Choice architecture interventions to improve diet and/or dietary behaviour by healthcare staff in high-income countries: a systematic review

OBJECTIVES: We were commissioned by the behavioural insights team at Public Health England to synthesise the evidence on choice architecture interventions to increase healthy purchasing and/or consumption of food and drink by National Health Service (NHS) staff. DATA SOURCES: MEDLINE, EMBASE, CINAHL, Cochrane Central register of Controlled Trials, PsycINFO, Applied Social Sciences Index and Abstracts and Web of Science were searched from inception until May 2017 and references were screened independently by two reviewers. DESIGN: A systematic review that included randomised experimental or intervention studies, interrupted time series and controlled before and after studies. PARTICIPANTS: Healthcare staff of high-income countries. INTERVENTION: Choice architecture interventions that aimed to improve dietary purchasing and/or consumption (outcomes) of staff. APPRAISAL AND SYNTHESIS: Eligibility assessment, quality appraisal, data abstraction and analysis were completed by two reviewers. Quality appraisal of randomised trials was informed by the Cochrane Handbook, and the Risk of Bias Assessment Tool for Nonrandomized Studies was used for the remainder. Findings were narratively synthesised. RESULTS: Eighteen studies met the inclusion criteria. Five studies included multiple workplaces (including healthcare settings), 13 were conducted in healthcare settings only. Interventions in 10 studies were choice architecture only and 8 studies involved a complex intervention with a choice architecture element. Interventions involving a proximity element (making behavioural options easier or harder to engage with) appear to be frequently effective at changing behaviour. One study presented an effective sizing intervention. Labelling alone was generally not effective at changing purchasing behaviour. Interventions including an availability element were generally reported to be successful at changing behaviour but no included study examined this element alone. There was no strong evidence for the effect of pricing on purchasing or dietary intake. CONCLUSION: Proximity, availability and sizing are choice architecture elements that are likely to be effective for NHS organisations. TRIAL REGISTRATION NUMBER: CRD42017064872.