Stakeholder perceptions of strategies to reduce fast food consumption in Cambodian adults

Key informants

A qualitative methodology was used in this study. Previously collected survey results were presented¹³ to relevant stakeholders including members of the working age population (18-59 years), both male and female; doctors, nurses, public health practitioners, community leaders, school leaders and social marketing experts. These roles were selected as these are the individuals who have sufficient knowledge and experience in the crucial issues. Individuals who were willing to participate were invited to attend a multidisciplinary meeting, and a participatory observation with a member of the research team. The aim of this phase of the study was to clearly define the problem and provide recommendations for measures aimed at reducing fast-food consumption among the working age population in Phnom Penh, Cambodia.

Sample size and sampling technique

A total of 10 potential key informants were selected, representing all the above key stakeholder groups. Potential key informants were contacted in advance and informed of the goal and the protocol of the research. Purposive sampling was used to select key informants, thereby enabling the researcher to select potential key informants who had an understanding of the researchers’ expectations and could provide the necessary data. Following the initial purposive sampling, a snowball sampling method was used to expand the number of participants in the research. The 10 informants were selected thus: four individuals were recruited from the working age population, covering both men and women, and representing those who consume fast-food (a) regularly, (b) seldom, and (c) never. The rest were one doctor, one nurse, one public health practitioner, one community leader, one school leader, and one social marketing expert (see Table 1). In cases where potential key informants were difficult to identify, a snowball sampling technique was used. Most of them are the experts in the field, therefore, all information was provided specifically.

Research instrument and data collection procedure

Validated qualitative data collection methods were used to collect data from the sources outlined above based on the triangulation principle. Methods included a multidisciplinary meeting and participatory observations at different levels to identify factors associated with fast-food consumption among the working age population, as well as the underlying causes of these factors. A multidisciplinary meeting was conducted with stakeholders, coordinated by an interviewer or facilitator, and observed by two note takers along with sound recorders. The multidisciplinary meeting took place in a room of a university in Phnom Penh in April, 2018. The duration of the meeting was around three hours. The meeting followed a semi-structured format, consisting of open-ended questions that would elicit personal opinions, perceptions, and experiences from key informants. The format for the meeting did not change during the course of the meeting and was based on three questions:

Key informants were contacted in advance by telephone or email to be invited to participate in the meeting. A member of the research team played the role of interviewer/facilitator. The two note-takers were trained in the process of taking clear notes throughout the meeting two days beforehand.

Data analysis

Thematic analysis was used to interrogate the data obtained from the multidisciplinary meeting and participant observations to identify factors associated with fast-food consumption and potential solutions among the working age population. The underlying causes of the problem were fully characterized so that policy recommendations for the reduction of fast-food consumption could be developed. The thematic analysis followed a six-step procedure developed by Braun and Clarke (2006).¹⁴ The six steps were implemented after all data (i.e. transcriptions from the multidisciplinary meeting and participant observations) had been translated from Khmer to English. Following this, translated data were checked by a member of the research team for completeness and consistency. Following the data check, the six-phase thematic analysis was conducted. In the first step, the researcher became familiar with the data by reading the translated transcriptions word by word and line by line. In the second step, the researcher started to assign codes which were derived from the raw data alone, and not from their opinions or ideas. Coding was conducted manually by writing notes on the transcribed texts with colored pens. This produced an initial list of ideas about the concepts present in the data. The researcher identified the codes and matched them with the appropriate data extracts. In the third stage, themes were identified. The long lists of different codes that had been identified in the previous phase was analyzed, and the researcher considered how different codes could be combined so as to create an overarching theme, and if necessary, a subtheme structure within each theme. The relationships between codes, themes, and subthemes were shown in an initial thematic map. Following this, in the next phase, the researcher reviewed the themes with the attached set of coded extracts. The initial thematic maps were then refined to reflect this phase. Further reviewing and refining of the coding was conducted by the researcher again and again until the researcher was satisfied with the coding process. The researcher then reviewed each theme individually and assigned it a name and description. Finally, the results of the thematic analysis were interpreted for report.

Validity and reliability

Validity and reliability of the qualitative data collection and analysis followed the approach suggested by Mays and Pope (2000),¹⁵ which comprised triangulation of the data across multiple sources, comparing results from multiple stakeholder interviews to the findings available. Their responses were considered. Addressing differences between individual informants’ accounts formed a part of the error reduction process, in turn helping to generate further original data. A clear and definitive data collection procedure, including participant selection and data analysis procedure also contributed to the quality of the study.

Ethical approval and consent for participation

The study design was received and approved by Khon Kaen research ethics committee, the human research ethics committee at the authors’ institution (Reference No. HE582071). All stakeholders/participants gave written informed consent prior to the commencement of the research process.

Health education and health promotion

Health education and health promotion were considered the most critical concepts in stakeholder feedback for reducing fast-food consumption in Cambodia. Stakeholders from several sectors highlighted the need to not only provide health education and health promotion, but also for health educators and health promoters to receive comprehensive training in the identification of target audiences or prospective customers. Some stakeholders expressed the opinion that the youth or teenagers should be targeted with educational and promotional material, owing to the popularity of fast-food among the youth and teenage population. Further, some stakeholders suggested promoting traditional Khmer food because it contains significantly less fat, salt, and sweet ingredients in comparison to western food.

“I think that mass media of fast food is a major challenge. Therefore, health educator and health promoters should study considerably for the contents of the campaigner education/promotion of fast-food company, fining out the tactics or tricks which attract the customers in their advertising or promotion and whether their advertising or promotion have adverse impact to the health of the consumers.” (Social marketer).

“… motivating and promoting to the youth or teenagers to change their behavior from consuming fast food to local Khmer food which has less fatty, salty and sweet ingredients or deducing the tax on local Khmer food, in turn, increasing tax on fast food if possible.” (Community leader).

“Currently, the mass media and social media play important roles in information distribution. Therefore, the use of platforms such as Facebook, Line messages, and television was proposed to reach the target audience quickly; however, the contents of the message must be creative to achieve penetration.”

“If the campaign or promotion is attractive with a creative idea fitted with the needs of the target audiences, it will be able to catch the audience attention quickly.” (Public health practitioner).

“A short video clip which can be broadcasted on social media or television about nutrition should be produced where the messages of the short video clips informing the target audiences why they should not eat this food.” (Social marketer).

Specific focus on educational institutions

All stakeholders stated that educational institutions should engage in health promotion and health education related to nutrition, especially the impact of fast-food on health.

“… It will be effective if the target of education and promotion focusing on educational institution … the schools are able to prepare the projects concerning to applying nutrition lessons in the classroom as well as practice the lessons which students have learnt to practice in their real life.” (School leader).

“… it is only the discipline or rules which force students to practice nutrition lessons in their real life; however, building an understanding about healthy diet along with teaching them how to be responsible in their own life.” (School leader).

Reducing the access to unhealthy food: marketing impact and obtainability

All stakeholders emphasized the necessity for the government to take a role in reducing the impact of fast-food. Stakeholders advocated controlling and limiting the advertisement of fast-food in the media, especially the youth and teenagers. It was also suggested to impose health standards on food manufacture and sale that must be met, in terms of maximum salt or sugar levels in foods, and limiting the number of fast-food outlets adjacent to educational institutions.

“The government should pay more attention to controlling the media advertising which revealed the meaning of unhealthy food to the people and also set or push the policy such as food labeling and food standard criteria.” (Social marketer).

“If possible, the government should set or push the policy on the fast-food restaurants or shops which are located next to the academic institution especially from primary school to high school.” (Community leader).

Implementing the government policy

Once government policy has been devised, the government must follow through to ensure that it is implemented and take measures to monitor and evaluate its impact. Only then will it be possible to determine whether it has achieved its goals, or whether it requires improvement.

“The government should have the willingness to take actions with the policy which has been set and implement it equally for all institutions and occasions.” (Medical doctor/Nurse).

“Monitoring during the implementing the policy is absolutely crucial in order for the aims of policy could be achieved.” (Public health practitioner).