1. Introduction
Climate change is a serious threat to public health, potentially destroying decades of global health progress and impacting every factor necessary for human survival, such as air temperature, fresh air, drinking water, food supply and safe housing [
1]. Currently, the world is not on course to achieve the emission targets necessary to limit global warming to below 2 °C compared to pre-industrial levels, following the Paris Agreement adopted in 2015 [
2]. The food system is a key driver of climate change, causing pollution to soil, water, air and deforestation; reducing biodiversity; and producing greenhouse gas emissions [
3]. Meat production is particularly damaging to the environment as it requires more land, water and feed to produce equivalent amounts of calories and the production of methane from ruminant animals is central to global warming [
3].
Noncommunicable diseases (NCDs) are the leading cause of death in NZ and account for 89% of all worldwide deaths [
4]. Of all the lifestyle risk factors for NCDs, diet is the most important [
4]. The NZ diet is rich in calorie-dense, nutrient-poor foods, high in fat, salt and sugar and most New Zealanders are eating below the recommended intake of vegetables, fruits and fibre and above the recommended intake of takeaways, protein, saturated fat and red and processed meat [
5]. The most recent NZ Adult Nutrition Survey indicates (2008/09) that only 32.8% of NZ adults meet the combined recommended vegetable and fruit intake of at least three servings of vegetables and at least two servings of fruit each day [
5]. For fibre, NZ adults are consuming less than the daily adequate intake of 30 g and 25 g, respectively, meaning that the intakes for male and female adults were 22.1 g and 17.5 g [
5].
NZ has the sixth highest meat intake per capita in the Organisation for Economic and Development (OECD) [
6]. Meat is a source of B vitamins, minerals and protein; however, it is also a major source of saturated fat, and salt in the case of processed meats, in NZ diets [
7]. The long-term consumption of increasing amounts of red meat, particularly processed meat, is associated with an increased risk of total mortality, cardiovascular disease, cancers such as colorectal cancer and Type 2 diabetes in both women and men [
8]. Plant-based diets can reduce the relative risk of coronary artery disease, cerebrovascular disease events, Type 2 diabetes and some cancers [
9,
10]. Diets lower in meat are also associated with lower body mass index (BMI), waist circumference and obesity risk [
11,
12]. The World Health Organization (WHO), the World Cancer Research Fund, the NZ Heart Foundation and the NZ Eating and Activity Guidelines (EAGs) recommend limiting the intake of red and processed meat [
13,
14,
15].
In 2019, the EAT-Lancet Commission recommended a largely plant-based diet, advising that profound changes must be made to the global food system to feed the world’s population of 10 billion within planetary boundaries by 2050 [
16]. There is a strong scientific consensus that a dietary shift towards plant-based foods and reduced meat intake will reduce the negative environmental impact of the food system and the prevalence of deaths and health-related costs associated with NCDs [
3,
16,
17,
18,
19]. However, despite this consensus, there has been little policy action on meat reduction in NZ or globally and meat intake remains high [
19,
20].
Meatless Mondays (MMs) is a global meat reduction campaign, originating in the US, which encourages people to forgo meat one day a week, reduce consumption by 15% and eat more plant-based foods to improve health and reduce the environmental burden connected with meat production [
21]. MMs and MFMs (a variation of MMs) have been implemented in restaurants, schools, hospitals and workplaces in at least 45 countries worldwide. At institutions where MMs have been implemented, menus are made up of a majority of plant-based and include some meat, whereas MFM menus are completely meat-free. There are few studies on the effectiveness of MMs or MFMs; however, research indicates that MMs in school settings result in significantly lower food-related greenhouse gas emissions, less water and land use, and are comparable in cost and nutrition [
22]. In hospitals, where MMs have been implemented, evaluations indicate evidence of behaviour change beyond Mondays, such as eating more fruit and vegetables, reducing meat intake, and eating more plant-based options at home or when dining out. Additionally, MMs resulted in more plant-based meals being purchased, increased awareness of MFMs and increased awareness of public health messages associated with the impact of meat on health and the environment [
23].
Te Whatu Ora, Health New Zealand, is the largest employer in NZ and a substantial emitter of greenhouse gases [
24,
25]. In 2020, the Nelson Marlborough District Health Board (DHB1) was the first workplace in NZ to launch a MFM policy at their staff and guest cafés as an extension of the existing National Healthy Food and Drink Policy (NHFDP). They offer a completely meat-free menu on Monday, a Fish Friday and also removed all processed meats from café menus. This study aimed to identify the enablers and barriers of MFM policies at three District Health Boards (DHBs) to offer policy recommendations for the future to facilitate implementation.
4. Discussion
This study showed that DHB staff had a strong interest in and general awareness of MFMs. Half of staff (51%) reported to be actively cutting back on meat and most supported MFMs, with key motivators identified as health, environment concerns and enjoyment of plant-based meals. These meat reduction results were higher than a 2019 NZ consumer poll (N = 1000), which showed 31% of people were cutting back on meat [
29]. The healthcare workplace setting is unique as staff have a high level of education and a focus on behaviours that support personal health; this could explain the finding of health as a key motivator for meat reduction [
30]. However, just below one-fifth of respondents identified as flexitarian, compared to a recent NZ consumer poll which indicated a third of New Zealanders are flexitarian, which may suggest an inconsistency or lack of awareness or understanding of the term ‘flexitarianism’ in the 2019 poll and in the present study [
29].
The results of this study are consistent with other research into the enablers of meat reduction, where health and environment are cited as key drivers [
31,
32,
33]. However, most research cites health as the most important motivator [
32]. Interestingly, amongst DHB3 staff, environmental concerns were the most prevalent factor for reducing meat, albeit only slightly higher than health, which perhaps indicates an increasing awareness of the impact of food choices on the environment at this location.
Other studies have found ‘trying new foods’ to be an important motivator, similar to the motivator found in this study of ‘enjoying plant-based foods.’ An unexpected finding was the perception that as part of MFMs, New Zealanders could broaden their food horizons by trying new plant-based foods and this behaviour could positively impact behaviour on other days of the week, e.g., cooking at home and eating out. This result is encouraging in NZ, where meat eating levels are high compared to other high-income countries (sixth in the OECD) and high levels of meat eating are considered status quo—a constant in our farming history and economy and considered part of our identity [
6].
A proportion of respondents did not feel that reducing meat would positively impact the environment. Some felt other sustainable actions would have more benefits, such as packaging, recycling, reducing food transportation and regenerative agriculture. This sentiment was echoed in the interviews and is aligned with other research in this area. A systematic review of studies from Australia, the Netherlands, Belgium, Switzerland, and the United Kingdom, found that less than a quarter of respondents were aware of the environmental impact of meat [
34]. Another study showed that of those who consider the environmental aspects of food, other aspects such as food production and distribution such as transport, deforestation, pollution, and packaging were considered of greater importance than the food choice itself [
35].
Awareness of the global MFM initiative was high and similar in both DHBs surveyed, which is a testament to the marketing efforts of overseas MFM groups, such as in the UK and US, to raise awareness of the campaign [
21]. As expected, awareness of MFMs in NZ hospitals was higher in DHB1, where the policy had been running for two years. However, awareness of MFMs itself does not necessarily indicate an understanding of the reasons behind MFMs, nor does it indicate that MFM has changed eating behaviours on Mondays (e.g., if staff are not eating at the cafés involved) or on other days of the week. Previous research in the US has shown that MFMs can increase awareness of health and environment-focused messages about MFMs, meat intake and production (perceived message effectiveness) [
23,
36]. MFMs have also been shown to positively impact eating behaviours on other days of the week, e.g., eating more fruits and vegetables and cooking more plant-based meals at home [
23]. As this study did not evaluate these behavioural effects, further research in this area is required.
While some objected to MFMs, almost two-thirds of the staff at both DHBs surveyed supported a MFM policy in its current format, with the complete omission of meat on Mondays. Interestingly, there was no significant difference in how positive respondents were towards MFMs at DHB1 where MFMs were operating, compared to DHB3, where they were not operating. This indicates that while there was some customer resistance, overall, the MFM policy has not substantially negatively impacted attitudes towards MFMs at DHB1.
Some participants felt that MFMs limited personal choice, consistent with the Norwegian Armed Forces’ research on MFM challenges due to interference with individual choices [
37]. New Zealanders, especially hospital workers, faced strict COVID-19 orders (mask-wearing, social distancing, testing, isolating, lockdowns), requiring motivation to change behaviour and beliefs about policy benefits [
36]. Hospital staff, already impacted by COVID-19 restrictions, were sensitive to further choice limitations, possibly affecting study responses at this time. Paternalistic public health policies (e.g., COVID-19 lockdowns, MFMs) raise debates on balancing public health and individual liberties [
38,
39,
40,
41]. Some respondents supported educational approaches for healthy, sustainable foods but were less supportive of MFMs impacting personal choice.
Hospital staff expressed dissatisfaction with perceived rights violations, defending meat consumption and opposing management’s beliefs. Staff’s preference for meat may be due to personal taste rather than a fundamental right. Doctors and nurses, with limited time, often rely on hospital cafés and also benefit from free meals. Despite restrictions, they could still eat meat by bringing food or using other outlets.
MFMs removed meat from hospital cafés for only one meal, once a week (4.8% of weekly meals). Considering individual opposition, it is vital to weigh policy impact with overall quality of life in enduring public health debates. The importance of hospital cafés providing tasty, balanced and affordable meals was identified in the current study. Objections to MFM meals included concerns about special diets (such as low carb or Keto) and nutritional considerations like protein and iron content. Some staff expressed that meat-inclusive meals were more satiating when working long hours in surgery. However, plant-based meals can also provide adequate protein through sources like soy products, legumes, whole grains, nuts, and seeds, which offer satiety through their high fibre, protein and water content. Protein deficiency is rare among New Zealanders [
7].
Food service managers faced challenges in providing varied, seasonal and affordable meals, with cost implications being a sensitive topic due to the rising cost of ingredients and decreased sales during the COVID-19 pandemic. There was no consensus on whether MFMs would save money, as some perceived cost benefits using legumes over meat, while others worried about losing customers to competitor cafés when not serving meat options on Mondays. Overall, perceptions in this study differed from studies in high-income countries that show lower food costs with flexitarian meals [
40,
41,
42]. One analysis indicated that healthy and sustainable diets, e.g., flexitarian, pescatarian, vegetarian and vegan could result in 22–34% lower food costs in upper–middle income to high-income countries such as the UK, Europe, Australia and NZ. It was an unexpected finding in this study, that hospital cafés were using expensive ready-made vegetarian alternatives such as vegan sausage rolls and plant-based burgers due to perceived consumer demand, with limited discussion amongst managers in the surveys about the use of cheaper options like legumes.
Participants acknowledged the environmental benefits of MFMs, such as reduced methane emissions and biodiversity loss, with sustainability managers being more confident and knowledgeable about these benefits compared to food service or café managers. Some food service managers were unsure about the health benefits of reducing red or processed meat intake, indicating a need for further education. Overall, most participants believed that hospitals had the opportunity to lead in health and sustainability by raising awareness amongst staff and visitors about healthy and sustainable eating options. If MFMs were implemented nationwide, it would make a strong statement about health and sustainability; however, there may be initial backlash from the farming industry and other groups.
Successful implementation of MFM policies in NZ requires thorough consultation with DHB staff, management, food service, dietitians and cultural advisors. Engaging food service and café staff is crucial for the success of MFMs, as seen in previous research [
37]. Clear communication, training and information sharing are essential to address concerns and gain buy-in from staff. Educational resources should emphasise the benefits of MFMs for human and planetary health, providing evidence-based explanations for the policy. Resources for café staff and customers could include information on the benefits of meat reduction, recipes, and frequently asked questions.
This study identified the misconception that MFMs aim to convert people to vegetarianism, which may hinder the success of MFMs. Clear information on the aims of MFMs is necessary. Evaluation of MFMs should include metrics such as participation, engagement and acceptance of MFMs, customer numbers in cafés, sales figures and awareness of associated public health messages. Resistance to changing eating habits, particularly due to sociocultural factors, was evident in this study. While most participants supported MFMs, alternatives were suggested, such as using positive language or increasing the ratio of plant-based options throughout the week. The ‘Meat-less’ approach used in MMs in the US, with a 3:1 ratio of plant-based to meat options, was favoured by several respondents. A mandated MFM with complete omission of meat on one day challenges personal choices and aims to change strong social norms around meat eating which make reducing meat intake challenging for individuals. However, broader concurrent education on the impact of meat consumption on health and the environment is needed, with the responsibility falling on public health practitioners and the education system.
For the success of MFMs, it is important to consider how supportive the wider food provision policy environment in NZ is of sustainable eating and meat reduction. The greater food environment such as the food outlets in the hospital vicinity can be considered broadly unsupportive of MFMs and meat reduction in NZ. While the Eating and Activity guidelines for NZ Adults and the NHFDP in hospitals mention sustainability, it is a very small component of these guidelines and there are no strong policies or implementation to support it [
15].
4.1. Strengths and Weaknesses
A strength of this study is the mixed methods approach, as qualitative data offer detailed, contextualised insights and quantitative data offer externally valid, generalisable insights. Furthermore, a mixed methods approach can help to offset weaknesses inherent to one design by using both. Another strength is that data were collected from both consumers who have first-hand experience with hospital café food, and from a range of managers from different sectors at varying levels of contemplation and implementation of MFMs. All those invited to take part in the interviews participated and many respondents provided lengthy comments to the open-ended questions in the online survey, perhaps indicating strong opinions were held on the topic of MFMs.
In this study, a majority of DHB staff surveyed supported an MFM policy; however, only three DHBs out of 20 were evaluated and large sociocultural differences exist across NZ DHB regions. Considering the total population at each DHB, online survey responses were low. Email surveys often obtain a low response, and survey respondents tend to be less busy, have a higher level of agreeableness, higher ‘extraversion’ (personality trait measured by psychometric testing) and want their opinions (either positive or negative) to be heard [
43]. Additionally, Likert scale responses are susceptible to central tendency bias [
44]. However, the results in this survey were not biased towards the centre, but were polarised towards the extremities, which also indicates people held strong views towards MFMs. Most survey respondents were female (76.3%) and allied health professionals, although numbers were representative of employees at DHBs involved [
24,
45].
4.2. Further Research
Further evaluation of the support of other NZ DHB regions for MFMs should be conducted before a national MFM policy is rolled out. As some staff cafés are open to the public, assessment of public support should also be considered. The research focused on food provided to DHB staff and café visitors, not patients staying in hospitals. Patient food presents another opportunity to reduce greenhouse gas emissions, raise awareness of the environmental and health impacts of meat production and save costs, and therefore, future policies should tackle this area. More research is also required to evaluate and quantify the environmental impact of MFMs in the NZ setting. Utilising the NZ lifecycle database of foods, the environmental impact (kgCO
2e/kg) of MFM meals compared with meat-inclusive meals could be calculated [
46]. Evaluation of water and land usage of foods would also be useful for an NZ setting, as this would differ from calculations completed abroad. Investigation of supply (and customer) costs of meat-free menus versus other days of the week would also be beneficial. Further research could also include interviews with public health dietitians and measurement of the nutritional profile of meals provided as part of MFMs, this may aid in alleviating concerns around the nutritional balance. Further research is also necessary to investigate how MFM policies can change eating behaviours relating to reducing population meat intake as current research in this area is limited.
4.3. Policy Recommendations
For successful food policy change in hospital cafés, consultation, education and support is crucial. A mandatory national MFM policy should be considered if there is majority support across NZ, with the alternative of a meat-less approach considered. Measures to promote plant-based options and engage key stakeholders are recommended. Consultation should involve key stakeholders, staff, public health dietitians and cultural advisors. Information sharing, training and evidence-based education to support the environmental and health benefits of the campaign are important for management and hospital staff. Support for food service staff should include training, recipes, marketing materials and evaluation tools. General recommendations include offering appealing, tasty and nutritionally balanced options, menu variety, increasing plant-based options and removing processed meats. Future recommendations include evaluation of the policy, accountability processes, information-sharing forums, widespread promotion and plans for how to address policy breaches.