Experiences with research on consumer KAB regarding

SALT SMART CONSORTIUM 13 14 June 2013 PAHO, Washington DC Experiences with research on consumer KAB regarding salt intake - methods, instruments, target audiences Hasan Hutchinson, Director General Office of Nutrition Policy and Promotion

Presentation Outline Applying the Applying a Social Marketing Framework to Salt Reduction to Health Canada s Eat Well Campaign I. Situation Analysis II. Literature Review & Research Findings III. Target Audience IV. Audience Analysis V. Supply Side VI. Demand Side / Communication Goal and Objectives VII.Marketing Mix Strategies VIII.Monitoring & Evaluation Plan IX. Work Plan & Timeline X. Budget / Funding Sources XI. Summary of Best Practices 2

Prevalence of hypertension I. Situation analysis Step A: Describe Background Data from the Canadian Health Measure Survey (CHMS 2007-2009) indicate that nearly one-fifth (19%) of Canadians aged 20 to 79, roughly 4.6 million people, had hypertension. Another 20% had readings in the pre-hypertension range. Leading causes of death and disability Cardiovascular disease Hypertension and Sodium Intake In Canada, it has been estimated that if the average sodium intake is decreased by 1,840 mg/day roughly equivalent to bringing it down from the current intake to the AI of 1,500 mg/day hypertension prevalence would be decreased by 30%. At-risk populations Everyone is at risk 3

Age Group Situation analysis Step A, Con t Adequate Upper Limit What Intake (AI) (UL) Canadians mg/day mg/day are eating* Adult 1500 2300 3200* Youth (9-13 years old) Children (4-8 years old) 1500 2200 3200* 1200 1900 2700* * Not including the amount added in preparation or at table 4 From Canadian Community Health Survey 2.2 (2004)

Situation analysis Step A, Con t Data are based on the Canadian Community Health Survey -Cycle 2.2 on Nutrition, Statistics Canada, 2004. 5

Sources of Sodium Diet Situation analysis Step A, Con t Food Breads 14% 5% added while cooking 6% added while eating Processed meats 9% 12% from natural Vegetable products 9% sources Soups 7% 77% from processed Pasta dishes 6% foods Cheese 5% Milk products 4% Red meat products 4% Poultry 4% Gravies and sauces 4% 6 From Canadian Community Health Survey 2.2 (2009)

Situation analysis - Step B : Current Nutrition Guidance & Legislation 7

Canada s Nutrition Labelling regulations: Situation analysis - Step B, Con t Nutrition Facts Ingredient List INGREDIENTS: Whole wheat, wheat bran, sugar/glucose-fructose, salt, malt (corn flour, malted barley), vitamins (thiamine hydrochloride, pyridoxine hydrochloride, folic acid, d- calcium pantothenate), minerals (iron, zinc oxide). Nutrition Claims Good source of fibre Health Claims A healthy diet 8

Situation analysis - Step B, Con t The Nutrition Facts table since 2005 Easy to find Easy to read On most prepackaged foods 9

Situation analysis - Step B, Con t 10

Situation analysis - Step C: Gap Analysis Key Education Gap: Lack of consistent messaging and need to improve the health literacy of Canadians. 11

II. Literature Review and research Findings What is Research Saying? Children A high intake of sodium is associated with HBP and is also likely to predispose children to develop hypertension later in life. Ageing g population o The realities of an aging population with higher rates of disease, and higher numbers of overweight have far-reaching social and financial implications for peoples quality of life, and for Canada s health care system. 12

Research findings, Con t The economic consequences of an unhealthy diet are significant and estimated at over $6.6 billion in 1998 and growing. Research has shown that sodium reduction interventions are among the most cost-effective ways of reducing the burden of cardiovascular disease. It has been estimated that a reduction of 1800 mg in the average sodium intake of Canadians would result in direct healthcare savings of $1.38 billion per year; including indirect costs, savings would be $2.99 billion per year. 13

III. Target Audience 14

IV. Audience Analysis: What do Canadians believe? While 89% of Canadians believe that their fellow Canadians consume too much sodium, only 41% of Canadians think they consume too much themselves. 45% of Canadians believe they consume the right amount of sodium, however only 24% monitor very closely the amount of sodium intake in their diet. Of the two-thirds of Canadians who say they take action on a regular basis to control their sodium intake, the top measures reported are to not add salt when cooking (42%) or at the table (40%). Consumers have no knowledge of the target daily amount of sodium (AI or UL). When asked, 72% of Canadians think that salt in processed foods is the single largest source of sodium in the Canadian diet, however only 16% report minimizing their consumption of processed foods and 14% report looking at the Nutrition Facts Table in an effort to control their sodium intake. 15

Audience Analysis, Con t: More beliefs The best way to reduce the sodium in my diet is to stop using the salt shaker. Ican't be eating too much salt because I don't add it to my food. Food does not taste good without salt. You can tell what foods are high in sodium because they taste salty. Sea salt and fleur de sel are better for you than table salt. If I cut down on the amount of salt I eat my body won't have enough. I don t have High Blood Pressure, therefore I don t need to watch my salt intake. 16

V. Overview of supply Nutrition Labelling Legislation Work by the food industry To decrease sodium in food products Data on sodium in Canadian Food products and work of the Food Directorate to reduce sodium In the food supply 17

VI. Communication goal and objectives Sodium Reduction Awareness and Education Objectives To increase awareness that most people in Canada eat too much sodium and can benefit from reducing their intake. To increase understanding and develop skills to reduce sodium intake within the context of healthy eating. To reduce consumers intake of sodium in the context of healthy eating. 18

Healthy Eating Awareness and Education Initiative 2010/11 2012 2013 2014 2015 Healthy Eating with Canada s Food Guide Foundation of the work Phase 1: Healthy Eating & Nutrition Labelling Nutrition Facts Education Campaign (NFEC) % Dil Daily Vl Value messages Phase 2: Healthy Eating & Sodium Reduction Eat Well Campaign Phase 3: Healthy Eating & Healthy Weights Focus on Food skills in support of the Curbing Childhood Obesity Framework 19

Phase 1: Nutrition Facts Education Campaign 20

Nutrition Facts Education Campaign Nutrition Facts Education Campaign in collaboration with Food & Consumer Products of Canada (FCPC) 34 participating food manufacturing companies FCPC members: on-pack messaging (792M packages), advertising and media partnerships (TVA and Shaw) and outreach in other vehicles (web, newsletters) Health Canada: provides messages and web based content and interactive tools Evaluation: To be completed in 2013/14 Results 2009 2012 use of the Nutrition Facts table (2010: 69%; 2012: 74%) 54% awareness of the new % DV image % DV awareness 48% changed shopping behaviour www.healthycanadians.gc.ca/dailyvalue 21

Phase 2: Sodium Reduction t British Columbia s Ministry of Health, Dietitians of Canada and EatRight Ontario (with support from Health Canada) led focus group testing with dietitians and consumers in Vancouver, Kitchener, Toronto and Ottawa; public focus group testing included participation from a variety of cultural and socioeconomic backgrounds. Health Canada led additional focus testing sessions in Halifax, Montreal, and Edmonton to enhance the testing ti of the messages and explore directions for tone. In each location, one session was held with the general population, and one session was held with Canadians with a lower socio-economic status t (low SES). Costa Rica has tested and adapted these messages. 22

Key Findings with Consumers Sodium is generally not a top-of-mind aspect of healthy eating. There is some confusion over the difference between salt and sodium. Messages that provided new and specific information resonated best with participants. Among the messages that were tested, those that provided statistical information had a strong impact. Consumers are looking for practical and tangible tips. Messages need to be customized for cultural groups to ensure using appropriate examples. Family physicians i and dietitians are the most commonly identified sources of information about sodium. 23

Sodium Messages: Get the Facts Fact: Sodium is found in salt. Fact: We eat too much sodium. Fact: Eating too much sodium can be harmful to our health. Fact: Most of the foods we eat contain too much sodium. More messages and tips @ HealthyCanadians.gc.ca/sodium 24

VII. Marketing Mix Strategies Health Canada: Awareness & Education Clear and consistent messages & campaign look & feel (carried by all) Media Industry / Retail Parents of children aged 2-12 Public Relations Web & Digital Engagement Intermediaries/ PTs / NGOs 25

Web & Digital Engagement Web and Social Media Major update and overall to consumer web content on new healthycanadians.gc.ca 152K unique page views (mid-oct/12 Mar/13) 1:30 average time on page Banners on media partners driving traffic 33K new visits from UTM coded banners Coordinated Facebook & Twitter messages from HC, media and retail partners HealthyCanadians.gc.ca/EatWell 26

Web & Digital Engagement g Health Canada Web Site Healthy Eating Toolbox Information for Intermediaries The toolbox includes resources for intermediaries such as articles, quizzes, fact sheets, interactive tools, presentations, media relations and social media materials from partners. hc-sc.gc.ca/fn-an/nutrition/part/tb-bo/index-eng.php 27

Media Broadcast - CORUS CONCEPT: The Wilsons Eat Well : Kortney and Dave Wilson and their 3 children learn about healthy eating and sodium reduction 28

Media TRANSCONTINENTAL CONCEPT: Canadian Livingi and Coupe de Pouce magazines follow 3 moms each on a healthy eating journey with advice from a dietitian. Included custom articles, print PSAs, 6 videos, blogging, Ask an expert, e-newsletters, quizzes, Facebook posts, Tweets and recipes. www.canadianliving.com/healthylife www.coupdepouce.com/viesaine 29

Media Survey Highlights OBJECTIVE Gauge the recall of the campaign, and impact on behaviour, knowledge and understanding of healthy eating messages. Research was conducted throughout the campaign with all 3 media collaborators. KEY CONCLUSIONS Results indicate that the media partnerships had an overall positive effect on attitudes towards healthy eating and intent to change healthy eating behaviours. 37% intend to change their healthy eating habits (Corus/Astral) Up to 48% recall for Astral vignettes 20% of those exposed to the campaign ate healthy meals more often in March (Astral) 57% recall Wilson family vignette about making healthier food choices (Corus) 44% average recall of print articles Average of 59% will choose sodium reduced foods 30

Industry / Retail Collaboration with Food Retailer Associations Retail Council of Canada members, Grocers Division Canadian Federation of Independent Grocers Focus on healthy eating and food skills messages such as planning, shopping and food preparation (highlighting meal plans, tips, tools, etc.) Total Reach: 90%+ of grocery sales in Canada (est. 20M+ customers/ wk) 31

Intermediaries / PTs / NGOs Intermediaries Hypertension Canada Chronic Disease Prevention Alliance of Canada 32

Provinces and Territories The BC Example Fact Sheets Integration of Sodium Messages Social Marketing Campaign With posters and other resources Interactivity Build a Low Sodium Menu www.healthyfamiliesbc.ca 33

Figure 1: HEAEI Logic Model VIII. Monitoring & Evaluation Plan Inputs Funding Human resources Facilities/Infrastructure Acts, regulations, policies, priorities Science and Technology Research Data Foundation Eating Well with Canada s Food Guide Components Healthy Eating/Nutrition Labelling NFEC Healthy Eating/Sodium Reduction Healthy Eating/ Healthy Weights Activities (A1) Assess awareness, knowledge and behaviour of target audience; identify focus; and plan initiative (A2) Outreach to and (A3) Negotiate and (A4) Develop campaign selection of potential develop partnerships components partners (A5) Disseminate information and resources; implement campaign (A6) Monitor, conduct surveillance and Evaluate Outputs Awareness and education activities, tools and resources Process Evaluation Delivery Partners Government (FPT), Industry, NGOs, Media, Health Professionals Target Audience Primary: Parents and Caregivers of Children aged 2-12 Secondary: Intermediaries such as health professionals and NGOs Immediate Outcomes (B1) Canadians are aware of and have access to healthy eating guidance (B2) Integration of the CFG and the HEAEI messaging into nutrition education and food environments across Canada Intermediate Outcomes (C1) Canadians are knowledgeable about and understand healthy eating: label reading, sodium reduction, and food skills (C2) Canadians make informed, healthy eating decisions Outcome Evaluation Ultimate Outcome (D1) Healthy Canadians HEAEI Evaluation Framework 34

Sodium reduction is a shared responsibility amongst food industry, fed/prov/terr governments, NGO s, intermediaries and consumers. 35

XI. Summary of Social Marketing Best Practices 1. Identify one segment of the public whose behaviour you hope to influence 2. Think like a consumer 3. What do they get in return? 4. Change does not occur over night 5. Surprise them! Let your taste buds enjoy the flavour of food with less sodium! 36

Thank you! Contact information: Hasan.hutchinson@hc-sc.gc.ca Eating Well with Canada s Food Guide www.health.gc.ca/foodguide Eat Well and Be Active Educational toolkit www.health.gc.ca/eatwell-beactive % Daily Value www.healthycanadians.gc.ca/dailyvalue il l Sodium Reduction www.healthycanadians.gc.ca/sodium EAT WELL campaign www.healthycanadians.gc.ca/eatwell 37

Sample Tips At the Grocery Store Read the information on food packages Buy unsalted and lower sodium foods whenever e e possible. Look for words such as sodium-free, low sodium, reduced sodium, or no added salt on the package. Compare food labels. Buy the products with the lowest amounts of sodium. Look for foods that contain less than 360 mg of sodium per serving. You can also use the % Daily Value (%DV) on the label to compare products and see if the food has a little or a lot of sodium. Choose a product that has less sodium, look for one with a sodium content of less than 15% DV. Make wise choices from the four food groups in Canada s Food Guide Vegetables and Fruit - Buy fresh or frozen vegetables whenever possible. Look for canned vegetables that are low in sodium. Buy low sodium vegetable juice and tomato juice. Grain Products - Choose breads, breakfast cereals, and bakery products that are lowest in sodium. Enjoy a variety of grains such as barley, quinoa and rice which are naturally sodium free. 5% DV or less is a little 15% DV or more is a lot. 38

Sample Tips At Home Make healthy meals and snacks Eat fewer packaged, ready-to-eat and take-out foods. Make your own soups, sauces and salad dressings. Enjoy more vegetables and fruit. Use fresh or frozen instead of canned whenever possible. Reduce the sodium in the foods you use Rinse canned vegetables and canned beans, peas and lentils to wash away some of the sodium. Use less of the seasoning that comes with taco kits, packaged macaroni and cheese, pasta and rice mixes. Add flavour without sodium Flavour foods with herbs and spices. Here are a few ideas: Basil - tastes great with tomatoes and pasta Cumin adds flavour to soups, stews and sauces 39

Sample Tips When Eating Out Make lower sodium menu choices Order smaller portions or share with someone. Ask for gravy, sauces and salad dressings on the side, and use only small amounts. Flavour your food with lemon or pepper instead of adding salt, sauces or gravy. Find the best menu choices Check the nutrition information of menu items before you order and choose foods with less sodium. This information may be in a poster or pamphlet at the restaurant or on the restaurant s website. 40

Additional Sodium-Related Resources Dietitians of Canada: www.eatracker.ca www.eatwise.ca Hypertension Canada Education Section www.hypertension.ca Canadian Stroke Network www.sodium101.ca Champlain Cardiovascular Disease Prevention Network www.giveyourheadashake.ca Heart and Stroke Foundation of Canada www.heartandstroke.com 41