Student food choices in a University cafeteria in Saudi Arabia

262 Pages·2017·4.97 MB·English

Student food choices in a University cafeteria in
Saudi Arabia: an empirical investigation
by
Aida Halimic

Submitted for the Degree of Doctor of Philosophy

School of Economics
Faculty of Arts and Social Sciences

Supervisors:

Professor Heather Gage
Professor Monique Raats

©Aida Mustafa Halimic 2017
Abstract
Background: One of the major health, social and economic problems in the Kingdom of Saudi
Arabia is the rising prevalence of overweight and obesity amongst young people and the
implications this has for the future burden of chronic diseases, such as type 2 diabetes. Nearly
10% of the Saudi population are now diagnosed with diabetes at a cost to the nation in 2010
estimated at $0.9 billion.
Aim: To investigate factors influencing choice of healthy food items by students in a university
cafeteria in Saudi Arabia.
Theoretical framework: Psychological theories of how individual factors affect behaviours
and concepts from the emerging field of behavioural economics underpinned the studies.
Methods: Three empirical studies involving students at the University of Ha’il, central Saudi
Arabia: 1. Questionnaire gathering background information about students’ health-related
behaviours and knowledge of behavioural risk factors for type 2 diabetes, 2. Investigation of
student purchasing patterns and intentions through a) a questionnaire probing willingness-to-
buy fruit (a healthier option) if available in the campus cafeteria, b) a controlled experiment
manipulating menu choices, 3. Analysis of actual purchasing decisions when fruit was
introduced to the campus cafeteria. Impacts of price variation and health messages were
explored in Studies II and III.
Results: 1. Students report poor health-related behaviours (dietary and physical activity);
knowledge of the link between lifestyle and type 2 diabetes is patchy. 2a. Over 50% of cafeteria
users said they would buy fruit if available. 2b. Choice of healthy items was responsive to price
manipulation. 3. When fruit was available, it was purchased by less than 10%. Health messages
had no effect on healthy item choices.
Conclusions: Pricing strategies may be effective to stimulate healthier choices. Additional
health education targeting individual psychological determinants of behaviour change may also
be required.

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Acknowledgements
The inspiration for doing this PhD thesis came from my mother Bisera who lived her life well,
acting upon her spiritual beliefs and doctors’ advice, but faced her death suddenly after diabetes
finally defeated her heart. This thesis is dedicated to the memory of my father Mustafa too who
did not have a chance to live my dreams, to go with me through my happiness, success,
irritation, frustration and disappointment and all stages that every woman goes through from
tender to maturity.
I extend my heartfelt gratitude to Professor Heather Gage for persevering with me as my
supervisor throughout the time it took me to complete this research and write the thesis from a
geographical distance of approximately 3,000 miles. Her expertise, wisdom, patience and
tolerance have consistently helped me to complete this thesis and made me believe that I am
able and strong enough to complete this academic journey.
I am grateful as well to my co-supervisor, Professor Monique Raats who has provided me with
advices that helped me write my thesis.
I thankfully acknowledge the assistance of Peter Williams in a number of statistical analyses
discussed in this thesis.
I must acknowledge as well the many friends, colleagues, students, and teachers at University
of Ha’il who assisted, advised, and supported my research and writing efforts over the years.
Especially, I need to express my deep appreciation to Mrs. Tahany (cafeterias’ Manager) who
helped me with the setting up of my experimental study and to Dr. Soher (Software Engineering
Department) who has generously given her time as a translator from Arabic to English
language.
Finally, I am forever indebted to my husband Mirsad for his unconditional support,
understanding, endless patience and encouragement when it was the most required with my
study.

Thank you all!

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Declaration
This thesis and the work to which it refers are the results of my own efforts. Any ideas, data,
images or text resulting from the work of others (whether published or unpublished) are fully
identified as such within the work and attributed to their originator in the text, bibliography or
in footnotes. This thesis has not been submitted in whole or in part for any other academic
degree or professional qualification. I agree that the University has the right to submit my work
to the plagiarism detection service TurnitinUK for originality checks. Whether or not drafts
have been so-assessed, the University reserves the right to require an electronic version of the
final document (as submitted) for assessment as above.

Signature:
Date: 31 December 2016

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Table of content
Abstract ...................................................................................................................................... ii
Acknowledgements .................................................................................................................. iii
Declaration ................................................................................................................................ iv
Table of content ......................................................................................................................... v
List of figures ........................................................................................................................... xii
List of tables ............................................................................................................................. xv
List of abbreviations .............................................................................................................. xvii
CHAPTER 1 .............................................................................................................................. 1
1 Introduction ........................................................................................................................ 1
Religion and the role of women ..................................................................................... 3
Health and health behaviours ......................................................................................... 4
Health risks of obesity ................................................................................................... 6
Prevalence of obesity ..................................................................................................... 7
Rationale and aim of the study....................................................................................... 9
CHAPTER 2 ............................................................................................................................ 13
2 Literature review: Psychological theories of behavioural change ................................... 13
2.1 Introduction ............................................................................................................... 14
2.2 Cognition models ...................................................................................................... 15
Health locus of control ................................................................................................. 16
Health Belief Model (HBM) ........................................................................................ 17
Protection Motivation Theory (PMT) .......................................................................... 18
v
2.3 Social cognition models ............................................................................................ 20
Theory of Reasoned Action (TRA).............................................................................. 20
Theory of Planned Behaviour (TPB) ........................................................................... 22
2.4 Behaviour change ...................................................................................................... 23
2.4.1 The Transtheoretical or Stages of Change (SOC) Model .................................. 24
2.4.2 Health Action Process Approach (HAPA) ........................................................ 26
2.5 Barriers to health behaviour change .......................................................................... 27
2.6 Conclusion ................................................................................................................. 29
CHAPTER 3 ............................................................................................................................ 31
3 Literature Review: Behavioural economics ..................................................................... 31
3.1 Introduction ............................................................................................................... 32
3.2 Policy approaches ...................................................................................................... 34
3.2.1 Policies supporting informed choice .................................................................. 34
3.2.2 Nudging.............................................................................................................. 38
3.2.3 Policy actions aimed at changing the market environment ............................... 42
3.2.4 Regulation .......................................................................................................... 47
3.3 Conclusion ................................................................................................................. 51
CHAPTER 4 ............................................................................................................................ 52
4 Methodology .................................................................................................................... 52
4.1 Introduction ............................................................................................................... 53
Overview of empirical work ........................................................................................ 54
Ethical considerations .................................................................................................. 55
4.2 Review of research approaches ................................................................................. 55
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4.3 Methods used in the empirical work ......................................................................... 59
4.4 Study I: Background knowledge and health-related behaviours ............................... 60
4.4.1 Introduction ........................................................................................................ 60
Data collection and sampling ....................................................................................... 60
Questionnaire design .................................................................................................... 61
Analysis........................................................................................................................ 62
4.5 Study II: Purchasing behaviours and intentions ........................................................ 62
4.5.1 Study IIa: Feasibility study ................................................................................ 62
Setting: Cafeterias at the University of Ha’il ............................................................... 62
Questionnaire design .................................................................................................... 64
Data Collection ............................................................................................................ 65
Sample size .................................................................................................................. 67
Data analysis ................................................................................................................ 67
Effect of feasibility outcomes on future research design ............................................. 67
4.5.2 Study IIb: Experimental study of food choice intentions of women students ... 68
Introduction .................................................................................................................. 68
Design .......................................................................................................................... 69
Experimental research .................................................................................................. 69
Identification of volunteers, consent and recruitment .................................................. 71
Baseline data collection ............................................................................................... 71
Information intervention .............................................................................................. 72
Food choice experiment ............................................................................................... 73
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Sample size .................................................................................................................. 74
Randomization ............................................................................................................. 75
Effect of Budget ........................................................................................................... 76
Shopping Experiment................................................................................................... 76
Data Analysis ............................................................................................................... 77
4.6 Study III: Market Experiment - Buying a Fruit item For Lunch Experiment (BAFFLE)
................................................................................................................................... 77
4.6.1 Introduction ........................................................................................................ 78
Intervention .................................................................................................................. 78
Data collection ............................................................................................................. 80
Revised processes ........................................................................................................ 82
Data entry ..................................................................................................................... 84
Assessing the impact of introducing fruit into cafeteria .............................................. 85
Assessing the impact of healthy labelling of fruit on sales .......................................... 87
Assessing the impact of a reduction in the price of fruit on sales................................ 87
Assessing the impact of free fruit on sales................................................................... 87
Selection of intervention weeks ................................................................................... 88
Data analysis ................................................................................................................ 89
4.6.2 Follow-up questionnaire .................................................................................... 89
Questionnaire design: (summarized in Table 29) ........................................................ 90
Data Collection ............................................................................................................ 91
Data analysis ................................................................................................................ 92
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CHAPTER 5 ............................................................................................................................ 93
5 Results .............................................................................................................................. 93
5.1 Introduction ............................................................................................................... 94
5.2 The Research Culture ................................................................................................ 94
5.3 Study I: Background knowledge and health-related behaviours ............................... 96
Characteristic and demographic profile of respondents ............................................... 96
Knowledge and understanding of diabetes .................................................................. 96
Health behaviour .......................................................................................................... 97
5.4 Study IIa: Purchasing behaviours and intentions - feasibility study ......................... 99
Characteristics of respondents ..................................................................................... 99
Food purchases........................................................................................................... 100
Factors affecting food choices ................................................................................... 101
Stated intentions to purchase ..................................................................................... 101
5.5 Study IIb: Experimental study of food choice intentions of women students ........ 102
Participant characteristics .......................................................................................... 102
Effect of price manipulation ...................................................................................... 104
Effect of information.................................................................................................. 106
Factors affecting healthy choices ............................................................................... 107
Shopping experiment ................................................................................................. 107
5.6 Study III: Market Experiment - Buying a Fruit item For Lunch Experiment (BAFFLE)
................................................................................................................................. 108
5.6.1 Sales analysis ................................................................................................... 108
Discrepancies in sales figures .................................................................................... 109
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Snack product purchases ............................................................................................ 110
Footfall in the cafeterias............................................................................................. 117
Revenue from sweet and savoury snacks ................................................................... 118
Intervention: effect of price changes.......................................................................... 123
Health information ..................................................................................................... 127
Temperature ............................................................................................................... 128
5.7 Follow up questionnaire .......................................................................................... 129
CHAPTER 6 .......................................................................................................................... 135
6 Discussion ...................................................................................................................... 135
6.1 Overview of work.................................................................................................... 136
6.2 Discussion of findings ............................................................................................. 137
6.2.1 Study I: Health related behaviours and knowledge of behavioural risk factors ....
.......................................................................................................................... 137
6.2.2 Study IIa: Purchasing behaviours and food choice intentions – questionnaire
study .......................................................................................................................... 140
6.2.3 Study IIb: Experimental study of food choice intentions ................................ 140
6.2.4 Study III: Market experiment: Buying a Fruit Item for Lunch Experiment
(BAFFLE) ...................................................................................................................... 143
Nudging...................................................................................................................... 145
Reasons for Low Purchase of Healthy Items ............................................................. 146
Inconsistency between intention and behaviour ........................................................ 147
6.3 Policy implications .................................................................................................. 148
6.4 Conclusions ............................................................................................................. 152
Appendix I ............................................................................................................................. 155
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