Integrated Pan-Canadian Healthy Living Strategy (IPCHLS) Public Information Strategic Direction

Back to: Public Information and the Healthy Living Strategy

Summary of Canadian Healthy Living Market Research and Implications for Public Education Activities Aimed at Families and Children

Prepared for:
Health Canada

By:
François Lagarde
Social Marketing and Communications Consultant
flagarde@videotron.ca
February 26, 2004

Table of Contents

• Executive Summary
• 1. Introduction
  • 1.1. Background and Purpose
  • 1.2. Methodology and Limitations
• 2. Audiences
• 3. Messages
• 4. Channels
  • 4.1. Multiple Channels
  • 4.2. Frequency Over a Period of Time
• 5. Partnerships
  • 5.1. Existing Initiatives
  • 5.2. With the Private Sector
• References

This document is a summary of 43 reports received from participants at a meeting held in September 2003 on the public information component of the Integrated Pan-Canadian Healthy Living Strategy. Reports submitted by participants focus on public information aimed at educating and motivating families and children to adopt healthy living behaviours. To further develop the public information component, the summary is organized around the following four areas: Audiences, messages, channels and partnerships. This review is limited to the reports received and is therefore not an exhaustive review of literature on the subject.

The review suggests the following implications for public education initiatives:

• The primary audiences for public information/education to influence parents' and children's eating and physical activity behaviours should be women (especially those in their thirties) and their children (elementary school age). Opportunities for men's/fathers' education and involvement should be created in the process. Furthermore, cultural differences in terms of nutrition and physical activity preferences, as well as family dynamics need to be taken into account.
• Messages should provide positive, motivational, clear, quick, easy, inexpensive, and tasty/fun ways (including self-assessments and how-to tips) on integrating healthy eating and enough active living into daily life. Proposed ways should demonstrate a wide range of benefits, and come from credible sources, as well as "real" people facing the same kind of issues as the key audiences.
• The following additional themes could also be addressed in public education initiatives:
  • How to shop, plan/prepare/cook, lunches, dining out, etc.
  • Healthy and tasty snacks
  • Food safety
  • Nutrition labelling
  • Options and opportunities for children to be active (school and non-school hours)
  • Active transportation and related safety concerns (e.g., kids walking/cycling to school)
  • Motivation (energy, time with family/friends, fun, weight control and a wide range of other benefits)
  • How to deal with time spent on TV/video/computer
  • School policies (food, physical education/activity)
• The following mix of channels should be considered by organizations promoting healthy living: Point-of-purchase (including labelling, stores, restaurants, cafeterias and facilities), settings (including schools, recreation, community, workplaces and health offices), mass media (including advertising, the Internet and media relations), and events (such as races).
• Public education initiatives require appropriate multi-year levels of resources to ensure they achieve a high enough frequency in message delivery over time.
• As a first step, an environmental scan would identify existing Canadian government, non-governmental and private sector initiatives. It would also show how to integrate some recommendations on priority audiences, messages, channels and sustainability.
• Given the extent of their marketing and advertising resources and skills, suitable private sector partnerships should be explored, especially with food companies. Partnerships between the private sector and government agencies for public education purposes may not be perceived as appropriate in all instances, especially when a government agency is also regulating the sponsoring corporation. Since active living does not benefit from the same exposure, private sector companies should be encouraged to include active living messages in their promotional activities (as some food companies are already doing). In addition, sustained investments by government and non-governmental organizations should also be considered for active living, as part or in addition to integrated healthy living initiatives.

1. Introduction

1.1 Background and Purpose

In September 2002, federal/provincial/territorial ministers of health announced that they would work together on short, medium and long-term pan-Canadian "healthy living" strategies that emphasize nutrition, physical activity, and healthy weights. In the short term, it was decided that the Integrated Pan-Canadian Healthy Living Strategy ("the Strategy") will emphasize healthy eating and physical activity, as well as their relationship to healthy weights. The Strategy will address other healthy living priorities as they are identified over the medium and long term.

The Strategy will emphasize far more than individual behaviour change. It is based on a population health approach that focuses on: the living and working environments that affect people's health; the conditions that support and enable people to make healthy choices; and, the services that promote and maintain health.

Public information is one of the four strategic directions for the Strategy. The other strategic directions are: leadership and policy development; knowledge development and transfer; and, community development and infrastructure.

Some 50 representatives from a wide range of government, non-governmental and private sector organizations met on September 23-24, 2003, to: 1) Explore how social marketing and health communications concepts and principles apply to the public information component of the Integrated Pan-Canadian Healthy Living Strategy; and 2) Provide direction for the key elements of a pan-Canadian public information strategy.

As a follow-up to the September 2003 roundtable, all participants were encouraged to send any research and reports containing social marketing/health communications /public information audience analyses, environmental scans, campaign strategies or campaign evaluations. Data and reports could cover any aspect of healthy living (including obesity, food, fitness/active living, etc.) with a focus on family (including grandparents) and children. This document is a summary of the 43 reports received from participants and is submitted for their consideration. It is also designed to serve as one of the reference documents for the further development of public education initiatives aimed at influencing Canadians to adopt healthy living behaviours, under the Public Information Strategic Direction of the Integrated Pan-Canadian Healthy Living Strategy. The market research and possible implications are summarized in four key areas: Audiences, messages, channels and partnerships.

Although a wide range of public awareness/education and advocacy initiatives will have to be implemented to achieve the goals pursued by the Integrated Pan-Canadian Healthy Living Strategy (Bauman et al., in press; GRIEPS, 2002; Bauman et al., 2001; Coffman, 2003; Hersey and Daugherty, 1999; California Project LEAN, 1998), this document focuses more specifically on public information aimed at educating and motivating families and children to adopt healthy living behaviours.

1.2 Methodology and Limitations

In November 2003, Health Canada wrote to all participants at the September 2003 Roundtable asking them to send research reports with a focus on families and children. Forty-three reports were received and served as the basis for this summary. A preliminary summary was prepared and presented to a working group, which met on December 9, 2003 to discuss a communications/public information approach for the Healthy Living Strategy.

This report is therefore not an exhaustive review of literature. It focuses on primarily Canadian reports that address the adoption of healthy living behaviours by individuals, and, more specifically, by families and children. Recommendations from this summary will, of course, need to be integrated with other reviews of literature. IPCHLS goals focus on approaches to create the conditions that support and enable people to make healthy choices, while influencing policy as well.

2. Audiences

In the most recent Canadian and international data, Carrière (2003) introduces the issue of parent and child factors associated with youth obesity as follows:
Overweight children have become a major health concern in Canada. Between 1981 and 1996, the prevalence of overweight among 7- to 13-year-old boys rose from 15% to 35%; among girls of the same ages, the prevalence increased from 15% to 29%. And beyond the overweight category, the prevalence of obesity tripled during the same period, from 5% for both sexes to 17% for boys and to 15% for girls. Such trends have been attributed to the lifestyles of an "obesogenic" society. Along with issues of social acceptance, body image and self-esteem, obese children are more likely to face short-term health problems (hypertension, glucose intolerance and orthopedic complications, for example) than their non-obese counterparts. Overweight children also tend to remain overweight as adults, and there are well documented long-term health consequences associated with childhood obesity. (...) Research indicates that parental obesity is a risk factor for obesity in children; therefore, the link between health behaviours of parents and those of their offspring is an important consideration. It is possible that behaviours predictive of obesity prevail in some households. Some researchers have reported evidence of parent-child correlations across a variety of behaviours, including diet and exercise. (pp. 30-31)

The research reviewed would suggest that the primary audiences for public information/education to influence parents' and children's eating and physical activity behaviours should be women (especially those in their thirties) and their children (elementary school age). Opportunities for men's/fathers' education and involvement should be created in the process. Furthermore, cultural differences in terms of nutrition and physical activity preferences, as well as family dynamics need to be taken into account.

The following rationales have been used to support the focus on women:

• On behalf of the National Institute of Nutrition and Health Canada, The Allium Consulting Group Inc. (2001) conducted 12 focus groups in 6 urban centres involving adults, aged 35-55, who are at a higher-than-average risk of developing diabetes. One of their recommendations is to "gear the 'lion's share' of promotional initiatives to women as they are generally the family 'leaders' in matters relating to diet and physical activity."
• Women with children at home:
  • 1) Influence the nutrition patterns of the whole family;
  • 2) Have bigger households and buy more food (3.9 people on average vs. 2.2 for households without children under 18 years of age, according to the Print Measurement Bureau;
  • 3) Control meal preparation - The Chatelaine Home CEO study highlights the fact that women of the house are the evening meal decision-maker in 84% of cases (Dairy Farmers of Canada, 2003);
  • 4) Influence family nutrition patterns that are often pursued during adolescence and adulthood;
  • 5) Represent approximately 40% of adult women (Dairy Farmers of Canada, 2003).
• Women in their thirties seem to face the most barriers for physical activity (Ipsos-Reid, 2002).
• Finding places to be active with the whole family is more of a concern with women in the 25-44 age category than with women in the older age group (45-64) (Roblin, 2001).
• Healthy eating is a particular challenge for women who work outside the home, and those with children at home (BCP, 2002).
• Although women are usually aware of the benefits and that it's not necessary to do a lot of strenuous exercise to enjoy the benefits, fewer women have taken steps to become active than women who have taken steps to eat healthier food (Ipsos-Reid, 2002).

The National Institute of Nutrition's (2002) Tracking Nutrition Trends IV report recommends that although women still account for the majority of primary grocery shoppers, men's opinions and preferences should not be discounted. In addition, fathers have been shown to influence their children's activity level, whereas mothers have greater impact on food consumption behaviors (CDC, 2000).

A number of reports also suggest that it would be wise to focus attention on elementary school-aged children:

• Carrière (2003) noted that between 1981 and 1996, the prevalence of overweight children has increased dramatically among both boys and girls aged 7 to 13.
• The Atlantic Health Promotion Research Centre (2003) suggests that promotion and education initiatives on healthy eating and active living should make nutrition education to children and youth mandatory, with active parent involvement.
• The Canadian Fitness and Lifestyle Research Institute (2000) reports that "Canadian parents are much less likely to be involved in their children's play as their children get older. Indeed, 76% of parents report playing active games or sports either often or very often with their 1-4 year-olds, yet only 20% of parents play actively with their 13-17 year-olds."

In addition to the reports submitted, members of the Working Group who met on December 9, 2003 suggested the following:

• Both mainstream and at-risk segments should be considered.
• Unique needs of Aboriginal and remote communities should be taken into account.
• Cultural differences are likely to be at play in many eating and activity choices.
• Seniors could play a positive role and face specific eating and activity challenges (Northwest Territories Health and Social Services, 2003).

3. Messages

Most studies portray a positive picture of the Canadian public's knowledge of and attitudes toward healthy eating and physical activity (Health Canada, 2003c; Environics Research Group, 2002; Ipsos-Reid, 2003, 2002). However, there is a need to provide "how to" and "how much" information to bridge the gap between intention and action.

A segmentation analysis conducted by the National Institute of Nutrition (2002) identified a sizeable segment called "Frenzied Families" representing 24% of the total market, which is the focus of this summary. "Their incomes are smaller, especially on a per capita basis, as their households are generally larger than in other segments of the market." According to the segmentation analysis, "combined with lack of time, anything that is convenient to use without interrupting the normal routine, not too expensive and promises quick results may become popular with Frenzied Families." In addition, "Frenzied Families learn about nutrition on the fly, without an opportunity to really study the subject. (…) From an educational point of view, these individuals would like to learn more about nutrition and what is 'good' or 'bad' for them. However, the materials have to be very simple and should not take too long to read or remember. Similarly, health claims on food packages will likely trigger the attention of this segment."

Messages should provide positive, motivational, clear, quick, easy, inexpensive, and tasty/fun ways (including self-assessments and how-to tips) on integrating healthy eating and enough active living into daily life. Proposed ways should demonstrate a wide range of benefits, and come from credible sources, as well as "real" people facing the same kind of issues as the key audiences.

The following additional themes could also be addressed in public education initiatives:

• How to shop, plan/prepare/cook, lunches, dining out, etc.
• Healthy and tasty snacks
• Food safety
• Nutrition labelling
• Options and opportunities for children to be active (school and non-school hours)
• Active transportation and related safety concerns (e.g., kids walking/cycling to school)
• Motivation (energy, time with family/friends, fun, weight control and a wide range of other benefits)
• How to deal with time spent on TV/video/computer
• School policies (food, physical education/activity)

This approach to healthy living messages to families and children is based on conclusions and recommendations found in most of the reports reviewed: Bazinet et al. (2003), CRFA (2003), Health Canada (2003b, c), Genesis Public Opinion Research Inc. (2003), Ipsos-Reid (2003), Lagarde (in press), Millward Brown Goldfarb (2003), Pérez (2003), Tremblay & Willms (2003), BCP (2002), Environics Research Group (2002), International Results Group, 2002; Ipsos-Reid (2002), Sage Research Corporation (2002), Fast Consulting (2002), Allium (2001), Ipsos-Reid (2001), NHLBI (2001), Roblin (2001), California Project LEAN (2000), Focus (2000), Samuels & Associates (2000), Sheeshka (2001), Reutter et al. (1999), Prospect et al. (1998).

Although weight control is a motivator for many individuals, motivational messages should emphasize healthy eating and physical activity, rather than just focusing on weight per se (Bazinet et al., 2003). In addition, many messages to mothers often address their children's behaviours and well-being, yet some messages should focus on mothers as 'women first' (Allium, 2001).

A review of the appeals used in the promotion of foods to children suggests that the following are the most popular motivators: taste, humour, action-adventure and fun (Hastings et al., 2003).

Other recommendations in reports include:

• Using interactive self-assessments is recommended to challenge the perception of many people who think that they are already meeting healthy eating and physical activity recommendations (Environics Research Group, 2002; Sheeshka, 2001; Reutter et al., 1999).
• Making clear and concrete recommendations on what is meant by "balanced diet" and serving sizes (Health Canada, 2003b, 2003c; Sage Research Corporation, 2002; Ciliska et al., 1999).
• Combining healthy eating and physical activity messages (as well as other health messages) is recommended (GRIEPS, 2002), but when and where appropriate, and not necessarily all the time (Fridinger and Kirby, 2002).
• Associating benefits other than "health" with the adoption of healthy living behaviours. The following list of benefits can be starting points for finding ways for making associations (Smith, 2003): taste, comfort, beauty, attractiveness, loved one's well-being, adventure, social status, efficiency, romance, approval of others, superiority over others, physical well-being, security, fear, fun and games, economy, rest, curiosity, durability, peace, excitement, risk and sympathy.

The sources of messages should be credible (e.g., Health Canada and, more specifically, Food and Activity guides, health professionals - doctors, dieticians, etc., combined with testimonials from "real" people) (BCP, 2002; Environics, 2002; Ipsos-Reid, 2002; Allium, 2001; Focus, 2000).

4. Channels

4.1 Multiple Channels

The following mix of channels should be considered by organizations promoting healthy living: Point-of-purchase (including labelling, stores, restaurants, cafeterias and facilities), settings (including schools, recreation, community, workplaces and health offices), mass media (including advertising, the Internet and media relations), and events (such as races).

The fact that multiple channels would be considered contributes to the intensity of exposure, which is a success factor in health campaigns (Snyder and Hamilton, 2002).

The range of promotional approaches being considered by the food industry is very wide: television (being dominant), sponsorships, in-school, point-of-sale, free samples of food items, free gifts/tokens (premiums) with food items, loyalty clubs, interactive food, novel packaging, tie-ins with movies, tie-ins with computer software and other forms of wider brand-building (Hastings et al., 2003).

The various points of purchase are likely to be the best opportunities in terms of time and location for taking action (eating and activity) and delivering messages when people are most receptive to receivinge them, including on labels, in grocery and convenience stores (Ciliska et al., 1999), restaurants (CRFA, 2003; Genesis Public Opinion Research Inc. 2003; Ciliska et al., 1999), cafeterias (Ipsos-Reid, 2001) and various physical activity facilities (Ipsos-Reid, 2002; Ipsos-Reid, 2001).

A wide range of settings where audiences live, work, learn, eat and play, in addition to various means of transportation are all timely channels for delivering messages. The following settings have been mentioned in various reports: Comprehensive and integrated initiative in schools (Atlantic Health Promotion Research Centre, 2003; GRIEPS, 2002; California Project Lean, 1998), recreational facilities / parks and public locations (NHLBI, 2001; Ciliska et al., 1999), and workplaces (Ciliska et al., 1999). Although doctors' offices are mentioned as a recommended channel (Ipsos-Reid, 2002; Angus Reid, 2000), it should be noted that, as far as physical activity for children is concerned, only 10% of Canadians look to counselling or advice from family physicians as the best way to encourage higher levels of physical activity among children (Environics Research Group, 2002).

Mass media and the Internet should also be considered (Allium, 2001; Angus Reid, 2000), following a more in-depth analysis of media habits. Ironically, the Internet and television are the two forms of media that physical activity promoters will have to consider to reach children and youth (Ipsos-Reid 2001). A coordinated and sustained media relations strategy should be considered, given there are an estimated 250 key mass media nutrition communicators (Dairy Farmers of Canada, 2003).

Events provide opportunities for information-seeking, trial and reinforcement, as well as establishing social norms. Savard and Lépine (2003) found that an event, such as a race, can have a positive impact on regular physical activity among both boys and girls aged 9-13, while raising awareness about a healthy diet. These events represent opportunities to deliver combined healthy eating and activity messages (Savard and Lépine, 2003), while attracting media attention (NHLBI, 2001). Ensuring that the event is widely publicized and covered should be a central part of the strategy to contribute to the development of a social norm in support of healthy living through frequent exposure of healthy living messages and stories in the media (see Bauman et al., 2001).

4.2 Frequency Over a Period of Time

Best practices in health communications suggest that successful campaigns tend to find an optimal balance between intensity of exposure and length. Since people vary in their timing and willingness to respond to a message, "the more times it (the message) is made available, the more likely they (audiences) are to hear/see it when they are ready to attend to it" (Hornik, 2002). In other words, successful campaigns are not just a matter of the right messages delivered to the right audiences, but also a result of the right levels of frequency over the time that messages are delivered.

Ciliska et al. (1999) recommend providing longer, more intensive interventions, rather than one or two contacts. Reutter et al. (1999) found that continued presentation of messages over time was critical for recognition of the You're Amazing program carried out in Alberta. They suggest that this type of program requires (at least) more than two years for effective dissemination of program messages.

Public education initiatives require appropriate multi-year levels of resources to ensure they achieve a high enough frequency in message delivery over time.

Consideration should be also be given to the fact that the winter season is a challenging period for Canadians who want to adopt healthy eating and physical activity behaviours (Health Canada, 2003b; Sage Research Corporation, 2002). Therefore, special efforts should be made to convey practical tips on healthy eating (especially in areas where the availability and variety of nutritious foods during winter is more limited) along with information on fun and safe physical activity opportunities during winter.

5. Partnerships

5.1 Existing Initiatives

An initial scan conducted by the Atlantic Health Promotion Research Centre (2003) identified 195 healthy eating and active living policies and programs. Many are aimed at the general public and have public education components, while some are specifically focused on families and children.

As a first step, an environmental scan would identify existing Canadian government, non-governmental and private sector initiatives. It would also show how to integrate some recommendations on priority audiences, messages, channels and sustainability.

5.2 With the Private Sector

A number of studies and reports signal how seriously companies are taking the rising consumer concerns about obesity (Young, 2003; Genesis Public Opinion Research, 2003). Parents acknowledge that companies have a responsibility to accurately and clearly label pre-packaged foods (Genesis Public Opinion Research, 2003). According to Ipsos-Reid (2002), "the market for healthy eating is crowded. Notable 'help' from private sector companies is likely continuing the current trend to improvement. The situation is much less favourable for physical activity, both in terms of the trend and others making efforts to tap into."

A systematic review of the evidence has shown that there is a link between food advertising and children's food habits - especially their preferences and purchasing behaviour (Hastings, 2003; Hastings et al., 2003). Hastings (2003) argues that although society would be better off without the tobacco industry, the same does not apply to the food industry. "In contrast to tobacco, a society without food companies is not a desirable or even feasible option. The challenge is for public health to work with the food industry to devise a set of checks and balances that will ensure the advantageous delivery of healthier food options" (Hastings, 2003). "The debate now shifts to what action is needed, and specifically to how the power of commercial marketing can be used to bring about improvements in (young) people's eating" (Hastings et al., 2003).

Given the extent of their marketing and advertising resources and skills, suitable private sector partnerships should be explored, especially with food companies. Partnerships between the private sector and government agencies for public education purposes may not be perceived as appropriate in all instances, especially when a government agency is also regulating the sponsoring corporation.

Since active living does not benefit from the same exposure, private sector companies should be encouraged to include active living messages in their promotional activities (as some food companies are already doing). In addition, sustained investments by government and non-governmental organizations should also be considered for active living, as part or in addition to integrated healthy living initiatives.

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Angus Reid Group, Inc. (2000). Diabetes benchmark study. Unpublished report.
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Bauman, A. et al. (in press). ParticipACTION: This mouse roared, but did it get the cheese? Canadian Journal of Public Health.

Bauman, A., Ford, I. and Armstrong, T. (2001). Trends in population levels of reported physical activity in Australia, 1997, 1999 and 2000. Canberra: Australian Sports Commission.

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Social Marketing and Communications Consultant
(514) 694-7129
flagarde@videotron.ca