Stakeholder definition.

We defined stakeholder as an individual or group affected by or who can influence the environmental intervention to promote healthy eating in the workplace.

Engagement objectives.

Our objectives of stakeholder engagement were (a) to identify the specific research needs in their worksite for promoting healthy eating, (b) to develop culturally appropriate healthy eating intervention; (c) to increase stakeholders’ participation in study process such as determining study objectives and methods, describing study intervention, recruiting participants, implementing and monitoring the healthy eating intervention; (d) interpreting study results; and (e) enhancing sustainability.

Identification of stakeholders.

We adopted the 7Ps framework [15] that identifies key groups to consider for engagement. The first, patients and the public, represented the current and potential consumers of patient-centered health care and population-focused public health. The second were providers, including individuals and organizations that provide care to patients and populations. Purchasers, the individuals, and entities responsible for underwriting the costs of health care, such as employers, made up the third group. The fourth group consisted of payers who were responsible for reimbursement of medical care, such as insurers. The fifth composed of public policy makers and policy advocates working in the non-governmental sector. Product makers, representing drug and device manufacturers, comprised the sixth group, and principal investigators, or other researchers, made up the seventh. Since this was not a typical patient focus study, but rather a community-based prevention trial in an institutional setting, we modified the definition of the 7Ps according to our context (Fig 1).

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Fig 1. Stakeholder mapping for the Nepal Pioneer Worksite Intervention Study to prevent cardiometabolic risk.

https://doi.org/10.1371/journal.pone.0276478.g001

Stakeholder engagement methods.

We involved stakeholders in all three phases.

Formation of study team.

After mapping out the stakeholder for the study, individuals representing each stakeholder category working in nutrition related research were purposively approached in-person and the study team was formed. We selected adult aged 18 years or older, employee of the hospital, who provided informed consent as stakeholder in each category. None of the stakeholders whom we approached declined to participate in the study. The stakeholders were represented as co-investigators and advisors.

Focus Group Discussions (FGDs).

We conducted four focus group discussions with 33 employees of the hospital to explore the current healthy eating environment, understand drivers and barriers for eating healthy, and to obtain their recommendations on improving environment to promote healthy eating at the hospital cafeteria.

The focus groups were conducted within the workplace setting in a private room to ensure confidentiality and open sharing of opinion. The FGDs were conducted in Nepali and audio taped after obtaining informed consent from the participants. The investigators, AS, or DT, moderated all FGDs in Nepali language and were assisted by a note-taker. In each session, a brief introduction of the study and ethical considerations about maintaining confidentiality of the participants, were explained. The moderator asked open-ended questions and probed for detail information. We used iterative process by discussing each FGD immediately after completion and suggesting necessary detail probing in emerging themes from finding.

In-depth interviews.

We conducted 9 in-depth interviews with purposively selected hospital employees including a finance manager, a cafeteria manager, an administrative manager and 6 cafeteria operators after receiving informed consent. The investigators DT or AS conducted semi-structured in-depth interviews in Nepali language using a pretested interview guide in a private room of the hospital. We used the iterative process for data collection. After each interview, we discussed each interview and identified the topics to be deeply explored into themes emerging in earlier interviews. All FGDs and interviews were transcribed verbatim into Nepali by trained research assistants. We used thematic analysis approach [16] to analyze the data.

Workshops.

We conducted three iterative workshops with the representation of hospital administration, cafeteria managers, cafeteria staff, nutrition department, employee, and researchers. The aims of the workshops were to consensually decide changes in cafeteria, clarify roles of each stakeholder and develop monitoring strategies. Each workshop was facilitated by DT, a co-investigator, and an employee, using a workshop schedule and discussion guideline. The workshops took 3 hours. In the first hour, the facilitator explained the link between healthy eating and cardiometabolic risks. In the second hour, the findings from the formative study were shared in an interactive session, and in the third hour a guided discussion with the participants was conducted. The themes of the guided discussion were: components of the healthy eating interventions, mode of intervention delivery, mode of implementation and monitoring, and method of evaluation, that enabled us to plan the study better. The stakeholders’ in workshops provided inputs in decision making. We presented the initial findings to the stakeholders and collected their feedback.

Food taste experiments.

A major theme that emerged in focus group discussions, in-depth interviews and workshop included acceptability of introducing whole grains in the cafeteria, especially brown rice. Therefore, the research team decided and conducted a brown rice tasting experiment with 40 employees of the hospital. After tasting brown rice, the participants perception on brown rice changed positively [17].

Individual consultation.

The results of the formative study with further action plan were discussed individually with the hospital administrator, cafeteria manager, cafeteria chefs, nutritionist of the hospital and few employees of the hospital to get further feedback.

Meeting of study team.

The study team met online every week for 30 to 60 minutes to discuss on a predetermined agenda and all decisions were taken jointly and recorded in written.

Information sessions.

A 20-minute information session was conducted in all departments of the hospital to provide information regarding the study and collecting feedback. About 22 sessions were conducted with participation of 4 to 20 employees in each session. In the first five minutes, the study design was explained, the next 5 minutes were dedicated for the call for participation and explanations regarding expectations from the participants, and 10 minutes for discussion and feedback.

Formation of cafeteria intervention committee.

A canteen intervention committee was formed comprising the representations of hospital administrator, human resource department, finance department, hygiene monitoring department, non-communicable disease prevention and management department, nutrition department, canteen managers, employee, and researchers. This committee steered the development, implementation and monitoring of the cafeteria intervention. The committee made the plans for the cafeteria intervention, implementation, and monitoring. It meets once a month to discuss the progress, problems, and solutions.

Formation of study team.

We formed a study team representing stakeholders from each category as investigator or an advisor. Investigators directly participated in the day-to-day implementation of the study while advisors provided suggestion and guidance when required [18]. Four employees consisting of a medical doctor, a laboratory personnel, a pharmacist, and a community programs expert jointed the team as co-investigators. They brought their scientific expertise and unique perspective as a customer of cafeteria. The hospital administrator, a cafeteria manager and a nutritionist joined as advisor.

Focus group discussions.

Majority of participants considered that the foods that were available in the hospital cafeteria were healthy. However, items such as confectionaries like cream donut, oily curry and meat, soda drinks, instant noodles etc. were considered unhealthy food. They emphasized that the foods were hygienically prepared and cheaper compared to hotels outside. Participants highlighted that the changes to improve food quality will be well received positively because most of them are health professionals. The most reported factors that would facilitate healthy eating were: (a) addition of healthy food options, (b) replacement of unhealthy foods with healthy options, and (c) appealing presentation of healthy foods. Active involvement of canteen management and administrator in the process of change was highly emphasized. The participants suggested to advertise healthy food options and educate both cafeteria operators and consumers on healthy eating. The major barriers to healthy eating were: (a) unavailability of healthy options, (b) lack of human resources to prepare healthy food, and (c) high price of healthy food and (d) food preferences. They suggested to add the healthy items which will demand less time and resources like adding the automated machines such as roti makers. The support staff commented that they might not be consuming the fruits even if they are added because of the high cost. However, health professionals expressed their willingness to pay more for access to healthy food. The participants were concerned that it would be difficult to change food preferences as the consumers prefer spicy and oily foods. Some of the unhealthy foods are greatly loved such as instant noodles, samosas, cream donuts, soda drinks etc., and changing food habit is challenging.

In-depth interviews.

Cafeteria operator commented that the higher-level authorities should be involved in making healthy changes, deciding the menu, and fixing the price. One of the canteen managers highlighted the need of a committee to involve the canteen operator, administrative staff, medical doctors, and nutritionist to decide on the change in food menu, price, and to monitor the availability of healthy options in canteen. The canteen operators mentioned that the hospital cafeteria provides food in subsidized price and does not intend to make profit. The operators were concerned about the lack of knowledge on healthy eating among the cafeteria staff and pointed that providing health education to them could facilitate making changes. They mentioned that the cafeteria staff receive training on hygiene occasionally but have never received training on healthy eating and healthy cooking. The major barrier for healthy eating reported by canteen operator were: (a) lack of adequate human resource to add food options; (b) lack of knowledge on the healthy cooking among cafeteria staff, (c) unavailability of healthy food options in the cafeteria and (d) no food supply for healthy foods such as brown rice, brown bread, organic vegetables etc. The canteen operator reported that they are not well-staffed to provide healthy foods such as whole wheat pan bread (roti), fruits and salad as their preparation is labor intensive. The human resource manager thought that increasing efficiency of the available staff was more important than adding staff. The stakeholders contributed to the interpretation of qualitative data and contextualize the findings. The details of the FGD and Interview results are available elsewhere [19]. In Brief, four focus group discussions of 33 participants and nine in-depth interviews among six canteen operators and three managers identified the availability of affordable healthy food options in the cafeterias, a commitment to such promotion by the cafeteria manager, operators, staff and hospital administration and the level of education of the employees, as the factors to promote healthy eating. In addition, the unavailability of healthy options, including the lack of food supply from local market, the higher cost of healthy foods, individual food preferences and limited human resources in the cafeteria were identified as barriers for healthy eating [19].

Workshops.

The discussions in the workshop were very interactive and productive. The cafeteria managers and cafeteria staffs emphasized the need for active involvement of the departments of finance and administration because these departments had major role deciding the menu and price of the food served in the cafeteria. This led to formation of canteen intervention committee with chairmanship of the hospital administrator and representatives from finance, human resource, nutrition, employee, and researchers. There was univocal agreement on the need of adding healthy food items. However, lack of human resource in the cafeteria was a major challenge. In response, automated roti (whole wheat pan bread) maker was suggested. The details on which food to add and which to remove were discussed and finalized in the workshop. In addition, the pre-post design was suggested in contrast to randomized trial to test the effectiveness of the changes in cafeteria on cardiometabolic risk because it would be unethical to provide healthy food items in some cafeterias only. Additionally, the risk of contamination was emphasized as customers do not exclusively go to one cafeteria. Consumers and chefs raised the concern on acceptability of brown rice in place of white rice. Hence, a brown rice tasting experiment was suggested.

Individual consultation.

Based on the findings of the FGDs, in-depth interviews and workshops, the study team prepared the description of the cafeteria intervention and proposed study design to test the effectiveness of the intervention on cardiometabolic risks. The proposal was described and discussed in-person with the stakeholders. Lack of comparison group was indicated as a weakness of the study in the initial pre-post design. As a result, six months of control period was added before intervention was implemented to be able to compare outcome measures with and without the intervention.

Meeting of study team.

In the weekly meeting of the study team, the implementation strategies were discussed and finalized in detail. This included details on disseminating information on study, call for participation, informed consent administration, data collection from the participants, enrolment planning, and intervention start dates. The internal insights of employees in the study team members guided the decision making. When the effectiveness study started, the progress on enrollment, problems and strategies were discussed weekly. For example, when there was slow blood sample collection, the representative from the laboratory suggested to provide breakfast voucher to the participants. Adding breakfast voucher worth 70 cents in subsequent blood draw appointment speeded up the sample collection. Similarly, it was difficult to enroll the nurses who had night duties. The doctor in the study team suggested to consider nurse’s duty roster and contact nurses immediately after completion of duty hours in the morning. This strategy helped to increase the participation of the nurses in the study.

Information sessions.

The information session helped to reach and interact with wider employee group. The department head provided date and venue for the information session. During the information session, feedback was obtained on the design of the study and participant recruitment. A major issue that came up was the involvement of supervisors in participants’ recruitment. The employees commented that presence of supervisors during the information session might be perceived as encouragement from them to participate. To make the participation voluntary, we conducted the sessions in absence of higher-level staff in each department, the identifiers of the participants were collected separately and were not disclosed to anyone.

Formation of cafeteria intervention committee.

The cafeteria intervention committee had key decisive role in designing, implementing, monitoring, and evaluating the cafeteria intervention. Each component of the intervention was discussed and decided by the intervention committee after weighing their benefits, financial implications, and perceived acceptance by the employee. The committee developed a monitoring sheet that the nutritionist and a research team member filled every week to measure the adherence to the defined intervention in all four cafeterias. The monitoring team also interacted with the chefs, cafeteria staffs and customers informally and collected their concerns. The monitoring data were assessed, and concerns were presented to the committee every month. The committee discussed the problems and strategies to address them. For example, in the initial week, there was problem of supply of whole grains such as brown rice and brown bread. The committee approached the local mill and a local bakery and ordered brown rice and brown bread for the cafeteria. After adding fruits on the menu, the sales of fruits in the first two months were low. The committee decided to launch a week-long campaign to promote fruits in each cafeteria which boosted their sales.