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Messages about Obesity – Making them Stick

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I Introduction

The Health Communication Unit (THCU) recently facilitated a webinar on health communication messages about obesity. Using our Health Communication Message Review Tool  as a framework, Jodi Thesenvitz and Nancy Dubois outlined the results of our recent literature search on obesity messaging (please note the literature search did not include other related key words such as nutrition or healthy weights). We suggested some possible ways of applying the literature to the development of health communication messages about obesity. Generic advice relating to all topics can be found at the link above.

This article, like the related webinar, is organized by the criteria in THCU's review tool noted above. For each, we briefly note any relevant literature we found and suggest an application to obesity message development (Apply It!).

Not an exhaustive review, the literature search results provide a starting point for conversation. We hope that others working in the field will contribute to the search for good data - local, regional, provincial and national - both published and informal (or grey literature). Please contribute your thoughts and sources on THCU's learning community at http://www.thcu.ca/blogs/lc/?p=49

A reference list for numbers noted in the article is available at http://www.thcu.ca/blogs/lc/wp-content/uploads/2008/02/references.xls.

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II Review Criterion 1:  The message is clearly linked to a behavioural goal.

While there are not many diet-specific campaign evaluations, there are some examples of success. For example, while the average effect of a large, well-research campaign is estimated at a behaviour change of 5%, a study of 37 fruit and vegetable campaigns found an average effect of 8%. Campaigns that took place in schools were even more successful with an effect of 12% (1).

Canadian knowledge about physical activity and nutrition is quite high already (32). Motivation is the problem, not general information gaps (5).

*Apply it!* Make behaviour change an explicit goal (1) instead of simply ‘raising awareness or increasing knowledge'.

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III Review Criterion 2: The message will get and maintain the attention of the audience.

Food marketers know how to get and maintain the attention of children. This creates a substantial challenge for health promoters. This is particularly true online where sophisticated message strategies are being used to sell food to kids including online games, freebies and viral campaigns (27).

*Apply it!* Consider building private sector partnerships, particularly with food companies (HL).

There has been a tremendous increase in stories about obesity over the last seven years. Getting the audience's attention about obesity is thus all the more difficult in this media saturated environment. (29).

*Apply it!* Find innovative ways to partner with the news media and other organizations (29).

*Apply it!* Emphasize new information in your message or campaign, such as study findings or new strategies for tackling obesity, which are intriguing to the media.

The number of times your target audience actually sees a message is key to having an impact. In fact this is probably the MOST IMPORTANT consideration (29).
Effectively reducing rates of obesity is possible if there is adequate exposure to messages (23).

*Apply it!* If you do not have the resources to achieve adequate exposure (aim to have all audience members see your message at least three times), reconsider your strategy. There may be better ways to use your limited resources to contribute to obesity reduction.

*Apply it!* Consider making use of settings that will provide the most ‘bang' for the buck in terms of exposure. For example, schools.

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IV Review Criterion 3: The strongest points are given at the beginning of the message.

*Apply it!* When testing messages and materials with members of the intended audience, first show the material for just ten seconds. Then ask, "What do you remember?" , "What was your gut reaction"?

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V Review Criterion 4: The message is clear.

The literature is not clear about whether simple or more complex messaging is best for nutrition-related messages (29).  

*Apply it!* Test messages with the intended audience to ensure they understand the recommended action, why they should do the recommended action and all other related content.

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VI Review Criterion 5: The action you are asking the audience to take is reasonably easy.

‘Easy' is a subjective term that requires testing through good audience analysis for specific focal groups.  However, the literature provides us with some starting points.
Parents in Northern Ontario tend to underestimate the weight and overestimate the physical activity of their children (24). In a U.S. study, parents felt weight was a problem only if it prevented activity or socializing (based on 11/12 year old children) (19).

An Australian study showed that parents often express views that are at odds with their stated ‘positions/knowledge ‘e.g. ‘daily treats are okay'; ‘It's okay if I put a treat in lunch since they eat healthy the rest of the day' The same study showed that children believe that anything permitted at school is inherently healthy, though this is frequently not the case. These implicit and explicit contradictions children receive are a barrier to them making healthy choices (AUS).

Yet another Canadian study shows that that although knowledge of what is desirable overall is relatively high, there are some specific areas of nutrition knowledge that are weak (16). Also, the lack of actionable information in many nutrition messages can cause frustration (30).

*Apply it!* Rather than only focussing on large, sometimes overwhelming behaviour changes (e.g., getting physical activity every day, making large nutrition changes), consider tackling small, specific audience barriers, as revealed by literature or other audience engagement techniques.  For example, give parents the tools to assess their children's weight, physical activity and eating habits objectively or try a focus on school lunches.  Consistent with this thinking, one FDA document recommends that nutrition messages focus on small, incremental steps such as planning ahead and ‘total calories count' (8). Another article recommends making misconceptions a focus of the campaign (1).

Overcoming obesity is about stimulus control and environmental cues (e.g., mindless eating, availability, portions, dish sizes, social settings, etc.) and NOT knowledge, intention, action (22).

*Apply it!*  Use ‘design thinking', a process of breaking down a behaviour into small incremental steps, behaviours, cues, settings that contribute to an overall behaviour, to find appropriate and significant ‘baby steps' on which to focus. (21)

Changing a person's eating habits is always harder than starting new ones.

*Apply it!* Emphasize what TO do, not what NOT to do (29).

Selecting a behaviour goal should take into consideration the environment. This is especially true for obesity since social networks and environmental factors are key (23). Behaviour goals need to go beyond the individual and address their environment (29). In fact, there is an increased risk of becoming obese if someone in your social network becomes obese. This risk is high if the individual is a family member (37%-40%) and even higher if the individual is a friend (141%) (20). The trend also suggests that people who eat alone tend to have higher consumption (22).

*Apply it!* Work toward policies that encourage eating together, e.g., remove vending machines and restrict food to the cafeteria (22).

Other people's opinions are very important when it comes to healthy eating. Consider the fact that 66% of online searching for health information involves looking for other people's opinions, reading blogs, visiting social networking sites (20).

*Apply it!* Set campaign objectives that are linked to social networks, for example: "make a pact with friends to eat healthy lunches."

*Apply it!* Use brief interpersonal interventions, ‘activity days' for example (1), to address the social nature of food consumption.

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VII Review Criterion 6: The message uses incentives effectively.

Choosing the right incentive can be a challenge. Many social marketing campaigns have poor results because the wrong message is aimed at the wrong groups, for example an educational message may be aimed at a group that needs a motivational one [with an incentive] (14).

*Apply it!* Make sure messages include an incentive when the intended audience needs motivation to do the recommended behaviour. At THCU, we sometimes call this the ‘so what' of a message or the ‘why should I care' component.

One study from the U.S. shows that children (11/12 yrs) are concerned with appearance, performance, fitting in, and although they thought health was a good thing, they didn't really think about it much (19).

*Apply it!* Ensure incentives used in the campaign are things that really matter to the target audience.

For parents, time is a major barrier to making healthy choices. In the U.S. parents noted time and not wanting new battles with children as barriers to talking about and enforcing nutrition goals (19). In Canada, women working and with children at home have the most barriers to healthy living, especially physical activity (HL).

Concern about nutritional behaviour is high but this is not enough to produce behaviour change - people have too many other obligations and issues (30). Although health is important to consumers, most of the time they find healthy eating inconvenient. Consumers believe that good health is important, but often not as important as other things in their lives (12).

*Apply it!* Messages need to address why they don't do the behaviour [as well as why they would] - which often has nothing to do with medical/health reasons (23). Finding the right incentive to counteract significant barriers requires creativity and consideration of the social and physical environment.

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VIII Review Criterion 7: Good evidence for threats and benefits (the incentive) is provided.

Arguing against criterion 5 (make sure the action you are recommending is easy) one study found that many consumers don't believe in small steps that are ‘easy' (5).

*Apply it!* When testing messages before dissemination, check with the audience to ensure that they believe the recommended action will achieve or contribute to the desired (or claimed) result. If not, find ways to improve the evidence or the claim.

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IX Review Criterion 8: The messenger is seen as a credible source of information.  

In today's society, everyone is surrounded by messages varying in content and accuracy when it comes to obesity (29).

*Apply it!* Profiling ‘real' people facing the same issues as the intended audience can increase credibility (HL).

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X Review Criterion 9: Messages are believable.

*Apply it!* Avoid extreme, inflated claims that the intended audience may not believe such as, ‘losing weight is easy' or ‘you'll feel a million times better!'  

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XI Review Criterion 10: The message uses an appropriate tone for the audience (for example, funny, cheery, serious, dramatic).

The current message environment has created a host of negative reactions to do with food.

*Apply it!* A positive tone may have a greater impact for some audiences (1). Test your message tone!

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XII Review Criterion 11: The message uses an appeal that is appropriate for the audience (i.e. rational or emotional).  

Rational appeals (using evidence, facts, etc) generally work best audiences that are already interested in your topic (33). Emotional appeals that raise concern, fear, etc. work better with audiences that are not already interested in the topic.

Many consumers are already uncomfortable with their dietary choices, for themselves and for their children. (30)

*Apply it!* Consider researching and developing separate messages for groups that are already uncomfortable with their choices, and those that are not already concerned. Different types of appeals are appropriate for these different segments.

*Apply it!* Use the literature guiding effective use of discomfort or fear messages carefully. Misuse of these types of appeals can cause boomerang effects (causing audience to do more of the unwanted behaviour because they feel overwhelmed or unsure of how to proceed). For more information on fear appeals take a look at the following THCU resource: http://www.thcu.ca/infoandresources/publications/fear%20appeals%20-%20web%20version.pdf

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XIIII Review Criterion 12: The message will not harm or be offensive to people who see it. This includes avoiding ‘victim blaming'.

There is the need for further investigation into the socioeconomic factors affecting nutrition behaviour (18).

*Apply it!* During message development, be sensitive to financial and other social barriers to healthy lifestyles that are part of many audiences' reality.

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XIV Review Criterion 13: Identity is displayed throughout.

*Apply it!* Check out the branding success stories of the VERB and TRUTH campaigns. These campaigns created an identity for a set of prevention or health promotion behaviours so that they represented an appealing lifestyle for their intended audience (29).

The VERB campaign: http://www.cdc.gov/YouthCampaign/
The TRUTH campaign: http://www.protectthetruth.org/truthcampaign.htm

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XV Review Criterion 14: The message is consistent with other campaign communications; with other related campaigns; with scientific evidence and well-accepted guidelines.

The wide variety of messages about obesity makes messages less credible overall. Consistency is key (1).

*Apply it!* Research other messages on the same topic.

*Apply it!* Work towards standard regional, provincial or national messaging whenever possible.