Sugary Drinks Reduction Campaign Focus Groups (HC POR-17-07)

Final Report

Prepared by:
Corporate Research Associates Inc.

Prepared for:
Health Canada

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For more information on this report, please email:
por-rop@hc-sc.gc.ca

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Table of Contents

• Executive Summary
• Background
• Detailed Analysis
  • Drink Consumption Habits
  • Perceptions of Sugary Drinks
  • Statement Review
  • Creative Concept Testing
  • Communications
• Research Methodology
  • Context of Qualitative Research
• Recommendations
• Appendices:
  • Appendix A - Recruitment Screener
  • Appendix B – Moderator's Guide
  • Appendix C – Creative Material Tested

Executive Summary

Corporate Research Associates Inc.
Contract Number: HT372-17-3214
POR Registration Number: 034-17
Contract Award Date: October 4, 2017
Contracted Cost: $59,217.65 (taxes included)

Background

Health Canada is currently working on a campaign to educate Canadians on the importance of replacing sugary drinks with water. Health Canada's Sugary Drinks Reduction Campaign (SDRC) aims to encourage parents of pre-teens and teens to reduce the provision of sugary drinks in their homes, with the goal of reducing their children's consumption of these drinks. The goal of the campaign is to increase parents' awareness of their influence on their children's choices at home, as well as to increase parents' awareness of sugary drinks reduction information and resources available to them by Health Canada.

Three concepts were evaluated in terms of message clarity, credibility, appeal, and relevance to the target audience. Findings from the study will be used to help inform and further develop the creative approach and the development of additional campaign products.

Methodology

A total of eight (8) traditional, in-person focus groups were conducted with parents of pre-teens / teens, with two groups conducted in each of the following markets: Calgary, St. John's, Quebec City and Sudbury. In each market one group included parents with marginal health literacy, while a second group included those with an adequate health literacy (as screened by the Newest Vital Sign health literacy screening tool). Group discussions were conducted November 14th to 20th, 2017.

Caution must be exercised when interpreting the results from this study, as qualitative research is directional only. Results cannot be attributed to the overall population under study, with any degree of confidence.

Political Neutrality Certification

I hereby certify as a Representative of Corporate Research Associates Inc. that the deliverables fully comply with the Government of Canada political neutrality requirements outlined in the Directive on the Management of Communications. Specifically, the deliverables do not include information on electoral voting intentions, political party preferences, standings with the electorate or ratings of the performance of a political party or its leaders.

Signed
Margaret Brigley, President & COO | Corporate Research Associates
Date: March 28, 2018

Key Findings

Findings of the Sugary Drinks Reduction Campaign Focus Groups suggest that parents perceive water to be a common drink in their household and do not readily identify a serious problem with sugary drinks in the home. Accordingly, they do not feel compelled to reduce sugary drink intake and were not clear on why such action is both warranted and required.

Health Canada defines sugary drinks as:

"Beverages high in free sugars. This includes: soft drinks, fruit-flavoured drinks, 100% fruit juice, flavoured waters with added sugars, sport and energy drinks, and other sweetened hot or cold beverages, such as iced tea, cold coffee beverages, flavoured milks and flavoured plant-based beverages."

When asked to consider what beverages constitute a sugary drink, parents readily identified a wide range of sugary drinks, and generally concurred that most beverages include some level of sugar.  Across audiences, water, coffee/tea, vegetable juice and white milk are typically not considered a sugary drink.

Across locations, parents generally perceive water, milk and juice to be the primary beverages consumed at home. Accordingly, for most, sugary drinks are not considered a significant problem in their home for youth, though their consumption is deemed more regular outside the home. Indeed, sugary drinks are primarily associated with a drink outside the home, for special occasions or when eating out.. Packaged sugary drinks are especially common for packed lunches given their convenience. Overall, parents generally perceive about one-third of their child's daily beverage consumption to be sugary drinks, and this is generally consistent regardless of nutritional literacy.

Parents' purchase of sugary drink is primarily influenced by taste, price and dietary needs. Without question, children's taste preference influences parents' purchase behaviour, as most parents are reluctant to waste money by purchasing product that won't be consumed. With cost and health considerations in mind, many parents have chosen to introduce water as a beverage of choice in the home.  Parents identified a variety of risks with drinking sugary drinks, most notably type 2 diabetes, obesity, and tooth decay. They also highlighted some other risks they associated with sugary drinks including addiction, mood swings, hyperactivity and acne.

Many parents openly discussed encouraging a balanced lifestyle that includes consumption of all kinds of foods and beverages in moderation. These parents do not look at drink consumption in isolation, but rather in relation to their children's overall diet (i.e., sugary foods and beverages) and to their level of physical activity. In essence, many felt that a little sugar will cause no harm given their child's high activity level. Having a balanced lifestyle was often mentioned as a value parents want to pass on to their children.

When considering key statements relating to sugary drinks, parents generally agree with the risks associated with sugary drinks and appreciate the value of drinking water at home. Many questioned the believability of the fact 'sugary drinks are the highest contributors of sugars in our diets', given the high prevalence of processed foods in society, and were hesitant to believe that 'teens are the highest consumers of sugary drinks'. In fact, in their households, many considered adults to be the bigger 'abusers' of sugary drinks. Further, parents were not convinced that 'teens are drinking the most at home in the afternoon/ evening, due to availability', given that did not ring true in their household. Most felt that the majority of their child's sugary drink consumption is outside the home.

Across location and audience type, many parents took exception to the statement 'parents are the highest influencers of their teen's consumption'. While they considered that true for younger children (pre-teens or young teenagers) it was felt that once teenagers are working outside the home, have their own disposable income, and spend less time at home, they make their own purchase decisions, with friends and advertising having greater influence than parents.

Key barriers to replacing sugary drinks at home typically include cost, taste and lack of need. Parents were not convinced that sugary drinks pose a serious problem in their household and see no need to take action.

While many parents profess to include water as a drink of choice in their home, they question if there are many ways to make water an appealing choice. Many felt the options are limited to adding fresh fruit, flavour shots, colouring the water, or encouraging use of a trendy water bottle.

When presented with three creative concepts (see appendix C), findings highlight that none of the three concepts include a strong call to action that encourages parents to take action.  That said, across locations there was a clear concept preference. Of the three concepts, only one concept (kaleidoscope) evoked a strong emotional response, although at times, this emotional response was polarizing, with some parents criticizing the ad for blaming them or being too forceful.  Regardless, findings suggest this concept is deemed empowering given its attention-getting use of statistics and it clearly has the potential to compel a shift in behavior. It is the only concept that was considered as supporting the claim that home consumption of sugary drinks among youth is problematic. This is particularly important given parents' perceived lack of need to change sugary drink consumption in their household.  Importantly, however, while the use of statistics is particularly attention-getting and empowering, this concept lacks clear messaging on why sugary drink consumption is a problem.

Of the other two presented concepts, there was general agreement on the perceived ineffectiveness of the 'Shhh...' concept due to its lack of personal relevance.  The 'refrigerator' concept, though well received and considered realistic, was not deemed compelling to motivate change.

Conclusions

When considering the final development of any social marketing campaign, findings suggest that a clear call to action is needed to encourage parents to visit the website.  Further, the website URL should consider an action-oriented name that is suggestive of healthy drinks. Parents have clear expectations of what information they would expect to find on a 'healthydrinks' website, including full provision of statistics, information on daily sugar intake, actual sugar content in common drinks, and healthy alternatives. Tools and resources deemed helpful include an app that provides guidance on sugary beverage intake or healthy alternatives, and a calculator to help determine a drink's sugar content. Finally, findings suggest the use of blogs has limited appeal to parents.  Direct mail design preference is mixed, though parents believe any information must clearly outline the risks of sugary drinks and why their consumption should be minimized.

Background

Health Canada is mandated to bring awareness to the health-related risks of food and beverages by promoting dietary guidance, which enables Canadians to make healthy choices and informed decisions about their health. Sugar is a nutrient of concern and as part of its Healthy Eating Strategy, Health Canada intends to provide more information and focus social marketing efforts to support consumers in making the healthiest choice with the ultimate goal of contributing to the reduction of sugar consumption.

The intent of the campaign is to not only educate on the risks of sugary drink consumption, but to increase awareness of sugary drink reduction information and resources among parents of pre-teens and teens and increase understanding among parents of pre-teens and teens about their role as influencers for their teens' consumption. To assist with finalizing the development of the campaign, Health Canada commissioned Corporate Research Associates to conduct a series of focus groups with parents of teens and pre-teens.

More specifically, the research objectives included, to:

• Explore perceptions towards sugary drinks, including beverage consumption patterns and actions related to replacing sugary drinks at home.
• Explore audience understanding of select terms to inform message development.
• Evaluate three creative concepts, assessing each creative's messages to determine if they are: clearly understood, credible, visually appealing, appropriate /relevant, and of value.
• Determine how effective each concept is for motivating change / empowering the audience to make change.
• Provide suggestions for potential changes to ensure campaign content resonates with the target audience.

This report presents a high level executive summary and description of the detailed methodology used, and the detailed findings of the focus group discussions. The working documents are appended to the report, including the recruitment screener, the moderator's guide and the creative material tested.

Detailed Analysis

Drink Consumption Habits

To begin the discussion, participants were asked to complete a series of individual written exercises to outline their household's drink consumption habits.

Drinking Habits and Considerations

Parents perceive water and juice to be the primary beverages consumed at home and sugary drinks are generally not considered a significant problem in their home.

Across locations and group types, parents consistently reported that their pre-teens/ teens primarily drink water or milk with a meal, or often juice with breakfast.  In fact, water, 100% fruit juices, and white milk were most commonly identified by parents as beverages their pre-teen or teen consume. Other popular beverages included fruit-flavoured drinks/punch, hot chocolate, smoothies (without ice cream), flavoured milks like chocolate milk, and sport drinks. Parents, for their part, were most commonly reporting that they drink water, brewed coffee or tea, 100% fruit juices, white milk, and regular soft drinks/pop.

Across groups, there was a general perception among parents that children are more inclined to drink sugary drinks when outside the home, hanging with friends or at functions (a movie, mall, eating out, etc.).  For the most part, parents indicated placing a concerted effort to have water in their child's diet, and for many this is driven by cost, as well as health concerns.

In terms of drink offerings at home, many parents valued a variety of drink options, accepting that their children consume sugary drinks in moderation. Indeed, a balanced diet was commonly cited as being an important consideration in the choice of drinks to consume, so as not to create a negative relationship with foods and beverages.  Accordingly, many felt that sugary drinks are fine in moderation, and commonly accepted sugary drinks as treats when eating out.

Parents with children who are involved in organized sports (e.g. gymnastics, hockey, dance, etc.) reported that they often provide sports drinks for their child when attending sporting events.  Others indicated that sports teams have directly impacted an increased intake of water and/ or chocolate milk, as a result of a recommendation from a trainer or coach.

"A two litre of chocolate milk has less than a 24-hour life span in my house." Adequate NVS

In most locations, parents of girls consistently reported that their pre-teen / teenage daughters drink water on a regular basis, and that water intake has been directly impacted by an increased sensitivity in relation to weight gain. Indeed, it was felt that water often became a beverage of choice in fear of gaining weight.

In an individual exercise, parents were asked to indicate where they personally stand, on a scale ranging from "I worry about my kids' consumption of sugary drinks" and "I don't worry about my kids' consumption of sugary drinks". Overall, most parents express some level of concern, with those who have marginal health literacy being more concerned than parents with adequate health literacy.  That said, as mentioned, parents generally concurred that sugary drinks in moderation is not necessarily a bad thing or something they would discourage.

Finally, some parents commented that while they are somewhat concerned about their teen's excessive consumption of sugary drinks, their level of concern has declined given children's high activity level.  Further some felt concern is often better placed in the teenage years on such issues as alcohol and drug use.

"When they were younger, you wanted to avoid anything with sugar in it because it made them hyper.  Now that they're older and involved in sports, I know they're going to burn it off." Marginal NVS

"At their age, I'm more worried about alcohol and chemical inputs than sugary drinks." Adequate NVS

Purchase Considerations

The purchase of sugary drink is primarily influenced by taste, price and dietary needs.

Parents' sugary beverage purchase behaviours are largely influenced by taste (what they like and what they know their children will drink), price, and dietary needs.  In each location, some parents indicated that their child's health needs (e.g. lactose intolerance, diabetes, allergies, etc.) influence their purchase habits. Further, parents reported being reluctant to buy something they know their children won't drink.

Price is an important consideration to most parents, particularly those with marginal NVS.  Many reported to make purchase decisions based on what is on sale, and often buy in bulk to take advantage of sale prices.  Across groups, parents voiced frustration with the basic premise that healthy drink alternatives were consistently more expensive than sugary drinks.

"A two litre of pop is way cheaper than milk." Marginal NVS

"All the good stuff is more expensive.  [Buying] water is more expensive or the same as pop, so it won't be first choice." Adequate NVS

In an individual exercise, parents were asked to indicate where they personally stand on a scale ranging from "what my kids prefer doesn't influence what drinks I buy" to "my kids' likes /dislikes influence what I buy" to explain their purchase behaviours. Overall, parents are divided between those who pay some attention to their children's taste when buying beverages for the household, and those who reportedly are not influenced in this regard. Notably, parents with adequate health literacy more commonly reported buying to please their children than do parents with marginal health literacy.

At the same time, parents were asked to indicate where they stand on a scale ranging from "I only buy what I know is healthy for my kids, regardless of whether they like it or not" and "I only buy what I know my kids will drink". Once again, parents across groups tend to be in between, with some slightly more likely to buy what their children like to drink and others who are a little more likely to favour healthy drink options. Opinions are less notably different based on parents' health literacy levels.

"I'll buy what I know is going to get drank. Otherwise it's a waste of money." Adequate NVS

Behavioural Changes

With cost and health considerations in mind, many parents have chosen to introduce water as a beverage of choice in the home.

A good number of parents indicated that they have tried to reduce sugar intake at home, with most replacing sugary drinks with water.  A change has primarily been driven by two key factors, namely health reasons / risks and cost.  In other instances, change was influenced by the introduction of a refrigerator with a built in, filtered water dispenser, by introducing a water bottle, by removing sugary drinks from the home or hiding them in a less accessible location, and through the addition of flavor shots or squirts (e.g. MIO).  Many parents reported that water bottles have become 'trendy' and something that all the kids carry, helping to make water a drink of choice.

"Water bottles have made a big difference in the amount of water my daughter drinks. It goes in her backpack everyday." Adequate NVS

When asked what might prevent them from replacing sugary drinks with water, a variety of reasons were mentioned. Specifically, many parents believe in encouraging a balanced lifestyle that includes consumption of all kinds of foods and beverages in moderation. These parents do not look at drink consumption in isolation, but rather in relation to their children's overall diet (i.e., sugary foods and beverages) and to their level of physical activity. In essence, many felt that a little sugar will cause no harm given their child's high activity level. Having a balanced lifestyle was often mentioned as a value parents want to pass on to their children.

"Banning or eliminating something completely isn't a good solution – it just makes them want it more. They need to understand why something is not a healthy choice. Let them know what the risks are." Adequate NVS

Accessibility of sugary drinks and costs were other factors mentioned to explain why parents did not follow-through with replacing sugary drinks with water in their home. In some locations, such as Atlantic Canada, participants commented that their tap water did not taste good or was not safe to drink.  Accordingly, buying water was not a cost effective solution since it was significantly more expensive than buying sweeter alternatives, especially when sweet drinks went on sale (juice drinks, pop, etc.). For many, the convenience of juice packs or portable drinks were important considerations when packing lunches every day for their children. In fact, some mentioned that there was a negative stigma among peers associated with their child not bringing a packaged drink to school with them.

"My son doesn't want to be the one kid that doesn't have a drink packed with his lunch. Water looks like a poor alternative." Marginal NVS

In an individual exercise, parents were asked to specify their personal opinion on a scale that ranged from "it is a struggle to get my kids to drink water" to "my kids will drink water when I offer it". Most parents, regardless of their health literacy level, felt that their children easily drink water when offered, without any struggle.  As mentioned, many indicated that water or milk are the primary beverages consumed with meals in their household.

Perceptions of Sugary Drinks

Parents typically described a sugary drink as a drink that contains some type of added sugar or sweetener, or natural sugar. There is a general perception that everything (aside from water) contains some sugar, but that all sugars are not created equally.  In particular, natural sugars (i.e. in drinks such as milk, 100% fruit or vegetable juices) were considered healthier or less problematic than drinks with added or artificial sugar. When asked to describe what defines a sugary drink, parents were more likely to comment on the types of sugar included in the drink (e.g., sweetener, added or natural sugar, fructose, glucose) than to reference the amount of sugar included.

"[A sugary drink is] any drink that has added sugar that adds to my total sugar intake for the day. Natural sugars such as fructose also apply." Adequate NVS

"Pretty much anything that isn't just plain water has sugar in it or added to it for flavour." Adequate NVS

"Tout breuvage contenant des sucres ajoutés ou édulcorants et des sucres artificiels." (Any beverage that contains added sugar or sweetener or artificial sugars.) Adequate NVS

"Those beverages which have sugar added (this can include coffee/tea) and/or contain natural sugars (such as fruit juices)." Marginal NVS

"Une boisson sucrée contient du sucre." (A sugary drink contains sugar.) Marginal NVS

Types of Sugary Drinks

Parents readily identify a wide range of sugary drinks, and water, coffee/tea, vegetable juice and milk are typically not considered a sugary drink. Overall, parents generally perceive about 1/3 of their child's daily beverage consumption to be sugary drinks. This is consistent with research on diets of pre-teens and teens (aged 9-18 years).

In an individual exercise, parents were asked to choose from a list of 18 drinks which ones they considered to be sugary drinks. Across groups, sugary drinks were most commonly identified as including the following:

• Fruit-flavoured drinks/punch
• Hot chocolate
• Regular soft drinks/pop
• Energy drinks
• Milkshake (with ice cream)
• Sports drinks
• Flavoured water with added sugars
• Iced tea
• 100% fruit juice
• Flavoured milks like chocolate milk

It should be noted that little difference of opinions is reported between parents based on their level of health literacy (marginal vs. adequate NVS).

Most parents, though not the majority, also consider the following beverages as being sugary drinks:

• Diet soft drinks/pop
• Smoothie (without ice cream)

Across groups and health literacy levels, few parents consider the following as sugary drinks:

• Brewed coffee/tea (notably drinks with added milk, cream and/or sugar)
• 100% vegetable juice
• Flavoured plant-based beverages like soy milk
• White milk
• Unsweetened plant-based beverages like soy milk

Finally, all parents across groups consider that water is not a sugary drink.

In an individual exercise, parents were asked to indicate the proportion of all beverages consumed daily by their pre-teens or teens that are considered sugary drinks. Nearly all parents reported that their children consume at least some form of sugary drink every day, most notably accounting for less than half of their daily consumption, and a notable portion being less than one quarter.

Risks

Parents identify a variety of risks with drinking sugary drinks, most notably type 2 diabetes, obesity and tooth decay.

Parents readily identified a wide range of serious health risks associated with drinking sugary drinks with obesity, type 2 diabetes, and tooth decay being mentioned most often.  Other key mentions included addiction, mood swings (highs and crashes), hyperactivity, with a few parents indicating that acne was another key side effect.

"Definitely tooth decay. You appreciate that when you have a kid that has 10-12 cavities and a need for lots of dental work." Adequate NVS

"All the emotional sugar highs – lots of ups and downs." Marginal NVS

It warrants mention, however, that many parents acknowledged that these risks are not limited to sugary drinks alone, but rather are also relevant for sugary foods.  In an individual exercise whereby parents were asked to specify their opinion on a scale ranging from "any sugar is bad for my health" to "some sugar can be healthy", opinions are generally neutral, which emphasizes a need for further education. This reinforced the previously discussed perception that sugar is acceptable in moderation. That being said, it should be noted that parents with adequate health literacy are slightly more likely than those with marginal health literacy to believe that any sugar has negative health impacts.

Statement Review

While parents agree with the risks associated with sugary drinks and appreciate the value of drinking water at home, other statements lack personal relevance and do not ring true to many.

Participants were presented with a series of seven (7) statements and asked to consider which statements (or part of the statement) effectively spoke to them and which were confusing or problematic. The statements included:

1. Replace sugary drinks with water in your home.
2. Sugary drinks are the highest contributor of sugars in our diets.
3. Teens are the highest consumers of sugary drinks.
4. Teens are drinking the most at home in the afternoon/evening, due to availability.
5. Parents are the highest influencers of their teen's consumption.
6. There are many ways to make water an appealing choice.
7. Drinking sugary drinks can lead to an increased risk of obesity, type 2 diabetes and tooth decay.

For the most part, parents responded well to two statements, namely: 'replace sugary drinks with water in your home' and 'drinking sugary drinks can lead to an increased risk of obesity, type 2 diabetes and tooth decay.'  These statements were deemed important, factual and true, with the second statement reminding them of the risks. That being said, the lack of supporting arguments or reasoning in the first statement made it sound too directive to some parents.

"This statement needs to be backed up. Tell us why we should replace sugary drinks. What are the risks or consequences if you don't?" Adequate NVS

Other statements, however, lacked relevance to many parents, given that they didn't reflect what they experienced in their household.  Further, many questioned the believability of the fact: 'sugary drinks are the highest contributors of sugars in our diets', given the high prevalence of processed foods in society.

The statement 'teens are the highest consumers of sugary drinks' was also questioned, as parents see more adults consuming excessive amounts of sugary drinks.  In fact, in their households, many considered the adults to be the bigger 'abusers' of sugary drinks.

"In my home it's the adults that drink all the pop in the house.  And look at who's filling up on all the coffee with 4-5 sugar!" Marginal NVS

Further, parents were not convinced that 'teens are drinking the most at home in the afternoon/ evening, due to availability', given that did not ring true in their household.  Most felt that the majority of their child's sugary drink consumption happens outside the home.

Many parents took exception to the statement 'parents are the highest influencers of their teen's consumption'. While they considered that true for younger children (pre-teens or young teenagers) it was felt that once teenagers are working outside the home, have their own disposable income, and spend less time at home, they make their own purchase decisions, with friends and advertising having greater influence than parents.

Finally, when considering that 'there are many ways to make water an appealing choice', some concurred, but others felt the options are limited to adding fresh fruit, flavour shots, colouring the water, or encouraging use of a trendy water bottle.

"There aren't a whole lot of options.  May be if it's a colour, or with fruit infusions or shaped ice?" Marginal NVS

Creative Concept Testing

Three distinct creative concepts were presented to participants in a storyboard format for a video.  In each location, the order of presentation was rotated to prevent order bias. After being shown each concept, participants were asked to share their personal reactions to the idea using a series of individual exercises.  Subsequently, each concept was discussed as a group, prior to moving on to the next concept.

General Considerations and Concept Preference

All three concepts lack a strong call to action to visit the website, and none provide sufficient justification supporting the need for parents to take action.

Across the three creative concepts, a number of general considerations warrant mention. Most notably, none of the concepts included a strong call to action that encouraged website visitation.  Further, while the concepts shared mixed success in terms of highlighting that there is a problem with sugary drink consumption, none justify why sugary drinks are problematic and why parents need to make a change.

After seeing all concepts, participants were asked to record (individually) which creative approach they considered most effective at encouraging the reduction of sugary drink consumption in their home.  This tally is not intended to provide a statistically reliable measure, but rather to provide a summation of opinions across group discussion.

As outlined below (Table 1), findings highlight a number of consistencies across locations when considering the preferred concept. Most notably, among English participants, there is strong preference for the Kaleidoscope concept, followed distantly by the Refrigerator concept.  Opinions in the French-speaking groups were more mixed, although the Kaleidoscope concept was still preferred.  This concept was generally preferred because of its inclusion of attention-grabbing facts, strong emotional reaction, and clearer motivation to shift behavior than with the other concepts. There was general agreement on the perceived ineffectiveness of the Shhh... concept due to its lack of personal relevance, and it was not the preferred concept for any of the English-speaking participants.

The following presents detailed reactions to each of the three concepts.

Concept A: Kaleidoscope

This concept evokes a strong emotional response.  While the use of statistics is attention-getting and empowering, the concept does not effectively convey why sugary drink consumption is a problem.

This concept was generally well received and evoked a strong emotional response across locations, although polarizing in some instances. Parents liked the concept's straightforward and simplistic approach. For many, the concept elicited a sense of guilt as a parent and pointed blame squarely on the parents (which was perceived unwarranted to some). This concept clearly left an impression and consistently generated a strong reaction.

"Je me sens attaqué comme parent. On me rend personnellement responsable de ce qui se passe." (I feel attacked as a parent. They imply that I am personally responsible for what is happening.) Adequate NVS

Key Message:  The main message of this concept was clearly understood, namely that parents should stop buying sugary drinks for their children.  Further, it suggests that parents are to blame for the problem associated with sugary drinks among youth, because they bring those types of drinks in the home.

"[The video is saying that] we as parents are responsible for what we buy for our teens and the drinks they consume." Marginal NVS

"[They say] that teens consume a ton of sugary drinks, consume mostly at home and it's the parents' fault. But it can be stopped." Marginal NVS

"[Le message est que] les parents ont le pouvoir de contrôler la consommation de boissons sucrées." (The message is that parents have control over sugary drink consumption.) Marginal NVS

"Parents, think about what you're putting in your fridge. If you don't buy it, it's not there for [your children] to choose." Adequate NVS

"[The ad says that] we are supplying teens with too many sugar drinks, even if we don't realize they are sugary. We are able to stop this consumption by not buying them." Adequate NVS

Target Audience:  Across groups, the target audience of this concept was clearly considered to be parents.  Most parents, however, felt the message was more important to communicate to youth rather than parents, given that teenagers make many purchase decisions outside the home.

"[C'est] dirigé aux parents. Si on n'achète pas de boissons sucrées, nos enfants ne peuvent pas les boire." (It's directed to parents; if we don't buy sugary drinks, our kids can't drink them.) Adequate NVS

Strengths / Likes:  The concept's inclusion of facts was well liked and considered hard hitting, "in your face", aggressive, attention-getting and memorable.  It was appreciated that the design clearly identified that there is a problem with sugary drinks. Reference to facts (70%) or 'because you buy it' were generally well liked. That said, the risks and consequences of sugary drinks is not adequately communicated.

"Ils nous mettent en image le choix qu'on fait tous les jours, mais ils ne nous disent pas quelle est la conséquence de nos choix." (They show us choices we make every day, but they do not tell us the consequences of our choices.) Adequate NVS

Participants appreciated the wide range of drink types shown in the visuals and felt they accurately reflected the diversity of sugary drinks in the market. Participants also liked the image of crushing the can, considering it powerful and suggestive of taking action. 

Some questioned the first-person approach, and the use of both 'you' and 'we' received a mixed response.  While some felt it was forceful and effective, others perceived it as aggressive in tone.  Overall, the phrases clearly helped to motivate action and establish personal relevance for viewers.

"As a parent this makes me feel empowered to make change.  It's straightforward and tells me that I have the power." Marginal NVS

Dislikes / Weaknesses:  Despite an overall positive reaction to this concept, there were a number of aspects of the concept that proved problematic to some. Most notably, while the use of facts was well liked, the concept lacked clarity to some, with parents questioning why sugary drinks are a problem or why a change is needed.

"So what?  I need to know why!  What's the harm?" Marginal NVS

"It gives the facts, but doesn't say why it's a problem." Adequate NVS

"What this is missing is why is it so bad? That link needs to be made." Marginal NVS

The animated kaleidoscope was criticized as lacking purpose and clarity and was considered out of synch with the rest of the concept. Participants questioned what it was trying to communicate.  The use of inanimate objects was questioned by some. While the animated beverage design was deemed interesting to some, others felt the idea was familiar and cited an animated gum ad (Excel) as a similar design currently in market. Others felt the floating images looked like it should be an ad for a company selling bottled water.

"The beginning imagery is disjointed from the rest. It doesn't really fit." Adequate NVS

Some parents took exception to showing a female (i.e. mother) carrying the grocery bag, believing it suggested that the purchase of sugary drinks is the mother's fault. Others felt that it reflected their household reality.

"As a mom, I don't need anything else that the family can blame on me!" Marginal NVS

"This is beating up on women.  It suggests that women are making the bad choices." Marginal NVS

As mentioned, this concept evoked a strong emotional response, conjuring anger among some parents.

"This gets my back up.  It's saying we're like drug dealers – we're giving the 'drugs' to our kids and harming them. It says you're at fault.  A bit of a guilt trip." Adequate NVS

"This is harsh.  It's pointing the finger.  I feel a bit attacked." Marginal NVS

Animation / Real Actors: Across groups, most concurred that the concept would be best suited using real people rather than animation, as it would establish greater personal relevance. Animation was generally considered to be more relevant to a youthful audience rather than parents.  A few, in fact, felt the visual of the large glass coming through the door was reminiscent of the 'Kool-Aid Man'.

Call to Action: More than any other concept, this idea was likely to result in some type of action, be it a change in purchase decision, contemplation of their family's behaviours or a discussion with family members. That said, despite the concept's directive nature, participants criticized it for lacking a clear call to action.  In particular, there was no apparent reason to visit the site for more information.  In addition, parents felt strongly that if they visited the website, the site must effectively back up the statistics that are presented in the concept.

Tagline: The English tagline '...don't sugar coat it' was well liked across groups and considered effective, memorable and a creative play on words.  By contrast, the French tagline 'C'est la vérité. Ne la diluez pas' was deemed weak, meaningless and not essential in conveying the concept's message. In fact, ending the ad with 'Vous avez le pouvoir d'arrêter' was considered as leaving a much more impactful impression to viewers. The two other taglines presented as alternatives ('C'est la vérité mais elle n'est pas sucrée' and 'La vérité n'est pas sucrée') were also deemed weak and irrelevant.

"'Don't sugar coat it' is a powerful play on words.  I like it!" Adequate NVS

Suggestions for Increased Relevance: When asked what would establish greater personal relevance, or make the concept more effective, a variety of suggestions were made, including:

• Create a stronger link between the presented facts and the risks associated with sugary drinks.
  Across locations, a number of participants suggested that when the drinks are spilling, sugar should be pouring out.  Alternatively, a few suggested a blue box imagery with diverse empty bottles. In addition, it was suggested that words should pour out with the sugar, naming the various risks of sugary drinks (i.e. obesity, type 2 diabetes, addiction, mood swings, acne, etc.).
• Use a more gender-neutral image for the shopping bag scenario.
• Include a more obvious call to action, such as 'to find out how visit the website'.
• Soften the ad to lessen the 'accusatory' tone that places the burden and responsibility solely on parents.
• Reconsider use of the French tagline "C'est la vérité. Ne la diluez pas."

Concept B: Shhh...

This concept was generally disliked, considered boring and lacking personal relevance to most.

This concept was poorly received across locations and group types and criticized for its 'silly' or 'corny' approach that did not effectively grab viewers' attention.

"It needs to either hit your funny bone or pull your heart strings. This doesn't bring out any emotions. I have no buy in to this." Marginal NVS

Key Message:  The main message of this concept was considered to be if you offer no other alternatives, your children will drink water, or that you can get your children to drink water by removing all other options. Many felt this suggested that mothers are trying to 'pull one over' on their kids or trick them into drinking water.

"[It says that] moms are sneaky and fun suckers." Marginal NVS

"Après avoir fait des efforts, la mère se rend compte que les habitudes sont changées et que même les amis ont subi l'influence de boire de l'eau." (After having put in efforts, the mother realizes that habits have changed and that even friends are now drinking water.) Marginal NVS

"Parents are easily able to switch kids' drinks to water without much fallout." Adequate NVS

"C'est un exploit et la mère n'en revient pas que les ados boivent de l'eau." (It's a success and the mother is surprised that the teens are drinking water.) Adequate NVS

Target Audience:  Across groups, the target audience of this concept was clearly considered to be parents.

Strengths / Likes:  Some participants appreciated the suggestion that water is an effective drink alternative to have in the home.  For a few, the 'shhh' grabbed attention, encouraging them to watch, and a few female participants considered the video recording scenario to be relevant to them personally and likened it to their own actions.

In the French-speaking groups it was felt that the tone of the ad is more positive, showing viewers what parents can do well to change behaviours, rather than parents being blamed for what they are doing wrong.

"Ça me dit ce que je fais de bien et comment je peux m'améliorer plutôt que ce que je fais de croche." (It tells me what I do well and how I can improve rather than what I do wrong.) Adequate NVS

Dislikes / Weaknesses:  For most parents, this concept was considered boring and ineffective at grabbing attention. Most parents questioned why the mother would be filming children drinking water and felt it was an unrealistic scenario that did not align with their home values or lifestyle.

At the same time, the mother's excitement at the fact that her children were drinking water implied that it was a 'victory' to her efforts, somewhat of an over-reaction to the situation. Many parents felt that it is not that big a deal to get their children to drink water at home. Further, the concept lacked rationale as to why sugary drinks are a problem, and why someone should make the change to water.

"On dirait que c'est plate de boire de l'eau; c'est comme un prix de consolation." (It makes it look like drinking water is boring; that it is a consolation prize.) Adequate NVS

In addition, parents criticized the concept for not showing how the mother got the youth to drink water, questioning if it was simply removing any other options. Indeed, the concept does not effectively explain how the behaviour shift was achieved, thus making it sound more like a fluke than a planned outcome.

"It shows you an end state but not how to get there." Adequate NVS

"J'ai l'impression qu'elle ne le croit même pas elle-même. Elle ne sait pas d'où sort son succès." (I get the feeling that she doesn't even believe it herself; that she has no idea where this is coming from.) Adequate NVS

The concept presented lacked personal relevance to most participants for a number of specific reasons:

• The scenario: It was felt video games are often played by teenagers in separate locations, or in front of multiple screens with headsets on, rather than in front of one screen in a room.  Many felt the scenario (kids gathering in a home) is not necessarily relevant to them today.
• The food: The type of snack shown (i.e. a sandwich) was considered unrealistic for a group of teenagers and not something they would typical provide to a group of friends.  Alternatively, popcorn or chips were deemed more realistic.
• The recording: Most parents disliked the mother sneaking up on the kids and video taking the scene.  They considered it to be sneaky and questioned who the mother would be sending the video to.

Animation / Real Actors: Once again, most felt the concept would be best suited using real people rather than animation, to establish greater personal relevance.

Call to Action: The concept lacks a clear call to action to encourage parents to make a change. Indeed, it does not specify how the mother achieved her success nor does it explain why a change in behaviour is warranted. Further, viewers are not motivated to click the link.

Tagline: The tagline was considered inaccurate and problematic to most.  While a few agreed that getting kids to drink water was a win, most felt that water was presented as the only offering or potentially the last resort.  Accordingly, some questioned how having no choice would make it a win. The French tagline, "Éliminez les boissons sucrées de votre maison, c'est facile et c'est gagnant" was not well received, as it speaks of eliminating sugary drinks rather than reducing them, in sharp contrast to parents' belief in moderation.

"La vie c'est la modération; mais pas l'élimination." (Life is all about moderation, not elimination.) Adequate NVS

"What worked? What was the "win"? Kids can change...but to see this, there needs to be a choice." Marginal NVS

When asked what would establish greater personal relevance, or make the concept more effective, suggestions included:

• Create a more relevant scenario (headphones, multiple screens);
• Show children choosing water (a real win) rather than other drinks available;
• Highlight why water is a better option than sugary drinks; and
• Include a clear call to action giving parents a reason to click on the link.

Concept C: Refrigerator

Although well received and considered realistic in the scenario presented, the concept was not deemed compelling to motivate change.

This concept was generally well received and parents appreciated its personal relevance in the various elements of the presented storyline.  While most appreciated that the idea was not personally threatening or critical of parents, there was no compelling motivation to take action.

Key Message:  The main message of this concept was considered to be that keeping sugary drinks out of your home will keep them out of your children's hands, or that 'out of sight is out of mind'.  While parents generally agreed with this message, the concept lacked rationale as to why a shift to water is required or justified.

"[This says] out of sight, out of mind. They won't care if I don't buy it." Marginal NVS

"Because making food/beverage choices can often be down "by rote" or on "auto-pilot", it is important to provide easy healthy choices." Marginal NVS

"L'adolescent est capable de se passer de boisson gazeuse." (The teenage is able to live without pop.) Marginal NVS

"Don't provide sugary drinks; 'out of sight, out of mind'." Adequate NVS

Target Audience:  The target audience of this concept was considered to be parents and to a lesser extent youth.  That said, many parents felt that youth would readily relate to the scenario presented.

"Le message est dirigé aux parents et aux ados. S'il n'y en a pas [de boissons sucrées], ils ne peuvent pas les boire." (The message targets both parents and teenagers; if there are no sugary drinks, they can't drink them.) Adequate NVS

Strengths / Likes:  Across groups and locations parents appreciated the portrayal of the teenager being 'zoned out' and wearing headphones.  This scenario was considered relevant and consistent with the reality they experience.  The absent-mindedness and 'auto-pilot' actions were also considered true to life, as was the messy kitchen to most.  The creative portrayal of the disappearing drink was liked by most, but considered familiar to other advertisements for some.

Parents liked that this concept did not point blame on the parents for their choices.

"This takes the blame off the parent and comes from a product point of view.  More focused on a choice-based scenario." Marginal NVS

Dislikes / Weaknesses:  A number of elements were considered problematic or lacking relevance to some parents.  Most notably, the comic book was criticized for being inappropriate and out of touch with current teenager behaviour.  Across groups, an iPad, iPhone or tablet was suggested as a more effective alternative.

In addition, some felt having a teenager make a healthy sandwich as a snack is not a common occurrence and considered microwave popcorn, cereal, cookies, crackers and cheese or another snack would be a more appropriate depiction.

Some felt including a jug of water in the fridge was not relevant to many homes given the prevalence of fridges with built in water dispensers (eliminating the need to open the fridge) or water coolers. It was also felt that showing other beverage options in the fridge would be a more realistic depiction of people's situation, still having the teenager choosing water.  Further, the concept was criticized for assuming that everyone knows what a sugary drink is.

A few parents did not like the message of 'out of sight, out of mind' as it did not suggest the importance of educating young people on the choices they make. It was recommended that the can of pop should remain and the teenager purposefully choosing water.  Further, parents criticized the concept for note indicating why a water choice is important.

"It's not telling us anything we don't already know.  There is no convincing message here." Marginal NVS

"No compelling reason to change. Why is it so important to?" Adequate NVS

Animation / Real Actors: Most felt the concept would be best suited using real people rather than animation, to establish greater personal relevance.  That said, it was assumed that the disappearance of the beverage would include some type of animation.

Call to Action: This concept did not motivate viewers to take action or click on the link.

"They've got to pop it up. It's boring It doesn't suggest I should do anything." Marginal NVS

Tagline: The tagline 'don't stock up on sugary drinks' was generally supported, but again was not justified as a course of action. Of the three taglines presented in the French groups, 'On ne pense pas à ce qu'on ne voit pas' was preferred over 'Pour la plupart des enfants, loins des yeux, loin du ventre' and 'Pour la plupart des enfants, ce qui est hors de la vue tombe vite dans l'oubli'.

A number of suggestions were made to enhance the concept, including:

• Show more relevant situations by replacing the comic book with a tablet or phone;
• Feature a different type of snack that is more realistic; and
• Include a stronger, more compelling call to action.

Website URL

The website URL should consider an action-oriented name that is suggestive of healthy drinks.

Throughout all concepts, parents were shown one specific URL, namely: Canada.ca/healthydrinks. When presented with two distinct options (Canada.ca/healthydrinks or Canada.ca/sugarydrinks) parents were more inclined to voice preference for a URL including 'healthydrinks' versus 'sugarydrinks'.  While some felt that 'sugarydrinks' made them curious, most believed including 'healthydrinks' implied that you would be able to get clear direction to a solution at the site and that information would be provided on what a healthier drink might include.

Some, in fact, felt that inclusion of 'sugarydrinks' served to promote the notion of sugary drinks.  In contrast, 'healthy drinks' was considered a more positive and healthy alternative, more in line with what they would expect from the federal government. That said, in English locations, parents felt the URL should be more action oriented, explicitly implying a change.

"It needs to be action oriented. Something that suggests I'll get direction on how to do that." Marginal NVS

Suggestions included naming such links:

• Canada.ca/drinkhealthy
• Canada.ca/drinkwater
• Canada.ca/choosehealthydrinks
• Canada.ca/killsugarydrinks
• Canada.ca/avoidsugarydrinks

Communications

Parents have clear expectations of what information they would find on a 'healthydrinks' website.

Information Searches

When looking for information on sugary drinks, participants consistently reported that they would first and foremost complete generic Google searches. If, however, they were to click on the link to Health Canada's website, parents have clear expectations as to what they would expect to find, including:

• Clear, unbiased facts / statistics
• Non-partisan information
• Daily recommendations of sugar intake
• An outline of how much sugar is in various types of sugary beverages
• Visual presentation of sugar content (i.e. teaspoons)
• A description of sugar defined
• Details on the risks associated with sugary drinks
• Conversion tools to help calculate a beverage's sugar content
• Direction as to how to read drink labels
• Healthy drink alternatives / substitutions
• Ideas for making water more appealing
• Healthy recipes
• Brief 15-30 second videos on how to make healthy alternatives
• A kid friendly zone that allows youth to find out sugar content for specific drinks
• Links to related sites that provide helpful information related to associated risks (e.g. Diabetes, obesity)
• Testimonials (telling how switching to water, or reducing sugary drinks impacted them)

Tools and resources deemed helpful would include an app that provides guidance on sugary beverage intake or healthy alternatives, a calculator to help determine a drink's sugar content.

When asked what would compel parents to make change, parents consistently mentioned that knowledge is essential.  Most did not believe that promotions or giveaways are necessary, though some suggested a water bottle giveaway or water flavouring could inspire change. In essence, to motivate a shift in behaviour, parents need to understand what the risks of drinking sugary drinks are and why they need to make change.  The use of well -grounded facts was felt to motivate change.

Blogs

The use of blogs has limited appeal to parents.

Across groups, following blogs was generally not a typical behaviour of parents.  Indeed, in most locations, only a few parents professed to follow blogs. Accordingly, participants offered few suggestions of what type of blogger would be ideal for the topic, with suggestions ranging from sport celebrities, to chefs, the Prime Minister, comedians, doctors or nutritionists.  Most parents concurred that they would not likely sign an online pledge to remove sugary drinks from their home, unless inspired by some type of incentive.

Direct Mail

Direct mail design preference is mixed, though parents believe any information must clearly outline the risks of sugary drinks and why they should be minimized.

When considering a direct mail initiative on the topic, English-speaking participants generally preferred a more creative approach (e.g. a postcard) rather than a formal letter from the federal government in an official government envelope.  By contrast, French-speaking participants indicated they would pay more attention to a formal government letter. The concept of a door hanger was consistently disliked across locations, and considered inappropriate given the large number of community mailboxes, or the impact of inclement weather on such an approach.

Across locations, some parents harshly criticized spending money on mass communications to the home, perceiving it to be a waste of money on an item that would be seen as frivolous and unnecessary.  The exception would be if the marketing piece provided important information that parents need to know (rather than a generic directive that is unjustified). Any material should clearly outline the risks of sugary drinks and why they should be minimized.

There was little appeal for an information piece that could be kept as a reminder, although it was suggested that a fridge magnet indicating sugar content of popular drinks may be of value. It should also be noted that a number of participants expressed a desire for the Government to clarify product labelling to help consumers more easily identify the amount of sugar contained in packaged foods.

Research Methodology

Target Audiences

The target audience for this study consisted in parents of children 11-18 years old.

Research Approach

A total of eight traditional focus groups were conducted, namely two groups in each of Calgary, AB (November 14, 2017); Quebec City, QC (November 15, 2017); St. John's, NL (November 16, 2017); and Sudbury, ON (November 20, 2017). Groups in Quebec City were conducted in French while they were in English in all other locations. In each location, one group was conducted with parents 18-69 years old with marginal health literacy (scoring less than 4 out of 6 on the Newest Vital Sign), while the second group was conducted with those who have adequate health literacy (scoring at least 4 on the Newest Vital Sign). Each group included a mix of gender, age, employment status, education, household income and household situation (e.g., single family, blended families). In addition, where possible a mix of cultural background was achieved, including the inclusion of new Canadians and Indigenous people representation. In each group, a total of 10 individuals were recruited, with each participant having received $75 in appreciation for their time. Each group discussion lasted approximately two hours.

Context of Qualitative Research

Qualitative discussions are intended as moderator-directed, informal, non-threatening discussions with participants whose characteristics, habits and attitudes are considered relevant to the topic of discussion.  The primary benefits of group qualitative discussions are that they allow for in-depth probing with qualifying participants on behavioural habits, usage patterns, perceptions and attitudes related to the subject matter.  This type of discussion allows for flexibility in exploring other areas that may be pertinent to the investigation.  Qualitative research allows for more complete understanding of the segment in that the thoughts or feelings are expressed in the participants' "own language" and at their "own levels of passion."  Qualitative techniques are used in marketing research as a means of developing insight and direction, rather than collecting quantitatively precise data or absolute measures.  As such, results are directional only and cannot be projected to the overall population under study.

Recommendations

The following recommendations are based on the study findings and are presented for Health Canada's consideration.

As Health Canada moves forward with the development of its sugary drink reduction social media campaign, findings underscore the importance of such a campaign's implementation.  Indeed, despite statistical evidence, and acceptance that sugar poses health risks, parents do not recognize the need for sugary drink consumption in their own household.  Further, they do not recognize the importance they play in influencing their pre-teen/teenagers' choice of healthy drinks. This highlights the importance of any campaign not merely suggesting change, but rather clearly outlining what risks are involved and why change is necessary. As the social media campaign is further developed, research findings suggest the following be considered.

1. Messages related to the reduction of sugary drinks consumption at home must be more clearly validated.  While the wording of the statements presented was not problematic, the overall relevance of some key messaging proved problematic to parents. In fact, the statements need to be supported by clear facts as validation.
   
   
2. The Kaleidoscope concept should be further developed.
   Only one of the concepts (Kaleidoscope) evoked a strong emotional response and motivated a behavioural shift, although it caused discomfort for some. Both other concepts were much softer in approach and, while liked by some, lacked a reason for parents to make a change and were less effective at eliciting a reaction.  The Kaleidoscope concept consistently resulted in an immediate reaction, and has the potential to effective drive behavioural change.  This concept was not liked by all, but was most impactful in driving change, reaffirming that a concept does not have to be liked to be effective.
   
   The Kaleidoscope concept, however, would require some modifications if further developed.  In particular:
   • The concept lacks clear identification of why sugary drinks are problematic. As mentioned, many parents do not consider sugary drinks are a problem in their home.  Modifying the beginning imagery to accurately depict why sugary drinks are a problem will create a strong link between the proposed imagery and why the prevalence of sugary drinks in the home is problematic. In multiple locations, suggestions for enhancing the concept included showing sugar pouring out of the drink containers and / or words spelling the various risks.  This treatment would clearly present the problem and effectively set the stage for the following facts and hard messaging;
     
   • Tone Adjustment.  While empowering and forceful, some felt the concept was too aggressive or accusatory. Although creating a stronger link as to why sugary drinks is problematic may itself balance the tone, consideration could be given to soften the tone that implies that parents are solely responsible for the sugary intake of their children;
   • French tagline. Remove or edit the French tagline for greater relevance and impact;
   • Call to Action.  The concept is lacking a clear call to action and should more explicitly invite parents to visit the website for more information and direction; and
   • Visual Adaptation. One visual that proved problematic for some was the mother carrying the grocery bag.  Consideration should be given to depicting a more gender-neutral grocery bag visual.
     
     
3. Inclusion of a clearer call to action is required.
   As mentioned, all concepts lacked a clear call to action.  Parents generally did not feel compelled to visit the website when prompted with the URL on screen.  Findings suggest a more direct call to action is required, clearly pointing the viewer to take action.  Explicit inclusion of a directives such as 'to find out more...' or 'learn more on...' were suggested.  Further, it was proposed that the actual URL be fine-tuned to be more action-oriented and direct.
   
   
4. If developed, a direct mail initiative should ensure it captures the attention of residents and stand out from other direct mail pieces.  Any such communication piece should express some urgency, clearly outlining the risks associated with sugary drinks, and why parents need to take action.   

Appendix A: Recruitment Screener

Sugary Drinks Reduction Campaign Screener – Final

Name:

Daytime phone:
Evening phone:

Email:

Group 1 2 3 4 5 6 7 8 

Focus Groups:

Calgary, AB (English)
Date: Tuesday, November 14, 2017
Location: eStyle 24-2500 4th Street SW
Time:
Group 1 – 6:00pm – Parents with Marginal NVS
Group 2 – 8:00 pm – Parents with Adequate NVS

Quebec, QC (French)
Date: Wednesday, November 15, 2017
Location: SOM Quebec 3340, rue de La Perade 3rd Floor
Time:
Group 3 – 6:00pm – Parents with Marginal NVS
Group 4 - 8:00pm – Parents with Adequate NVS


St. John's, NL (English)
Date: Thursday, November 16, 2017
Location: MQO Research 55 Duckworth Street
Time:
Group 5 – 6:00pm – Parents with Marginal NVS
Group 6 - 8:00pm – Parents with Adequate NVS

Sudbury, ON (English)
Date: Monday, November 20, 2017
Location: Oraclepoll Research 130 Elm Street
Time:
Group 7 – 6:00pm – Parents with Marginal NVS
Group 8 - 8:00pm – Parents with Adequate NVS

Specification Summary

• Six (6) English focus groups, namely two in each of Calgary, Sudbury, and St. John's;
• Two (2) French (first language) focus groups in Quebec City
• Groups 1, 3, 5, 7: In each market, one group will include parents (18-69 years old) of pre-teens and teens aged 11-18 years old with marginal health literacy as screened by the NVS
• Groups 2, 4, 6, 8: In each market, one group will include parents  (18-69 years old) of pre-teens and teens aged 11-18 years old with adequate health literacy as screened by the NVS
• Mix of age (18-69 years old), gender, employment status, education, household income and family composition for each group
• Mix of household situation (e.g. single family, blended families)
• Max 5 per group unemployed, student, stay at home parent or retired
• Mix of cultural backgrounds including some new Canadians and Indigenous people representation, where possible
• Recruit 10 participants per group
• Incentive: $75 per participant

Hello/Bonjour, my name is_ and I am with Corporate Research Associates, a market research company. We are conducting a study on behalf of the Government of Canada, specifically for Health Canada, and we are looking for people to take part in a small group discussion. We would like to speak with someone in your household who is a parent or guardian of a child between the ages of 11 and 18 years old. Would that be you? If no, ask to speak with someone else and repeat intro.

The purpose of the study and the small group discussions is to hear people's views on some advertisements. Those who qualify and participate in the group discussion will receive $75 in appreciation for their effort.

May I ask you a few quick questions to see if you are the type of participant we are looking for to take part in this small group discussion?  This will take about 6 or 7 minutes. The information you provide will remain completely confidential and you are free to opt out at any time. Thank you.

Gender (By Observation):

1. Female Recruit 4 per group
2. Male Recruit 6 per group

1. To begin, into which of the following age groups do you fall?  Are you...?

1. Less than 18  Thank and Terminate
2. 18-29  Recruit mix in each group
3. 30-39  Recruit mix in each group
4. 40-49  Recruit mix in each group
5. 50-59  Recruit mix in each group
6. 60-69  Recruit mix in each group
7. Over 70  Thank and Terminate

2. To confirm, are you a parent or guardian of a child aged 11-18 years old?

1. Yes  Continue
2. No  Thank and Terminate

3.  Do you, or does anyone in your household currently work or have worked in any of the following areas?

1. Marketing/Market Research
2. Public relations
3. Advertising
4. Media (TV, Radio, Newspaper)
5. Communications and creative agency
6. Medical sector
7. Government department, federal, provincial or municipal that is responsible for health or public health
8. An organization involved in health promotion or advice on nutrition or healthy eating

If yes to any of the above, thank and terminate

4. And do you, or does anyone in your household currently work or have ever worked in the food and beverage industry, including...?

1. Food or beverage manufacturing
2. Associations or organizations representing the interests of the food and beverage industry
3. Associations or organizations representing a particular type of food and/or beverage
4. Other areas of the food and beverage industry (Please specify:)

If yes to any of the above, thank and terminate

5. What is your employment status?  Are you currently ... ?

Read responses in order—Code one only

1. Employed full-time  
2. Employed part-time
3. Self-employed
4. Unemployed  Max 5 per group
5. Student  Max 5 per group
6. Stay at home parent  Max 5 per group
7. Retired  Max 5 per group
   Volunteered
8. Refused

6. If employed, ask: What is your current occupation?

Terminate if similar occupations as in Q3 or Q4

7. If retired, ask: What was your occupation before you retired?

Terminate if similar occupations as in Q3 or Q4

8. We would like to invite a good cross section of people of different income levels. Which of the following best describes your total household income before taxes last year?  Would you say...?

Read responses in order—Code one only

1. Less than $30,000  Recruit a good mix in each group
2. At least $30,000 but less than $50,000  Recruit a good mix in each group
3. At least $50,000 but less than $75,000  Recruit a good mix in each group
4. At least $75,000 but less than $100,000  Recruit a good mix in each group
5. $100,000 or more       
   Volunteered
6. Refused

9. What is the highest level of education you have finished?

Recruit a good mix in each group

1. Elementary  
2. Some High School/Professional Training 
3. Completed High School 
4. Some College / Technical Training
5. Completed College / Technical Training 
6. Some University
7. Completed University

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

Aim for a mix in each group where possible 

1. As a single parent with your children at least some of the time
2. With a partner or spouse and your children.
3. As a blended family (with a spouse and yours and/or their children)
4. Other (Specify:)

11. To make sure that we speak to a diversity of people, could you tell me what is your ethnic background?  Do not read

1. Caucasian
2. Chinese
3. South Asian (i.e. East Indian, Pakistani, etc)
4. Black
5. Filipino
6. Latin American
7. Southeast Asian (i.e. Vietnamese, etc)
8. Arab
9. West Asian (i.e. Iranian, Afghan, etc)
10. Korean
11. Japanese
12. Indigenous people (First Nations, Métis, or Inuit)
13. Other (please specify)
14. I'd prefer not to say

12. Which of the following statements best describe yourself?

Aim for a good mix in each group

1. I pay close attention to the food and beverages I consume, and I am very interested in health-related information
2. I pay some attention to the food and beverages I consume, and I am moderately interested in health-related information.
3. I do not pay close attention to the food and beverages I consume, and  I am not really interested in health-related information.

13. Have you ever attended a small group discussion for which you received a sum of money?

1. Yes Continue – Max of 5
2. No Go To Invitation

14.  How many group discussions have you attended in the past 5 years?

15.  What was the subject of all of the group discussions you have ever attended?

16. When was the last time you attended a group discussion?

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

1. Yes See instructions
2. No See instructions

Once they have received the email and are looking at the label, proceed with the interview:

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

Note to interviewer:

• The questions must be asked in order.
  Continue even if the respondent gets the first few questions wrong. However, if Q.17E is answered incorrectly, do not ask Q.17F.
• 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 - Groups 2, 5, 8, 11
  Score of 4-6: qualifies for Adequate Health Literacy Group - Groups 3, 6, 9, 12

17A.The first question based on the information from the label is, if you eat the entire container, how many calories will you eat?

• Record Answer:
• Do not read: Correct Answer: 1,000 is the only correct answer

17B.If you are allowed to eat 60 grams of carbohydrates as a snack, how much ice cream can you have?

• Record Answer:
• Do not read: Correct Answer: Any of the following is correct:
  • (a) 250 ml or 1 cup (or any amount up to 250 ml or 1 cup), or
  • (b) 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.

17C.Your doctor advises you to reduce the amount of saturated fat in your diet. You usually have 42 g of saturated fat each day, which includes one serving of this particular ice cream. If you stop eating ice cream, how many grams of saturated fat would you be eating each day?

• Record Answer:
• Do not read: Correct Answer: 33 is the only correct answer

17D.If you usually eat 2,500 calories in a day, what percentage of your daily value of calories will you be eating if you eat one serving of this ice cream?

• Record Answer:
• Do not read: Correct Answer: 10% is the only correct answer

17E.Pretend that you are allergic to the following substances: penicillin, peanuts, latex gloves and bee stings. Is it safe for you to eat this ice cream?

• Record Answer:
• Do not read: Correct Answer: No

17F.Ask only if answer in Q.14E is "No": Why not?

• Record Answer:
• Do not read: Correct Answer: Because it has peanuts/peanut oil

Score of 0-3 Correct Responses: qualifies for Marginal Health Literacy Group – Groups 2, 5, 8, 11
Score of 4-6 Correct Responses: qualifies for Adequate Health Literacy Group – Groups 3, 6, 9, 12

Invitation

Based on your responses, it looks like you have the profile we are looking for. I would like to invite you to participate in a small group discussion, called a focus group, we are conducting at _ PM, on As you may know, focus groups are used to gather information on a particular subject matter; in this case, the discussion will touch on the beverage choices you make, as well as reviewing some advertisements.  The discussion will consist of 8 to 10 people and will be very informal.  It will last approximately two hours, refreshments will be served and you will receive $75 as a thank you for your time.  Are you interested and available to attend?

1. Yes  Continue
2. No   Thank and Terminate

The discussion you will be participating in will be audio and video recorded for use by the research team only to analyze the findings.  Please be assured your comments and responses are strictly confidential. Are you comfortable with the discussion being recorded?

1. Yes  Continue
2. No  Thank and Terminate

The discussion will take place in a room that is equipped with a one-way mirror for observation, allowing Health Canada employees who are involved in this research to observe the discussion without disturbing it. Some people may also be observing the discussion remotely [SPECIFY ONLY IF ASKED: via web streaming, through the use of a secure online portal].  Your participation will be anonymous and only your first name will be given to these people. Would this be acceptable to you? 

1. Yes    Continue
2. No   Thank and Terminate

During the group discussion, participants will be asked to read materials and write out short responses. Is it possible for you to take part in these activities in English without assistance?  

1. Yes Continue
2. No Thank and Terminate

Terminate if person gives a reason such as verbal ability, sight, hearing, or related to reading/writing ability.

Since participants in focus groups are asked to express their thoughts and opinions freely in an informal setting with others, we'd like to know how comfortable you are with such an exercise.  Would you say you are...?

1. Very comfortable Continue
2. Comfortable Continue
3. Not very comfortable Thank & Terminate
4. Not at all comfortable Thank & terminate

Thank you. Just a reminder that the group discussion will be held on [DATE] from [TIME] to [TIME]. To make sure that the discussion begins on time, we ask that you arrive 15 minutes before the start. We will not be able to include you if you arrive late and you will not receive the financial incentive.

Please bring your glasses if you need them to read, and anything else you need to take part in the group discussion. Also, everyone is asked to bring a piece of I.D, picture if possible.

Someone from our company will call you back one or two days before the group discussion. To do that, we will need your contact information. Record at the top of the screener

As these are small groups and with even one person missing, the overall success of the group may be affected, I would ask that once you have decided to attend that you make every effort to do so. If something comes up and you are unable to attend, please call_ (collect) at _as soon as possible so we can find a replacement.

Thank you, and we look forward to hearing your thoughts during the group discussion.

Attention Recruiters

1. Recruit 10 per group
2. Check quotas
3. Ensure participant has a good speaking (overall responses) ability-If in doubt, Do not invite
4. Do not put names on profile sheet unless you have a firm commitment.
5. Repeat the date, time and location before hanging up.

Confirming – Day before group

1. Confirm in person with the participant the day prior to the group– do not leave a message unless necessary
2. Confirm all key qualifying questions Q1 & Q2
3. Verify time location (ask if they are familiar)
4. Remind them to arrive 15 minutes before the start
5. Ask them to bring reading glasses or anything else they need to read and/or take part in the discussion (such as hearing aid)

Appendix B: Moderator's Guide

Moderator's Guide – Final

Sugary Drinks Reduction Campaign - Focus Groups

Objectives (not to be shared)

• Explore perceptions towards sugary drinks, including beverage consumption patterns and actions related to replacing sugary drinks at home.
• Evaluate three campaign creatives, assessing each creative's messages to determine if they are: clearly understood, credible, visually appealing, appropriate /relevant, and of value.
• Determine how effective each campaign is for motivating change / empowering the audience to make change.
• Provide direction for potential changes to ensure campaign content resonates with the target audience.
• Explore audience understanding of select terms to inform message development.

Introduction 10 minutes

• Welcome: Introduction of self and role as moderator (encourage participation/guide discussions)
• Discussion topic: Beverage choices you make, and marketing
• Sponsor: Government of Canada, specifically Health Canada
• Length: Our discussion should last about two hours, without a break
• Process: All opinions are important; looking to understand agreement and disagreement; talk one at a time; interested in hearing from everyone
• Logistic: Audio/video taping; observation from Government of Canada (in-person or remote)
• Confidentiality: Participation is voluntary; comments are anonymous; no names in reports; participation in research has no effect on your dealings with the Government of Canada. I'd ask that you keep our discussion today confidential, and not share its content with others.
• Participant introduction: First name, who lives in your home (probe for number age of children), and what is your favourite non-alcoholic beverage.

Eating Habits  20 minutes

For the first part of our discussion, I'd like to learn more about the beverages you and your family drink.  As part of our discussion today, I'll be asking each of you to complete a few exercises.  These will help me get your personal opinions, before our general discussion. I've put all the exercises on a few placemats. [Moderator distributes first placemat]

The first exercise {#1} shows a lot of different types of beverages that you may or may not purchase and/or consume often.  You'll see under each picture there is a square and a triangle.  Please check in the square, which of these you usually drink.  Then, check in the triangle which ones your pre-teen /teen (child 11-18) usually drinks. 

You'll notice on your sheet a RED circle.  Before we finish the first exercise, in the RED circle, please check which of these drinks you would consider to be a sugary drink.

On another placemat, I have three more exercises for you to complete.

Exercise #2: 'Define Sugary Drinks'. Describe how you determine if a drink is considered a 'sugary drink'. What does that expression mean?

Exercise #3: 'My Opinion'. Put an X where you think you fit between each pair of statements. Try not to think about these too much; I am interested in your first reaction. We'll walk through this together so you're clear on how to do it. Then I'll give you a few minutes.

Exercise #4: Teen Consumption: Many beverages on your placemat would be considered a sugary drink.  You'll see [Exercise #4] a visual of a pitcher or jug. 

Assuming that a full jug would be all the beverages your child consumes in a typical day, I want you to colour in how much of that jug would be sugary drinks.  I'll give you a minute.

I'd like to learn more about what your household drinks...

• Why do you buy the beverages you do? [e.g. price, taste, habit]
  • How are your children influencing the beverages you buy?
• What type of beverages did you consider to be sugary drinks? [refer to images on sheet]
• How do you distinguish sugary drinks from non-sugary drinks? What's the difference?
• When does your child usually drink sugary drinks? (Meal time or other)?
  • Under what circumstances do you give your child sugary drinks? (e.g. sports)
• Are you worried about your child's consumption of sugary drinks?
• What do you consider to be the risks of drinking sugary drinks?

Drink Replacement

• Have you ever tried to reduce sugary drink intake at home?
  • If yes, what did you do? If not, why not?
• Have you tried substituting sugary drinks with water?
  • If no, why not? What might prevent from doing so?
  • If so, how did that go?
  • What would make water more appealing your kids?
  • Would your kids drink water with dinner if that was the only option?
• What would motivate you to replace sugary drinks with water in the home?

Statements 10 minutes

I'd like to get your thoughts on a few statements related to sugary drinks.  These statements could appear on Health Canada's website, or on promotional material. You each have two highlighters (YELLOW and GREEN).  As we read through each statement together, please highlight anything that strongly speaks to you in GREEN, and anything that is confusing or not believable, highlight that in YELLOW. (So green is good, yellow is caution).  Let's read through them together...

1. Replace sugary drinks with water in your home.
2. Sugary drinks are the highest contributor of sugars in our diets.
3. Teens are the highest consumers of sugary drinks.
4. Teens are drinking the most at home in the afternoon/evening, due to availability.
5. Parents are the highest influencers of their teen's consumption.
6. There are many ways to make water an appealing choice.
7. Drinking sugary drinks can lead to an increased risk of obesity, type 2 diabetes and tooth decay.

• Any statements problematic for you?  What if anything would you change?

Concept Testing  60 minutes

Today I'd like to get your thoughts on some creative concepts being considered related to sugary drinks. I have three creative concepts to share with you – they are each 15 second videos which would appear online. As you see these creative concepts, keep in mind these are just ideas at this point.  I'm looking for your reactions to each approach or idea.  I'm going to share each concept with you one at time. Please note that these are draft concepts only. The videos will be produced in colour.

Moderator presents campaigns one at a time – rotate order

Before we discuss each one, I'm going to ask you to share your individual thoughts on that campaign on an exercise sheet. I'd like you to do two things: first, jot down what you consider the main message and then indicate to what extent you agree or disagree with each of 8 statements in relation to this idea.  [moderator reviews statements out loud and scale and gives them a moment to complete the exercise]

Ask for each campaign:

Overall reaction

• Overall reactions?
• What is its main message?

Attention / Target

• What, if anything, grabs your attention? 
• Is this speaking to you, or someone different? 
  • Does it reflect your family values and lifestyle?
• How does this make you feel as a parent?
• What would make it more relevant to you?
• What do you like about this idea?
• What don't you like?
• Concept 1: Preference between animated or live?
• Anything confusing or problematic?
• Comments on the tagline?

Repeat for each concept

I've shared three creative concepts with you today.  Each of these concepts included the website Canada.ca/healthydrinks.  What if this was Canada.ca/sugarydrinks?  Would it make a difference?

I'd like to know which approach you would consider most effective in speaking to you and encouraging you to make a change in your household?  On your exercise sheet, please rank your order of preference.

• Which one did you consider strongest?  Why?
  • What ideas from the other concepts might make your preferred approach even stronger?

Communication  20 minutes

The campaigns I shared with you all spoke about sugary drinks.

• If you were outside your home at a place where you were buying some type of beverage (convenience store, movie theatre, mall, etc.) and saw an ad like these, what would you do?
• If you were looking for information on sugary drinks, where would you go?
• Imagine that you went to the Health Canada website for more information. 
  • What would you expect to find there?
  • Any types of information / resources or tools that you would expect to see?
• Do you pay attention to blogs? 
  • What kind of blogger or celebrity would you pay attention to?
  • If you saw information on this topic on a blog, what would you do?
• Would you share tips on replacing sugary drinks with water on social media?
• How likely would you be to sign an online pledge to replace sugary drinks with water at your home?

Image that the Government of Canada produced some type of direct mail on this topic that went to households.

• Would you be more likely to notice and respond to a creative mail piece (for example, a postcard) received at your home or a Government of Canada letter in an envelope?
  • What about a door hanger?
• What type of incentive might encourage you to replace sugary drinks with water in your household? Probe: Contest/giveaway, coupon?
• If an information sheet on replacing sugary drinks with water was available, would you keep it as a reminder or reference?

Any final thoughts on what the Government of Canada can do to make information about sugary drinks more interesting to you.  Moderator consult with backroom time permitting

Thanks & Closure

That ends our discussion. Thank you for your time and comments. Direct them to the hostess to receive the incentive

Statements

• Replace sugary drinks with water in your home.
• Sugary drinks are the highest contributor of sugars in our diets.
• Teens are the highest consumers of sugary drinks.
• Teens are drinking the most at home in the afternoon/evening, due to availability.
• Parents are the highest influencers of their teen's consumption.
• There are many ways to make water an appealing choice.
• Drinking sugary drinks can lead to an increased risk of obesity, type 2 diabetes and tooth decay.

Individual Exercise Sheet

Concept A:

Main Message:

Concept B:

Main Message: 

Concept C:

Main Message: 

Appendix C: Creative Material Tested

1 Let's not sugarcoat it.

Referred to as the "Kaleidoscope" concept in the report

2 Parenting win

Referred to as the "Shhh" concept in the report

3. Disappearing drinks

Referred to as the "Refrigerator" concept in the report