Consumer Opinions of "High in" Front of Pack Labelling Strategies - Final Report

POR Registration #: POR 060-16
Contract #: HT372-163723/001/CY
Contract Cost: $88,865.61 (HST included)
Contract Award Date: October 28, 2016
Delivery Date: March 30, 2017

Prepared for: Health Canada por-rop@hc-sc.gc.ca

Ce rapport aussi disponible en français.

Prepared by: Sage Research Corporation

Table of Contents

• Summary
• Introduction
  • Purpose
  • Method
• Results
  • Tasks 1 and 2
    • Consumer Accessibility of "High In" FOP Symbol Information (Task 1)
    • Consumer Understanding of "High In" FOP Symbols (Tasks 1 and 2)
    • Consumer Appraisal of "High In" FOP Symbols (Tasks 1 and 2)
    • Consumer Use of "High In" FOP Symbols (Tasks 1 and 2)
  • Task 3
    • Consumer Preferences for "High In" FOP Symbols
  • Overall Reaction to Introducing "High In" Symbols
• Appendices
  1. Screening Questionnaires
  2. Discussion Guides
  3. Task 1 Materials
  4. Task 2 Materials
  5. Task 3 Materials

Political Neutrality Certification

Sage Research Corporation certifies that the final deliverables fully comply with the Government of Canada's political neutrality requirements outlined in the Communications Policy of the Government of Canada and Procedures for Planning and Contracting Public Opinion Research.

Rick Robson
Vice-President
Sage Research Corporation

Summary

Health Canada is proposing to improve food labelling with front of package (FOP) information on sodium, sugars and saturated fat in packaged foods. This is part of Health Canada's Healthy Eating Strategy which aims to make healthier food choices easier for Canadians. This consumer opinion research is one component informing the development of a FOP labelling approach that would flag all foods that are "High In" sodium, sugars, and/or saturated fat. Consumer research was conducted in December 2016 to explore consumer access, understanding, appraisal and use of four FOP "High In" labelling approaches on foods with greater than 15% of the daily value of sodium, sugars, and/or saturated fat.

Picture Octagon Triangle Exclamation

Fourteen in-person focus groups (8-9 persons per group) were conducted between December 6 and December 15, 2016 in six cities across Canada. The target groups consisted of English and French-speaking adults with marginal health literacy (six focus groups) and adequate health literacy (six focus groups), and youth 14-17 years of age (two focus groups). Health literacy was assessed using the Canadian version of the Newest Vital Sign^©Pfizer tool (used with permission). Participants completed three tasks: (1) a simulated grocery shopping task, (2) a food package labelling task, and (3) a utility ranking task. In the grocery shopping task, participants were asked to select healthier food products among mock products that varied in terms of presence versus absence of a "High In" FOP labelling approach (varied design and placement) for the nutrients (sodium, sugars, and/or saturated fat) they were high in. The food product labelling task probed participants' preferred FOP labelling approach, size, and placement on the FOP so it is "quickly and easily noticed and understood". In the final task, participants subjectively ranked their perceptions of the four FOP "High In" labelling approaches based on how quick and easy they were to notice and understand.

Simulated Grocery Shopping Task

Close to half of the participants noticed the "High In" FOP labels on at least one of the FOP labelled mock products; however, manipulation of the contrast and positioning of "High In" FOP labels on different food packages could have limited consumer awareness and attention to them. Note that prior to the shopping activity, particpants were told the research was funded by Health Canada. This also may have made some participants more likely to bypass the front of the package and go straight to the Health Canada information on the label, compared to what they would normally do in the grocery store, where shoppers typically look at the fronts of packages. Overall, most participants selected products with FOP labels for the fewest "High In" nutrients, but a few participants mentioned they used the presence of a "High In" symbol to make their healthier choices. Some participants questioned the credibility and source of the "High In" FOP labels given that most nutrition information on the front of the package is believed to be put there at the discretion of manufacturers to promote and market their products, which led to some uncertainty about the real meaning and value of the "High In" symbols. For some, this was a motivation to seek out further information and to check the Nutrition Facts table (NFt) to quantitatively define "High In", while for some others it led to them to disregard the "high in" symbol and evaluate the healthiness of the product on other criteria. For some participants the "High In" FOP label was perceived as credible and was taken at face value as sufficient grounds for rejecting a product as a less healthy choice.

Food Package Labelling Task

The Exclamation symbol was a preferred choice of many participants in the food product labelling task because its design was attention-getting. However, some participants felt that the use of text in a list reduced their interest and inclination to take the time to read the text. Participants who preferred the Picture symbol felt that it conveyed a "softer" cautionary message as compared to the stronger message of the Exclamation symbol, and that it could be useful for those who cannot or will not take the time to read the words. However, other participants had difficulty interpreting the nutrients represented by the pictures, particularly for sugar and saturated fat. Fewer participants showed preference for the Octagon symbol, stating that the meaning of the arrow within the octagon was not clear. The Triangle design was not well received as participants felt that it did not convey the intended 'High in" meaning. Participants preferring either Picture or Octagon felt that the separate symbols for each nutrient made it easy to quickly identify the different "High In" nutrients as opposed to reading the list of text in the integrated approaches. They also noted that the increasing amount of FOP space taken up with each additional "High In" nutrient makes it more salient to them. Nonetheless, some found this to be somewhat "overpowering" when all three nutrients were flagged. Those preferring Exclamation tended to choose the larger size of the symbol to improve its visibility on the FOP. While most participants preferred to place their chosen "High In" FOP label in a consistent position on the FOP across products, there was no group consensus for a preferred absolute location.

Utility Ranking Task

Participants with adequate health literacy were about equally split between preferring Picture versus Exclamation, and tended to have positive attitudes towards both. Participants with marginal health literacy were somewhat more likely to prefer Picture compared to Exclamation, but still usually had a positive attitude towards Exclamation. Youth preferred Exclamation compared to the other three approaches. The octagon with the upward arrow was mistaken by some participants as being a positive message about the product nutrients. The Triangle approach was perceived by many participants to be part of the manufacturer's marketing of the product and less likely to be perceived as conveying a sense of warning or caution.

CONCLUSIONS

All tested symbols were useful to various degrees for a wide range of consumers of varying health literacy levels. Both the Picture and Exclamation "High In" FOP symbols appeared to be quickly and easily noticed and understood. Adult participants tended to prefer Picture and Exclamation. Among participants with adequate health literacy, Picture and Exclamation were equally likely to be preferred. Participants with marginal health literacy were somewhat more likely to prefer Picture compared to Exclamation, but still usually had a positive attitude towards Exclamation. Youth preferred Exclamation compared to the other three approaches. This research helped identify key design components that limited their access, understanding, appraisal and use by consumers of varying health literacy levels. Participants suggested that a FOP labelling concept should be complemented by consumer information and education so they know how to look for this when shopping.

Limitations of the Research

This qualitative research is designed to reveal a rich range of opinions and interpretations rather than to measure what percentage of the target population holds a given opinion. The results must not be used to estimate the numeric proportion or number of individuals in the population who hold a particular opinion because they are not statistically projectable. The findings should be interpreted as directional only in nature.

Contract cost: $88,865.61 (HST included)

Introduction

Purpose

The nutrition labelling regulations provide product-specific nutrient information to help consumers make informed food choices. In response to commitments made in the 2015 mandate letter to the Minister of Health, Health Canada is proposing to introduce a new, mandatory FOP nutrition symbol on prepackaged foods. Foods that exceed a predetermined threshold for sodium, sugars or saturated fat would be required to place a symbol on the principal display panel to indicate that the food is high in that nutrient(s). The proposed interpretive, nutrient-specific FOP approach could serve as an important part of a comprehensive suite of policies to help make healthier choices easier for Canadians and to help combat the contribution of excess sodium, sugars and saturated fat to diet-related chronic diseases. Health Canada is considering a variety of symbols that could be used to convey the FOP "high in" message. One strategy is to use shapes and symbols that are already meaningful to consumers (e.g., stop signs, yield signs, arrows, images, exclamation marks) combined with text. The symbol should be simple and intuitive for most Canadians - it should not require an explanation for consumers to understand. Health Canada undertook research in the form of focus groups. The objectives of the research were to assess how consumers understand and use a range of proposed "High In" FOP symbols. This will help determine which "High In" FOP symbol best helps Canadians identify foods high in nutrients of concern

Method

Approach and recruitment:

A total of fourteen in-person focus groups were conducted between December 6 and December 15, 2016 (n=11 English; n=3 French). The target groups consisted of adults with either marginal or adequate health literacy, and youth 14-17 years of age (Table 1). Health literacy was assessed using the recently adapted Canadian version of the Newest Vital Sign^©Pfizer (used with permission). Administration of this scale involves showing a Nutrition Facts table (NFt) for ice cream, and then asking a series of six questions about the NFt which are coded as correct (1) or incorrect (0). The number of correct answers is summed, and a person with a score of less than 4 is classified as being at risk of marginal or limited health literacy, and a person with a score of 4 or more is classified as being likely to have adequate health literacy. Participants received an honorarium of $100 at the end of their discussion group.

Exclusion Criteria:

• Neither participants nor anyone in their immediate family or household work in any of the following: Government of Canada, a government department or agency responsible for health or public health, a nonprofit organization involved in health promotion, a medical profession, an organization that provides advice on nutrition and healthy eating, a food manufacturer, a firm that does package design, advertising, public relations, marketing research, or media.
• Must not have attended a qualitative session in the past six months, nor attended five or more qualitative sessions in the past five years.
• Must have never participated in a discussion group on food products or packaging.

There was a total of 125 participants (108 adults, 17 youth), with eight to nine participants in each focus group. The following are the detailed participant profiles.

Mock-up Product Design

Mock-up beverage, yogurt, popcorn and cereal products were specifically created for these focus groups. No real brands or existing products were used. These mock-ups mimicked current labelling conditions (i.e. Nutrition Facts table, list of ingredients) and product attributes, including combinations of nutrient content claims, health claims, and marketing attributes (e.g. organic labels, non-GMO labels, package colour, brand name, product image, etc.).

Focus Group Activities

• Task 1 - Shopping: Participants "shopped" at three food stations - beverages, yogurt, and popcorn. At each food station there were three mock products to choose from. Food products varied in terms of presence versus absence of a "High In" FOP symbol, the nutrients (sodium, sugars, and/or saturated fat) they were high in, and the symbol design and location. Participants were instructed to make a "healthier choice." They could choose one, more than one, or none of the products. Participants were given about two minutes at each food station to make their selections.
• Task 2 - Labelling: Participants were divided into three groups. Each group was given two mock cereal boxes with no "High In" FOP symbols, a sheet telling them what nutrient each cereal was "High In", and a sheet of removable symbols for each cereal with the four symbol designs, each in three sizes. For each of the two cereal boxes, the groups were instructed to choose a symbol design and stick it on the package. The symbol criteria they were asked to use were: "quickly and easily noticed" and "easily understood." Additional instructions were: (1) must use the same symbol design on both packages, but can use different sizes of the design; (2) allowed to cover something up on the front of the package in order to ensure an effective location. Decisions were made as a group.
• Task 3 - Ranking: Each participant was given an envelope containing cut-outs of the four different "High In" symbol designs and a form to use to rank the four designs, keeping in mind "quick and easy to notice" and "easily understandable."

Picture Octagon Triangle Exclamation

Analysis of focus group data:

A qualitative analysis of the discussion groups was conducted to explore consumer access, understanding, appraisal and use of the various FOP "High In" labelling approaches. The materials used in the analysis were audio recordings of the focus groups, transcripts of the English focus groups, notes taken by a note-taker for the French focus groups, the questionnaires completed by participants, and photographs of the packages from Task 2 - Labelling. For each focus group, these data were reviewed by the moderator and coded for themes and subthemes. The coded summaries were aggregated and again reviewed for themes and subthemes, with attention to potential variation by target group (marginal health literacy, adequate health literacy, youth). The data from the questionnaires were tabulated, and the pictures from the Task 2 exercise were coded for label type, size and placement.

Results

Tasks 1 and 2

Consumer Accessibility of "High In" FOP Symbol Information (Task 1)

In general, for any given food category, generally close to half of participants of varying health literacy noticed a "High In" FOP symbol on at least one of the food products (Table 3). In each of the three food categories, the food product with the fewest "High In" nutrients was selected as the healthier choices by the largest number of participants (Table 3). In general, participants were aware that food packages also had nutritional content information (Nutrition Facts table) on the back (or side) of the package. Many participants looked at the back of the food packages when tasked with choosing healthier foods.

Some participants chose food products referring to use of the "High In" symbols, and others chose food products without any reference to awareness or use of the "High In" symbols. For participants who chose food products with a larger number of "High In" nutrients, some mentioned seeing the "High In" symbols but selected the product anyway.

Table 3. Shopping for healthier food choices (Task 1)¹

¹ Note that the sample sizes for the two adult target groups are slightly less than the total number of participants because of either an incomplete product selection form or difficulty interpreting the form.

A number of factors contributed to participants' access of the "High In" FOP symbols in Task 1:

• Pre-conceived labelling beliefs appeared to moderate consumer accessibility of FOP information. Some participants said that they do not expect to find much clear or credible health-related information on the FOP because they perceive the front as being all about "marketing" and trying to get someone to buy the product. These participants said they paid little attention to the FOP and more attention to the NFt and/or ingredients list when asked to make the healthier food choice.
• A lack of familiarity with "High In" FOP symbols was also mentioned. Some participants said they did not expect "High In" information on the FOP, so they did not look for it. Some participants pointed out that they had never seen symbols like this on foods. Task familiarity influenced participants' search for label information. In this regard, several participants said they "learned" to look for the symbols in the course of doing the task. For example, they did not see the "High In" symbols on the products at their first food station, they noticed the symbols at the second food station, and then made a point of looking for the symbols at the third food station.
• Presence of health conditions for which limiting certain nutrients or food ingredients was important interfered with consumer access of "High In" FOP symbols. Those self-identifying as needing to limit certain nutrients (e.g. sugar, sodium, cholesterol, calories) or who had allergies said that they focused on the back of the package to access the Nutrition Facts table (NFt) and/or the ingredients list to make their food decisions because they are accustomed to search for the information relevant to their health conditions in these sections of the label.
• Heuristic decision making limited participants' attention to and interaction with the "High In" FOP labels. Some participants particularly focused on non-GMO ingredients, organic ingredients, or "natural" ingredients as key to making a healthier choice, and this seemed to limit their interest in looking at other information on the package.

Label specific design factors contributed to accessibility of the "High In" FOP symbols in Task 1:

• FOP design elements: Some participants said they paid little attention to the "High In" FOP symbols (or at least not as an element stating something about the product being high in something) because they assumed it was part of the manufacturer's package design - e.g. a logo of some sort. While some participants went on to look more closely for other food label information, others used their perceptions of the color scheme to make their decision (e.g. light/bluish colour scheme of the VitaMIn water was perceived to be like "water") and did not always look at the NFt or ingredients, or notice the "High In" symbol (if there was one).
• Contrast of the "High In" FOP symbol: Some participants felt that the various "High In" FOP symbols did not stand out from the other FOP label information due to the black and white nature of the designs. Some participants suggested using other colours in the designs to make them stand out more. A common suggestion was to color the octagon shapes red, as in an actual stop sign. A few participants countered that whether or not a coloured design stands out will depend on the particular colour relative to the background colour on the package - i.e. a red symbol on a red background still might not stand out. A few suggested some manufacturers might deliberately manipulate the background colour to reduce the contrast between the symbol and the background. For example, when asked on what made the "High In" design stood out the most, some mentioned the white-on-black "High In" FOP label against the black background on Caramel Corn package was very visible whereas the "black-on-black" colour scheme of the Greek-Style Yogurt made the "High In" FOP labelling less noticeable.
• Location: For research purposes, the "High In" FOP symbols were deliberately placed in different locations across the different packages. Accessibility of these locations varied among participants. For example, some participants noticed the "High In" symbols on Caramel Corn (near the bottom center) and Cinema Pop (symbol on bottom right), but not on Ordinary Pop (symbol on top right). This could be because of the number of symbols on the packages - three on Caramel Corn and two on Cinema Pop versus only one on Ordinary Pop. The larger number of symbols on the former two occupy more space on the package which could make the symbols on those packages more noticeable. A few participants noticed only the "High In" symbol on the Ordinary Pop package and not on the other two packages. They said the "High In" symbol stood out in the upper right corner of the Ordinary Pop package because of the perceived high contrast between the black-and-white symbol and the blue background.

Consumer Understanding of "High In" FOP Symbols (Tasks 1 and 2)

Most participants who noticed a "High In" symbol said that this signaled to them that the food was high in the named nutrient(s). Participants often used the word "warning" to describe the "High In" FOP symbols. A number of product and consumer factors contributed to consumer understanding of the symbols. Product factors included the package design elements and the sufficiency of the label information; consumer factors were food/nutrition knowledge and perceptions of the credibility of the label information.

• FOP design elements: One participant, who noticed the 3 nutrient specific octagon FOP symbols on the Caramel Corn package, said his initial reaction was that the arrows pointing up were signaling that the product is low in these nutrients. He then changed his mind and decided the upward pointing arrows meant the product was high in these nutrients. A frequent criticism of this FOP approach is that the meaning of the arrows is ambiguous. Some participants said they did not attend to the Triangle symbol because they assumed it was part of the manufacturer's package design - e.g. a logo of some sort. Triangle was widely criticized as not looking like a warning about a nutrition or health-related issue.
• Sufficiency of the information: This affected participants' search for other information to better understand what "High In" meant. For some, the "High In" FOP symbol motivated them to access the NFt in order to understand the levels of the nutrients flagged by the "High In" symbol. For them, the issue was understanding "how high is high".
• Credibility of the "High In" FOP symbol: As noted earlier, participants believed that any nutrition and health-related claims on the front of the package are controlled by the manufacturer, and are intended to help sell the product. Some participants assumed that the "High In" symbols must be government regulated while others were not so sure who was responsible for the "High In" FOP symbols. Some participants questioned why a manufacturer would voluntarily put a "warning" symbol on their package. Others suggested that if this is based on Health Canada regulations, it would help to be made aware of this. The implication was that the government would be a more trustworthy source than would manufacturers.

Consumer Appraisal of "High In" FOP Symbols (Tasks 1 and 2)

Few consumers relied solely on the "High In" FOP symbols to evaluate the nature of the food and its relative healthiness. Food marketing (e.g. brand names and package design) and claims were frequently mentioned as influential in participant evaluations of the healthiness of the different food products, whether or not a "High In" FOP symbol was also present on the FOP. Many participants attended, to varying degrees, to FOP design elements (e.g. colour and pictures) and marketing information (e.g. brand name, product claims) when appraising the healthiness of the foods.

• Package design elements: Package colors such as the light/bluish colour scheme of the VitaMin Boost made many participants judge the product to be healthier. The purple colour of the "Indulgence" yogurt suggested to some that this meant "High In" sugar and not a healthier choice.
• Marketing of the food: Brand names such as the "Boost" part of the VitaMin Boost name suggested to some youth that this looked like an "energy drink", which to them was not a healthier choice. The brand name "Indulgence" for yogurt was perceived as meaning "High In" sugar, again not a healthier choice. FOP claims such as the "No added sugar" claim on a fruit beverage was perceived by some participants as containing "natural" sugars so a "High In" sugar FOP symbol was acceptable to them; and the combination of the brand name VitaMin Boost and the claim "Source of 7 vitamins and minerals" was understood by some to mean that it may not be healthy or necessary to take extra vitamins.
• Sufficiency of the information: When participants noticed a "High In" symbol on more than one product in a category, some also wanted to be able to evaluate if there were differences between two products that have a "High In" FOP symbol. In this case the "High In" FOP symbols motivated them to access the NFt in order to evaluate and compare across products the levels of the nutrients flagged by the "High In" symbol. Some participants took the symbol at face value as sufficient grounds for rejecting a product as a healthier choice.

Participants' food and nutrition preferences influenced their use of the "High In" FOP symbols to appraise the different food products. Some participants believed that FOP information related to nutrition or health is there at the discretion of the manufacturer, and that the role of any such information is to motivate a consumer to buy the product by delivering a positive message about the food rather than a negative "High In" warning. Because of the perceived "marketing" role of the FOP, some participants said they considered only what they perceived to be trustworthy food information, the NFt or ingredients list, to evaluate the foods. In general, more attention appeared to be paid to the NFt or ingredients list, the specific role of the food in their diet, the perceived taste of the food, and personal food beliefs than to the "High In" FOP symbols when participants were appraising foods to make their food choices.

• Ingredient profile of the food: Participants with past experiences with popcorn served in cinemas being high in the butter considered Cinema Popcorn not to be a healthier choice. Some participants did not want a product containing an artificial sweetener/sucralose, rejecting the yogurt and the fruit beverage with the FOP claim "Contains sucralose", stating that they would not buy products with artificial sweeteners/sucralose. Several participants said they did not like sparkling beverages and rejected Fruit Quench on this basis.
• Dietary role of the food: Some participants considered selecting a healthier product to be important only for products that are consumed frequently, and not for those they would consider a treat, such as popcorn. These consumers focused their evaluation of the foods on perceived taste, selecting the popcorn that they would most enjoy eating, often the Caramel Corn - a high sugar, high fat, high sodium choice, and rejecting those products that did not appeal to them from a taste perspective.
• Taste: When participants talked about which products would likely taste the best, they usually named products that had "High In" symbols. Also, in the two product categories where products differed in the number of "High In" nutrients, the product with the most "High In" nutrients tended to be perceived as the best tasting. They often did not link this explicitly to the "High In" symbols, but some did, and the implication is that these nutrients do tend to be associated with better flavour. This perspective showed up, for example, in the popcorn category, where some people said popcorn is only an occasional treat, and therefore it does not matter if the product is high in one of these nutrients - these participants all selected Caramel Corn (3 "High In" nutrients). What this indicates is that people may trade off potential negative nutritional attributes with the value of having a great taste. If a product is perceived to be a "treat", and particularly if it is only consumed occasionally, then "High In" symbols may have little effect on selecting a healthier product.
• Food beliefs: Some participants had a general belief about the healthiness of "Greek" yogurt and selected Greek-Style Yogurt on the assumption that it is the healthiest. These were people who said they eat Greek yogurt because they believe in the healthiness of Greek yogurt. Some participants considered "water" to be healthier/better than fruit juice, leading to the judgement of the vitamin/mineral water, VitaMin Boost, as having a similar healthiness profile to "water." Some participants perceived it to be very much like water, and did not focus on the additives. They judged "water" to be "better for you" than fruit juices. Fruit juice was evaluated by many to be high in sugar and thus less healthy. For others "natural sugar" was more acceptable than "added sugar", and Tropical Twist was acceptable as a healthier choice. The "High In" sugar was less of a concern if they perceive the sugar in the product to be "natural sugar."

Consumer Use of "High In" FOP Symbols (Tasks 1 and 2)

Although just under half of participants noticed the "High In" symbols in a given product category, fewer (roughly one-quarter of participants) mentioned using a "High In" symbol when explaining their decision about healthier choices in a given product category. This trend did not appear to be different among marginal or adequate health literacy groups. Youth participants were primarily using other FOP elements such as colour, pictures, product name, or claims.

Participants who said they used the "High In" FOP symbols as part of making a decision about healthier food choices did so in one of two ways. Participants with adequate health literacy groups tended to use it as a trigger to go to the NFt to get more information about the meaning of the "High In" FOP symbol, while many of those at risk of marginal/limited health literacy used the "High In" FOP symbol to outright reject the product without referring to other label information.

Participants at risk of marginal health literacy had a tendency to explain their healthier food choices only using FOP cues and information. Those with adequate health literacy used both FOP and back of pack information (NFt and list of ingredients) to make their healthier food choices. Overall, the food information on both the FOP and back of pack (BOP) were important sources of information used by participants trying to make healthier food choices. At least three-quarters of respondents referred to using the food information on BOP and somewhat more than that referred to information on the FOP.

Many participants felt there should be an information campaign if "High In" FOP symbols are introduced, and two of the objectives of the campaign should be to confirm that this is government regulated and educate consumers on the meaning and the use of the symbols.

Task 3

Consumer Preferences for "High In" FOP Symbols

All tested symbols were useful to various degrees for a wide range of consumers of varying health literacy levels. Adult participants tended to prefer Picture and Exclamation. Among participants with adequate health literacy, Picture and Exclamation were equally likely to be preferred. Participants with marginal health literacy were somewhat more likely to prefer Picture compared to Exclamation, but still usually had a positive attitude towards Exclamation. Youth preferred Exclamation compared to the other three approaches.

Overall, consumers preferred the Picture and the Exclamation "High In" symbols for ease of access and understanding. Octagon did less well and Triangle was poorly received. Although it shares common elements with the Exclamation and Picture approaches, Triangle was the least favoured design. Participants thought it resembled a marketing logo and did not convey any sense of "warning" or "caution". As a result, they felt consumers would quickly dismiss the symbol without reading and understanding the "High In" message.

Picture Octagon Triangle Exclamation

A number of design elements influenced consumers' preferences for the "High In" FOP symbols. These included the use of specific icons, the text and size of the text, the total number of elements in the overall design, and the perceived strength of the background symbol.

• Use of separate symbols for each nutrient: The individual elements representing each nutrient in Picture and Octagon were perceived by many participants to enhance access to and understanding of the "High In" FOP symbol. They noted that as the number of "High In" octagons or pictures increases, the information becomes more visible and salient. Additionally, some felt separate symbols are quicker and easier to process and understand than reading stacked lines of text (as in the Exclamation and Triangle designs).
• Use of icons: Nutrient specific icons used in the Picture "High In" FOP design were perceived to facilitate access and understanding across a wider audience. For example, icons were thought to more easily convey the meaning of nutrients for those who cannot read English/French and those more visually oriented. For some however, the nutrient specific icons did not clearly resemble the intended nutrients, particularly those used to represent sugars and saturated fat. A similar concern was noted with the use of the upwards arrow in Octagon to denote "High In". While the upward arrow facilitated the simplicity of this approach, many participants raised concerns regarding the potential for misinterpretation as they felt its connotation is ambiguous and could be misperceived to have a positive meaning.
• Use of "High" or "High In" text: In contrast to the upward arrow used in Octagon, most participants preferred the inclusion of the text "High In" as it communicated a clearer, cautionary message. Additionally, some noted that the use of smaller text (e.g. Picture approach) detracted from the FOP symbol's ability to attract consumer attention.
• Perceived strength: Compared to both of the octagon based approaches, some participants preferred the use of triangles as this conveyed a softer "yield" or "caution" message rather than a "don't buy this" message. For others, the use of triangles was deemed to be less attention-getting than the use of octagons. Despite not having distinct symbols for each nutrient, many felt the exclamation point in Exclamation was visually powerful and effective at attracting consumers' attention. Participants mentioned that the combination of an octagon shape with an exclamation mark sent a stronger "caution" or "warning" message, compared to the approaches with triangles. As raised in group discussions, the octagon shape strengthens the caution to mean "stop" while the exclamation mark provides complementary messages of "pay attention", "stop and think" and "caution". Additionally, participants noted the inclusion of the text "High In" clearly conveyed the caution message in contrast to the upward arrow in the octagon, despite both containing octagons. While some thought Exclamation was too strong and conveyed a "stop, don't buy it" message, many felt it was appropriately strong and could encourage consumers to refer to the NFt for more information.

Preference vs. Utility

Preference is often used as a proxy for effectiveness. In some cases, consumer preferences for FOP symbol approaches in Task 3 were consistent with perceived or observed impact in Tasks 1 and 2. For example, Triangle was rarely accessed and used by consumers when making food choices in Task 1, never chosen for product labelling in Task 2, and seen as the least preferred option in Task 3. However, preference rationales did not always align with observed utility. For example, while some participants did not prefer Exclamation due to it being perceived as too strong, food choices of participants in Task 1 were influenced relatively more by this approach than the softer Triangle and Picture approaches. Therefore, while participants' preferences provide important and nuanced insights into the potential design elements that facilitate or hinder consumer uptake, it should be considered in the context of other findings across the full spectrum of consumer competencies needed for "High In" FOP symbols to facilitate informed decisions and impact consumer food choices.

Overall Reaction to Introducing "High -In" Symbols

When asked whether they thought "High In" symbols would be a good thing, most participants supported such an initiative. The main benefit is that it would make it easier to quickly identify less healthy foods. Additional comments included:

• It would encourage people to learn to pay more attention to sodium, saturated fat and sugars in their diet.
• It would be helpful for people who tend not to look at the NFt.
• It could be more effective than advertising to get people to think about eating healthier foods.
• It would be good for teaching children how to select healthier foods.
• It could affect how you eat at home - i.e. if you have a food with "High In" nutrients, you might be more likely to be careful about how much of it you consume at any one time when you see the symbol on the package.
• It could motivate manufacturers to offer healthier foods so that they do not have to put this symbol on their products.

A small number of participants expressed some skepticism:

• The approach appears to be patronizing.
• Food packages already have the NFt, so an additional symbol is not necessary.
• Most people probably will not pay attention to the "High In" symbols.
• The presence of "High In" symbols on most products would reduce their impact and lead to choosing products using other criteria.
• The impact of a "High In" symbol may be affected by the products around it on the grocery shelf.

Many participants felt that if "High In" symbols are introduced, there should be an information campaign to inform consumers about the symbols. This suggestion was triggered both by the recognition that in the Task 1 shopping exercise people quite often did not attend to the "High In" symbols, and the fact that some had questions about who the symbols are intended for and how they should be used. Suggested components of the campaign included the following types of information:

• Tell the public that the symbols are being introduced so that they know to look for them when shopping.
• Identify that this is a government regulatory initiative in order to assure people as to the credibility of the symbol.
• As appropriate to the symbol design selected, explain the symbol. For example, if the decision is to use Picture, explain what each picture signifies.
• Explain "how high is high."
• Explain what product categories will have "High In" symbols, and the criteria for deciding which products will get a "High In" symbol.
• Explain who the symbol is intended for, and related to this, what would be appropriate ways of using the symbol.

Appendix : Study Materials

Appendix 1. Screening Questionnaires

Note: Questions 8-14 are from the Newest Vital Sign^©Pfizer, adapted for use in Canada by Health Canada, and used with permission from Pfizer

a) Adult Screening Questionnaire

Hello/Bonjour (pause), I'm ___________ of Research House, a marketing research company. We are conducting a study on behalf of the Government of Canada, specifically for Health Canada. I'd like to ask you some questions to see if you would be interested in possibly taking part in this study.

Would you prefer that I continue in English or in French? Préférez-vous continuer en français ou en anglais? [If prefers French, either switch to the French screener and continue, or say the following and then hang up and arrange French-language call-back] Nous vous rappellerons pour mener cette entrevue de recherche en français. Merci. Au revoir.

The purpose of the study is to hear people's views on the food choices they make for themselves and possibly for other family members.

I'd like to describe to you what would be involved in participating in this study. We are organizing discussion groups which involve a small number of people who will be asked to look at some items, write out short comments on the items and then share their opinions with others in the discussion group. We are having a few of these sessions and would be interested in possibly having you participate.

The session will last for 2 hours. People who take part will be compensated for their time and light refreshments will be served.

Your participation is voluntary. All information collected will be used for research purposes only and handled according to the rules of the Privacy Act of Canada.

Would you be interested in taking part in this study?

I need to ask you a few questions to make sure we are getting the right mix of people for this research. This will take about 8 to 10 minutes.

Note to recruiter: When terminating a call with someone, say: Thank you for your cooperation. We already have enough participants who have a similar profile to yours, so we are unable to invite you to participate.

1) Record gender

2) Into which of the following age groups do you fall? (Read list)

3) Do you or does any member of your family work in any of the following areas? (Read list)

4a) The next question is about grocery shopping. Are you primarily responsible for grocery shopping for your household?

4b) Do you share the responsibility for grocery shopping about equally with someone else in your household?

5a) Were you born in Canada or were you born elsewhere?

5b) About how long ago did you come to Canada? (Read list)

FOR CALGARY AND VANCOUVER ONLY: Ask Q.5c if Canadian-born in Q.5a

5c) Would you identify yourself as non-Aboriginal or Aboriginal, that is are you of First Nations, Inuit or Métis descent?

6a) What is your current marital status? Are you ….? (Read list)

6b) Do you have a child or children under 20 years old living in your home?

7) We are asking participants to help us learn a little bit more about nutrition information that now appear on all pre-packaged foods that you would buy grocery shopping. 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?

8) 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 patient gets the first few questions wrong. However, if Q.13 is answered incorrectly, do not ask Q.14.

• 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

Score of 4-6: qualifies for Adequate Health Literacy Group

Ice Cream Container Label for Respondent

9) 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: ________________

Correct Answer: 1,000 is the only correct answer

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

Record Answer: ________________

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.

11) 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 ice cream.

If you stop eating ice cream, how many grams of saturated fat would you be eating each day?

Record Answer: ________________

Correct Answer: 33 is the only correct answer

12) 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?

Record Answer: ________________

Correct Answer: 10% is the only correct answer

13) 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: ________________

Correct Answer: No

14) ASK ONLY IF ANSWER IN Q.13 IS "NO": Why not?

Record Answer: ________________

Correct Answer: Because it has peanuts/peanut oil [either answer is correct]

Score of 0-3 Correct: qualifies for at risk of Marginal Health Literacy Group

Score of 4-6 Correct: qualifies for likely to be Adequate Health Literacy Group

Thank you. I have just a few more questions to ask you.

15) What is the highest level of education you have received? (Do not read)

IF MARRIED/COMMON-LAW in Q.6a, ASK; OTHERWISE GO TO Q.16b:

16a) We would like to invite a cross-section of people with different income levels. Which one of the following groups best describes your annual household income from all sources before taxes? (Read list)

GO TO Q. 17a

IF CURRENTLY SINGLE in Q.6a, ASK:

16b) We would like to invite a cross-section of people with different income levels. Which one of the following groups best describes your annual household income from all sources before taxes? (Read list)

I have just a few more questions to ask you.

17a) Have you ever taken part in an in-depth research interview or a discussion group involving a small group of people where people were asked to discuss different topics?

17b) What topics have you ever discussed?

__________________________________________________________________________

(If related to food products or packaging, thank participant for their time and end the interview)

17c) And when was the last time you attended an interview or discussion group?

17d) In the past 5 years, how many in-depth research interviews or discussion groups have you attended? Would you say less than 5 in total, or would you say 5 or more?

Let me tell you some more about this study to see if you would like to take part.

18) As I mentioned earlier, the research involves taking part in a discussion group. In the group discussion, you will be asked to look at some items, write out short comments on the items and to voice your opinions in front of others. Do you feel comfortable doing this?

Terminate if person gives a reason such as verbal ability, sight, hearing, or related to reading/writing ability, or if they think they may have difficulty expressing their thoughts.

Participants in the discussion group will be asked to turn off any electronic devices during the discussion. Would you be willing to do so?

There may be some people from Health Canada who have been involved in this project observing the session in-person or remotely via a webcam set-up. However, they will not take part in the discussion in any way, and they will not be given your name. Is this acceptable to you?

The discussion group session will be recorded. These recordings are used to help with analyzing the findings and writing the report. Your name will not appear in the research report. Is this acceptable to you?

INVITATION

Thank you. We would like to invite you to take part in one of our discussion groups. The discussion will last 2 hours, and refreshments will be provided. Following your participation in the discussion group, you will be given $100.

Would you be willing to attend?

We ask that you arrive 15 minutes early, to make sure we can start on time. If you use glasses to read, please remember to bring them with you. Also everyone who is participating in the discussion group is asked to bring a piece of I.D.

As we are only inviting a small number of people to attend, your participation is very important to us. If for some reason you are unable to attend, please call so that we can get someone to replace you. You can reach us at [Insert Research House phone #]. Please ask for [Insert Research House contact name].

Someone from our company will call you back within two or three days to confirm these arrangements. To do that, we need to have your contact information.

Name:________________________________________________________________________

Evening phone:_______________________ Day time phone:________________________

Email address:_________________________________________________________________

Thank you very much!

Recruited by:__________________________________________________________________

Confirmed by:_________________________________________________________________

b) Teen Recruitment Questionnaire

For 16-17 year-Olds Go to Page 6 (Quota 6 of 12 recruits are to be 16-17)

Parent Introduction for 14-15 Year-Olds (Quota 6 of 12 recruits are to be 14-15)

Hello/Bonjour (pause), I'm ___________ of Research House, a marketing research company. We are conducting a study on behalf of the Government of Canada, specifically for Health Canada with youth 14 and 15 years of age. Is there a child in your home who is currently age 14 or 15?

Are you the parent or guardian for that teen?

Would you prefer that I continue in English or in French? Préférez-vous continuer en français ou en anglais? [If prefers French, either switch to the French screener and continue, or say the following and then hang up and arrange French-language call-back] Nous vous rappellerons pour mener cette entrevue de recherche en français. Merci. Au revoir.

We are currently conducting a research study with youth between the ages of 14 and 17. The purpose of speaking to teens in this age group is to help develop insight into decisions about food choices they make for themselves. The goal of the research is to improve information on food product labels that would be available to them.

For this study, we will be organizing discussion groups which are scheduled to run for 2 hours, from 5:00 pm to 7:00 pm. The discussion groups involve a small number of teens who will be asked to look at some items, write out short comments on the items and then share their opinions with others in the discussion group. Teens who take part will be compensated for their time and sandwiches will be served.

All information collected will be used for research purposes only and handled according to the rules of the Privacy Act of Canada.

Would you be willing to give us your permission for your child to take part in this important project?

Do you think your child would be willing to take part in this type of discussion group?

Just a few more details about how these discussion groups are run.

1. A) There may be some people from Health Canada who have been involved in this project observing the session in-person or remotely via a webcam set-up. However, they will not take part in the discussion in any way, and they will not be given your child's name. Is this acceptable to you?

1. B) The discussion group session will be recorded. These recordings are used to help with analyzing the findings and writing the report. Your child's name will not appear in the research report. Is this acceptable to you?

I would like to ask you a few questions to make sure we are getting the right mix of teens for this research.

1. C) Do you or does any member of your family work in any of the following areas? (Read list)

1. D) Has your child ever taken part in an in-depth research interview or a discussion group involving a small group of people where people were asked to discuss different topics?

1. E) What topics were discussed?

__________________________________________________________________________

(If related to food products or packaging, thank participant for their time and end the interview)

1. F) And when was the last time your child attended an interview or discussion group?

1. G) In the past 5 years, how many in-depth research interviews or discussion groups has your child attended? Would you say less than 5 in total, or would you say 5 or more?

I have a few questions about your daughter or son and when we're through, I would like to speak to the child.

P1) Is your child a girl or a boy?

P2) Is she/he currently 14 or 15 years of age?

P3) What is the primary language you speak at home?

P4) What is your daughter's/son's name?

Record Name: ________________

Thank you. Now I would like to speak to (Insert Name of Child) to make sure they feel comfortable about taking part in a group discussion. Once I have done that, I would like to speak to you again.

Introduction for 14-15 Year-Olds (Quota is 6 of 12 recruits)

Hi (Insert Name of Child), I'm ___________ of Research House, a marketing research company. Your mother/father gave me permission to talk to you about a research study.

We are looking for a group of young people ages 14 to 17 to take part in a study that is being done for the Government of Canada and specifically for the department called Health Canada. The purpose of the study is to hear people's views on the food choices they make for themselves.

I'd like to tell you a little bit about the study to see if you would be interested in taking part in this study.

We will be organizing discussion groups which are scheduled to run for 2 hours, from 5:00 pm to 7:00 pm. The discussion groups involve a small number of people between 14 and 17 years of age who will be asked to look at some items, write out short comments on the items and then share their opinions with others in the discussion group. Teens who take part will be compensated for their time and sandwiches will be served.

Your participation is voluntary. All information collected will be used for research purposes only and handled according to the rules of the Privacy Act of Canada.

Would you be interested in taking part in this study?

I need to ask you a few questions and give you some information about this study. This will take about 2 to 3 minutes.

Note to recruiter: When terminating a call with someone, say: Thank you for your cooperation. We already have enough participants who have a similar profile to yours, so we are unable to invite you to participate.

1) As I mentioned, the research study involves taking part in a group discussion. In the group discussion, you will be asked to look at some items, write out short comments on the items and to voice your opinions in front of others. Do you feel comfortable doing this?

Terminate if person gives a reason such as verbal ability, sight, hearing, or related to reading/writing ability, or if they think they may have difficulty expressing their thoughts.

2) Participants in the discussion group will be asked to turn off any electronic devices during the discussion. Would you be willing to do so?

3) There may be some people from Health Canada who have been involved in this project observing the session in-person or remotely via a webcam set-up. However, they will not take part in the discussion in any way, and they will not be given your name. Is this acceptable to you?

4) The discussion group session will be recorded. These recordings are used to help with writing the report. Your name will not appear in the research report. Is this acceptable to you?

Invitation

Thank you. We would like to invite you to one of our discussion groups. The discussion will last 2 hours, and sandwiches will be provided. Following your participation in the discussion group, you will be given $100.

Would you be willing to attend?

We ask that you arrive 15 minutes early, that is by 4:45, to make sure we can start on time. If you use glasses to read, please remember to bring them with you. Also everyone who is participating in the discussion group is asked to bring a piece of I.D.

We are only inviting a small number of people to attend, so it is very important to us that you do come for this discussion group. If for some reason you are not able to come, please call so that we can get someone to replace you. You can reach us at [Insert Research House phone #]. Please ask for [Insert Research House contact name].

Recruiter to Speak Again with Parent of 14-15 Year-Olds

Now I need to talk to your mother/father again. Would you please put her/him back on the phone.

Thank you for allowing me to speak with (Insert Name of Child). She/he has indicated that they would be interested in being part of this study. Here are a few other details about the group discussion we talked to (Insert Name of Child) about.

• The discussion will last 2 hours, and sandwiches will be provided. Following their participation in the discussion group, (Insert Name of Child) will be given $100.
• The discussion group will be held at: provide facility details to parent
• We ask that (Insert Name of Child) arrives 15 minutes early, that is by 4:45, to make sure we can start on time. If (Insert Name of Child) uses glasses to read, please have them bring them to the discussion group. Also everyone who is participating in the discussion group will need to show a piece of I.D.
• We are only inviting a small number of teens to attend, so it is very important to us that they do shown up for this discussion group. If for some reason (Insert Name of Child) is not able to attend, please call so that we can get someone to replace them. You can reach us at [Insert Research House phone #]. Please ask for [Insert Research House contact name].

One last thing. Someone from our company will call you back within two or three days to confirm these arrangements. To do that, we need to have your contact information.

Name:________________________________________________________________________

Evening phone:_______________________ Day time phone:________________________

Email address:_________________________________________________________________

Thank you very much!

Recruited by:__________________________________________________________________

Confirmed by:_________________________________________________________________

Introduction for 16-17 Year-Olds (Quota is 6 of 12 recruits)

Hi, I'm ___________ of Research House, a marketing research company. We are looking for a group of young people ages 14 to 17 to take part in a study that is being done for the Government of Canada and specifically for the department called Health Canada. The purpose of the study is to hear people's views on the food choices they make for themselves.

I'd like to tell you a little bit about the study to see if you would be interested in taking part in this study.

We will be organizing discussion groups which are scheduled to run for 2 hours, from 5:00 pm to 7:00 pm. The discussion groups involve a small number of people between 14 and 17 years of age who will be asked to look at some items, write out short comments on the items and then share their opinions with others in the discussion group. Teens who take part will be compensated for their time and sandwiches will be served.

Your participation is voluntary. All information collected will be used for research purposes only and handled according to the rules of the Privacy Act of Canada.

Would you be interested in taking part in this study?

I need to ask you a few questions and give you some information about this study. This will take about 3 to 5 minutes.

Note to recruiter: When terminating a call with someone, say: Thank you for your cooperation. We already have enough participants who have a similar profile to yours, so we are unable to invite you to participate.

1) Record gender

2) Does any member of your family work in any of the following areas? (Read list)

3) Are you currently 16 or 17 years of age?

4) What is the primary language you speak at home?

5) As I mentioned, the research study involves taking part in a group discussion. In the group discussion, you will be asked to look at some items, write out short comments on the items and to voice your opinions in front of others. Do you feel comfortable doing this?

Terminate if person gives a reason such as verbal ability, sight, hearing, or related to reading/writing ability, or if they think they may have difficulty expressing their thoughts.

6a) Have you ever taken part in an in-depth research interview or a discussion group involving a small group of people where people were asked to discuss different topics?

6b) What topics were discussed?

__________________________________________________________________________

(If related to food products or packaging, thank participant for their time and end the interview)

6c) And when was the last time you attended an interview or discussion group?

6d) In the past 5 years, how many in-depth research interviews or discussion groups have you attended? Would you say less than 5 in total, or would you say 5 or more?

7) Participants in the discussion group will be asked to turn off any electronic devices during the discussion. Would you be willing to do so?

8) There may be some people from Health Canada who have been involved in this project observing the session in-person or remotely via a webcam set-up. However, they will not take part in the discussion in any way, and they will not be given your name. Is this acceptable to you?

9) The discussion group session will be recorded. These recordings are used to help with writing the report. Your name will not appear in the research report. Is this acceptable to you?

Invitation

Thank you. We would like to invite you to one of our discussion groups. The discussion will last 2 hours, and sandwiches will be provided. Following your participation in the discussion group, you will be given $100.

Would you be willing to attend?

We ask that you arrive 15 minutes early, that is by 4:45, to make sure we can start on time. If you use glasses to read, please remember to bring them with you. Also everyone who is taking part in the discussion group is asked to bring a piece of I.D.

We are only inviting a small number of people to attend, so it is very important to us that you do come for this discussion group. If for some reason you are not able to come, please call so that we can get someone to replace you. You can reach us at [Insert Research House phone #]. Please ask for [Insert Research House contact name].

One last thing. Someone from our company will call you back within two or three days to confirm these arrangements. To do that, we need to have your contact information.

Name:________________________________________________________________________

Evening phone:_______________________ Day time phone:________________________

Email address:_________________________________________________________________

Thank you very much!

Recruited by:__________________________________________________________________

Confirmed by:_________________________________________________________________

Appendix 2. Discussion Guides

Provided by client at least 45 minutes prior to the 1st session each night:

Note: In Montreal Dec 12, the 1^st group is English and the 2^nd is French, so both English and French materials need to be provided prior to the first English group.

• For Task #1, simulated shopping: 3 yogurt, 3 popcorn and 3 beverage packages
• For Task #2, labelling exercise: 6 cereal packages total - two for each group (corresponding with the cereal names on each Task 3 folder); three sets of Task 2 folders - one set for each group
• For Task #3, symbol preference: 14 sets of Task 3 envelopes - one set for each focus group. The set for each focus group should consist of 11 envelopes - 9 envelopes plus 1 extra if needed and an envelope for the moderator.

Room set-up:

• Webcam
• At each seat: pens, glue stick (for Task #3, symbol preference)
• For Task #1, simulated shopping: arrange for three product stations (either separate small tables if possible, or use the main table); separate stations for beverages, popcorn and yogurt; packages not visible at start of session; position products facing forward so the front of package will be facing participants when visible; clipboard for each person with product selection sheet attached (or thick pads if clipboards not available)
• For Task #2, labelling exercise: Place the cereal boxes (3 pairs) so they're easily accessible; keep packages out of sight; Task 2 folders to be used in labelling exercise
• For Task #3, symbol preference: Task 3 envelopes with FOP labels and preference ranking sheets enclosed

Note: Prior to the start of the main group discussion, participants will have signed in. The sign-in includes acknowledgement/consent to recording and to observation.

1) Introduction (10 minutes)

1. Introduce self, and explain purpose of research: My name is (moderator name) and I work for a marketing research company called Sage Research. This study is being done on behalf of the Government of Canada, specifically by the department called Health Canada.

   The purpose of this study is to hear people's views on the food choices they make for themselves. As part of this, I'll be showing you some food packages and getting your reactions.

2. Review group discussion procedures:
   • Role of moderator: ask questions, make sure everyone has a chance to express their views, keep track of time
   • Role of the participants: Want everyone to participate and feel free to agree or disagree with others in the group
   • Confidentiality: participation is voluntary and your name will not appear in the report; the report will combine results from several discussion groups
   • Recording: The session is being audio (voice) recorded. The recording will be used to help in preparing the report on this research. A copy of the audio (voice) recording will be given to the researchers at Health Canada, but before it is given to them any personally identifying information will be removed. Health Canada will use the recording for research purposes only.
   • Presence of observers from Health Canada behind the one-way mirror and via webcam - they are not given the full names of people participating; they are here to learn first-hand people's views on the topics we'll be talking about this evening
   • Please turn off cell phones
3. Participant self-introduction: First name and number of people in household (probe on relationship to participant - partner, children including ages, parent)

2) Warm-up (10 minutes)

When you are grocery shopping, what information do you look at on the packages of new foods such as a new version of an existing product, or a new or unfamiliar product? How does this information help you with your food choices?

When finished: I'd like to give you a sense of what we're going to be doing for the rest of the session.

Many people find it hard to understand food labels. Health Canada wants to improve food labelling so that it is easier for people to make healthier food choices at the grocery store. Health Canada wants your help to make food labels better, so that they're quicker and easier for you to know which foods are high in saturated fat, sodium and/or sugars. This is because too much saturated fat, sodium and/or sugars can increase your risk of chronic disease and obesity and risk factors like high blood pressure and high cholesterol.

For the rest of the session I'm going to give you some things to do using food labels.

3) Task #1: Simulated Shopping (30 minutes)

Moderator: Distribute clipboard with product selection sheet to each participant

For the first activity, I'm going to ask you to go shopping at three product stations. At one station you'll see a selection of yogurt products, at another station you'll see a selection of beverages, and at another station you'll see a selection of popcorn products.

For this activity, imagine you are in a grocery store. Your task is to select healthier food choices for your household.

I'll give you two minutes at each product station to look over the products and make your selections. At each product station you can choose one product, or you can choose more than one product, or you can decide not to choose any at all. It's up to you. Remember, your task is to select healthier products for your household.

We didn't put prices on the packages, but assume that all the products at each station cost the same.

You'll see on the sheet on the clipboard there is place for you to record your choices. Please check off the products you choose and jot down some key points about why you did or did not choose certain foods so that you can remember to mention them in the group discussion. Don't worry about spelling or grammar - the notes are just for you as a memory aid.

To make sure there are only 2 or 3 people at each product station, I'm going to divide you into groups, and ask you to go to each product station as a group. I'll give each group two minutes at a station for each person in the group to make their own choices. After I say 'switch', please move as a group to the next product station on your right. This way, each group will get a chance to shop at each product station.

I'll divide you into groups in a minute. Does anyone have any questions before we start?

Moderator:

• Set-up/uncover product stations, divide people into groups, and have them go to their respective product stations
• Tell people to start, and give them about two minutes before asking them to "switch"
• Ensure products are lined up and the FOP of each package is facing forward (towards the participants) between each rotation for the next group

Group Discussion: I'd now like to hear what products you did or did not choose, and I'd like to hear from everyone. Someone start us out and tell us about the products you did or did not choose.

Moderator: Let a few people talk. Depending on what people are saying, either continue in this fashion, or start going product category by product category in order to get group discussion in the context of each product category.

Probes:

Access of FOP "High In" labels:

• What food label information did you first look at on your foods?
  • Probe on what FOP information they looked at first and if/when they noticed FOP "High In" labels for sugars, sodium and/or saturated fats (Note to moderator: if someone refers only to other sides of the package, probe on what they noticed first when they looked at the front of the package.)
  • Probe on what made it easy to notice the FOP "High In" label (location, graphic, size, symbol, etc.) (Note to moderator: The FOP labels are placed in different places on different packages - some are linked to the images of the food, others to the brand name and some to other regulated information on the FOP such as weight of the food package. This was done so that you can probe on what is important about positioning in terms of how easily accessible the FOP label is.)
    • Probe on the different FOP high in labelling approaches that they noticed on the packages - what made an approach easier for you to notice than another?
    • How did where you placed the FOP label make it quicker or easier to notice? i.e. probe on location, other label information it was near, etc.
    • How does the actual design of the different FOP approaches make them easier to notice?

      (Note to moderator: For example you will notice that some of the FOP approaches had different design elements - such as a gray border for the FOP "High In" label (as in Vitamin BOOST) as compared to the FOP "High In" label on Cinema Popcorn - so probe on what they felt made FOP approaches quick and easy to notice.)

• Probe on what other information elsewhere on the package they looked at
  • Probe on what drew their attention to information (e.g. on the sides, top, or BOP)

Understanding of FOP "High In" labels:

• How did the food label information that you looked at help you make your food decisions?
  • Probe on the FOP information they think is important for making healthier food choices for their household
  • Probe on their understanding of FOP label information for choosing healthier foods for the other family members
  • Probe on what they think about foods with FOP "High In" labels as well as health claims, nutrient content claims, and/or marketing claims. (Note - want to know if this undermines their understanding and/or credibility of the FOP label)

Appraisal of products with & without FOP "high-in" labelling:

• How did they evaluate label information for choosing healthier foods for different family members (i.e. did they evaluate the same nutrition information differently to make healthier food choices for other household members?)
• How does FOP "High In" labelling change how healthy they think a food is?
  • Probe on what they think about the food products without FOP "High In" labels as compared to those with FOP "High In" labels? (e.g. differentiate between healthiness, taste, price, etc.) (Note to moderator, in each of the Beverage and Yogurt categories, there will be one package without a "high-in" label)

Use of FOP "high-in" labelling strategies:

• How useful was the FOP "High In" labelling when you were comparing foods and making healthier food choices?

Moderator: Collect product selection sheets

4) Task #2: Labelling Exercise (30 minutes)

In this next activity, I'm interested in which Front of Pack symbol approaches quickly and easily show you that a food is high in saturated fat, sodium, or sugars. We'll work in groups again, so please stay in the group you're already in.

Each group will get two cereal packages, and an envelope with some labels.

Moderator: Give a Task 2 folder and the corresponding cereals indicated on the front of the folder to each group.

Please open your envelope. [pause] You should have a sheet of paper with the names of "High In" nutrient warnings for each of the two packages of cereal.

Take a look at the paper to see whether each cereal is high in saturated fat, sodium, and/or sugar.

You also have two laminated sheets with front-of-pack "High In" labelling designs, one for each cereal.

You can see that on each page of labels, there are four different symbol designs. That is, there is a different symbol design in each of the four rows of labels. You can also see that each symbol design comes in three sizes, namely small, medium, and large.

For each of the two cereal packages, your group will choose the front-of-pack label that you think would be quickly and easily noticed and understood by other consumers. Once your group has decided on your preferred FOP approach, stick your "High In" label on the front of your cereal packages where your group thinks that it would be quickly and easily noticed by consumers.

Two more things:

1. Your group must use the same preferred symbol design for both cereal packages. You may, however, use different sizes on the two packages.
2. On each cereal package, place the "High In" label on package where you think it will be quickly and easily noticed and understood by consumers. You can place it anywhere, even if it covers up something already there.

Does anyone have any questions before we start?

I'll give you 4 or 5 minutes to complete this task.

Group Discussion: Now, I would like each group to present their cereals and their preferred "High In" labels. Please tell us which design and size you chose, why you chose it, where you placed it on your product and why. Which group would like to present their labelled cereal first?

Probes:

• What is important about WHERE you placed the front-of-package label?
  • Probe on consistency of location, proximity to certain information that attracts their eye (brand name, food image, etc.)
  • Probe on if placement of "High In" label on top of/beside the brand name, food image or other regulated information (e.g. weight, health claim, nutrient content claim, marketing claim) on the front of the package affects how quickly they notice it
  • Probe on how proximity of other label information affects their understanding and use of the "High In" FOP label

5) Task #3: Symbol Preference Ranking (15 minutes)

As you saw in the previous activity, many packaged foods have high amounts of saturated fat, sodium, and sugars. Health Canada would like to put this information on the front of the packages of foods that are high in saturated fats, sodium, and/or sugars in a way that is quick and easy for you to notice and understand.

In this next task we would like you to rank your preference for 4 different symbol approaches to label foods high in saturated fats, sodium and/or sugars.

Moderator: Pass out Task 3 envelopes to each participant

Open your envelope labelled "Task 3". You should have 4 symbols and a ranking sheet that looks like this (hold up). I would like you to rank the symbols based on which you would prefer to convey warning information about high levels of saturated fats, sodium and/or sugars on packaged foods.

Please rank the four symbols on the ranking sheet, with the one you most prefer on the left side over to the one you least prefer on the right side. When you have all four ranked the way you want, use the glue stick to glue them onto the ranking sheet.

Do you have any questions?

You will have 2 minutes for this activity and then we'll talk about your preferred choices.

Group Discussion: Let's talk about your preferred choices of symbols and how you ranked them. Let's have one person start by presenting their symbol preferences and others can jump in after to share whether their preferences are similar or different. Who would like to start us off? (Note to moderator: Interested in design elements: integrated vs stand alone, different use of symbols with or without wording)

Probes:

• Most preferred and least preferred (why) and how they differ from the more neutral preferences (middle choices)
• Preference for wording "High In" versus no wording (e.g. Octagon with arrow up)
• Preference for graphical elements representing sodium, sugars, saturated fat versus wording alone
• Preference for integrated symbol with all 3 nutrients together versus standalone symbol for each nutrient (in a line)
• Preference for wording ("high" vs "High In")
• What makes an approach quickly and easily noticeable compared to others?

Moderator: Collect ranking sheets and envelopes

6) Closing

Thank you very much for your help this evening!

Please leave all the materials where they are, and stop at the desk on your way out to receive the honorarium we promised you as a thank you for your participation.

Group 1: I'm doing another discussion session and there may be some people in the waiting area, so please don't discuss what we did in this session.

Moderator: Take pictures of the cereal packages. Then remove the labels and place back on the appropriate laminated sheets and place sheets in the correct folders. These will be reused in the other discussion groups.

FOP Labelling Project Discussion Guide

Provided by client at least 45 minutes prior to the 1st session each night:

Note: In Montreal Dec 12, the 1^st group is English and the 2^nd is French, so both English and French materials need to be provided prior to the first English group.

• For Task #1, simulated shopping: 3 yogurt, 3 popcorn and 3 beverage packages
• For Task #2, labelling exercise: 6 cereal packages total - two for each group (corresponding with the cereal names on each Task 3 folder); three sets of Task 2 folders - one set for each group
• For Task #3, symbol preference: 14 sets of Task 3 envelopes - one set for each focus group. The set for each focus group should consist of 11 envelopes - 9 envelopes plus 1 extra if needed and an envelope for the moderator.

Room set-up:

• Webcam
• At each seat: pens, glue stick (for Task #3, symbol preference)
• For Task #1, simulated shopping: arrange for three product stations (either separate small tables if possible, or use the main table); separate stations for beverages, popcorn and yogurt; packages not visible at start of session; position products facing forward so the front of package will be facing participants when visible; clipboard for each person with product selection sheet attached (or thick pads if clipboards not available)
• For Task #2, labelling exercise: Place the cereal boxes (3 pairs) so they're easily accessible; keep packages out of sight; Task 2 folders to be used in labelling exercise
• For Task #3, symbol preference: Task 3 envelopes with FOP labels and preference ranking sheets enclosed

Note: Prior to the start of the main group discussion, participants will have signed in. The sign-in includes acknowledgement/consent to recording and to observation.

1) Introduction (10 minutes)

1. Introduce self, and explain purpose of research: My name is (moderator name) and I work for a marketing research company called Sage Research. This study is being done on behalf of the Government of Canada, specifically by the department called Health Canada.

   The purpose of this study is to hear people's views on the food choices they make for themselves. As part of this, I'll be showing you some food packages and getting your reactions.

2. Review group discussion procedures:
   • Role of moderator: ask questions, make sure everyone has a chance to express their views, keep track of time
   • Role of the participants: Want everyone to participate and feel free to agree or disagree with others in the group
   • Confidentiality: participation is voluntary and your name will not appear in the report; the report will combine results from several discussion groups
   • Recording: The session is being audio (voice) recorded. The recording will be used to help in preparing the report on this research. A copy of the audio (voice) recording will be given to the researchers at Health Canada, but before it is given to them any personally identifying information will be removed. Health Canada will use the recording for research purposes only.
   • Presence of observers from Health Canada behind the one-way mirror and via webcam - they are not given the full names of people participating; they are here to learn first-hand people's views on the topics we'll be talking about this evening
   • Please turn off cell phones
3. Participant self-introduction: First name and what is your favorite food

2) Warm-up (10 minutes)

When you are shopping for snacks or foods in a convenience store or a grocery store, what information do you look at on the packages of new foods such as a new version of an existing product, or a new or unfamiliar product? How does this information help you with your food choices?

When finished: I'd like to give you a sense of what we're going to be doing for the rest of the session.

Many people find it hard to understand food labels. Health Canada wants to improve food labelling so that it is easier for people to make healthier food choices when shopping. Health Canada wants your help to make food labels better, so that they're quicker and easier for you to know which foods are high in saturated fat, sodium and/or sugars. This is because too much saturated fat, sodium and/or sugars can increase your risk of chronic disease and obesity and risk factors like high blood pressure and high cholesterol.

For the rest of the session I'm going to give you some things to do using food labels.

3) Task #1: Simulated Shopping (30 minutes)

Moderator: Distribute clipboard with product selection sheet to each participant

For the first activity, I'm going to ask you to go shopping at three product stations. At one station you'll see a selection of yogurt products, at another station you'll see a selection of beverages, and at another station you'll see a selection of popcorn products.

For this activity, imagine you are in a convenience store or a grocery store buying something for yourself. Your task is to select healthier foods for yourself.

I'll give you two minutes at each product station to look over the products and make your selections. At each product station you can choose one product, or you can choose more than one product, or you can decide not to choose any at all. It's up to you. Remember, your task is to select healthier products for yourself.

We didn't put prices on the packages, but assume that all the products at each station cost the same.

You'll see on the sheet on the clipboard there is place for you to record your choices. Please check off the products you choose and jot down some key points about why you did or did not choose certain foods so that you can remember to mention them in the group discussion. Don't worry about spelling or grammar - the notes are just for you as a memory aid.

To make sure there are only 2 or 3 people at each product station, I'm going to divide you into groups, and ask you to go to each product station as a group. I'll give each group two minutes at a station for each person in the group to make their own choices. After I say 'switch', please move as a group to the next product station on your right. This way, each group will get a chance to shop at each product station.

I'll divide you into groups in a minute. Does anyone have any questions before we start?

Moderator:

• Set-up/uncover product stations, divide people into groups, and have them go to their respective product stations
• Tell people to start, and give them about two minutes before asking them to "switch"
• Ensure products are lined up and the FOP of each package is facing forward (towards the participants) between each rotation for the next group

Group Discussion: I'd now like to hear what products you did or did not choose, and I'd like to hear from everyone. Someone start us out and tell us about the products you did or did not choose.

Moderator: Let a few people talk. Depending on what people are saying, either continue in this fashion, or start going product category by product category in order to get group discussion in the context of each product category.

Probes:

Access of FOP "high in" labels:

• What food label information did you first look at on your foods?
  • Probe on what FOP information they looked at first and if/when they noticed FOP "high in" labels for sugars, sodium and/or saturated fats (Note to moderator: if someone refers only to other sides of the package, probe on what they noticed first when they looked at the front of the package.)
  • Probe on what made it easy to notice the FOP "high in" label (location, graphic, size, symbol, etc.) (Note to moderator: The FOP labels are placed in different places on different packages - some are linked to the images of the food, others to the brand name and some to other regulated information on the FOP such as weight of the food package. This was done so that you can probe on what is important about positioning in terms of how easily accessible the FOP label is.)
    • Probe on the different FOP high in labelling approaches that they noticed on the packages - what made an approach easier for you to notice than another?
    • How did where you placed the FOP label make it quicker or easier to notice? i.e. probe on location, other label information it was near, etc.
    • How does the actual design of the different FOP approaches make them easier to notice?

      (Note to moderator: For example you will notice that some of the FOP approaches had different design elements - such as a gray border for the FOP "high in" label (as in Vitamin BOOST) as compared to the FOP "high in" label on Cinema Popcorn - so probe on what they felt made FOP approaches quick and easy to notice.)

  • Probe on what other information elsewhere on the package they looked at
    • Probe on what drew their attention to information (e.g. on the sides, top, or BOP)

Understanding of FOP "high in" labels:

• How did the food label information that you looked at help you make your food decisions?
  • Probe on the FOP information they think is important for making healthier food choices for their themselves
  • Probe on what they think about foods with FOP "high in" labels as well as health claims, nutrient content claims, and/or marketing claims. (Note - want to know if this undermines their understanding and/or credibility of the FOP label)

Appraisal of products with & without FOP "high-in" labelling:

• How did they evaluate label information for choosing healthier foods for themselves?
• How does FOP "high in" labelling change how healthy they think a food is?
  • Probe on what they think about the food products without FOP "high in" labels as compared to those with FOP "high in" labels? (e.g. differentiate between healthiness, taste, price, etc.) (Note to moderator, in each of the Beverage and Yogurt categories, there will be one package without a "high-in" label.)

Use of FOP "high-in" labelling strategies:

• How useful was the FOP "high in" labelling when you were comparing foods and making healthier food choices?

Moderator: Collect product selection sheets

4) Task #2: Labelling Exercise (30 minutes)

In this next activity, I'm interested in which Front of Pack symbol approaches quickly and easily show you that a food is high in saturated fat, sodium, or sugars. We'll work in groups again, so please stay in the group you're already in.

Each group will get two cereal packages, and an envelope with some labels.

Moderator: Give a Task 2 folder and the corresponding cereals indicated on the front of the folder to each group.

Please open your envelope. [pause] You should have a sheet of paper with the names of "HIGH IN" nutrient warnings for each of the two packages of cereal.

Take a look at the paper to see whether each cereal is high in saturated fat, sodium and/or sugar.

You also have two laminated sheets with front-of-pack "high in" labelling designs, one for each cereal.

You can see that on each page of labels, there are four different symbol designs. That is, there is a different symbol design in each of the four rows of labels. You can also see that each symbol design comes in three sizes, namely small, medium, and large.

For each of the two cereal packages, your group will choose the front-of-pack label that you think would be quickly and easily noticed and understood by other consumers. Once your group has decided on your preferred FOP approach, stick your "high in" label on the front of your cereal packages where your group thinks that it would be quickly and easily noticed by consumers.

Two more things:

3. Your group must use the same preferred symbol design for both cereal packages. You may, however, use different sizes on the two packages.
4. On each cereal package, place the "high-in" label on the package where you think it will be quickly and easily noticed and understood by consumers. You can place it anywhere, even if it covers up something already there.

Does anyone have any questions before we start?

I'll give you 4 or 5 minutes to complete this task.

Group Discussion:

Now, I would like each group to present their cereals and their preferred "high in" labels. Please tell us which design and size you chose, why you chose it, where you placed it on your product and why. Which group would like to present their labelled cereal first?

Probes:

• What is important about WHERE you placed the front-of-package label?
  • Probe on consistency of location, proximity to certain information that attracts their eye (brand name, food image, etc.)
  • Probe on if placement of "high in" label on top of/beside the brand name, food image or other regulated information (e.g. weight, health claim, nutrient content claim, marketing claim) on the front of the package affects how quickly they notice it
  • Probe on how proximity of other label information affects their understanding and use of the "high in" FOP label

5) Task #3: Symbol Preference Ranking (15 minutes)

As you saw in the previous activity, many packaged foods have high amounts of saturated fat, sodium and/or sugars. Health Canada would like to put this information on the front of the packages of foods that are high in saturated fats sodium, and/or sugars in a way that is quick and easy for you to notice and understand.

In this next task we would like you to rank your preference for 4 different symbol approaches to label foods high in saturated fats, sodium and/or sugars.

Moderator: Pass out Task 3 envelopes to each participant

Open your envelope labelled "Task 3". You should have 4 symbols and a ranking sheet that looks like this (hold up). I would like you to rank the symbols based on which you would prefer to convey warning information about high levels of saturated fats, sodium, and/or sugars on packaged foods.

Please rank the four symbols on the ranking sheet, with the one you most prefer on the left side over to the one you least prefer on the right side. When you have all four ranked the way you want, use the glue stick to glue them onto the ranking sheet.

Do you have any questions?

You will have 2 minutes for this activity and then we'll talk about your preferred choices.

Group Discussion:

Let's talk about your preferred choices of symbols and how you ranked them. Let's have one person start by presenting their symbol preferences and others can jump in after to share whether their preferences are similar or different. Who would like to start us off? (Note to moderator: Interested in design elements: integrated vs stand alone, different use of symbols with or without wording)

Probes:

• Most preferred and least preferred (why) and how they differ from the more neutral preferences (middle choices)
• Preference for wording "high in" versus no wording (e.g. stop sign with arrow up)
• Preference for graphical elements representing sodium, sugars, saturated fat versus wording alone
• Preference for integrated symbol with all 3 nutrients together versus standalone symbol for each nutrient (in a line)
• Preference for wording ("high" vs "high in")
• What makes an approach quickly and easily noticeable compared to others?

Moderator: Collect ranking sheets and envelopes

6) Closing

Thank you very much for your help this evening!

Please leave all the materials where they are, and stop at the desk on your way out to receive the honorarium we promised you as a thank you for your participation.

Group 1: I'm doing another discussion session and there may be some people in the waiting area, so please don't discuss what we did in this session.

Moderator: Take pictures of the cereal packages. Then remove the labels and place back on the appropriate laminated sheets and place sheets in the correct folders. These will be reused in the other discussion groups.

Task Materials

Appendix 3. Task 1 Materials

Popcorn

Yogurt

Beverages

Task #1: Mock Products

Task #1: Product Selection Sheet

Appendix 4. Task 2 Materials

Task #2: Mock cereal packages

Appendix 5. Task 3 Materials

a) FOP Symbol Designs

b) Preference Ranking Sheet