you buy soup packs from the HaHP fruit shop in the RAH foyer?
Response rate:
173/240 =100%
Number (%)
Daily 2-3 days a week Once a week Rarely Never Total P Value
Total 0 (0) 1 (1) 6 (4) 38 (22) 128 (74) 173 (100)

Question 15g - How often do you buy dried fruit from the HaHP fruit shop in the RAH foyer?
Response rate:
174/240 =100%
Number (%)
Daily 2-3 days a week Once a week Rarely Never Total P Value
Total 0 (0) 2 (1) 12(7) 38 (22) 122 (70) 174 (100)

Question 15h - How often do you buy fruit juices from the HaHP fruit shop in the RAH foyer?
Response rate:
175/240 =100%
Number (%)
Daily 2-3 days a week Once a week Rarely Never Total P Value
Total 1 (1) 10 (6) 16 (9) 35 (20) 113 (65) 175 (100)

Question 15i - How often do you buy nuts from the HaHP fruit shop in the RAH foyer?
Response rate:
180/240 =100%
Number (%)
Daily 2-3 days a week Once a week Rarely Never Total P Value
Total 0 (0) 4 (2) 18 (10) 39 (22) 119 (66) 180 (100)

Question 15j - How often do you buy pulses from the HaHP fruit shop in the RAH foyer?
Response rate:
173/240 =100%
Number (%)
Daily 2-3 days a week Once a week Rarely Never Total P Value
Total 1 (1) 2 (1) 8 (5) 33 (19) 129 (75) 173 (100)

Question 16a - Has the HaHP fruit shop influenced you to try
any new kinds of fruit and vegetables that you hadn't eaten
before - weighed fruit?
Number
Response rate:
177/240 =100%
Yes No Total P Value
Total 51 (29) 126 (71) 177 (100)

Question 16b - Has the HaHP fruit shop influenced you to try
any new kinds of fruit and vegetables that you hadn't eaten
before - weighed vegetables?
Number (%)
Response rate:
168/240 =100%
Yes No Total P Value
Total 25 (15) 143 (85) 168 (100)

Question 16c - Has the HaHP fruit shop influenced you to try
any new kinds of fruit and vegetables that you hadn't eaten
before - 5 pack of fruit?
Number
Response rate:
171/240 =100%
Yes No Total P Value
Total 36 (21) 135 (79) 171 (100)

Question 16d - Has the HaHP fruit shop influenced you to try
any new kinds of fruit and vegetables that you hadn't eaten
before - cut fruit packs?
Number (%)
Response rate:
184/240 =100%
Yes No Total P Value
Total 64 (35) 120 (65) 184 (100)

Question 16e - Has the HaHP fruit shop influenced you to try
any new kinds of fruit and vegetables that you hadn't eaten
before - vegetable packs?
Number (%)
Response rate:
166/240 =100%
Yes No Total P Value
Total 12 (7) 154 (93) 166 (100)

Question 16f - Has the HaHP fruit shop influenced you to try
any new kinds of fruit and vegetables that you hadn't eaten
before - soup packs?
Number (%)
Response rate:
169/240 =100%
Yes No Total P Value
Total 11 (6) 158 (94) 169 (100)

Question 16g - Has the HaHP fruit shop influenced you to try
any new kinds of fruit and vegetables that you hadn't eaten
before - dried fruit?
Number (%)
Response rate:
173/240 =100%
Yes No Total P Value
Total 17 (10) 156 (90) 173 (100)

Question 16h - Has the HaHP fruit shop influenced you to try
any new kinds of fruit and vegetables that you hadn't eaten
before - fruit juices?
Number (%)
Response rate:
170/240 =100%
Yes No Total P Value
Total 16 (9) 154 (91) 170 (100)

Question 16i - Has the HaHP fruit shop influenced you to try
any new kinds of fruit and vegetables that you hadn't eaten
before - nuts?
Number (%)
Response rate:
168/240 =100%
Yes No Total P Value
Total 14 (8) 154 (92) 168 (100)

Question 16j - Has the HaHP fruit shop influenced you to try
any new kinds of fruit and vegetables that you hadn't eaten
before - pulses?
Number (%)
Response rate:
167/240 =100%
Yes No Total P Value
Total 6 (4) 161 (96) 167 (100)

Question 17 - Do you ever buy fruit and vegetables from the
HaHP fruit shop to take home?
Number (%)
Response rate:
236/240 =100%
Yes No Total P Value
Total 150 (64) 86 (36) 236 (100)

Question 18 – If so how
often?
Response rate:
146/240 =100%
122
Number (%)
Daily 2-3 times per week Once a week Rarely Never Total P Value
Total 0 (0) 57 (39) 48 (33) 41 (28) 0 (0) 146 (100)

Question 19a - Since the HaHP fruit shop opened, would you say that your
use of the WRVS shop for the purchase of snacks (but not drinks) has changed?
Number (%)
Response rate:
229/240 =100%
Less More About the same Did not use Total P Vaue
Total 51 (22) 4 (2) 108 (47) 66 (29) 229 (100)

Question 19b - Since the HaHP fruit shop opened, would you say that
your use of the hospital vending machines for the purchase of snacks
(but not drinks) has changed?
Number (%)
Response rate:
Less More About the same Did not use Total P Value
221/240 =100%
Total 35 (16) 2 (1) 41 (19) 143 (65) 221 (100)

Question 20 - Are you more likely to choose fruit as a snack during
your time at work now that the HaHP fruit shop is available?
Number (%)
Response rate:
228/240 =100%
Yes No Don't like fruit Total P Value
Total 152 (67) 71 (31) 5 (2) 228 (100)

Question 21 - What prevents you from using the HaHP fruit shop more?
Number (%)
Response Location Know- Money Working Know- Likes/ Transport Cost Don't Other Total
rate: of shop ledge Available hours ledge dislikes home
eat fruit/
194/240
of how to spend
of how of family
veg
=100%
to cook on food
to
prepare
Total
Gender
40 (21) 5 (3) 9 5) 91 (47) 3 (2) 13 (7) 17 (9) 7 (4) 4 (2) 65 (34) 194 (100)
Male 7 (17) 0 (0) 3 (7) 15 (37) 0 (0) 3 (7) 3 (7) 3 (7) 1 (2) 18 (44) 41 (21)
Female 32 (21) 5 (3) 6 (4) 76 (50) 3 (2) 9 (6) 13 (9) 4 (3) 3 (2) 47 (31) 151 (79)
Total
Age group
192 (99)
16-25 9 (43) 0 (0) 0 (0) 13 (62) 0 (0) 1 (5) 2 (10) 1 (5) 1 (5) 4 (19) 21 (11)
26-35 4 (11) 1 (3) 3 (8) 22 (61) 0 (0) 0 (0) 2 (6) 0 (0) 1 (3) 11 (31) 36 (19)
36-45 11 (22) 1 (2) 1 (2) 23 (47) 1 (2) 7 (14) 4 (8) 2 (4) 0 (0) 18 (37) 49 (25)
46-55 15 (22) 3 (4) 5 (7) 28 (41) 2 (3) 2 (3) 7 (10) 4 (6) 0 (0) 23 (34) 68 (35)
56+ 1 (5) 0 (0) 0 (0) 5 (26) 0 (0) 2 (11) 2 (11) 0 (0) 2 (11) 9 (47) 19 (10)
Total
Deprivation
Category
193 (99)
1 (Most
affluent)
5 (33) 1 (7) 0 (0) 6 (40) 0 (0) 1 (7) 4 (27) 1 (7) 0 (0) 3 (20) 15 (8)
2 5 (19) 0 (0) 0 (0) 9 (35) 0 (0) 4 (15) 0 (0) 1 (4) 1 (4) 10 (39) 26 (14)
3 9 (32) 1 (4) 1 (4) 13 (46) 0 (0) 1 (4) 2 (7) 0 (0) 1 (4) 5 (18) 28 (15)
4 4 (12) 1 (3) 3 (9) 17 (52) 1 (3) 3 (9) 3 (9) 2 (6) 0 (0) 14 (42) 33 (18)
5 12 (22) 0 (0) 3 (6) 33 (61) 0 (0) 2 (4) 6 (11) 1 (2) 1 (2) 14 (26) 54 (30)
6 4 (22) 0 (0) 1 (6) 7 (39) 0 (0) 2 (11) 2 (11) 1 (6) 1 () 8 (44) 18 (10)
7 (Most
deprived)
0 (0) 0 (0) 1 (14) 3 (42) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 4 (57) 7 (4)
Total
Occupation
181 (93)
Professional 28 (27) 0 (0) 4 (4) 54 (52) 0 (0) 6 (6) 8 (8) 3 (3) 2 (2) 33 (32) 103 (54)
Scientific &
Technical
2 (17) 2 (17) 0 (0) 3 (25) 1 (8) 0 (0) 2 (17) 0 (0) 1 (8) 2 (17) 12 (6)
Ancillary
(Hotel
Services)
2 (11) 0 (0) 3 (16) 10 (53) 0 (0) 1 (5) 0 (0) 2 (11) 0 (0) 7 (37) 19 (10)
Admin &
Clerical
4 (14) 2 (7) 0 (0) 10 (35) 1 (3) 4 (14) 4 (14) 0 (0) 1 (3) 11 (38) 29 (15)
Maintenance/ 1 (17)
Estates
0 (0) 0 (0) 0 (0) 0 (0) 1 (17) 1 (17) 0 (0) 0 (0) 3 (50) 6 (3)
Other 3 (15) 1 (5) 2 (10) 10 (50) 1 (5) 1 (5) 2 (10) 2 (10) 0 (0) 8 (40) 20 (11)
Total
Notes:
189 (97)
Question 21 applied to all 240 survey respondents and, of these, 46 (19.2%) did not answer the question.
These respondents were excluded from the analysis of responses by these particular groups.
Respondents were able to give more than one answer so the percentages do not add up to 100.
Source: HaHP Fruit Shop Evaluation 2004
126

Question 22 - What would help you to use the HaHP fruit shop more?
Response rate:
180/240 =100%
Number (%)
Ordering
service with
customer
pick up from
fruit shop
Mobile
trolley
around
hospital
Recipes/
cooking
suggestion
s
Broade
r
product
range
Ordering
service
with
hospital
delivery
Different
opening
hours
Price Total
promotion
s/offer
Total 29 (16) 89 (49) 39 (22) 15 (8) 42 (23) 38 (21) 52 (29) 180
(100)
Gender
Male 3 (8) 16 (40) 6 (15) 2 (5) 9 (23) 6 (15) 15 (38) 40 (22)
Female 25 (18) 72 (52) 32 (23) 13 (9) 33 (24) 32 (23) 35 (25) 138 (78)
Total 178 (99)
Age group
16-25 3 (18) 8 (47) 1 (6) 1 (6) 4 (24) 7 (41) 3 (18) 17 (9)
26-35 5 (13) 23 (61) 7 (18) 5 (13) 10 (26) 12 (32) 13 (34) 38 (21)
36-45 8 (17) 26 (54) 9 (19) 4 (8) 13 (27) 8 (17) 14 (29) 48 (27)
46-55 12 (21) 26 (46) 17 (30) 4 (7) 14 (25) 10 (18) 16 (28) 57 (32)
56+ 1 (5) 6 (32) 5 (26) 0 (0) 1 (5) 1 (5) 6 (32) 19 (11)
Total 179 (99)
Deprivation Category
1 (Most affluent) 2 (13) 9 (60) 5 (33) 0 (0) 5 (33) 1 (7) 2 (13) 15 (9)
2 2 (7) 15 (52) 7 (24) 3 (10) 6 (21) 1 (3) 10 (35) 29 (17)
3 5 (20) 13 (52) 4 (16) 0 (0) 7 (28) 3 (12) 5 (20) 25 (14)
4 5 (16) 13 (42) 6 (19) 6 (19) 5 (16) 8 (26) 11 (36) 31 (18)
5 12 (23) 26 (50) 13 (25) 3 (6) 13 (25) 18 (35) 15 (29) 52 (31)
6 1 (8) 8 (62) 2 (15) 1 (8) 2 (15) 4 (31) 2 (15) 13 (8)
7 (Most deprived) 2 (40) 1 (20) 0 (0) 0 (0) 2 (40) 1 (20) 2 (40) 5 (3)
Total 170 (94)
Occupation
Professional 17 (18) 51 (55) 14 (15) 8 (9) 29 (31) 24 (26) 21 (23) 93 (53)
Scientific & Technical 1 (9) 2 (18) 3 (27) 1 (9) 1 (9) 0 (0) 5 (46) 11 (6)
Ancillary (Hotel Services) 1 (5) 8 (42) 3 (16) 0 (0) 1 (5) 7 (37) 3 (16) 19 (11)
Admin & Clerical 5 (18) 15 (56) 11 (41) 3 (11) 4 (15) 3 (11) 11 (41) 27 (16)
Maintenance/Estates 0 (0) 0 (0) 0 (0) 1 (20) 0 (0) 0 (0) 3 (60) 5 (3)
Other 4 (21) 13 (68) 5 (26) 2 (11) 6 (32) 3 (16) 8 (42) 19 (11)
Total 174 (97)
Notes:
Question 22 applied to all 240 survey respondents and, of these, 60 (25.0%) did not answer the question.
Information on gender, age group, deprivation category and occupation was missing for some respondents. These
respondents were excluded from the analysis of responses by these particular groups.
Respondents were able to give more than one answer so the percentages do not add up to 100.
Source: HaHP Fruit Shop Evaluation 2004
127

Question 23 - The HaHP fruit shop opens from 8:15am to 7:15pm.
Do you feel that the fruit shop opening hours suit your needs?
Number (%)
Response rate:
233/240 =100%
Yes No Don't use shop Total P Value
Total 164 (70) 38 (16) 31 (13) 233 (100)

Question 24a - Are you satisfied with the service at the HaHP fruit shop?
Response rate:
227/240 =100%
Number (%)
Very good Good OK Poor Don't use shop Total P Value
Total 120 (53) 63 (28) 8 (4) 1 (0) 35 (15) 227 (100)

Question 24b - Are you satisfied with the quality at the HaHP fruit shop?
Response rate:
225/240 =100%
Number (%)
Very good Good OK Poor Don't use shop Total P Value
Total 80 (36) 74 (33) 29 (13) 7 (3) 35 (16) 225 (100)

Question 24c - Are you satisfied with the prices at the HaHP fruit shop?
Response rate:
224/240 =100%
Number (%)
Very good Good OK Poor Don't use shop Total P Value
Total 78 (35) 77 (34) 32 (14) 1 (0) 36 (16) 224 (100)

Question 24d - Are you satisfied with the choice at the HaHP fruit shop?
Response rate:
225/240 =100%
Number (%)
Very good Good OK Poor Don't use shop Total P Value
Total 91 (40) 69 (31) 27 (12) 2 (1) 36 (16) 225 (100)

133