Please use this identifier to cite or link to this item: https://hdl.handle.net/10321/4822
Title: Design of a worksite intervention to lower cardiometabollc risk In South Africa
Authors: Singh, Shivneta 
Keywords: Non-communicable diseases;Food environment;Behavioural intervention;Cardiometabolic risk
Issue Date: May-2023
Abstract: 
Background: Non-communicable diseases (NCDs) continue to increase globally, with an unduly larger
impact in low to middle income countries (LMICs). NCDs are the main cause of death worldwide. There is
strong evidence that lifestyle changes, such as weight loss, increased physical activity, and improved diet
quality can help avert or slow down type 2 diabetes and reduce cardiometabolic risk factors, for example,
high blood glucose, plasma lipids, and blood pressure. Regardless of the verification of research data,
supporting the use of lifestyle interventions to prevent diabetes (improve glucose tolerance and lower high
blood pressure), and implementing interventions in real-life settings has been proven to be difficult.
Aim: The purpose of the study was to guide the development of an acceptable, appropriate, and feasible
worksite intervention targeting the food environment and behavioural intervention to reduce cardiometabolic
risk at a worksite in South Africa (SA).
Methodology: In this cross-sectional study both qualitative and quantitative methods were used. The
capacity of the built environment was explored through structured observations of the food and physical
environment to offer healthy food and promote physical activity. Semi-structured in-depth interviews (IDIs)
were conducted with worksite managers and canteen managers to assess the appropriateness,
acceptability and feasibility of changes at worksites and explore the perceptions, provisions, facilitators and
barriers to healthy eating at the worksite environment. Purposive snowballing sampling was used to recruit
worksite managers and canteen managers for the IDIs. Focus Group Discussions (FGDs) were conducted
amongst employees to explore the perceptions, provisions, drivers of and barriers to healthy eating at the
worksite. An Organisational Readiness to Implement Change (ORIC) questionnaire was administered face
to face at the worksite canteens and online through emails to employees aged between 18 to 65 years to
determine the worksite readiness to implement changes at the worksite. Canteen staff were approached to
rate possible intervention components for the purpose of tailoring the interventions and identifying the best
way to deliver the intervention. The interventions were rated by canteen managers or canteen staff on a
scale from one to five with regards to the feasibility of implementing different components of the intervention:
with one (1) being impossible to implement and five (5) being easy to implement. A scoping review was
carried out to gather data from empirical findings on the categorisation of healthy foods through Front of
Pack (FOP) labelling schemes and was reported using the Preferred Reporting Items for Systematic
Reviews and Meta-Analyses (PRISMA) extension for Scoping Reviews (PRISMA-ScR) guidelines. Key
findings from the formative work were used to select suitable food and physical environment interventions
for the worksite. Worksite canteen intervention training was conducted to train canteen managers for the
implementation of the food environmental intervention using the training manual that was developed by the
researcher.
Results: The study was conducted at six Unilever SA worksites, three in KwaZulu-Natal (KZN) and three
in Gauteng province. The Unilever worksites comprised of five factories and one Head Office, namely,
Unilever Maydon Wharf (Personal Care and Home Care), Unilever Indonsa (Savoury dry food plant - Knorr,
Robertson’s, Rajah), Unilever Khanyisa (Home Care), Boksburg (Home care) and Lordsview (Ice cream -Ola) and La Lucia Head Office (Head Office). The study was also conducted at Retailability Head Office, a
fashion apparel brand, which borders on the Unilever Head Office, making a total of seven worksites. The
findings of the structured observations for the physical environment indicated that walking tracks were
demarcated within the worksites; however, there were no signage prompts to encourage walking.
Stairwells were clean, well lit, easily visible and accessible at each building; however, the health benefits
of using the stairs were not displayed.
The food environment was observed at six canteens including La Lucia Head Office and Retailability,
Unilever Maydon Wharf, Unilever Indonsa, Unilever Khanyisa and Unilever Boksburg. There were two
canteens at La Lucia Head Office: the main canteen and a coffee shop. There was no canteen at Unilever
Lordsview, but there was a dining area with packaged food sold at the vending machine. Regarding the
observation of the food environment, the worksite canteens offered five subsidised contract dishes among
other unsubsidised dishes of which the healthy meal was the most expensive in a four-week menu cycle.
Pre-made pre-packaged food options were sold at the canteens and displayed near to the point of sale.
Ten semi-structured IDIs were conducted with worksite managers, to assess the appropriateness,
acceptability and feasibility of changes at worksites and to explore the perceptions, provisions and
facilitators of and the barriers to healthy eating at the worksite environment. Several themes emerged from
the IDIs with worksite managers with regards to participation in a lifestyle intervention namely: availability,
worksite resources and barriers to participation.
Four semi-structured IDIs were conducted with canteen managers to assess the appropriateness,
acceptability and feasibility of changes at worksites and barriers to healthy eating at the worksite
environment. Numerous themes emerged from the IDIs with canteen managers including the enablement
of a healthy food environment, information dissemination, employee preference and canteen enablers.
Five FGDs were conducted, each group comprising of 4-6 employees, until data saturation was reached to
understand the appropriateness, acceptability and feasibility of a range of possible changes at the worksite.
Many themes emerged from the FGDs such as nutrient-dense foods, nutrient-poor foods and energy-dense
beverages as well as the food environment and healthy longevity.
Worksite readiness to implement change was determined through the ORIC questionnaire. The ORIC
statements that Unilever employees agreed with most scored 4.51 on the scale of “I believe this change
will benefit our worksite”, followed by 4.49 on the scale of “I am committed to implementing this change”
and 4.41 on the scale of “I want to implement this change”. The lowest scores (disagreement) were 3.35
for “I have the equipment we need to implement this change”, 3.37 for “I have the resources we need to
implement this change” and 3.46 for “I have the expertise to implement this change”. All statements were
significantly different from ‘3’, on average. All mean values were >3 which indicates there was a significant
agreement with all the statements. Factor analysis with promax rotation was applied to the 31 statements.
A Kaiser-Meyer-Olkin Measure of Sampling Adequacy (KMO) of 0.958 and a significant Bartlett’s test indicated that the data was adequate for successful and reliable extraction. The alpha value for factor 1
and 2 was >.7, therefore indicating reliability.
Composite variables were formed by calculating the average of the agreement scores for all items included
in a variable. It was observed that there was a significant agreement for commitment (COM) and
implementation (IMP) (with agreement that they desired the change and were committed to it being
significantly higher than their agreement that they could implement the change). Results from a paired ttest showed agreement that they desired the change and were committed to it and were significantly higher
than agreement that they could implement the change, t (299) = 15.229, p<.001. Further analysis to
determine differences across worksites was conducted. Analysis from ANOVA showed that there was a
significant difference in COM (commitment) across worksites, F (3, 296) = 5.375, p=.001. Post hoc analysis
using Tukey’s test indicated that agreement to commitment was significantly higher at Maydon Wharf than
at La Lucia Head Office (p=.043) and at Khanyisa (p=.021); and at Indonsa than at La Lucia Head Office
(p=.031) and at Khanyisa (p=.021). Furthermore, there was a significant difference in IMP (implementation)
across worksites, F (3, 296) = 9.960, p<.001.
The ORIC statements that Retailability employees agreed with the most scored 4.58 on the scale: “I am
committed to implementing this change”, followed by 4.53 on the scale of “I believe this change will make
things better”, 4.50 on the scale of “I feel that implementing this change is a good idea” and 4.50 on the
scale of “I feel this change is compatible with our values”. The lowest scores (indicating disagreement)
were 3.11 for “I have the equipment we need to implement this change”, 3.24 for “I have the resources we
need to implement this change” and 3.46 for “I have the expertise to implement this change.” All statements
were significantly different from ‘3’, on average. All mean values were >3 which indicated there was
significant agreement to all the statements. Factor analysis with promax rotation was applied to these 31
items. Two factors were extracted which accounted for 72.19% of the variance in the data. A Kaiser-MeyerOlkin Measure of Sampling Adequacy (KMO) of .784 and a significant Bartlett’s test indicated that the data
was adequate for successful and reliable extraction. The alpha value for factor 1 and 2 was >.7, therefore
indicating reliability. It was observed that there was a significant agreement for commitment (COM) and
implementation (IMP) (with agreement that they desired the change and were committed to it being
significantly higher than their agreement that they could implement the change). Results from a paired ttest showed that agreement that they desired the change and were committed to it was significantly higher
than agreement that they could implement the change, t (37) = 6.727, p<.001.
The intervention rating scale was completed by 12 canteen managers and canteen staff using a scale from
one to five for the feasibility of implementing different components of the intervention. Interventions that
were easy to implement were reported by 100% (n=12) of participants for increasing fruit and vegetable
choices, 92% (n=11) for the provision of free water, followed by 75% (n=9) for the addition of a salad bar
and ready-to- eat healthy meals. The one-sample t-test was done to determine whether the average
‘implementability’ score differed significantly from the central score of ‘3’. The easiest interventions to
implement were reported by 83% (n=10) of participants being the strategic positioning of healthier alternatives to make healthy items more accessible with 75% (n=9) recommending traffic light labelling and
healthy option stations. The most difficult to implement was reported by 25% (n=3) of participants for the
display of kilojoules of a product translated into the number of minutes to perform a certain physical activity.
A scoping review was conducted on FOP labelling schemes to inform the selection of a FOP labelling
scheme best suited for canteen foods at worksites in SA. Several articles (n = 2513) were identified and
screened after excluding duplicates (n = 2474). Overall, 1347 articles were excluded from the study
because their abstracts and titles did not match the qualifying criteria. A total of six articles was used in the
qualitative analysis after a full-text review of the remaining articles. It was concluded that grading foods
into categories of healthfulness through evidence of key nutritional dimensions is a practical tool to inform
food environmental interventions that may assist in public health promotion by influencing consumer choice
in workplace canteens and beyond.
The results from the observations, IDIs, FGDs, ORIC questionnaire, canteen rating intervention scale and
scoping review were used to guide the development of the physical and canteen intervention and canteen
staff were capacitated with training to implement the food environment intervention. A list of interventions
detailing the tools to be used and responsibilities for executing the six weeks’ intervention with two weeks’
maintenance classes for phase three of the study, titled the South African Pioneer Worksite Multicomponent
Lifestyle Intervention Study (WMLIS) was developed by the research team.
Conclusion: Interventions are a useful tool that can be used in worksite settings to improve employees'
overall occupational well-being. Interventions targeting the food environment and behavioural intervention
can promote healthy eating behaviours and reduce cardiometabolic risk. It is important to take into account
organisational complexity and the built environment when designing an intervention. In this study, formative
research methods were used to engage worksite stakeholders to develop an intervention plan that is both
theoretically and practically grounded to foster institutionalisation of the intervention. The findings of this
study was used to contextualise and guide the development of acceptable, appropriate and feasible
worksite food environment and behavioural intervention to reduce cardiometabolic risk among South
African employees. The methods used allows for drawing of general conclusions for the implementation of
lifestyle and food environment changes at worksites in SA. It is recommended that the study should be
scaled up to other worksites to determine the comparativeness of this study to the response of other
worksites regarding the acceptability, appropriateness and feasibility of worksite interventions.
Description: 
Thesis submitted in fulfilment of the requirements of the degree of: Master of Applied Science in Food and Nutrition: Consumer Science, Durban University of Technology, South Africa, Durban, 2022.
URI: https://hdl.handle.net/10321/4822
DOI: https://doi.org/10.51415/10321/4822
Appears in Collections:Theses and dissertations (Applied Sciences)

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