Testing of Messages on Healthy Eating, Research Report

Prepared for: Health Canada

POR Registration #: POR-126-16
Contract Number: HT372-164731/001/CY
Contract Award Date: March 29, 2017
Date of Delivery: July 28, 2017
Contact Information: por-rop@hc-sc.gc.ca

Ce rapport est aussi disponible en français.

For more information on this report:
cpab_por-rop_dgcap@hc-sc.gc.ca

Contents

• Executive Summary
• Introduction
• Methodology/Research Approach
• Target Audience
• Detailed Findings
• Conclusions
• Appendix A: Discussion Guide
• Appendix B: Screener

Executive Summary

Earnscliffe Strategy Group (Earnscliffe) is pleased to present this report to Health Canada summarizing the results of the qualitative research on the Testing of Messages on Healthy Eating.

Health Canada is mandated to develop and promote evidence-based dietary guidance, which is communicated through Canada’s Food Guide (CFG) and other life stage guidance. Health Canada is revising Canada’s Food Guide to strengthen healthy eating recommendations and communicate guidance in ways that better meet the needs of different users. The purpose of this specific research is to provide insight on how proposed foundational statements and related terminology resonate with the intended target audience. The total cost to conduct this research was $54,525.83, including HST.

The objectives of the research were to evaluate the foundational statements in order to determine whether they were: clear, credible, relevant and of value to the audience; practical, easy to understand, easy to remember; appealing and appropriate to the cultural and emotional sensitivities of the audience; of the appropriate tone; and, able to collectively motivate the audience to take personal actions.

To meet these objectives, Earnscliffe conducted a wave of qualitative research. The research included a series of eight focus groups in four cities across Canada: Toronto, ON (June 12); Moncton, NB (June 13); Vancouver, BC (June 13); and, Montreal, QC (June 14). The focus groups in Montreal were conducted in French.

The focus groups were conducted with Canadians eighteen years of age and older. In each city, one focus group was conducted with those at risk of marginal health literacy (as screened by the Newest Vital Sign, scoring < 4/6), while the other group was conducted with those with adequate health literacy (as screened by the Newest Vital Sign, scoring 4+). Each group included a mix of sexes, ages, household incomes, education levels, as well as a mix of cultural background and Indigenous peoples. Please refer to the Recruitment Screener in the Appendix of this report for all relevant screening and qualifications criteria.

For the purposes of this report, the term “diet” refers to the practice of eating food and the food one eats.

It is important to note that qualitative research is a form of scientific, social, policy and public opinion research. Focus group research is not designed to help a group reach a consensus or to make decisions, but rather to elicit the full range of ideas, attitudes, experiences and opinions of a selected sample of participants on a defined topic. Because of the small numbers involved the participants cannot be expected to be thoroughly representative in a statistical sense of the larger population from which they are drawn and findings cannot reliably be generalized beyond their number.

The key findings from the research are presented below.

• Overall reaction to the statements was generally positive. Participants felt that the statements were clear and that the language used was appropriate and easy to understand. Worth noting, is that this was consistent across all groups; there were no differences in terms of geography, or more importantly, health literacy.
• The advice was deemed practical, relevant and easy to remember. In fact, most participants felt that the statements were in line with what they know about healthy eating and were consistent with their own personal practices and efforts to eat healthy. Indeed, those more knowledgeable about the current Canada’s Food Guide volunteered that these statements represented a modern and relevant update to the resource.
• With respect to tone, participants felt that the statements hit the mark in terms of providing sound advice in a way that was direct yet conveyed a sense of understanding. They did not feel they were made to feel guilty about their diet and/or choices. In fact, most said that while they try hard to eat healthy, there are occasions when circumstances influence one to make an unhealthy choice and the fact Health Canada recognized that, was appreciated.
• On the question of proportionality, most participants were able to distinguish between the various proportionality terms used throughout the statements. Having said that, there tended to be one or two participants in each group who would have preferred some guidance in terms of quantity (i.e., suggestions about the quantity of fruits and/or vegetables, number of servings, etc.). Others tended to argue that they preferred that there were no metrics that they needed to try to live up to and preferred the advice to choose or limit one type of food over another.
• Nearly all participants could see themselves in these messages. The general consensus was that the guidance was applicable for all diets (i.e., vegan, vegetarian and omnivore) although some, particularly omnivores, had the sense the guidelines were encouraging Canadians toward a vegetarian diet. While most agreed that a diet based primarily on plant-based foods was appropriate, there was a sense that guidance relating to the consumption of meat was diminished and not exactly in line with their preferences. For a small number, the perception of being encouraged to eat a vegetarian diet undermined the overall effectiveness of the collection of messages.
• In terms of the appeal and appropriateness of the statements to cultural and emotional sensitivities, reactions were somewhat mixed. Most appreciated that the messages were attempting to represent the diversity of Canada and the cultural variations of foods eaten in this country. However, the qualifier in the first statement about choosing foods that you enjoy and that reflect your culture and traditions was felt to be limiting or distracting. Participants value the opportunity to experience different foods and incorporate other cultural influences in their diet. Further, there were some who pointed out that the diet of their own culture was actually unhealthy due to traditional cooking methods or ingredients. These people were actively seeking to avoid the foods of their culture in order to eat a healthier diet.
• While some participants indicated that they would be motivated to do something as a result of these messages, most felt that it served as more of a helpful reminder and to encourage personal reflection. Many felt that they were already making a concerted effort to heed the guidance communicated in the statements and that the information was not all that new. Some suggested that they would be motivated to get clarification on some of the terms (e.g., healthy fats, saturated/unsaturated fats, etc.).
• Finally, participants tended to believe that the statements were organized into two types of guidance: first, guidance about nutrition and healthy eating choices; and, second, guidance about lifestyle choices and healthy eating habits. While reactions were generally favourable towards both types of guidance, they tended to be a little more favourable toward the statements about lifestyle and healthy eating habits. Participants felt these statements conveyed an important holistic approach to healthy eating. When asked if they would make any changes to the presentation of the information, some felt it would be interesting to begin with the guidance about healthy eating habits as a way of framing the advice about specific nutrition choices.

Research Firm:

Earnscliffe Strategy Group Inc. (Earnscliffe)
Contract Number: HT372-164731/001/CY
Contract award date: March 29, 2017

I hereby certify as a Representative of Earnscliffe Strategy Group that the final deliverables fully comply with the Government of Canada political neutrality requirements outlined in the Communications Policy of the Government of Canada and Procedures for Planning and Contracting Public Opinion Research. Specifically, the deliverables do not include information on electoral voting intentions, political party preferences, standings with the electorate or ratings of the performance of a political party or its leaders.

Signed:
Stephanie Constable
Principal, Earnscliffe

Date: July 26, 2017

Introduction

Earnscliffe Strategy Group (Earnscliffe) is pleased to present this report to Health Canada summarizing the results of the qualitative research on the Testing of Messages on Healthy Eating.

Health Canada is mandated to develop and promote evidence-based dietary guidance, which is communicated through Canada’s Food Guide (CFG) and other life stage guidance. Health Canada is revising Canada’s Food Guide to strengthen healthy eating recommendations and communicate guidance in ways that better meet the needs of different users. The purpose of this specific research is to provide insight on how proposed foundational statements and related terminology resonate with the intended target audience. The foundational statements will translate the Dietary Guidance Policy into short, simple, concise public-focussed messages. Feedback from the research will help inform the development of messages.  The objectives of the research were to:

• Evaluate the foundational statements in order to determine if content is:
  • clear, credible, relevant and of value to the audience;
  • practical, easy to understand, easy to remember;
  • appealing and appropriate to the cultural and emotional sensitivities of the audience;
  • utilizing the right tone; and,
  • able to collectively motivate the audience to take personal actions;
• Elicit suggestions for potential changes to ensure the statements resonate with the target audience; and,
• Discuss audience understanding of select terms in order to inform development of messaging.

Research Approach

To meet these objectives, Earnscliffe conducted a wave of qualitative research. The research involved a series of eight focus groups in four cities across Canada: Toronto, ON (June 12); Moncton, NB (June 13); Vancouver, BC (June 13); and, Montreal, QC (June 14). The focus groups in Montreal were conducted in French.

All sessions were two hours in length. In Toronto and Vancouver, the groups were conducted at 6:00 pm and 8:00 pm, while in Moncton and Montreal, the groups were conducted at 5:30 pm and 7:30 pm. Participants received an honorarium (of $100.00) as a token of appreciation for their time. Please refer to the Discussion Guide in the Appendix of this report for details about our approach to the research.

Target Audience

The focus groups were conducted with Canadians eighteen years of age and older. In each city, one focus group was conducted with those at risk of marginal health literacy (as screened by the Newest Vital Sign, scoring < 4/6), while the other group was conducted with those with adequate health literacy (as screened by the Newest Vital Sign, scoring 4+). Each group included a mix of sexes, ages, household incomes, education levels, as well as a mix of cultural background and Indigenous peoples.  Please refer to the Recruitment Screener in the Appendix of this report for all relevant screening and qualifications criteria.

For the purposes of this report, the term “diet” refers to the practice of eating food and the food one eats.

Detailed Findings

Except where specifically identified, the findings in this qualitative report represent the combined results for both English and French. These findings are discussed in three sections. The first section presents the findings of the initial exploratory (warm-up) discussion on healthy eating. The second section explores specific reactions to the foundational statements in terms of their clarity, understandability and relevance as well as their interpretation of the terminology around proportionality (how much we should eat of different types of foods in relation to other foods). The third section explores participants’ thoughts on the flow of information as well as their motivation to take action.

Exploratory Discussion

The focus groups began with an initial exploratory discussion around healthy eating. This discussion helped set the stage for a more detailed conversation about healthy eating but also provided useful context for understanding participants’ current practices and efforts.

The initial warm-up discussion focussed on what participants’ felt was the most important thing when it comes to healthy eating and the kinds of things they are doing in their lives to eat healthy.

Most participants felt that they were making efforts to eat healthy. Not surprisingly, efforts varied depending on a variety of factors, including (but certainly not limited to): stage of life (age); health; socio-economic status; culture; beliefs; etc. The following is a list of the various choices – both nutritional and lifestyle – participants suggested that they are making in their day-to-day lives to eat healthy; these are not displayed in any particular order:

Nutrition choices

• Limit salt/sodium, sugar, processed foods, junk food
• Eat lots of fresh fruit and vegetables
• Eat a balanced meal with a variety of foods from different food groups
• Eat whole foods
• Eat organic (concern about pesticides, GMOs, etc.)
• Drink lots of water

Lifestyle choices

• Eat out less and prepare more meals at home
• Read nutrition labels
• Adopt a vegetarian/vegan diet
• Try to bake foods more rather than frying foods
• Involve children in food/meal preparation

It is worth noting that as part of this discussion, a sideline topic of conversation around the cost of eating healthy tended to come up spontaneously in several of the groups. There was a sense among some participants that healthy eating can be cost prohibitive. They explained that the cost of fresh and whole foods, can have an undesirable influence on the choices they make; pushing them to eat prepared and processed food which is often perceived to be more cost effective.  

Foundational Statements: Understanding and Tone

The discussion explored participants’ understanding of the foundational statements both in terms of messaging and tone to determine whether they were clear, understood and relevant. The discussion also explored participants’ interpretation of the various proportionality statements.

The following summarizes the overall reactions and general findings; a more detailed analysis of each statement follows.

• Overall reaction to the statements was generally positive. Participants felt that the statements were clear and that the language used was appropriate and easy to understand. Worth noting, is that this was consistent across all groups; there were no differences in terms of geography, or more importantly, health literacy.
• The advice was deemed practical, relevant and easy to remember. In fact, most participants felt that the statements were in line with what they know about healthy eating and were consistent with their own personal practices and efforts to eat healthy. Indeed, those more knowledgeable about the current Canada’s Food Guide volunteered that these statements represented a modern and relevant update to the resource.
• With respect to tone, participants felt that the statements hit the mark in terms of providing sound advice in a way that was direct yet conveyed a sense of understanding. They did not feel they were made to feel guilty about their diet and/or choices. In fact, most said that while they try hard to eat healthy, there are occasions when circumstances influence one to make an unhealthy choice and the fact Health Canada recognized that, was appreciated.
• On the question of proportionality, most participants were able to distinguish between the various proportionality terms used throughout the statements. Having said that, there tended to be one or two participants in each group who would have preferred some guidance in terms of quantity (i.e., suggestions about the quantity of fruits and/or vegetables, number of servings, etc.). Others tended to argue that they preferred that there were no metrics that they needed to try to live up to and preferred the advice to choose or limit one type of food over another.
• Nearly all participants could see themselves in these messages. The general consensus was that the guidance was applicable for all diets (i.e., vegan, vegetarian and omnivore) although some, particularly omnivores, had the sense the guidelines were encouraging Canadians toward a vegetarian diet. While most agreed that a diet based primarily on plant-based foods was appropriate, there was a sense that guidance relating to the consumption of meat was diminished and not exactly in line with their preferences. For a small number, the perception of being encouraged to eat a vegetarian diet undermined the overall effectiveness of the collection of messages.
• In terms of the appeal and appropriateness of the statements to cultural and emotional sensitivities, reactions were somewhat mixed. Most appreciated that the messages were attempting to represent the diversity of Canada and the cultural variations of foods eaten in this country. However, the qualifier in the first statement about choosing foods that you enjoy and that reflect your culture and traditions was felt to be limiting or distracting. Participants value the opportunity to experience different foods and incorporate other cultural influences in their diet. Further, there were some who pointed out that the diet of their own culture was actually unhealthy due to traditional cooking methods or ingredients. These people were actively seeking to avoid the foods of their culture in order to eat a healthier diet.

Detailed Analysis

Participants were provided with the complete series of statements to read. Afterwards, each statement was explored individually. As they read each statement, participants were asked to indicate whether they had a positive reaction (✔); neutral reaction (–); negative reaction (X); or, whether they felt the statement was confusing or unclear (?). The following table outlines participants’ reactions overall but also breaks down reactions by marginal and adequate health literacy (HL). Findings are also provided about the specific terminology used and proportionality statements. The tables also outline any notable differences in reactions to the terminology in French, only where the findings were different from the English.

Reactions to specific terminology

Choose those that you enjoy and that reflect your culture and traditions. Reaction to this statement was mixed.

Those who reacted positively to this wording felt that it was an important recognition of Canada’s multi-culturalism and diversity. It was also felt to convey open-mindedness particularly around the importance of trying new foods and learning from others. It was particularly well-received by those of different ethnic backgrounds.

Those who reacted with a more neutral reaction, reacted to the words “your”, “culture” and “traditions”. Some felt that the word “your” presented an unnecessary limitation on the spirit of the message. Participants argued that they enjoy a variety of foods from many cultures and traditions and felt that the message suggested they should not enjoy those foods (and restrict themselves to foods from their own culture and traditions). Further, there were some who pointed out that foods from their own culture and traditions was unhealthy due to traditional cooking methods or ingredients (i.e., unhealthy cooking methods such as frying or foods with thick sauces, etc.). These people were actively seeking to avoid the foods of their culture and traditions in order to eat healthier.

Enjoy. The word “enjoy” appears twice in this statement and appears to have different meanings in each instance. In the first instance, “make it a habit to enjoy a variety of nutritious foods…”, participants felt “enjoy” was synonymous with “choose”, or “eat” – a directive to include a variety of foods in their diet. In the second instance, “choose those that you enjoy…”, some participants felt the word “enjoy” was a little problematic arguing that there are many foods they “enjoy” that are not necessarily healthy choices. They believed that interpretation of the word in this instance could be too liberal and could lead to unhealthy choices.

Habit. Participants understood the word “habit” to mean “routine”, “ongoing”, “repetitive” and in the context of this statement, “something you do every day”.

Variety. The word “variety” was understood to mean “a selection” or “a range” of different foods – not all from the same food group – an integral part of a balanced diet.

Balanced. When asked what the word “balanced” refers to, participants explained it is a concept that encompasses eating a variety of different foods (from different food groups), portion control, treating oneself from time to time, etc.

Lifestyle. When we asked about the meaning of the word “lifestyle”, participants suggested it was a broader concept that encompasses not just one’s eating habits but other factors that influence one’s life (i.e., exercise regimen, employment status, income, schedule, whether one has children or not, etc.).

Nutritious. While not discussed in all the groups, there was a sense that “nutritious” was an older term to describe healthy eating. Participants preferred the term “healthy” which was felt to be more modern.

Diet. Of the limited reactions, they tended to be negative. Most felt that the term implies “restriction” or “imbalance”; that you’re “eating foods to lose weight.”

Choose / Eat. Participants suggested that the terms “choose”, in this context, or “eat”, used elsewhere, were blanket terms that implied a sense of permission. Participants did not come away with a sense of proportionality so much as permission or a direction about a behaviour.

Notable differences (French)

Prenez l’habitude de savourer une variété d’aliments nutritifs et de boissons nutritives au quotidien. Manger sainement c’est choisir des aliments que vous aimez et qui reflètent votre culture et vos traditions.

Savourez. The wording of the French statement appears to change the meaning for some participants. Participants reacted positively to the word “savourez”, and felt that the word encouraged taking the time to eat, and thinking about the food they eat. For those participants, the word also implied viewing eating as an experience, rather than being simply a synonym for “choose” or “eat” as the English version (“enjoy”) implies.

Choisir des aliments que vous aimez. Some participants felt that this statement was a little problematic, arguing that there are many foods they like that are not necessarily healthy choices. They believed that interpretation of the word “aimez” in this instance could be too liberal and could lead to unhealthy choices.

Reaction to specific terminology

Those who reacted positively to this statement appreciated that it was simple and direct. They indicated that it was also matter-of-fact and hard to disagree with. Conversely, while those with neutral to negative reactions said that they understood the importance of plant-based foods in a well-balanced diet, the emphasis on plant-based foods in this statement was felt to be unnecessarily restrictive. The guidance was interpreted as “become a vegetarian or vegan.”

Plant-based foods. Those who had a neutral or negative reaction felt that this statement too narrowly focused on “plant-based foods” and overlooked the importance of balance (and the inclusion of meat specifically). They argued that it did not present a balanced view and seemed to be encouraging people to become vegan or vegetarian.

Probing did reveal that there was some confusion around the concept of “plant-based foods”. When asked to provide examples of “plant-based foods”, many participants struggled to provide any examples beyond vegetables and fruits. Usually one or two in each group added beans and/or lentils, at which point others agreed and acknowledged they had not initially considered those foods.

Foods that come from plants. Many participants felt that the terms “plant-based foods” and “foods that come from plants” were interchangeable. Others felt that the terms meant different things and probing for examples of “foods that come from plants” indicated that this term seems to encompass more foods (i.e., beans, legumes, tofu, grains, nuts, “anything that comes out of the ground”).

Animal-based foods. Reaction to the term “animal-based foods” was mixed. While it made sense and participants were able to easily identify different foods that fit that description, some had an almost visceral reaction (hard time separating the animal from the term). Despite this challenge, most participants were hard pressed to come up with a more appropriate term for the category of foods that are not “plant-based” or “from plants” other than “non-plant-based foods”. In fact, many suggested they would prefer that a list of acceptable foods be provided rather than rolling up into a category, particularly where the category name is not common place.

Natural. While reactions to this term were limited, participants described “natural” as “organic”, “unprocessed”, “fresh”, and “no additives or preservatives”.

Local. Participants explained that “local” was a term that referred to “fresh”, “in your area”, “not shipped”, “ready to eat”, and, “in your own backyard”.

Proportionality

Choose mostly / Eat mostly. Participants said that the concept of “choose/eat mostly” implies “one must only choose” or should “focus” on a specific food group. In this example, participants felt that “choose mostly plant-based foods” was restrictive. The tone was interpreted as a directive to “limit meat and become a vegetarian.”

Notable differences (French)

Sélectionnez en majorité des aliments d’origine végétale.

En majorité / Majoritairement / Principalement. Participants felt that these three terms were synonymous. In this particular instance, participant felt that this statement implies that the largest proportion of what they eat (or of their meal) should be plant-based foods.

Reactions to specific terminology

For the most part, participants felt this was a continuation of the previous statement but with more specific guidance about what people could eat; they said it provided guidance about having a balanced, well-rounded diet. This speaks to participants’ reactions to the tone of the previous statement, which was felt to be more of a directive (with direction to eat plant-based food rather than meat).

Protein foods. Those who questioned the guidance emphasizing a plant-based diet in the previous statement, appreciated the mention of protein in this statement. The overwhelming majority of participants were familiar with the term “protein foods”. Participants could easily point to several examples of “protein foods” including: meat, eggs, cheese, tofu, beans, fish, nuts, etc. Milk rarely came up spontaneously as a “protein food”.

Protein foods that come from plants. Most understood this term and could offer examples (i.e., beans, lentils mentioned most often). Participants also appreciated that the advice to favour foods that come from plants was a caveat built into this statement versus the former where the advice was restricted to eating plant-based foods.

Unhealthy protein. While there was not a lot of discussion related to this term, when it was raised, there was a sense that in the proper quantities, “unhealthy proteins” were acceptable. When participants were talking about “unhealthy protein” they often referred to bacon.

Whole grains and whole grain foods. While many participants felt these two terms were interchangeable, when asked to provide examples for each, the research suggests there was some confusion around these terms. Those who felt there was a distinction between the two terms, felt that “whole grain foods” referred to both “whole grains” and the by-product of “whole grains” (i.e., flour, pasta, cereals, etc.). When asked, there was a preference for “whole grain foods” as it allowed for greater flexibility of choice.

Milk. Not many participants instinctively thought of milk as a “protein food” although they did spontaneously suggest a number of dairy products when asked for examples of “protein foods”. Most did not think milk was very high in protein. In fact, most tended to view milk as a beverage rather than a food in and of itself. Some thought of it as a means of consuming nutrients like calcium.

Fatty meats. When asked what the term “fatty meats” referred to, the overwhelming majority of participants described it as an unhealthy protein.

Lean meat. Participants felt this term referred to meat with “less fat”. Some also suggested that it referred to a part or specific cut of meat.

Carbohydrate. Reactions to the term “carbohydrate” were mixed. Some participants had a negative impression of carbohydrates. Others felt that this was an unfair, arguing that carbohydrates can be an important part of a balanced diet. Participants were easily able to point to several examples (i.e., rice, bread, pasta, etc.) but also made the point that carbohydrates are found in some vegetables.

Starch. While reactions to this term were limited, participants felt the term was synonymous with “carbohydrate”. However, participants tended to think the term, “starch”, was less modern and more traditional. 

Proportionality

Eat plenty / Choose plenty. “Eat/Choose plenty” was described as a little less than “mostly” but still “a lot of” a particular food or portion of a meal.

Eat some / Choose some. Participants suggested that “some” referred to “a little less than plenty”. 

Notable Differences (French)

Dégustez des légumes et des fruits en abondance, des grains entiers et quelques aliments protéinés, surtout ceux de source végétale.

Dégustez. Some participants felt that this word helped to make the statement more positive by implying that they should take time to appreciate their food, and making it more of a suggestion. These participants preferred it to the previous statement’s use of the term “sélectionnez”. “Dégustez” and “savourez” were deemed to be synonymous by some, while others felt that “dégustez” implied having a taste, or “faire collation”.

Reactions to specific terminology

Healthy fats. The term “healthy fats” was a term that was generally understood by most participants, although not all could provide an example of a healthy fat. For the most part their understanding of the term tended to be linked to an understanding of the fact that some fats are healthy and some are unhealthy. Those who could provide examples of “healthy fats” most often mentioned avocados, fish oils, omega, and nuts.

Saturated fats / Unsaturated fats. When asked to explain the difference between “saturated fats” and “unsaturated fats”, most participants acknowledged that the terms were confusing and that they have trouble remembering which is a “healthy fat” and which is an “unhealthy fat”.

Fatty fish. Many participants had heard the term “fatty fish” before. Unlike “fatty meats”, most had the sense that “fatty fish” were healthy. 

Reactions to specific terminology

There were a number of elements that contributed to the overall positive reaction.

First, this guidance was very much in line with what most said they were actively doing to eat healthy (i.e., limiting processed and prepared foods, preparing more meals at home, reducing their consumption of sodium and sugar, etc.).

Second, the tone of the statement, particularly the wording “if you choose these foods…”, was felt to be very appropriate.  Participants explained that while they try hard to make healthy choices, sometimes circumstances – such as time constraints, finances, mood, etc. – influences them to eat unhealthy. The tone of this statement came across as very understanding which was appreciated.

Participants took away from this statement that they should not eat processed or prepared foods but appreciated that “limit” was understanding of the fact they are not perfect and will eat these foods on occasion.

Processed foods. Participants suggested that the term “processed foods” refers to foods that are “not fresh” and that have been altered with chemicals and additives. “Food you buy off a shelf.” Participants described “processed foods” as “unhealthy”, “with additives and chemicals”. Most understood and agreed with the guidance to limit “processed foods”.

Prepared foods. “Prepared foods” on the other hand, while also described as “not fresh”, refers to food that is pre-cooked, restaurant and/or fast food. As with “processed foods”, participants tended to believe “prepared” foods were “unhealthy”. They had the sense that they did not have control over what was in “prepared” meals. No one disagreed with the guidance to limit “prepared food”.

To be clear, the nuance between these two terms (“processed foods” and “prepared foods”) relates to the idea that “processed” implies “altered with chemicals and additives” whereas “prepared” is something that someone else made (a grocery store, fast food restaurant, food manufacturer, etc. and not a friend of family member).

Sodium and sugars. Participants were very familiar with the terms “sodium” and “sugar”. They explained that the term “sodium” can be used interchangeably with the word “salt”.

Proportionality

Limit or less often. The terms “limit” and “less often” were interpreted as advice not to eat something often. In this particular instance, participants interpreted this statement as advice not to eat processed or prepared foods but if you’re going to eat it, eat it “once in a while” or “in a pinch”. For some it implied “permission” to eat processed or prepared foods on occasion (i.e., as a treat, when in a rush, etc.).

Avoid. Participants preferred the tone of the word “limit” because they would prefer Health Canada provided suggestions rather than direction and “avoid” came across as a directive.

Small amounts. Similarly, participants thought the term “small amounts”, referred to eating less processed or prepared foods.

Notable differences (French)

Gardez votre consommation d’aliments transformés ou préparés riches en sodium, sucres et gras saturés au minimum. Si vous en consommez, choisissez-les moins souvent et en petite quantité.

Au minimum. Participants thought that “au minimum” meant as little as possible, or on occasion. They noted that sometimes for a special occasion, or as a treat once a week, they would eat the unhealthy foods mentioned in the statement, and felt this was in line with what was being recommended.  As compared to the word “limit” in English, which conveys this same meaning, “au minimum” does not appear to provide the same guidance in terms of the concept of avoidance.

Riches en. There was some confusion around this term. Some viewed the term as negative, meaning more than you should have in your diet. Others felt the meaning depended on the context in which the term was used. “Riche en sodium” was seen as unhealthy, whereas “riche en vitamines” was seen as healthy. 

Reactions to specific terminology

Participants described this as a common sense statement and very much in line with what most raise spontaneously as things they try to do to eat healthy (i.e., watch their sodium and sugar intake in particular).

Many praised the tone and felt it was a helpful encouragement to prepare more meals at home.

While most felt this statement was very similar to the previous statement, the main difference tended to be linked to the concept of cooking with foods lower in sodium, sugars and saturated fats. Some were confused in that they “cook” with ingredients whereas they assume foods with reduced sodium, sugars or saturated fats are prepared foods and therefore not ingredients one cooks “with.”

Cook. When prompted, participants explained that “cook” refers to the preparation of food (yourself). However, most participants felt that the term “cook” implies some form of heating – whether boiling, frying, baking, broiling, etc. For most, it did not refer to preparing/making a sandwich, salad, snack or smoothie. There were a handful of participants for whom “cook” does encompass these meals as well.

Prepare and make. Most felt that the terms “prepare” and “make” inferred a broader range of meal preparation than the term “cook”, that also included sandwiches, salads, snacks and smoothies. There were no discernible differences between these two terms.

Make water your drink of choice.

• Replace sugary drinks with water. (Option 1)
• Choose water instead of sugary drinks. (Option 2)
• Avoid sugary drinks. (Option 3)

Reactions to specific terminology

Very few participants disagreed with this statement. It was felt to be simple and to the point.

Those with neutral or negative reactions explained that they do not like the taste of water and prefer drinks with more flavour. Some said that they would be hard pressed to eliminate some juices and/or sports drinks from their diets. Those who reacted positively were quick to suggest that lemon and other herbs and fruits could be infused into water to make it taste better.

Sugary drinks. The term “sugary drinks” was generally well understood and most participants were easily able to identify a number of examples including: pop, juice (including 100% fruit juice), powdered juice, and specialty coffees, etc. “Sugary drinks” did not spontaneously include chocolate milk, however. When asked, most agreed that chocolate milk should be considered a sugary drink.

Discussions relating to wording about sugar content in beverages demonstrated that many knew that “sugary drinks” includes drinks such as 100% juices where no sugar has been added.

Drink and beverage. For the most part, the term “drink” and “beverage” referred to any liquid. However, participants felt that the term “beverage” more readily referred to an alcoholic beverage. When asked, most preferred the term “drink”.

Proportionality

Avoid. Participants felt this was a directive to “eliminate” sugary drinks from their diet.

Replace. The term “replace” was viewed as a little more subtle and a suggestion to remove sugary drinks from one’s diet.

Choose. The term “choose” in this context was the most lenient and viewed as an encouragement.

In terms of preference, most participants preferred “choose” because they felt allowing individuals to make their own choices was the appropriate tone for Health Canada.

Notable differences (French)

L’eau est la boisson idéale.

• Remplacez les boissons sucrées par de l’eau. (Option 1)
• Au moment de choisir une boisson, optez pour de l’eau au lieu des boissons sucrées. (Option 2)
• Évitez les boissons sucrées. (Option 3)

Remplacez. Participants felt this term was clear and to the point. They liked the suggestion of a substitution.

Optez. Those who liked this statement appreciated the suggestive tone.

Évitez. The term “évitez” was the least popular. Participants felt that the tone was negative, and did not leave room for balance in their diet. Some viewed it as an order, rather than a suggestion.

When asked their preference, most participants selected “remplacez”.

Plain milk, unsweetened fortified plant-based or soy beverages can also be healthy beverage choices.

Reactions to specific terminology

For the most part, those who reacted negatively questioned the advice particularly around soy beverages. A number of participants raised concerns about the health benefits of soy beverages.

Plain milk. There was a certain level of confusion associated with the term plain milk. Most thought that it referred to all dairy (cow’s) milk. Some thought it referred to milk that was not flavoured and therefore did not include chocolate milk. Some participants thought it meant unpasteurized and “straight from the cow”.

Unflavoured milk. When asked, participants suggested that this term referred to “regular milk”, “plain milk”, and even “natural milk”.

Unsweetened fortified plant-based beverages. This term was not known to most participants. While it was described as a bit of a mouthful, most were able to decipher it and provide some examples (i.e., almond, soy, coconut, cashew, etc.).

Soy beverages. While the majority of participants understood the term “soy beverages”, many questioned the guidance that soy milk is a healthy beverage choice. Some said that this conflicted with information they had that soy was an unhealthy food.

Reactions to specific terminology

Those who reacted positively to this statement felt that it was a helpful reminder about eating habits and being cognizant of the circumstances that may trigger unhealthy choices. Those who reacted with a neutral reaction explained that they were confused about how the language “how, where, when and why you eat” contributes to healthy eating. Interestingly, the interpretation other participants offered for “how, where, when and why you eat” – that the speed with which one eats alters their digestive system and how taking time to chew one’s food can help with hunger cues – helped alleviate their confusion.

Healthy eating. Generally, participants explained that “healthy eating” referred to nutrition but also to habits and practices that encourage good behaviour (i.e., eliminating distractions, chewing food, etc.). Reactions to the concept of “healthy eating” in this context tended to be mixed. For some it was thought-provoking while for others it was a bit confusing. Results of the focus groups suggest that if the intent of the message was to encourage healthy eating habits (i.e., eating at regular times), then all could agree with the intent.

Be mindful of your eating habits.

• Enjoy your food.
• Take time to eat.
• Notice when you are hungry and when you are full.

Reactions to specific terminology

Reaction to this statement was overwhelmingly positive and participants understood the main message of this statement. Most came away with a sense that by doing all these things, one would be less likely to over-eat.

Be mindful. Participants felt that the term “be mindful” implied awareness but with the nuance that one also had to think about their choices and habits.

Be aware. The term “be aware” did not seem to carry the same weight (as the term “be mindful”) in terms of conveying the importance of weighing healthy eating choices and habits.

Enjoy your food. Worth noting, some raised the concern mentioned earlier about the negative connotation associated with this wording which they argued opens up to the enjoyment of bad foods as well; “not all foods I enjoy are healthy.”

Take time to eat. Participants’ understanding of this statement included “chew your food”; “don’t eat on the go”; “don’t rush”; and, “enjoying what’s in front of you”. Participants inferred from this statement that by doing so, they eat more slowly which allows them to more quickly notice when they are full which often leads them to eat less than they would if they eat their food quickly. This guidance was felt to be appropriate and a helpful reminder about something they know and understand.

Hunger cues. While reactions to this term were limited, participants described a variety of cues including: “rumbling” in one’s stomach, that can sometimes be audible; decreased energy; noticeable change in mood (i.e., irritability).

Notable differences (French)

Portez attention à vos habitudes alimentaires.

• Savourez vos aliments.
• Prenez le temps de manger.
• Apprenez à reconnaître vos signaux de faim et de satiété.

Plan. Cook. Eat together.

• Plan what you eat.
• Cook more often.
• Eat with family and friends often.
• Share your foods skills, food traditions and culture.

Reactions to specific terminology

Eat with family and friends often. While most agreed with the sentiment that sharing meals socially helps encourage healthy eating habits, some participants made the point that when they eat with family and friends, particularly at large family gatherings, they often do not make healthy choices and often over indulge.

Food skills. Asked spontaneously to explain the meaning of the term “food skills”, most participants suggested that the term referred to the sharing of recipes and technical proficiency.

Participants were then presented with the following definition of the term “food skills” and asked whether the term “food skills” reflected all of these things.

Food skills is the knowledge and skills to plan, purchase and prepare foods and healthy meals; such as reading labels, food safety, creatively using leftovers, chopping, mixing, making grocery lists, etc.

The majority of participants did not feel the term “food skills” encompassed all of these things; especially not the ability to meal plan, creatively use leftovers, and/or check food safety.

Homemade and from scratch. When asked, participants felt that “homemade” and “from scratch” were synonymous and implied a healthier meal because it is “something that you make yourself” and that you know what is in it and how it was prepared (i.e., baked vs. fried, etc.).

Notable differences (French)

Planifiez, cuisinez et mangez ensemble.

• Prévoyez ce que vous allez manger.
• Cuisinez vos repas plus souvent.
• Mangez souvent en compagnie de votre famille et de vos amis.
• Faites connaître votre culture et vos traditions à travers votre savoir-faire alimentaire et culinaire.

Le savoir-faire alimentaire et culinaire désigne les connaissances et les aptitudes permettant de planifier, d’acheter et de préparer des aliments et des repas santé; on pense entre autres à la lecture des étiquettes, à la salubrité des aliments, à la créativité au moment de cuisiner des restants, à couper et à mélanger les aliments, à faire des listes d’épicerie, etc.

Savoir-fare alimentaire et culinaire. Reactions to this term were mixed. The marginal health literacy group, like the English groups, felt that this term did not encapsulate all that was intended as per the definition provided. However, most in the adequate health literacy group felt that it captured all of the intended messages.

Final Observations

The focus groups concluded with a short discussion about participants’ general thoughts on the totality of the information and whether they would be motivated to take action as a result of this information.

Participants tended to believe that the statements were organized into two types of guidance: first, guidance about nutrition and healthy eating choices; and, second, guidance about lifestyle choices and healthy eating habits. While reactions were generally favourable towards both types of guidance, they tended to be a little more favourable toward the statements about lifestyle and healthy eating habits. Participants felt these statements conveyed an important holistic approach to healthy eating. When asked if they would make any changes to the presentation of the information, some felt it would be interesting to begin with the guidance about healthy eating habits as a way of framing the advice about specific nutrition choices.

While some participants indicated that they would be motivated to do something as a result of these messages, most felt that it served as more of a helpful reminder and to encourage personal reflection. Many felt that they were already making a concerted effort to heed the guidance communicated in the statements and that the information was not all that new. Some suggested that they would be motivated to get clarification on some of the terms (e.g., healthy fats, saturated/unsaturated fats, etc.).

Conclusions

The statements were well received in English and French. They were generally felt to be clear, relevant and well understood. In fact, views of both the marginal and adequate literacy groups were generally consistent which suggests that the language was appropriate for those of all levels of health literacy.

The guidance conveyed in the statements was deemed practical and relevant. Indeed, much of the information  fit with what participants know and practice in terms of healthy eating. Those who were more familiar with the current Canada’s Food Guide, felt that this was a modern refresh that provided sound advice, without a guilt-inducing tone.

Indeed, in terms of the tone of the statements, most felt that Health Canada had done a very good job of providing useful, relevant information in a manner that was appropriate and appreciated. Participants felt that the tone was direct yet conveyed a sense of understanding. For example, when given a choice, most preferred statements that nudged them into making healthy choices (i.e., “choose” instead of “avoid” or “replace”).

Having said all this, it is important to note that there was a sense, particularly among omnivores, that while the guidance was applicable for all diets (i.e., vegan, vegetarian and omnivore), it seemed to be steering Canadians toward a plant-based diet. For a small number, the perception of being encouraged to eat a vegetarian diet undermined the overall effectiveness of the collection of messages.

In terms of the appeal and appropriateness of the statements to cultural and emotional sensitivities, reactions were somewhat mixed. Most appreciated that the messages were attempting to represent the diversity of Canada and the cultural variations of foods eaten in this country. However, some felt that the language suggesting they choose foods from their own cultures was limiting given their enjoyment of a variety of ethnic foods. Further, some also made the point that food reflective of their cultures and traditions was not always healthy.

Finally, in terms of motivation to act, many felt that they were already making a concerted effort to heed the guidance communicated in the statements and that the information was not all that new. Some suggested that they would be motivated to get clarification on some of the terms (e.g., healthy fats, saturated/unsaturated fats, etc.) and that it encouraged personal reflection.

Appendix A: Discussion Guide

English ***we're duplicating content by presenting both languages here. Suggest you remove text "English" and provide a link somewhere to the French Appendix A***

INTRODUCTION

***Text needed vs. hourglass image*** =10 MIN Time=10 MIN

Moderator introduces herself/himself and her/his role: role of moderator is to ask questions, make sure everyone has a chance to express themselves, keep track of the time, be objective/no special interest

• The name of the firm the moderator works for, and the type of firm that employs them (i.e. an independent marketing research firm)
• The research purpose and research sponsor, described, at a minimum, in the same manner as in recruiting: explore the topic of healthy eating and food choices.
• Role of participants: speak openly and frankly about opinions, remember that there are no wrong answers and no need to agree with each other
• Results are confidential and reported all together/individuals are not identified/participation is voluntary. The length of the session (1.5 - 2 hours)
• The presence and purpose of any recording being made of the session (audio and video taping of the discussion
• The presence of any observers, their role and purpose, and the means of observation (one-way mirror, colleagues viewing in the back room)
• Turn off cell phones for the duration of the discussion

Moderator will go around the table and ask participants to introduce themselves.

Introduction of participants: To get started, please give your first name, whether you have any hobbies/pastimes, and who lives in your household (i.e., whether you live with someone including children (number and ages of children).

WARM-UP DISCUSSION

***Text needed vs. hourglass image*** =10 MIN Time=20 MIN

As I mentioned earlier, the focus of our discussion today/tonight will be on healthy eating.

• What do you think is the most important thing when it comes to eating healthy?
• In your day to day life, what in particular do you do, if anything, to eat or try to eat healthy?

FOUNDATIONAL STATEMENTS

***Text needed vs. hourglass image*** =60 MIN Time =80 MIN

Health Canada is revising Canada’s Food Guide to reflect the latest scientific evidence and to be more modern and relevant. We are conducting this research to help them develop messages that will provide the guidance Canadians need to make informed choices.

For this discussion, I would like to share with you a statement handout that outlines the draft messages. Take some time to read the statements and as you’re going along, feel free to mark up your paper. Feel free to put a “✔” beside any words/phrases/elements that you like, an “X” beside any word/phrases/elements that you don’t like, and, a “?” beside anything that is confusing or unclear; although it is not necessary to do so if you are not moved in one way or another.

STATEMENT-SPECIFIC PROBES

Let’s take some time to review each statement, one-by-one.

For each, in addition to the statement-specific probes outlined below, the moderator will first review the following:

• Did you put a “✔”, “X”, or “?” beside any part of this statement?
  • What did you like about it?
  • What did you dislike about it?
  • What did you find confusing or unclear?
  • Is there anything you would change?
  • How did this make you feel?

Make it a habit to enjoy a variety of nutritious foods and beverages each day. Many foods fit healthy eating, choose those that you enjoy and that reflect your culture and traditions.

• Talk to me about the use of the word “habit”. What does the word “habit” mean/suggest in this statement?
• What about the word “enjoy” in either of these sentences? What does it mean/suggest?
  • What about “eat” or “choose” instead of “enjoy” in this sentence? For example: Eat a variety of nutritious foods and beverages each day OR Choose a variety of nutritious foods and beverages each day. Do they mean different things? How so?
  • What is your preference? Why do you say that?
• What about the word “variety”? What does the word “variety” mean/suggest?
• What about the term “nutritious foods”? What about the term “healthy foods”?
  • Is there a difference between “nutritious foods” and “healthy foods”? If yes, what is the difference?
  • What is your preference? Why do you say that? Would you suggest another word?
• Another word that is often used in healthy eating messaging is “lifestyle”, particularly in the context of choosing foods that fit your “lifestyle”. What does the word “lifestyle” mean to you?
• What about when you hear the words “eating style”, what does that mean/suggest to you?
• What about the term “balanced” in the context of a “balanced meal” – what does that mean to you?
• When describing categories of foods that make up a healthy meal, what categories do you use?
• Often when discussing healthy eating, we hear the term “diet” - what does that mean to you?
• What about the term “healthy diet” or “balanced diet” – what do those terms mean to you?
  • Are they the same or different? Why do you say that?

Choose mostly plant-based foods

• What about the term “plant-based foods”? What does the term “plant-based foods” mean/suggest? What types of foods do you think of when you hear “plant-based foods”?
• How does the term “plant-based foods” compare to the term/concept of “foods that come from plants”? Are they the same or different? Why do you say that?
• People often use the term/word “natural” when describing foods. What does the term “natural” mean to you?
  • Are “natural” foods “plant-based”? Why or why not?
  • Can the word/concept of “natural” be used to describe other kinds of foods? Which ones? Why?
• When you hear that a food is “local”, or “locally grown”, what does that mean to you?
• The term to describe foods that aren’t plant-based is often “animal-based foods”. What does the term “animal-based foods” mean/suggest? What types of foods do you think of when you hear “animal-based foods”?
• What about the term “animal-based foods”, could that work or does that mean something different? Why do you say that?
  • What would you classify as an animal-based food?

Eat plenty of vegetables and fruit

Eat whole grain foods/whole grains

• What does the term “whole grain foods” mean to you?
• What about “whole grains” – what does it mean to you?
  • Are those two terms the same or different? In what ways?
  • What types of foods do you think of when you hear “whole grain foods”?
  • And, what types of foods do you think of when you hear “whole grains”?
• [MODERATOR TO PROBE ONLY IF QUESTIONS RAISED]: According to Health Canada, “whole grains” includes: barley, brown rice, oats, quinoa, and wild rice. “Whole grain foods” includes “whole grains” but also the foods made from these grains (i.e., pasta, bread, etc.).
  • Is there a difference in your mind?
  • Do you have a preference?
• When you hear the word “carbohydrate” what does it refer to in your mind?
  • What foods do you think of when you hear “carbohydrate”?
• What about the word “starch”?
  • What foods do you think of when you hear “starch”?
  • Are those two terms the same or different? In what ways?

Eat some protein foods, especially those foods that come from plants

• What does the term “protein foods” mean to you?
  • What types of foods do you think of when you hear “protein foods”?
  • What about the term “protein-rich foods”, what does that mean to you?
  • Is it the same or different?
• What does “protein foods that come from plants” mean to you?
  • What types of foods do you think of when you hear “protein foods that come from plants”?
• What do you consider a healthy protein? Probe: Are there foods that are considered ‘unhealthy proteins’?
• Is milk a protein food? Why or why not?
• What about beans and/or lentils – are they protein foods? Why or why not?
• What does the term “fatty meats” mean to you? Is it an unhealthy protein?
  • What types of foods would you include in this category?
• What about the term “lean meat”? What does that mean?

Include foods that have healthy fats

• What does the term “healthy fats” mean to you?
  • Can you give me an example of a healthy fat?
  • Can you give me an example of a food or foods that have healthy fats?
  • Are there other terms to describe foods with healthy fats?
  • Have you ever heard the term “fatty fish”? What do you think it means?
    • Do “fatty fish” contain unhealthy or healthy fats?
• What does the term “unsaturated fat” mean to you?
  • Can you give me an example of foods containing unsaturated fat?
• What does the term “unhealthy fat” mean to you?
  • Can you give me an example of a food or foods that have unhealthy fat?
• What about the term “saturated fat”, what does that mean to you?
  • Can you give me an example of foods that contain saturated fat?

Limit processed and prepared foods high in sodium, sugars, or saturated fat

• What does the term “processed foods” mean to you?
• What does the term “prepared foods” mean to you?
  • Are they the same or different? In what ways?
• What about “limit processed foods and fast foods” – does that change the foods that come to mind? Why or why not?
• What kinds of food would you classify as processed?
  • Do you see all processed foods as negative (unhealthy)? Why or why not?
• What kinds of food would you classify as prepared?
  • Do you see all prepared foods as negative (unhealthy)? Why or why not?
• What types of foods do you think of when you hear the terms “fatty foods”, “salty foods” and “sugary foods”?
  • What does high in fat/sugar/sodium mean to you?
  • Can you give me an example of a food high in saturated fat/sugar/sodium?
• What about foods from restaurants? Where do they fit? What about fast food? Where does it fit? What about ready to eat foods from a grocery store or café?

[MODERATOR TO PROBE THE FOLLOWING ONLY IF NOT RAISED SPONTANEOUSLY]

• What do you think of the following terms? What do they mean?
  • Convenience foods
  • Pre-packaged foods
  • Ready-made foods
  • Ultra-processed foods
  • Packaged foods
  • Processed foods
  • Fast foods
  • Confectionary

If you choose these foods, eat them less often and in small amounts.

Cook with foods that are lower in sodium, sugars and saturated fats

• What does “lower in” mean to you?
• What type of meals/meal preparation does the term “cook with” bring to mind?
• Is there a difference between what foods you “cook” versus “prepare”, “use”, or “make”?
• Does the term “cook” include preparing things like salads, smoothies, sandwiches that don’t need to be cooked? Why or why not?

Make water your drink of choice

• What do the terms “drink” and “beverage” mean to you?
  • Are they the same or different? In what ways?
  • Do you have a preference? Why do you say that?
• What about the term “hydration” or “hydrated”, what does it mean to you?
• Are these terms associated only with water or with other drinks/beverages as well? Why do you say that?

Replace sugary drinks with water.
Choose water instead of sugary drinks.
Avoid sugary drinks.

• Here we are presenting three options. Do each of these statements mean the same thing or are they different? In what ways?
  • Do you have a preference? Why do you say that?
• What kinds of drinks/beverages would you consider as “sugary drinks”?
• What kinds of drinks/beverages would you consider as “sugar-sweetened”?
• What about “beverages with sugar added” – what kinds of drinks/beverages come to mind?
• [IF NOT MENTIONED] What about 100% fruit juice? In your opinion, is this considered a sugary drink? Why or why not?
• [IF NOT MENTIONED] And, what about chocolate milk? Into which category does it fall? Why do you say that?

Plain milk, unsweetened fortified plant-based or soy beverages can also be healthy beverage choices.

• What does the term “plain milk” mean to you?
  • Does it refer to dairy milk (only) or to other milks (i.e., soy, almond, etc.) as well? Why or why not?
  • What kinds of drinks/beverages do you consider to be “milk”?
• What does the term “unsweetened fortified plant-based milk” mean to you?
  • What kinds of beverages do you consider unsweetened fortified plant-based milk?

Healthy eating is more than the foods you eat. It is also about how, where, when and why you eat.

Be aware/mindful of your eating habits

• What does it mean to be “aware” of what you’re eating?
• What does it mean to be “mindful” of your eating habits?
  • Are they the same or different? In what ways?

Enjoy your food.

Take time to eat.

• You may have heard this advice before – eat without distraction. When it comes to eating, what do you see as distractions?

Notice when you are hungry and when you are full.

• Have you ever heard the term “hunger cues” before? What do you think it means? What is a hunger cue?

Plan. Cook. Eat together.

Plan what you eat.

Cook more often.

• What does the term “cook” mean to you?
  • Does this mean cooking from scratch at home or can it mean popping a frozen meal into the microwave?
  • Does the act of “cooking” make you think of dinner or can it apply to all meals and snacks? Why do you say that?
• When you hear the term “homemade”, what does that mean to you?
  • What types of food do you think of when you hear the term homemade?
  • How are those types of foods prepared?
• When you hear the term “from scratch”, what does that mean to you?
  • What types of food do you think of when you hear the term from scratch?
• When you hear the term “wholesome”, what does that mean?
  • What types of foods would you say are “wholesome”?
• And, what about the term “whole food”? What does that mean to you?

Eat with family and friends often.

Share your food skills, food traditions and culture.

• What does the term “food skills” mean to you?

Food skills is the knowledge and skills to plan, purchase and prepare foods and healthy meals; such as reading labels, food safety, creatively using leftovers, chopping, mixing, making grocery lists, etc.

• When you hear the term “food skills”, do you think of all these things? Why or why not?
• What do the terms “ethnic food”, “cultural food”, and “traditional food” meant to you?
  • Are they the same or different? Why do you say that?
• What does the term “food traditions” mean to you?

There is one more concept that I would like to explore that was not necessarily included in the statements.

• When you hear the word “calories” in relation to healthy eating, what do you think of?
  • Is there a difference between talking about “calories from food” vs. talking about “energy from food”. If yes, what is it?

PROPORTIONALITY TERMINOLOGY

***Text needed vs. hourglass image***=20 MIN Time=100 MIN

I would like to spend the last few minutes of our time together discussing language around proportionality. By proportionality, I mean approximately how much we should eat of different types of foods in relation to other foods.

Referring back to the statements…

Choose mostly plant-based foods
Eat plenty of vegetables and fruit
Eat whole grain foods/whole grains
Eat some protein foods, especially those foods that come from plants

• When you read the statement “choose mostly” plant-based foods, about how many plant-based foods does that mean? Generally, what portion of your regular diet would that include?
  • What about the statement “choose_more than_”? OR “choose_more often than_”? For example, choose whole gain foods more than grain foods. Or choose whole grain foods more often.
• What about when you read “eat plenty” of vegetables and fruit OR “eat mostly” fruits and vegetables, what does that mean?
• What would you consider “some” protein foods?
  • When you read “especially those foods that come from plants”, what does “especially” mean to you? About what proportion of your diet would that include?

Limit processed and prepared foods high in sodium, sugars, or saturated fat. If you choose these foods, eat them less often and in small amounts.

• What would it mean to you if you were asked to limit processed and prepared foods in your diet?
  • What does the word “limit” imply in terms of how much you should eat?
• Is there a difference between “limiting” your intake of processed and prepared foods, and “avoiding” those foods? In your view, does one discourage consumption more than the other?
• What about eating little to no processed foods and prepared foods high in sodium, sugars or saturated fat?
  • What does eat processed and prepared foods high in sodium, sugars, or saturated fat “less often” mean to you?
• What do you think is a “small amount”? Is eating a small amount of processed and prepared foods high in sodium, sugars or saturated fat different than eating little to no processed foods, or choosing processed foods the least?

Replace sugary drinks with water. Choose water instead of sugary drinks. Avoid sugary drinks.

• What do each of these terms – “replace”, “choose instead”, and “avoid” mean?
  • Are they the same or different? How so?
• Now consider these terms: “swap sugary drinks for water” and “substitute sugary drinks with water”
• Is one of these sentences clearer?
• Is there one statement that more strongly discourages consuming sugary drinks?

WRAP-UP

***Text needed vs. hourglass image***=20 MIN Time=120 MIN

• Overall, did you feel these statements were clear? Relevant? Why or why not?
• Do you believe this advice is practical and easy to understand? Why or why not?
  • Would it be easy to remember? Why or why not?
• How did you feel about the tone of these statements? Was it appropriate?
• Would they motivate you to take action? Why or why not?
  • If yes, what actions would you take?
• Does the order that the messages are presented in on the handout make sense?
  • Would you suggest a different order?

• This concludes what we needed to cover tonight. We really appreciate you taking the time to come down here to share your views. Your input is very important.
• Reminder to those in the first group about reserving comments so as not to influence the second group.

STATEMENT HANDOUT

Make it a habit to enjoy a variety of nutritious foods and beverages each day. Many foods fit healthy eating, choose those that you enjoy and that reflect your culture and traditions.

• Choose mostly plant-based foods.
• Eat plenty of vegetables and fruit, whole grains and some protein foods, especially those foods that come from plants.
• Include foods that have healthy fats.
• Limit processed and prepared foods high in sodium, sugars, or saturated fat. If you choose these foods, eat them less often and in small amounts.
• Cook with foods that are lower in sodium, sugars and saturated fats.
• Make water your drink of choice.
  • Replace sugary drinks with water. (Option 1)
  • Choose water instead of sugary drinks. (Option 2)
  • Avoid sugary drinks. (Option 3)
• Plain milk, unsweetened fortified plant-based or soy beverages can also be healthy beverage choices.

Healthy eating is more than the foods you eat. It is also about how, where, when and why you eat.

• Be mindful of your eating habits
  • Enjoy your food.
  • Take time to eat.
  • Notice when you are hungry and when you are full.
• Plan. Cook. Eat together.
  • Plan what you eat.
  • Cook more often.
  • Eat with family and friends often.
  • Share your foods skills, food traditions and culture.

French ****provide a link to the French Appendix A***

Appendix B: Screener

English ***we're duplicating content by presenting both languages here. Suggest you remove text "English" and provide a link somewhere to the French Appendix B***

FOCUS GROUP SUMMARY

GROUP 1 MARGINAL HEALTH LITERACY

• Score 0-3 on health literacy test (Q.S14-Q.S19)
• Good mix of demos (gender, age, income, household situation, ethnicity, etc.)
• Recruit 10 for 8 to show

GROUP 2 ADEQUATE HEALTH LITERACY

• Score 4-6 on health literacy test (Q.S14-Q.S19)
• Good mix of demos (gender, age, income, household situation, ethnicity, etc.)
• Recruit 10 for 8 to show

• Respondent's name:
• Respondent's phone number: (home)
• Respondent's phone number: (work)
• Respondent's fax number:
• Respondent's email:
• Sample source: panel random client referral
• Interviewer:
• Date:
• Validated:
• Quality Central:
• On list:
• On quotas:

Hello/Bonjour, my name is [insert] and I’m calling on behalf of the Earnscliffe Strategy Group, a national public opinion research firm. We are organizing a series of discussion groups on issues of importance to Canadians, on behalf of the Government of Canada, specifically for Health Canada. The purpose of the study and the small group discussions is to hear people’s views on their understanding of healthy eating messages and related terminology. We are looking for people who would be willing to participate in a discussion group that will last up to two hours. These people must be 18 years of age or older. Up to 10 participants will be taking part and for their time, participants will receive an honorarium of $100.00. May I continue?

• Yes CONTINUE
• No THANK AND TERMINATE

Would you prefer that I continue in English or French? Préférez-vous continuer en français ou en anglais? [IF FRENCH, CONTINUE IN FRENCH OR ARRANGE A CALL BACK WITH FRENCH INTERVIEWER: Nous vous rappellerons pour mener cette entrevue de recherche en français. Merci. Au revoir].

Participation is voluntary. We are interested in hearing your opinions; no attempt will be made to sell you anything or change your point of view. The format is a ‘round table’ discussion led by a research professional. All opinions expressed will remain anonymous and views will be grouped together to ensure no particular individual can be identified. But before we invite you to attend, we need to ask you a few questions to ensure that we get a good mix and variety of people. May I ask you a few questions?

• Yes CONTINUE
• No THANK AND TERMINATE

READ TO ALL: “This call may be monitored or audio taped for quality control and evaluation purposes.
ADDITIONAL CLARIFICATION IF NEEDED:

• To ensure that I (the interviewer) am reading the questions correctly and collecting your answers accurately;
• To assess my (the interviewer) work for performance evaluation;
• To ensure that the questionnaire is accurate/correct (i.e. evaluation of CATI programming and methodology – we’re asking the right questions to meet our clients’ research requirements – kind of like pre-testing)
• If the call is audio taped, it is only for the purposes of playback to the interviewer for a performance evaluation immediately after the interview is conducted or it can be used by the Project Manager/client to evaluate the questionnaire if they are unavailable at the time of the interview – all audio tapes are destroyed after the evaluation.

IF “YES” TO ANY OF THE ABOVE, THANK AND TERMINATE.

S2. DO NOT ASK – NOTE GENDER

• Male 1 ENSURE GOOD MIX OF GENDER
• Female 2

S3. Could you please tell me which of the following age categories you fall in to? Are you...

• 18-24 years 1 ENSURE GOOD MIX OF AGE
• 25-29 years 2
• 30-34 years 3
• 35-44 years 4
• 45-54 years 5
• 55-64 years 6
• 65+ years 7
• DK/NR 9 THANK AND TERMINATE

S4. What is your current employment status?

• Working full-time 1 ENSURE GOOD MIX OF EMPLOYMENT STATUS
• Working part-time 2
• Self-employed 3
• Retired 4
• Unemployed 5
• Student 6
• Homemaker 7
• Other (please specify) 8
• DK/NR 9 THANK AND TERMINATE

S5. Which of the following categories best describes your total household income? That is, the total income of all persons in your household combined, before taxes [READ LIST]?

• Under $20,000 1 ENSURE GOOD MIX OF INCOME
• $20,000 to under $40,000 2
• $40,000 to under $60,000 3
• $60,000 to under $80,000 4
• $80,000 to under $100,000 5
• $100,000 to under $150,000 6
• $150,000 or more 7
• DK/NR 9 THANK AND TERMINATE

S6. What is the last level of education that you have completed?

• Some high school only 1 ENSURE GOOD MIX OF EDUCATION
• Completed high school 2
• Some college/university 3
• Completed college/university 4
• Post-graduate studies 5
• DK/NR 9 THANK AND TERMINATE

S7. Which of the following best describes your current household situation? Are you living…?

• By yourself 1 ENSURE GOOD MIX OF HOUSEHOLD SITUATION
• As a single parent with your children
• at least some of the time 2
• With a partner or spouse 3
• With a partner or spouse and your children 4
• As a blended family (with a spouse and yours and/or their children) 5
• With your parents only or with siblings 6
• Other (please specify) 7
• DK/NR 9 THANK AND TERMINATE

S8. To make sure that we speak to a diversity of people, could you tell me what is your ethnic background? DO NOT READ

• Caucasian 1 ENSURE GOOD MIX OF ETHNICITY
• Chinese 2
• South Asian (i.e., East Indian, Pakistani, etc.) 3
• Black 4
• Filipino 5
• Latin American 6
• Southeast Asian (i.e. Vietnamese, etc.) 7
• Arab 8
• West Asian (i.e. Iranian, Afghan, etc.) 9
• Korean 10
• Japanese 11
• Aboriginal (First Nations, Métis, or Inuit) 12
• Other (please specify) 13
• DK/NR 14

AIM FOR 1 ABORIGINAL IN TORONTO AND MONTREAL, REQUIRED IN VANCOUVER (NOT REQUIRED IN MONCTON) AND MIN 2 NON-CAUCASIAN IN EACH GROUP.

S9. Have you participated in a discussion or focus group before? A discussion group brings together a few people in order to know their opinion about a given subject.

• Yes 1 (MAX 1/3 PER GROUP, ASK S10, S11, S12)
• No 2 SKIP TO S13
• DK/NR 9 THANK AND TERMINATE

S10. When was the last time you attended a discussion or focus group?

• If within the last 6 months 1 THANK AND TERMINATE
• If not within the last 6 months 2 CONTINUE
• DK/NR 9 THANK AND TERMINATE

S11. How many of these sessions have you attended in the last five years?

• If 4 or less 1 CONTINUE
• If 5 or more 2 THANK AND TERMINATE
• DK/NR 9 THANK AND TERMINATE

S12. And what was/were the main topic(s) of discussion in those groups?

IF RELATED TO FOOD, HEALTHY EATING, NUTRITION/DIET, CANADA’S FOOD GUIDE, THANK AND TERMINATE.

S13. We are asking participants about nutrition information that appears on all pre-packaged foods. To do that, I need to email you a sample nutrition label and ask you some questions about it. I would like to do that now so we can continue with the questions. Do you have immediate access to your email?

• Yes 1 SEE INTERVIEWER INSTRUCTIONS
• No 2 SEE INTERVIEWER INSTRUCTIONS

INTERVIEWER INSTRUCTIONS:

IF YES: Email nutrition label email and confirm they can view the label before proceeding with asking the remaining questions on the screener.

IF NO: Set up a time for a call-back when they are able to have the email in front of them during the recruitment call and continue with the screening questions.

ONCE THEY HAVE RECEIVED THE EMAIL AND ARE LOOKING AT THE LABEL, PROCEED WITH THE INTERVIEW:

The label you are looking at appears on a 500 ml container of ice cream. Please keep it open on the screen while I ask you some questions about the information on the label. Some other people said they found it useful to have pen and paper in front of them for some of the questions.

NOTE TO INTERVIEWER:

• The questions must be asked in order.
  Continue even if the respondent gets the first few questions wrong. However, if Q.S18 is answered incorrectly, do not ask Q.S19.
• Do not in any way prompt a respondent who is unable to answer a question. You can repeat the question if asked or if you think it might help the respondent.
  Prompting may jeopardize the accuracy of the test. Just say, “Well then, let’s go on to the next question.”
• The respondent is to be given as much time as needed to answer the questions.
• Note: The average time needed to complete all 6 questions is approximately 3 minutes. Do not tell respondents if they have answered correctly or incorrectly. If asked, say something like: “I can’t tell you at the moment, but for now, you are doing fine. Now let’s go on to the next question.”
• Scoring the answers: Score by giving 1 point to each correct answer for a maximum of 6 points

SCORE OF 0-3 QUALIFIES FOR MARGINAL HEALTH LITERACY GROUP – GROUP 1
SCORE OF 4-6 QUALIFIES FOR ADEQUATE HEALTH LITERACY GROUP – GROUP 2

ICE CREAM CONTAINER LABEL TO BE EMAILED

Text description: Image of a nutrition facts table, with weight and % daily value details for calories, fat, cholesterol, sodium, carbohydrates and protein, and vitamins, as well as an ingredient list.

S14. The first question based on the information from the label is: if you eat the entire container, how many calories will you eat?

RECORD ANSWER:

DO NOT READ: Correct answer: 1,000 is the only correct answer

S15. If you are allowed to eat 60 grams of carbohydrates as a snack, how much ice cream can you have?

RECORD ANSWER:

DO NOT READ: Correct answer: Any of the following is correct:

1. 250 ml or 1 cup (or any amount up to 250 ml or 1 cup), or
2. half the container

NOTE: If the respondent answers “two servings”, ask “How much ice cream would that be if you were to measure it into a bowl?” The answer to this probe must correspond to (a) or (b) above to count as correct.

S16. Your doctor advises you to reduce the amount of saturated fat in your diet. You usually have 42 g of saturated fat each day, which includes one serving of this particular ice cream. If you stop eating ice cream, how many grams of saturated fat would you be eating each day?

RECORD ANSWER:

DO NOT READ: Correct answer: 33 is the only correct answer

S17. If you usually eat 2,500 calories in a day, what percentage of your daily value of calories will you be eating if you eat one serving of this ice cream?

RECORD ANSWER:

DO NOT READ: Correct answer: 10% is the only correct answer

S18. Pretend that you are allergic to the following substances: penicillin, peanuts, latex gloves and bee stings. Is it safe for you to eat this ice cream?

RECORD ANSWER:

DO NOT READ: Correct answer: No

S19. [ASK ONLY IF ANSWER TO Q.S18 IS “NO”] Why not?

RECORD ANSWER:

DO NOT READ: Correct answer: Because it has peanuts/peanut oil

PARTICIPANT GETS 1 POINT FOR EACH CORRECT ANSWER

TOTAL SCORE OF 0-3 QUALIFIES FOR MARGINAL HEALTH LITERACY GROUP – GROUP 1
TOTAL SCORE OF 4-6 QUALIFIES FOR ADEQUATE HEALTH LITERACY GROUP – GROUP 2

INVITATION

S20. Participants in discussion groups are asked to voice their opinions and thoughts. How comfortable are you in voicing your opinions in front of others? Are you… (READ LIST)

• Very comfortable 1 MINIMUM 4 PER GROUP
• Fairly comfortable 2 CONTINUE
• Comfortable 3 CONTINUE
• Not very comfortable 4 THANK AND TERMINATE
• Very comfortable 5 THANK AND TERMINATE
• DK/NR 9 THANK AND TERMINATE

S21. Sometimes participants are asked to read text and/or review images during the discussion. Is there any reason why you could not participate?

• Yes 1 THANK AND TERMINATE
• No 2 CONTINUE
• DK/NR 9 THANK AND TERMINATE

S22. Based on your responses, it looks like you have the profile we are looking for. I would like to invite you to participate in a small group discussion, called a focus group, we are conducting at [TIME], on [DATE].

As you may know, focus groups are used to gather information on a particular subject matter; in this case, the discussion will touch on the food choices you make. The discussion will consist of 8 to 10 people and will be very informal. It will last up to two hours, refreshments will be served and you will receive $100.00 as a thank you for your time. Would you be willing to attend?

• Yes 1 RECRUIT
• No 2 THANK AND TERMINATE
• DK/NR 9 THANK AND TERMINATE

PRIVACY QUESTIONS

Now I have a few questions that relate to privacy, your personal information and the research process. We will need your consent on a few issues that enable us to conduct our research. As I run through these questions, please feel free to ask me any questions you would like clarified.

P1) First, we will be providing the hosting facility and session moderator with a list of respondents’ names and profiles (screener responses) so that they can sign you into the group. This information will not be shared with the Government of Canada department organizing this research. Do we have your permission to do this? I assure you it will be kept strictly confidential.

• Yes 1 GO TO P2
• No 2 READ RESPONDENT INFO BELOW

We need to provide the facility hosting the session and the moderator with the names and background of the people attending the focus group because only the individuals invited are allowed in the session and the facility and moderator must have this information for verification purposes. Please be assured that this information will be kept strictly confidential. GO TO P1A

P1a) Now that I’ve explained this, do I have your permission to provide your name and profile to the facility?

• Yes 1 GO TO P2
• No 2 THANK & TERMINATE

P2) An audio and/or video tape of the group session will be produced for research purposes. The tapes will be used only by the research professional to assist in preparing a report on the research findings and will be destroyed once the report is completed.

Do you agree to be audio and/or video taped for research purposes only?

• Yes 1 THANK & GO TO P3
• No 2 READ RESPONDENT INFO BELOW

It is necessary for the research process for us to audio/video tape the session as the researcher needs this material to complete the report.

P2a) Now that I’ve explained this, do I have your permission for audio/video taping?

• Yes 1 THANK & GO TO P3
• No 2 THANK AND TERMINATE

P3) Each month we submit the names of individuals that have participated in our focus groups to the Marketing Research and Intelligence Association Qualitative Central system (www.mria-arim.ca). Qualitative Central serves as a centralized database to review participation in qualitative research and focus groups. You will not be contacted for any reason whatsoever as a result of being on this list.

Do we have your permission to submit your name and phone number to MRIA’s Qualitative Central system?

• Yes 1 THANK & GO TO INVITATION
• No 2 GO TO P3A

P3a) To participate in this focus group we must have your permission to add your name to the Qualitative Central system as it is the only way for us to ensure the integrity of the research process and track participation in qualitative research. The system is maintained by the industry body, the Professional Marketing Research Society, and is solely used to track your participation in qualitative research (such as focus groups). You will not be contacted for any reason whatsoever as a result of being on this list.

Now that I've explained this do I have your permission to add your name to our qualitative central list?

• Yes 1 THANK & GO TO INVITATION
• No 2 THANK & TERMINATE

AS REQUIRED, ADDITIONAL INFO FOR THE INTERVIEWER:

Please be assured that this information is kept confidential and is strictly accessed and used by professional market research firms to review participation and prevent “professional respondents” from attending sessions. Research firms participating in MRIA’s Qualitative Central require your consent to be eligible to participate in the focus group - the system helps ensure the integrity of the research process.

AS REQUIRED, NOTE ABOUT MRIA:

The Marketing Research and Intelligence Association is a non-profit organization for marketing research professionals engaged in marketing, advertising, social, and political research. The Society's mission is to be the leader in promoting excellence in the practice of marketing and social research and in the value of market information.

Invitation:
Wonderful, you qualify to participate in one of our discussion sessions. As I mentioned earlier, the group discussion will take place the evening of [Day, Month, Date] @ [Time] for up to 2 hours.

Do you have a pen handy so that I can give you the address where the group will be held? It will be held at: [PROVIDE FACILITY NAME AND ADDRESS].

We ask that you arrive fifteen minutes early to be sure you find parking, locate the facility and have time to check-in with the hosts. The hosts may be checking respondents’ identification prior to the group, so please be sure to bring some personal identification with you (for example, a driver’s license). If you require glasses for reading make sure you bring them with you as well.

As we are only inviting a small number of people, your participation is very important to us. If for some reason you are unable to attend, please call us so that we may get someone to replace you. You can reach us at [INSERT PHONE NUMBER] at our office. Please ask for [NAME]. Someone will call you in the days leading up to the discussion to remind you.

So that we can call you to remind you about the discussion group or contact you should there be any changes, can you please confirm your name and contact information for me?

First name Last Name
email
Daytime / Evening phone number

If the respondent refuses to give his/her first or last name or phone number please assure them that this information will be kept strictly confidential in accordance with the privacy law and that it is used strictly to contact them to confirm their attendance and to inform them of any changes to the discussion group. If they still refuse THANK & TERMINATE.

French ****provide a link to the French Appendix B***