Exploring University Food Environment and On-Campus Food Purchasing Behaviors, Preferences, and Opinions

ARTICLE IN PRESS Research Article Exploring University Food Environment and On-Campus Food Purchasing Behaviors, Preferences, and Opinions Rajshri Roy, PhD1; Danielle Soo, MSc1; Denise Conroy, PhD2; Clare R. Wall, PhD1; Boyd Swinburn, PhD3 ABSTRACT Objective: Cross-sectional observation of a university food environment and a survey of food purchasing preferences, behaviors, and opinions of students and staff to formulate strategies for interventions. Design: A modified food environment-quality index was used to assess food outlets. A cross-sectional survey with closed (n = 42) and open-ended (n = 2) questions assessing students and staff purchasing, choice determinants, and opinions about the food environment. Setting: Six campuses of 1 large urban university. Participants: Food outlets (eg, convenience stores, restaurant and caf
e, takeout, vending machines) (n = 57). University students and staff (n = 1,954). Analysis: The researchers calculated descriptive statistics and Pearson chi-square tests to compare the percentages of healthy and/or unhealthy products in high- vs low-scoring outlets. Kruskal−Wallis H test was used to determine differences in healthiness between outlet types. Pearson chi-square tests were used to examine the influence of gender, and student and staff differences in survey responses. Results: Median food environment-quality index was 79 out of 199 (interquartile range = 7). Six food outlets were categorized as healthy and 2 as unhealthy; the rest were intermediate. Overall, healthy items were less available, accessible, and promoted and cost more than unhealthy items. The majority of respondents in the survey (79%) purchased food and beverages on campus; males consuming them more frequently than did females (P = .001) and students consumed them more frequently than did staff (P = .001). Value for money, healthfulness, and taste determined the choice. Respondents suggested increasing value for money and healthy options. Conclusions and Implications: Interventions that improve food availability, accessibility, prices, and promotions through policies are warranted and would be well-received among both university students and staff. Key Words: food environment, food purchasing determinants, university foods, young adults (J Nutr Educ Behav. 2019;000:1−11.) Accepted March 3, 2019.

INTRODUCTION Young adults (aged 18−35 years) are the poorest consumers of vegetables1−3 and the highest consumers of energydense foods.4−6 Burgers, pizzas, fries, and soft drinks are the most common type of products consumed.6 These less healthful dietary practices increase as young adults become working adults

with higher incomes.7,8 Young adults are gaining weight more rapidly than did their parents’ generation.9 In New Zealand (NZ), approximately 230,000 young adults (49.2% of the adult population) are overweight or obese.10 Students gain an average of 3.38 kg within the first year of education as a result of changes in lifestyle, poor physical activity, and unhealthy

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Discipline of Nutrition and Dietetics, University of Auckland, Auckland, New Zealand Faculty of Business and Economics, University of Auckland, Auckland, New Zealand 3 School of Population Health, University of Auckland, Auckland, New Zealand Conflict of Interest Disclosure: The authors have not stated any conflicts of interest. Address for correspondence: Rajshri Roy, PhD, Discipline of Nutrition and Dietetics, School of Medical Sciences, University of Auckland, Building 504, Room 238, 85 Park Road, Grafton, Auckland, New Zealand; E-mail: [email protected] Ó 2019 Society for Nutrition Education and Behavior. Published by Elsevier Inc. All rights reserved. https://doi.org/10.1016/j.jneb.2019.03.003 2

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dietary behaviors, particularly autonomy in food choices11−14 and stress or comfort eating.15,16 The prevalence of weight gain doubles as young adults move from their twenties to their thirties and become working adults.7 The 8 universities in NZ teach approximately 177,000 young adults (part- and full-time) and employ around 20,500 working adults.17 Because students and staff typically spend a substantial amount of time on campus, the food environment within tertiary education settings can have an important role in influencing their dietary behaviors.18 Therefore, these settings have a strong responsibility to provide a food environment that enables young adults to make healthier food choices.19 It is

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ARTICLE IN PRESS IQR indicates interquartile range. a Observation used a composite scoring system known as the food environment-quality index; bKruskal−Wallis H test showed no statistically significant difference in composite food environment score among the different food outlet types (x2 =5.303; P = .51); cNo difference in availability scores (x2 =1.666; P = .95) among food outlet types; d No difference in accessibility scores (x2 =3.710; P = .72) among food outlet types; eStatistical difference in cost scores (x2 =20.288; P = .002) among food outlet types; f No difference in promotion scores (x2 = 4.945; P = .55) among food outlet types.

IQR

6 3 3 2 0 80 24 24 5 25

Median IQR

10 6 5.5 5 3.5 90 27 26.5 13 23.5

Median IQR

0 0 0 0 0 77 22 26 4 25

Median IQR

8.25 3.75 2.25 2.5 3.25 77 25 25 2.5 24.5

Median IQR

6 4 3 4 1 79 24 25 7 25

Median

Vending Machines (n = 29) Convenience Stores (n = 2) Bar/Pubs (n = 1) Takeout (Franchise) (n = 5) Takeout (Local) (n = 6)

IQR

0.5 1 0 0.5 0 76 25 25 1 25

Median IQR

8 3.5 1.5 4 1.5 80 25 25 8 25

Median

Food environment observation. The researchers used a modified audit tool, the food environment-quality index (food environment-QI),20,22 to assess the availability, accessibility, cost, and promotion of food and beverages at all food outlets (n = 57) within 6 campuses of the university. These campuses, which housed different faculties, were all located in the Auckland, NZ, metropolitan region. The geographical boundaries of each campus building were outlined and all food outlets within each campus’s boundary were identified for audit. A taxonomy of food outlets was adapted to categorize the type of food outlet as caf
e or restaurant, convenience store, coffee cart, independent takeout, franchise takeout, vending machine, or bar or pub (Table 1).20 Food outlet lists and the food and beverage items they sold

Composite scoreb Availabilityc Accessibilityd Coste Promotionf

Data Collection

Coffee Cart (n = 3)

A cross-sectional observational study audited all food outlets across 6 campuses of a large urban university in NZ. Over a corresponding 8-week period, staff and students from the same university completed an anonymous researcher-designed survey19 assessing food purchasing, food choice behaviors, and opinions about the campus food environment.


/ Cafe Restaurant (n = 11)

METHODS Study Design and Setting

Food Outlet Type

unknown whether NZ universities are obesogenic, because to the authors’ knowledge no published studies assessed this important setting in the country. Therefore, the researchers attempted to use a quantitative survey instrument to collect detailed information about the food environment20 in a large NZ university. The aim was to conduct a survey of students and staff to determine influences on food purchases and opinions about the food environment.19,21 These measures may lead to an in-depth understanding of the nature of an organizational food environment to which younger and working adults are exposed, and whether they need to be modified to improve their dietary choices.

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Food Environment Quality Index Score

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Table 1. Comparison of Food Environment Observation a Scores Across 4 Outcome Measures by Type of Food Outlets

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ARTICLE IN PRESS Journal of Nutrition Education and Behavior  Volume 000, Number 000, 2019 were obtained from a business list developed by the university commercial services that owned, leased, and operated all outlets within the university. University commercial services made the final decision in negotiation with the vendor regarding what was to be stocked for each type of outlet, including vending machines. The food environment-QI was composed of a positive scoring system. Three of 4 outcome measures (availability, accessibility, and promotion) were validated;20 the cost outcome measure was added for the current study. Food availability was defined as food and beverages that were present and ready for purchase within a food outlet. Food accessibility was the ease with which food could be obtained by consumers. Food promotion was any form of display, rebate, coupon, or sale used to encourage purchasing at the point of purchase (POP). The healthiness of food was classified using the National Healthy Food and Drink Policy criteria, which outline the type of foods permitted for sale using the traffic light system and health star ratings.23 One point was allocated if a healthy product was available, easily accessible, and promoted. One point was allocated if an unhealthy product was unavailable, not easily accessible, and not promoted.20 The price of each food or beverage was compared with the mean price of identical or similar products sold in major NZ supermarkets and food outlets, called the reference price. One point was allocated to the outlet if a healthy product cost below its reference price, and 1 point was allocated if the cost of an unhealthy product was higher than its reference price. The maximum achievable score was 199. For foods that did not have nutritional information (eg, cakes, muffins, or sweet pastries), a registered dietitian determined the caloric value of each food using FoodWorks Professional software (version 8) with New Zealand FOODFiles as the database (Xyris Software, Brisbane, Australia, 2012). Foods and beverages were placed in appropriate subcategories (eg, beverages such as coffee and tea were categorized under dairy drinks [full-fat or reduced-fat milk], because

this was the form in which they were served unless otherwise specified). Food products such as protein bars were categorized under muesli bars because of the similarities in caloric value. Once scoring was completed for all 4 outcome measures, these values were summed to indicate the healthiness of each food outlet (Table 2).20 Cutoff points for defining an outlet as healthy, intermediate, and unhealthy were determined using the spread of data by dividing the total scores under each measure into tertiles.20 Food outlets with composite scores > 86 were classified as healthy, and those < 70 as unhealthy. Food outlets with scores of 70−86 (inclusive) were classified as intermediate. Before data collection, the modified food environment-QI audit tool was pretested and refined to ensure it performed consistently throughout each food outlet. Because the data were to be collected by 1 auditor, scoring of all outcome measures during pretesting was discussed between the principal investigator and the auditor, identifying reasons for discrepancies between scores and revising the tool until consensus was reached for the final audit tool (Supplementary Data 1). Data were collected during fall and winter in NZ between April and May, 2017.

Survey Implementation The survey by Tam et al19 was modified, informed by previous research, and divided into 4 sections with 44 questions: demographic characteristics, food purchasing behaviors, determinants, and consumptions and opinions about the current campus food environment. Demographic items included age, sex, study status (part-time or full-time), degree level, and hours spent on campus (Table 3). Food purchasing behavior questions ascertained motives for and frequency of purchasing different types of foods and beverages. Opinion items regarding the food environment employed a 5-point Likert scale (strongly agree, agree, neutral, disagree, or strongly disagree) or a 0−10 scale (poor to excellent) to determine views on the current and potential opportunity to change aspects of the food environment. Most questions were closed-

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ended (n = 42), but participants were provided with the opportunity to provide open-ended suggestions (n = 2) regarding improvement to the campus food environment. Before the survey was implemented, the questionnaire was tested by academic staff and students (n = 10) within the university marketing department to ensure that questions were easily understood, free from bias, and appropriately structured. Feedback was used to design the final survey instrument (Supplementary Data 2). A minimum of 382 respondents were required to achieve power for a population of 47,000 based on the precision level of § 5%, the confidence interval of 95%, and P = .05.24 The survey was administered online (version 042016, Qualtrics survey software, Qualtrics Labs, Inc, Provo, UT, 2016) over 8 weeks between April and June, 2017. The survey was advertised on all 6 campuses (5,000 staff and 42,000 students25) using electronic newsletters and the university Facebook page. All enrolled students and current staff were eligible to participate. Participants could complete the survey only if they selected either staff or student on the first page. Participation was anonymous, but to encourage completion, a lucky draw incentive (iPad Pro, Apple, Cupertino, CA) was used. To ensure respondents were current staff and students, only university e-mails were considered in the draw. Survey responses were separated from the lucky draw entry to maintain anonymity.

Data Analysis Data from the observational study of the food outlets were entered into SPSS software (version 25.0, SPSS Statistics for Windows, IBM Corp, Armonk, NY, 2017) for statistical analysis. Descriptive statistics (medians and interquartile range [IQR]) were computed for each outcome measure and the composite food environment-QI scores were calculated. Kruskal−Wallis H test was used to compare scores between outlet types to determine differences in healthiness. The percentage of healthy and/or unhealthy products across the outcome measures in high- vs low-scoring outlets was calculated. Pearson chi-square goodness

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Availability Foods and Beverages Sugary drinks

Other Chocolate and candy

High-energy snacks

Lower-energy snacks

Promotion

Top Tertile (%)

Bottom Tertile (%)

Top Tertile (%)

Bottom Tertile (%)

Top Tertile (%)

Bottom Tertile (%)

Top Tertile (%)

Bottom Tertile (%)

55 41 41 7 62 38 55 35 48 31 31 48 21 7 79 72 10 3 3 0 17 0 7 21 10 10 28 7 0 3 10 14 24 7 14 3

44 33 33 33 44 22 33 0 11 33 22 44 0 0 33 22 67 56 0 0 67 0 44 78 11 67 22 11 0 0 0 0 44 0 0 0

32 24 32 6 32 24 38 27 38 6 3 35 18 6 53 47 12 3 3 0 15 0 6 15 9 9 12 6 0 3 9 3 21 6 6 3

17 17 17 17 17 0 17 0 0 0 0 0 0 0 17 17 100 83 0 0 83 0 67 83 17 83 0 0 0 0 0 0 67 0 0 0

59a 46a 62a 18a 49a 46a 8b 3b 3b 13a 23b 8b 8a 0b 0b 5b 49a 21a 0a 0a 51a 0a 18a 36a 8a 33a 8a 0a 0b 0b 0b 3b 0b 3b 8b 0b

10a 0a 0a 0a 10a 10a 0b 10b 0b 10a 30b 10b 10a 0b 0b 10b 0a 0a 0a 0a 0a 0a 0a 10a 0a 0a 0a 0a 0b 0b 0b 0b 10b 0b 0b 0b

0 0 0 0 17 0 17 0 0 0 0 0 0 0 33 17 0 0 0 0 17 0 0 17 0 0 0 0 0 0 0 0 0 0 0 17

55 9 46 9 18 27 18 9 0 9 0 18 0 0 36 18 0 9 9 0 18 0 0 9 0 0 9 9 0 9 9 0 0 0 0 0 (continued)

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Dairy drinks

Cost

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Diet drinks

Subcategory Sugar-sweetened soft drinks Sugar-sweetened flavored water/iced tea Sugar-sweetened energy drinks Sports drinks Fruit drinks Flavored milk (> 1,600 kJ/serving) Diet soft drinks Diet flavored water/iced tea vitamin water ($4.2) Diet energy drinks Plain milk (full-fat) Plain milk (reduced-fat/skim) Flavored milk (< 1,600 kJ/serving) Yogurt (full-fat) Yogurt (reduced/low-fat) Water (include plain, mineral, soda) 100% fruit or vegetable juice Chocolate Candy/lollipops Fruit chews/leather Frozen desserts (> 300 kJ/serving) Chips/extruded (processed) snacks (> 600 kJ/serving) Rice crackers (> 600 kJ/serving) Popcorn (> 600 kJ/serving) Cookies (> 600 kJ/serving) Crackers (> 600 kJ/serving) Muesli bars (> 600 kJ/serving) Cakes/muffins/sweet pastries (> 900 kJ/serving) Ice cream (> 600 kJ/serving) Chips/extruded (processed) snacks (< 600 kJ/serving) Rice crackers (< 600 kJ/serving) Popcorn (< 600 kJ/serving) Cookies (< 600 kJ/serving) Crackers (< 600 kJ/serving) Muesli bars (< 600 kJ/serving) Cakes/muffins/sweet pastries (< 900 kJ/serving) Ice cream (< 600 kJ/serving)

Accessibility

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Table 2. Types of Foods and Beverages Made Available and Accessible and Promoted, and Their Cost Across the Top and Bottom Tertiles, Defined Using Total Composite Scores.

ARTICLE IN PRESS Food or beverage products that were priced higher than the reference price; b Food or beverage products that were priced lower than the reference price. Note: Reference price was the mean price of identical or similar products sold in major New Zealand supermarkets and food outlets.

Less healthy meals

Healthy meals

a

0 9 0 0 9 0 0 0 18 9 9 18 55 0b 0b 0b 0b 10b 0b 10b 0b 0a 0a 0a 0a 0a 15 24 0 3 12 12 18 12 0 0 3 3 9 17 31 0 3 38 17 48 31 14 14 3 17 35

Subcategory

Fruits and nuts

Fresh fruit Dried fruit/nuts/seeds Canned fruit Other (specify) Sandwiches Sushi rolls Salads Hot mixed dishes (with vegetables as major component) Deep-fried takeout foods (eg, french fries/Chiko Rolls) Meat pies and pastries (savory) Pizza Hamburgers/hot dogs Hot mixed dishes (with vegetables not as major components)

11 67 0 0 22 0 22 33 44 22 22 33 78

17 83 0 0 0 0 0 0 0 0 0 0 50

13b 3b 0b 0b 15b 10b 21b 8b 5a 10a 0a 5a 39a

17 0 0 0 33 0 33 0 0 0 0 17 0

Bottom Tertile (%) Top Tertile (%) Bottom Tertile (%) Top Tertile (%) Bottom Tertile (%) Top Tertile (%) Bottom Tertile (%) Top Tertile (%) Foods and Beverages

Table 2. (Continued)

Availability

Accessibility

Cost

Promotion

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of fit was used to compare these nonparametric data across different types of food outlets. P < .05 was significant. Responses to complete surveys were collated and expressed as percentages. Similar responses were collated for questions that made multiple responses possible (eg, Why do you prefer not to purchase food or beverages on campus?), to provide a summary of responses in a specific category. The researchers calculated descriptive statistics and performed Pearson chisquare goodness of fit to examine any influence of gender, and staff or student differences that might have been interesting. For 1 item using a scale with a rating of least likely to most likely, results were reported as means § SD. Open-ended responses were organized in Microsoft Excel 2010 (Microsoft Corporation, Redmond, WA) and synthesized inductively into major themes.

RESULTS Food Environment Observation Results The study audited 57 food outlets including 29 vending machines across 6 campuses. The overall median composite score was 79; scores ranged from 68 to 100 (IQR = 7). Frequently prevalent foods and beverages were water (67% of all outlets), fruit drinks (60%), sugar-sweetened beverages (SSBs) (58%), diet beverages (56%), and mixed dishes without vegetables (53%). Of the 28 food outlets, 5 were categorized as healthy and 1 as unhealthy; the rest were intermediate (23). Fifteen food outlets achieved composite scores that were equal to or above the median (79). Descriptive statistical analysis (Table 1) of the food outlets showed minimal spread depicting low variation within each of the 4 outcome measures’ scores. The promotion of foods had low IQR (Table 1). Table 2 shows the types of foods and beverages that were made available, accessible, and promoted. Most healthy products sold in outlets were also priced higher than reference prices. Lowscoring outlets did not have major

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Table 3. Participant Demographic Characteristics Participant Characteristics Studentsa Total Age, y < 25 > 25 Hours on campus < 20 > 20 Study status Full-time Part-time Other Degree level Undergraduate Postgraduate Student location Domestic International Staffb Total Age, y < 25 > 25 Hours on campus <20 > 20 Staff status Full-time Part-time Other Staff type Academic Professional Affiliate

Male

% Male

Female

% Female

100

386

25

1,158

75

1,420 124

92 8

340 46

88 12

1,065 93

92 8

510 1,034

33 67

100 286

26 74

405 753

35 65

1,482 46 15

96 3 1

374 12 1

97 3 0.3

1,266 278

82 18

313 73

81 19

961 197

83 17

1,405 139

91 9

336 50

87 13

1,065 93

92 8

410

100

86

21

320

78

33 377

8 92

7 82

8 95

26 294

8 92

29 381

7 93

1 85

1 99

26 294

8 92

336 66 6

82 16 1.4

76 7 3

88 8 4

259 61 3

81 19 1

131 262 12

32 64 3

39 44 3

45 51 4

93 218 10

29 68 3

Total

%

1,544

P

.46

.001

.001 1,112 46 5

96 4 0.4 .98

.01

1.0

.001

.01

.64

a Total respondents = 1,954, students = 1,544, student respondents = 79%; respondents = 21%. Note: Pearson chi-square test was used to examine the influence of sex.

differences in price regardless of the healthiness of products. Of the 29 vending machines, 1 was categorized as healthy (score = 91) and 1 as unhealthy (score = 68). Ten vending machines sold beverages, 10 sold a mixture of food and beverage products, and the remaining 9 sold only snacks. The most widely available snacks in vending machines were chocolates and candy, followed by chips. Analysis of the vending machines found that 15 vending machines (52%) sold water.

b

Total respondents = 1,954, staff = 410, staff

Survey Results Demographic characteristics of respondents. The survey was submitted by 1,979 respondents; 25 incomplete surveys were excluded. Table 3 lists the characteristics of those who successfully completed the survey (n = 1,954) Food purchasing behavior and determinants. Most respondents (79%) reported purchasing food or beverages on campus; most spent < $20 daily (52%). A total of 41% of respondents reported that they were likely to

purchase food and beverages each time they were on campus. Figure 1 displays determinants for food purchases. Poor value for money was reported as the main reason for no campus expenditure (54%), followed by preference for eating food brought from home (28%). Respondents reported purchasing food for lunch (66%), followed by snacks in the afternoon (37%) from university food outlets. Beverages were purchased most frequently in the morning for breakfast (45%), followed by during the afternoon (35%) and at lunch (29%).

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120

Overall %

Female %

P = .001

Male % P = .05

100

80

P = .001 P = .001

P = .001

P = .001

P = .001

60 P = .001 P = .05

P = .001

P = .001

40

%

20

0 Helps Control Weight

Usually Helps Cope Familiar to Looks Nice Smells Nice Keeps me what I Eat with Stress Me Awake or Alert

Keeps me healthy

Makes me feel good

Nutritious

Accessible

Value for Money

Taste

Figure 1. Percentage of respondents who affirmed the role of each determinant in their food choice decisions, overall and then split for gender. Determinants with P ≤ .05 differed significantly between males and females calculated by Pearson chi-square test for gender and determinant. Most staff (75%) reported attending a function, event, or meeting at the university catered by university caterers. Food consumption. Respondents consumed hot foods (eg, meat pies and french fries) weekly or more (24.5%); males consumed them more frequently than did females (P = .001) and students consuming them more frequently than did staff (P = .001). Baked goods (eg, cakes, slices, and cookies) and candy (such as chocolate and lollipops) were reportedly consumed (23%) weekly or more; male students were the most frequent consumers (P = .001). Twenty percent of respondents also reported consuming savory snacks such as chips once a week or more, with significant differences between males and females (P = .02). Healthier snacks such as nuts, fruits, and muesli or cereal bars were least frequently consumed, with only 10% consuming them once a week or more. Half of all respondents reported consuming coffee, tea, and/or hot chocolate once a

week or more. A total of 20% of respondents reported consuming soft drinks, energy drinks, and sports drinks once a week or more.

Opinions About the Campus Food Environment Figure 2 represents the most popular opinions about the campus food environment and changes suggested by staff and students. The figure summarizes responses to 3 closed-ended questions: Please indicate how much you agree with the below statements: On campus, I would like to see more . . .; From campus food retailers I would also like to see . . .; and How much do you agree with the following in regard to vending machines on campus . . . ?

Food Type and Variety The closed-ended item examining food and beverage type that respondents would like to see showed that 60% of respondents wanted increased availability of fresh fruit and 62%

wanted food trucks to be available on campus. More than half of respondents (57%) wanted hot food options to be made available for longer hours, and more ethnic food options (56%). Staff (61%) reported that they wanted more healthy foods and beverages available at university-catered events, and 44% of staff reported that if these options were made available, they would choose them.

Food Costs Most respondents wanted less expensive food (75%) and monetary incentives for choosing healthier options (66%) at the university and showed interest in incentives for choosing sustainable options (60%). More students than staff wanted to see less expensive food (P = .05).

Food Labeling Half of respondents (52%) reported that they would like visual guides for healthier choices; 48% wanted

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Figure 2. Ten most recommended changes suggested by respondents (n = 1,954) for the university food environment based on the level of agreement. Results were based on how much participants agreed with the following 3 statements for each change: 1 “On campus I would like to see more...”; 2 “From campus food retailers I would like to see...”; and 3 “How much you agree with the following in regard to vending machines on campus.” health symbols or rating systems to guide food choices (eg, traffic light labeling). Some respondents (45%) reported wanting website information for menu items and their nutritional content. Moreover, 44% wanted detailed nutritional information and 39% asked for kilojoule/calorie labeling. Staff (37.5%) reported that they would appreciate healthy eating guidelines when choosing options for catered events.

Vending Machines A total of 40% of respondents wanted only healthy options to be available in vending machines. Only 13% of respondents wanted vending machines completely removed; 25% reported that they wanted more vending machines. In addition, 30% of all respondents reported the need for a greater variety of foods and beverages in vending machines. Most respondents (64%) were neutral about adding, removing, or changing the number of vending machines.

Open-Ended Questions Less than half of the respondents (n = 762; 39%) answered open-ended

questions (n = 2) regarding aspects of foods and beverages they would like to see changed on campus that were not mentioned in the closed-ended questions. The most commonly reported aspects of change related to the decreased cost of foods and/ or increased value for money (55%), increased healthy food (25%), and increased variety (15%). A second open-ended item examining food and beverage types that respondents wanted to see on campus was answered by 35% of respondents (n = 687). Fresh and healthier choices such as salads, sandwiches, and sushi were the most popular suggestion (40%), followed by ethnic cuisines (35%) and vegetarian or vegan choices (20%).

DISCUSSION This was a unique study in NZ that analyzed an urban university food environment through a validated tool,20,22 assessed current opinion, and explored the determinants of food purchases of staff and students.19 Results of this study are not a full representation of other tertiary education settings and the wider population in NZ. Nevertheless, the findings indicate that a

disproportionately high ratio of energy-dense and nutrient-poor food and beverage products relative to healthy food and beverage products26,27 were made available and easily accessible and were promoted across all food outlets. This agrees with existing literature illustrating that universities have higher concentrations of unhealthy food and beverage products sold relative to healthier alternatives.20,28−31 Consistent with the literature, this study found that a majority of staff and students purchased some food or beverage items on campus,19,32 and these consumers demanded food that is fresh, healthy, and of greater variety, and that has better pricing.19,28 Observation of the food environment and the survey identified aspects that might be addressed to encourage healthier choices when purchasing. The most popular changes to the campus food environment suggested in the survey were an increase in the availability of healthy food and the food variety. This is in line with the food environment observation and other studies.19,28 Most food outlets were categorized as intermediate. However, some outlet types, such as franchise takeout, typically sell specialized

ARTICLE IN PRESS Journal of Nutrition Education and Behavior  Volume 000, Number 000, 2019 products that are high-energy foods. For example, a franchise food outlet that sold milk and cookie bars achieved a composite score of 74, which was slightly below the median score (79) for food outlets. The composition of this food outlet was predominantly sweet biscuits (>1,600 kJ/serving) and flavored milk (>600 mL). Because this outlet served only these specific food products, the unavailability and inaccessibility of other unhealthy products meant that this food outlet was able to gain a higher score. However, most outlets, particularly vending machines, were composed of unhealthy food and beverage products with minimal variety, and this was reinforced in the open-ended questions of the survey. Tam et al19 also found that 76% of respondents preferred their universities to increase the availability and variety of foods and beverages, particularly fresh fruits.

There is a need and demand to implement price manipulations and increase availability of healthy foods at university food outlets. Findings from this study found that overall, most food outlets priced food and beverage products higher than the reference prices regardless of the healthiness of products. Cost or poor value for money was also the most common reason why respondents did not purchase food or beverages. Respondents reported bringing food from home or purchasing off campus. They wanted to see food at a lower cost, and this was reinforced by the open-ended questions of the survey. A qualitative study19 reported that 98% and 90% of respondents chose good value for money and cheap as determinants of food purchasing. Like all consumers, university consumers want better value for products that are less profitable for food outlets.19,28,33 However, changes to the cost of food were shown to be a feasible intervention in some studies that had improved purchases without affecting revenue.34,35 Such interventions were also supported

by multiple studies conducted in the workplace and school settings.36−38 The promotion of foods had a low IQR, indicating the lack of POP promotion of foods and beverages across all food outlets (whether healthy, unhealthy, or intermediate). The survey elements visual guide for healthier choices and health symbols or rating systems to guide food choices were synonymous, which explains why individuals responded agree or strongly agree with similar frequency. Therefore, most respondents reported interest in detailed nutritional information. An increase in promoting healthy foods at POP and the nutritional information of menu items results in the increased sale of healthy food over the course of a semester, which is feasible for vendors to maintain and is acceptable to consumers.39−41 As currently designed and scored, the tool requires categories that allow for more nuanced tracking of food environments. The reference prices assume that the majority of consumers purchase available products from the selected stores and outlets used to obtain them. Accessibility to these common food outlets was not considered, which could potentially influence the final reference pricing of products and not accurately reflect the exact purchasing cost. The study excluded food outlets situated outside campus boundaries. The observed environment may not have completely reflected the food environment to which staff and students were exposed. The absence of an alcohol category in the audit tool may have resulted in discrepancies in the scoring of 3 food outlets that sold alcohol, thus potentially misrepresenting their true nutritional quality. There were more female respondents than male, indicating selection bias. Females are known to be more interested in healthy food.42 Results may have been biased toward the perspective of staff members given their slight overrepresentation. There were many partial responses, which showed that the data may not have been wholly representative of the target audience.

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IMPLICATIONS FOR RESEARCH AND PRACTICE Making healthy foods easily accessible and available is effective in improving food selection behaviors.43 For food outlets that serve made-to-order hot meals, sweet baked foods, or both, revising recipes to reduce saturated fat, added sugar, and salt (eg, preparing baked rather than deep-fried foods, increasing the vegetable content in dishes to at least 50%, or reducing portion sizes), in accordance with the NZ national healthy food and drink policy and nutrition guidelines for NZ adults, could be considered.23,44 Vending machines sold high-energy snacks and SSBs; introducing or changing to healthier versions of snacks and beverages might be implemented. Increasing the availability and accessibility of healthy options on campus could be effective in improving the food environment for staff and students.

Universities need to increase healthy food variety and their value for money while catering to the taste preferences of staff and students. The respondents wanted freshly cooked healthy foods, which are usually associated with a higher price point,20 but they demanded value for money. Promotion pricing strategies could be targeted that aim to increase healthier food and beverage purchases (eg, bundle pricing in meals might promote salads and/or fresh fruit instead of deep-fried chips, or water/diet beverages instead of SSBs).45 However, further research is needed to investigate the effects of a simultaneous price increase in unhealthy foods and price reduction in healthy foods to minimize the effect on profits for campus food vendors.46,47 Also, there were significant differences in cost scores within different outlet types, so future interventions could look at increasing outlets such as convenience stores with high-cost outcome scores. This

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might provide valuable insights into the relations between price-based interventions and self-sustainability of a healthier food environment. Reducing the prices of healthy foods and/or increasing the prices of unhealthy food is highly likely to promote consumers to improve their dietary behaviur.48,49 A potential barrier to this could be persuading vendors to provide healthier snacks at a lower cost without hindering total profit. However, even as little as a 10% reduction in cost might influence a consumer’s purchasing power.36,48 Increases in unhealthy food price by 10% and/or reductions in the price of healthy food by 10% were supported by multiple studies conducted in the workplace and school settings36−38,49 and may be viable solutions for improving the on-campus food environment.

Price manipulation is an important lever for change to improve purchase behaviors of university staff and students. Although respondents wanted changes to the university food environment in terms of healthier food, snacks such as nuts, fruits, and muesli or cereal bars were reported to be least frequently consumed. Therefore, the promotion of healthy food and beverage items might be more prominent. Visual promotions of unhealthy foods and beverage products could be restricted or changed for a healthier alternative. Nutrition promotion and education at POP and price discounts and incentives were shown to increase sales and influence food consumption behaviors in the long term.34 Respondents reported that they wanted visual guides for healthier choices and health symbols or rating systems to guide food choices at the POP, which recent research50 showed to be effective. The NZ National Healthy Food and Drink Policy23 could also be provided to staff to enable them to make healthy choices when choosing foods from caterers’ menus for university events, functions, and/or meetings.

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ACKNOWLEDGMENTS This work was supported internally by the University of Auckland through the university’s Food and Health Program Seed Funding (Project No. 3712865). The authors thank their colleagues from Commercial Services at the university who greatly assisted the research by circulating the survey on the university social media pages and helped the researchers liaise with the food vendors on campus for the audit.

SUPPLEMENTARY DATA Supplementary data related to this article can be found at https://doi. org/10.1016/j.jneb.2019.03.003.

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