Healthy Eating Strategy - Dietary Guidance Transformation - Focus Groups to inform approach for communicating healthy eating information - Final Report

Prepared for Health Canada

Supplier name: Earnscliffe Strategy Group
Contract number: HT372-182894/001/CY
Contract value: $234,102.10
Award date: July 26, 2018
Delivery date: January 11, 2019

Registration number: POR 23 - 18
For more information on this report, please contact Health Canada at:
hc.cpab.por-rop.dgcap.sc@canada.ca

Ce rapport est aussi disponible en français.

Healthy Eating Strategy - Dietary Guidance Transformation - Focus Groups on to inform approach for communicating healthy eating information

Prepared for Health Canada
Supplier name: Earnscliffe Strategy Group
July 2018

This public opinion research report presents the results of focus groups conducted by Earnscliffe Strategy Group on behalf of Health Canada. The research was conducted in August and December, 2018.

Cette publication est aussi disponible en français sous le titre : Stratégie en matière de saine alimentation - Modification des recommandations alimentaires - Groupes de discussion visant à guider la façon de communiquer des renseignements sur une saine alimentation

This publication may be reproduced for non-commercial purposes only. Prior written permission must be obtained from Health Canada. For more information on this report, please contact Health Canada at: hc.cpab.por-rop.dgcap.sc@canada.ca or at:

Health Canada, CPAB
200 Eglantine Driveway, Tunney's Pasture
Jeanne Mance Building, Floor 15, Room 1572C
Ottawa Ontario K1A 0K9

Catalogue Number:
H14-320/2019E-PDF

International Standard Book Number (ISBN):
978-0-660-30799-2

Related publications (registration number: POR 23-18:

Catalogue Number H14-320/2019F-PDF (Final Report, French)
ISBN 978-0-660-30800-5

EXECUTIVE SUMMARY
INTRODUCTION
RESEARCH APPROACH
TARGET AUDIENCE
DETAILED FINDINGS
CONCLUSIONS
APPENDIX A: DISCUSSION GUIDE
APPENDIX B: SCREENER

EXECUTIVE SUMMARY

Earnscliffe Strategy Group (Earnscliffe) is pleased to present this report to Health Canada summarizing the results of the two phases of qualitative research to inform the approach for communicating healthy eating information.

Health Canada is revising Canada's Food Guide (CFG) to reflect the latest scientific evidence, and to be more modern and relevant to users. This includes a release of a suite of products using new communication tools to meet the needs of a variety of users - policy makers, health professionals, educators, and the general public. The focus of this wave of research was to inform the approach to communicating healthy eating information including general healthy eating messages and amounts and types of food. The total cost to conduct this research was $234,102.10, including HST.

The objectives of the research were twofold:

To assess pubic and stakeholder views and acceptance of the draft Canada Food Guide visual and brand concepts to ensure understanding and usefulness.
To test messaging provided at different levels of detail and for different targets (consumers and health professionals) to assess for comprehension and their usefulness for application into practice.

To meet these objectives, Earnscliffe conducted two waves of qualitative research.

Phase 1

This phase included a series of six focus groups with the general population and two mini-groups with health professionals and educators.

As part of this phase we tested three at-a-glance tools that communicate healthy eating information as an entry point to Canada's dietary guidance. The at-a-glance tools were tested in both digital and print formats. We also tested social media graphics for each of the three executions.

The focus groups with the general public were conducted in August 2018 in three cities: Saskatoon; Ottawa; and, Kitchener. In each city, the first group was conducted with those at risk of marginal health literacy [as screened by the Newest Vital Sign (NVS) and scoring <4/6)]; while the second group was conducted with those with adequate health literacy (score 4+). The two mini-groups with health professionals and educators were conducted in Saskatoon and Ottawa.

All of the groups were approximately ninety minutes in length. The sessions in Ottawa were conducted in French.

Phase 2

This phase included a series of sixteen (16) focus groups and nine (9) one-on-one interviews with three key audiences. The focus groups were conducted with members of the general public and health professionals, while the interviews were conducted with policy makers.

As part of this phase we tested a number of different approaches to communicate specific healthy eating information. The variations explored in the groups focused on different approaches to communicate on the amounts (including frequency, proportionality and portion) and types of food to consume and limit.

Members of the general population reviewed Dietary Shift Messaging; Directive Messaging (including messaging variations); and, Portion and Proportionality Images. Health professionals and policy makers reviewed Dietary Shift Messaging; Directive Messaging; and Detailed Information for Health Professionals and Policy Makers.

Eight (8) focus groups were conducted with members of the general public in December 2018 in four Canadian cities: Toronto; Halifax; Edmonton; and, Montreal. In each city, the first group was conducted with those at risk of marginal health literacy [as screened by the Newest Vital Sign (NVS) and scoring <4/6)]; while the second group was conducted with those with adequate health literacy (score 4+).

Eight (8) focus groups were conducted with health professionals in December 2018 in four Canadian cities: Toronto; Halifax; Edmonton; and, Montreal. Health professionals included registered dietitians, registered nurses working in public health, food service managers, and professionals who work in health, wellness or education. In each city, one group was conducted with a mix of health professionals responsible for nutrition assessment, screening and intervention; while the second group was conducted with a mix of health professionals responsible for nutrition education.

All of the focus groups were approximately 2 hours in duration. The groups in Montreal were conducted in French.

Finally, nine (9) interviews were conducted with policy makers across Canada in December 2018. The interviews were approximately 30-40 minutes in length.

Please refer to the Recruitment Screeners in the Appendix of this report for all relevant screening and qualifications criteria.

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

The key findings from the research are presented below.

Phase 1

The objective of Phase 1 was to gather views on three at-a-glance tools that communicate healthy eating information as an entry point to Canada's dietary guidance. The at-a-glance tools were tested in both digital and print formats. We also tested social media graphics for each of the three executions.

The overwhelming majority of participants reacted more positively and enthusiastically to concepts that featured real photographs and images to drawings and icons. These images tended to elicit feelings and emotions and made the guidance more relatable.
The advice provided about how to eat, including healthy eating behaviours and habits, was noticed and described as an important evolution over the current food guide.
Among the general population, there was significantly greater interest in a digital version rather than a printed version. Some, especially health professionals and educators, could see utility in having both.

Specific Reactions to the Concepts

***Exhibit A1: Concept 1 - Eat well. Live well. Together.***

Reaction to this concept was very positive: it was often described as appealing and attention-grabbing; and, of the three, it was the one most directly about food and nutrition. Participants described the look and feel as professional and modern and felt the imagery generally corresponded with the messages. They also felt this concept effectively conveyed the importance of eating healthy.
Participants were very enthusiastic about the at-a-glance tool with much praise for the effective use of colour throughout and the variety of colourful images featuring appetizing food. Reactions to the social media examples were slightly less enthusiastic as they featured an empty plate which lacked colour and vibrancy and a visual depiction of the foods to eat healthy.
Indeed, one of the more powerful components of this concept was the plate full of healthy food options. Participants appreciated the variety displayed on the plate, especially the sense of proportion that it conveyed.
Reactions to the tagline, "Eat well. Live well. Together.", were generally very favourable. Most felt it was clear, relevant and to the point. It also fit well with the visual elements of this concept and the message about why healthy eating is important (to live better and longer).

***Exhibit A2: Concept 2 - For the love of eating well.***

Reaction to this concept was mixed. It was often described as attention-grabbing and effective at conveying the social benefits and pleasure derived from enjoying food.
As compared to Eat Well. Live Well. Together., this concept very clearly illustrated the lifestyle advice about how to eat. However, not everyone felt that there was enough guidance about specific nutritional information. Professionals and those with adequate health literacy appreciated the lifestyle advice, whereas those with marginal health literacy questioned its relevance.
The majority of participants appreciated the photos of happy people coming together around food. The photos were appealing, attention-grabbing, and representative of Canada's diverse populations, which was an important distinction highlighted in all of the groups.
However, not all were convinced of the main message this concept conveyed. Many came away feeling that this concept was about the enjoyment of food rather than healthy eating (and nutrition).
Participants felt that the tagline, For the love of eating, fit with this concept but questioned whether it fit with Canada's Food Guide. Some argued that eating for pleasure and eating healthy are not always the same thing.
In contrast to Eat Well. Live Well. Together., the social media examples were the strongest element of this concept. The layout and visuals of people laughing and enjoying each other's company were attention-grabbing.
With respect to the digital version, participants appreciated the variety of foods displayed in the visual at the bottom but felt the guidance about proportionality was not as effectively communicated as it was with the image of the plate in Eat Well. Live Well. Together.

***Exhibit A3: Concept 3 - Bringing healthy eating to life.***

Reaction to this concept was neutral to negative. The approach using cartoon images was described as amateur, out of date, and a source of confusion in that many images did not correlate with the messages (i.e., two hands sharing one plate for "Eat meals with others". As a result, it was deemed less credible than the others.
The overwhelming majority of participants did not believe they would use this concept. The few who would, thought it might be helpful to use to talk to very young children (i.e. school teachers and parents).
The social media examples were described as attention-grabbing but perhaps not in a favourable way. Participants felt that the colours, while vibrant, were a little jarring.
Reactions to the tagline, Bringing healthy eating to life, were generally favourable. It fit well with this concept and Canada's Food Guide, although it lacked the punch of Eat Well. Live Well. Together.

Phase 2

The objective of Phase 2 was to gather views on a number of different approaches to communicate specific healthy eating information. The variations explored in the groups focused on different approaches to communicate on the amounts (including frequency, proportionality and portion) and types of food to consume and limit.

Generally, participants were satisfied with the materials currently being developed and there was a sense that Health Canada was on the right track.
Members of the general public with adequate health literacy, health professionals and policy makers tended to prefer language that was more specific and direct. They felt this was appropriate as it correlated with their perception of the importance of conveying healthy eating guidance to Canadians.
Members of the general public with marginal health literacy tended to prefer language that was less directive and more permissive.

DIETARY SHIFT MESSAGING

The dietary shift messaging was tested with all three audiences. For members of the general public, the objective was to test comprehension and understanding; while for health professionals and policy makers, the objective was to understand how they would use the messaging in their work.

Reactions to the dietary shift messaging were generally positive across all of the audiences. It was felt to be clear, concise, relevant, helpful, and easy to remember.
Given participants see this as an overview, most were comfortable with the lack of specificity in terms of frequency, proportions and portions. However, many felt it would be helpful to include examples for references that were less familiar such as: whole grain foods; unsaturated fats and oils; and, highly processed spreads.

Exhibit A4: SAMPLE - Dietary Shift Messaging

To follow Canada's Healthy Eating Patterns:

Increase Or Eat more
- Beans, peas, lentils or tofu
- Nuts and seeds
- Vegetables and fruits, especially dark green and orange
- Fish and shellfish
- 1% and skim milk, fortified soy beverage and lower fat yogurt
Switch to
- Whole grain foods
- Unsaturated fats and oils
Limit Or Eat less
- Sugary drinks
- Candies and chocolate
- Processed meats
- Highly processed spreads and dressings

DIRECTIVE MESSAGING

The directive messaging was tested with all three audiences. For members of the general public, the objective was to test comprehension and understanding; while for health professionals and policy makers, the objective was to understand how they would use the messaging in their work.

Exhibit A5: SAMPLE - Directive Messaging

How much to eat

To follow Canada's food guide healthy eating patterns:

Eat vegetables or fruits at each meal and snack. Choose vegetables more often than fruits.
- Eat at least one dark green vegetable every day.
- Eat orange vegetables several times per week.
Eat 2 to 4 whole grain foods every day.
Eat protein foods.
- Eat beans, peas, lentils or tofu most days of the week.
- Eat nuts or seeds most days of the week.
- Eat fish or shellfish 2 to 3 times per week. Choose fatty fish most often.
- Choose lean meats, poultry and eggs. These can be eaten most days of the week.
- Choose 1% or skim milk, fortified soy beverage or unsweetened lower fat yogurt with added vitamin D. Have them 2 to 3 times every day.
- Choose lower sodium and lower fat cheese. Eat it less than once per day.
When cooking and preparing foods with oil or fat, choose unsaturated fats.

Reaction to the directive messaging was viewed as a compliment to the dietary shift messaging for those interested in more detailed, specific guidance. While most came away feeling that the language was plain and clear, and there was widespread appreciation for taking an encouraging, positive approach, there was a sense that it was vague especially where frequency, portions and proportions were concerned.
Read in its entirety as one cohesive document, participants felt that there was a lot to remember and questioned their (and their constituents') ability to implement all of the guidance. Indeed, health professionals saw themselves using the information primarily for consultative and menu planning purposes as they worried about providing this to their constituents as a take-away.
In this sense, many thought it would be useful to use these messages individually in messaging about specific topics (i.e., fruits and vegetables, protein foods, etc.).
In terms of the specific messaging and variations (see table below), there seemed to be several agreed upon preferences:
- Most seemed to prefer the use of specific ranges over words like "several" or "a few times a week" which were felt to be vague and open to interpretation.
- Similarly, participants indicated that they preferred specific references to the size of a portion/serving such as "1 cup" which was universally understood to something like "a handful" as participants felt people's hands vary in size.
- References to things participants could easily visualize, such as "the size of a deck of cards", were also effective.
- The variation that seemed to come the closest to hitting all of these marks was presented for fish: provision of the frequency numerically, "2 to 3 times per week; the portion, "the size of a deck of cards"; and, examples of fatty fish, "this includes char, herring, mackerel, salmon, sardines and trout".

Exhibit A6: SAMPLE - Specific Message Variations

How much to eat - message options

Eat vegetables and fruits daily. At least half of your choices should be vegetables.
Eat vegetables or fruits at each meal and snack. Choose vegetables more often than fruits.
Eat at least one dark green vegetable every day.
Eat 1 to 2 dark green vegetables daily.
You should eat 1 cup of dark green vegetables every day.
Eat 1 to 2 handfuls of dark green vegetables every day.
Eat orange vegetables several times per week.
Eat orange vegetables 3 to 5 times per week.
Eat 2 to 4 whole grain foods every day.
Switch to whole grain foods.
Eat beans, peas, lentils or tofu most days of the week.
Eat legumes or tofu almost every day.
Eat nuts or seeds most days of the week.
Eat fish or shellfish 2 to 3 times per week. Choose fatty fish most often.
A serving is about the size of a deck of cards.
This includes char, herring, mackerel, salmon, sardines and trout.
Choose lean meats, poultry and eggs. These can be eaten most days of the week.
Choose 1% or skim milk, fortified soy beverage or unsweetened lower fat yogurt with added vitamin D. Have them 2 to 3 times every day.
You need 1% or skim milk, fortified soy beverage or unsweetened lower fat yogurt at least 2 times a day for adequate vitamin D.
Choose a different fortified plant-based beverage if you don't drink milk or soy beverage.
Choose lower sodium and lower fat cheese. Eat it less than once per day.
Cheese can sometimes be included in a healthy eating pattern.
Try to limit your consumption of cheese.
A portion of cheese is the size of 1 or 2 thumbs.
When cooking and preparing foods with oil or fat, choose unsaturated fats.
Choose vegetable oils and margarine instead of butter, lard or shortening.

PORTION AND PROPORTIONALITY IMAGES

The portion and proportionality images depicting different meals were tested among members of the general public.

The portion and proportionality images were met with generally favourable reaction. Indeed, images and visual cues were often volunteered as effective ways to communicate portions and proportions.
Some felt that images in which the different food categories were easily distinguishable were felt to be more effective in terms of demonstrating appropriate portions and proportions than images of mixed meals such as stir-fry and stew.

***Exhibit A7: SAMPLE - Portion and Proportionality Images***

DETAILED INFORMATION FOR HEALTH PROFESSIONALS AND POLICY MAKERS

The level of detail and format of detailed information on amounts and types of foods were tested in two different table formats with health professionals and policy makers. This was to ensure the information is communicated to health professionals and policy makers in a way that supports their understanding and implementation of more specific healthy eating information. Participants were made aware that the focus is on the level of detail and the organization of information and that the values in the tables were only placeholders and would be replaced with guidance.

***Exhibit A8: SAMPLE - Format Table 1***
High-Level Food Categories (grey) Sub level food categories (white)	2-3 YRS	4 - 8 YRS	9 - 13 YRS	14 -18 YRS	19 - 50 YRS	51 -70 YRS	71 + YRS
Vegetables and Fruit
Dark green vegetables	1/day		2/day
Deep yellow or orange vegetables	3/week
Starchy vegetables	5/week
Other vegetables	1/day	1-2/day
Fruit	1-2/day
Grains
Whole grain and whole wheat	1/day	1-2/day	2/day		2-3/day	1-2/day
Refined grain	3-4/week		1/day
Protein Foods
Milks, Fortified soy beverages and Yogurts	2-3/day
Cheeses	1/week		5/week	4/day	1/week	5/week
Legumes	3/week	4/week	5/week	1/day	1-2/day	1/day
Nuts and seeds	5/week
Red, Organ, & Game Meats, Poultry and Eggs	2/week	4/week	5/week	1/day			4/week
Fish and shellfish	2/week		3/week				2/week
Oils, Fats, Condiments, Sauces & Dressings
Unsaturated fats and oils	2/day	1-2/day
Condiments, sauces and lower fat dressings	2/week		3/week

***Exhibit A9: SAMPLE - Format Table 2***
High-Level Food Categories (grey) Sub-Level Food Categories (white)	2 - 3 YRS	4 - 8 YRS	9 - 13 YRS	14 - 18 YRS	19 - 50 YRS	51 - 70 YRS	71 + YRS
Vegetables and Fruit
Dark green vegetables	#/day	#/day	#/day	#/day	#/day	#/day	#/day
Orange vegetables	#/week	#/week	#/week	#/week	#/week	#/week	#/week
Starchy vegetables	#/week	#/week	#/week	#/week	#/week	#/week	#/week
Other vegetables	#/day	#.5/day	#.5/day	#/day	#.5/day	#/day	#/day
Fruit	#.5/day	#.5/day	#.5/day	#.5/day	#.5/day	#.5/day	#.5/day
Grains
Whole grain and whole wheat	#/day	#.5/day	#/day	#/day	#.5/day	#.5/day	#.5/day
Refined grain	#.5/day	#.5/day	#/day	#/day	#/day	#/day	#/day
Protein Foods
Milks, Fortified soy beverages and Yogurts	#.5/day	#.5/day	#.5/day	#.5/day	#.5/day	#.5/day	#.5/day
Cheeses	#/week	#/week	#/week	#/week	#/week	#/week	#/week
Legumes	#/week	#/week	#/week	#/day	#.5/day	#/day	#/day
Nuts and seeds	#/week	#/week	#/week	#/week	#/week	#/week	#/week
Red, Organ, & Game Meats, Poultry and Eggs	#/week	#/week	#/week	#/day	#/day	#/day	#/week
Fish and shellfish	#/week	#/week	#/week	#/week	#/week	#/week	#/week
Oils, Fats, Condiments, Sauces & Dressings
Unsaturated fats and oils	#/day	#.5/day	#.5/day	#.5/day	#.5/day	#.5/day	#.5/day
Condiments, sauces and lower fat dressings	#/week	#/week	#/week	#/week	#/week	#/week	#/week

The format tables were generally met with positive reaction from health professionals and policy makers. There was a sense that this information would be particularly useful for menu planning and nutrition education purposes.
The aspects that health professionals and policy makers praised most often spontaneously included the provision of guidance: at the sub-level food category level and according to a number of age groups.
Health professionals responsible for nutrition education felt that the level of information in the tables was more rigid than other messaging approaches in terms of the frequency, proportion and portion of food and likely not necessary to educate their constituents. While health professionals liked the information presented in detailed sub-level food categories to make the information more relevant and useful for their work, most, especially those in nutrition education, felt totaling up the daily/weekly amounts of food at the high-level food categories would be particularly useful.
Information on alternatives to provide for situations where specific sub-level food categories are excluded (e.g., for those with certain health conditions such as allergies or preferences such as with vegetarians) would also be helpful. Indeed, the majority of health professionals and policy makers, felt this would be particularly helpful for those requiring information on alternatives to provide for situations where specific sub food groups are excluded. For example, with certain health conditions such as allergies or preferences such as with vegetarians.
In terms of the two formats tested, most health professionals and policy makers working across different life spans tended to prefer Table 1. The most important advantage of Table 1 was that it illustrated where changes in amounts and types of food occurred making it much clearer and easier to see/understand.
The few who preferred Table 2, typically health professionals involved in menu planning, appreciated the clarity of stating frequency, proportions and portions for each age and sub-level food category. They claimed this format removed any doubt.

Research Firm:

Earnscliffe Strategy Group Inc. (Earnscliffe)
Contract Number: HT372-182894/001/CY
Contract award date: July 26, 2018

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

Signed:
Date: January 11, 2019
Stephanie Constable
Principal, Earnscliffe

INTRODUCTION

Earnscliffe Strategy Group (Earnscliffe) is pleased to present this report to Health Canada summarizing the results of the two phases of qualitative research exploring visual and messaging approaches for communicating healthy eating information.

The specific objectives of the research were twofold:

To assess pubic and stakeholder views and acceptance of the draft Canada Food Guide visual and brand concepts to ensure understanding and usefulness.
To test messaging provided at different levels of detail and for different targets (consumers and health professionals) to assess for comprehension and their usefulness for application into practice.

Feedback from the research was/will be used to inform the development of food guide resources.

RESEARCH APPROACH

To meet these objectives, Earnscliffe conducted two waves of qualitative research.

Phase 1

Phase 1 included a series of six focus groups with the general population and two mini-groups with health professionals and educators.

The purpose of this phase was to test three "at-a-glance" tools that communicate healthy eating information as an entry point to Canada's dietary guidance. The at-a-glance tools were tested in both digital and print formats. We also tested social media graphics for each of the three executions.

The focus groups with the general public were conducted in three cities: Saskatoon (August 22, 2018); Ottawa (August 23, 2018); and, Kitchener (August 25, 2018). The mini-groups with health professionals and educators were conducted in Saskatoon (August 22, 2018) and Ottawa (August 23, 2018).

In Saskatoon and Ottawa, the first group was composed of six to eight health professionals and educators. The second and third groups were conducted with eight to ten members of the general population. The sessions were approximately ninety minutes in length. All groups in Ottawa were conducted in French. General population focus group participants were given an honorarium of $100 as a token of appreciation for their time, while the health professional and education mini-group participants received $250.

Phase 2

Phase 2 included a series of eight focus groups with the general public, eight focus groups with health professionals, and nine one-on-one interviews with policy makers.

The purpose of this phase was to test a number of different approaches to communicate additional information to complement the Dietary Guidelines and the Healthy Eating Recommendations. The variations explored in the groups looked at on different approaches to communicate frequency, proportionality and portion and quality of food sources to consume and limit.

The focus groups with members of the general public and health professionals were conducted in four cities. The focus groups were conducted in: Toronto (December 11, 2018); Halifax (December 12, 2018); Edmonton (December 13, 2018); and, Montreal (December 15, 2018). The focus groups with health professionals were conducted: Toronto (December 10, 2018); Halifax (December 11, 2018); Edmonton (December 12, 2018); and, Montreal (December 13, 2018). The nine interviews with policy makers were conducted between Monday, December 10th and 14th, 2018.

The sessions were approximately two hours in length. All groups in Montreal were conducted in French. General population focus group participants were given an honorarium of $100 as a token of appreciation for their time, while the health professionals received $285.

Please refer to the Recruitment Screeners in the Appendix of this report for all relevant screening and qualifications criteria.

TARGET AUDIENCE

Phase 1

The focus groups were conducted with members of the general population aged 18 or older. In each city, the first general public group was conducted with those at risk of marginal health literacy [as screened by the Newest Vital Sign (NVS) and scoring <4/6)]; while the second group was conducted with those with adequate health literacy (score 4+). Each group included a mix of sexes, ages, household incomes, education levels, as well as a mix of cultural background and Indigenous peoples.

The mini groups were conducted with a mix of health professionals and educators. These categories included elementary school teachers, community level educators such as those who work at recreation centres, and community centres, and registered nurses working in public health or community. All participants were screened to ensure that they had hands-on experience educating on and communicating about healthy eating.

Phase 2

The focus groups with members of the general population were conducted with those aged 18 or older. In each city, the first general public group was conducted with those at risk of marginal health literacy [as screened by the Newest Vital Sign (NVS) and scoring <4/6)]; while the second group was conducted with those with adequate health literacy (score 4+). Each group included a mix of sexes, ages, household incomes, education levels, as well as a mix of cultural background and Indigenous peoples.

The focus groups with health professionals were conducted with a mix of individuals, including: registered dietitians, registered nurses, food service managers, and professionals working in health, wellness and education. In each city, the first group was conducted with health professionals responsible for nutrition assessment, screening and intervention; while the second group was conducted with health professionals responsible for nutrition education.

The interviews with policy makers were conducted with senior officials identified by Health Canada.

Please refer to the Recruitment Screener in the Appendix of this report for all relevant screening and qualifications criteria.

DETAILED FINDINGS

Phase 1

In Phase 1, the focus groups began with an exploration of three draft at-a-glance tools (both digital and printed versions) followed by the social media graphics for each concept. The digital and print versions were the same, with the exception of how participants were seeing them. Participants were asked to review the digital version using their laptops/tablets (for health professionals and educators) and smartphones (for members of the general public), followed by the printed versions of each concept. The social media graphics were presented on screen.

Overall Reactions to the At-a-Glance Tools

The overwhelming majority of participants reacted more positively and enthusiastically to concepts that featured real photographs and images than they did to drawings and icons. When real food was displayed, the guidance became more personal, relatable, much more appetizing and an important reminder to eat healthily and generally better. In contrast, the drawings were described as robotic and childish. Participants had a hard time identifying with them and often thought they would be better for children than themselves. Indeed, a number of educators thought they could use the drawings to discuss healthy eating with their (younger) students.

The advice provided about how to eat, including healthy eating behaviours and habits, was noticed, particularly by health professionals and educators, and described as an important evolution over the current food guide. However, some participants, more often than not those with marginal health literacy, questioned how these behaviours correlated with healthy eating. Typically, during the groups, other participants described why they felt this type of advice was helpful which seemed to be convincing and helpful for those initially confused (or resistant).

The following summarizes participants' views of each concept. For the purposes of this report, reactions to the social media executions were incorporated into the specific findings for each concept below.

Specific Reactions to the Digital Graphics

Concept 1: EAT WELL. LIVE WELL. TOGETHER.

***Exhibit B1: At-a-Glance Graphic - Eat well. Live well. Together.***

Reaction to this concept was very positive. It was often described as appealing and attention-grabbing. Of the three at-a-glance tools, participants felt this one most directly linked to food and nutrition; in line with their expectations for Canada's Food Guide.

Initial positive reactions tended to revolve around praise for the effective use of colour throughout particularly the variety of colourful images featuring appetizing food. Participants also praised the background colours describing them as interesting, pleasing to the eye, and complimentary of the food images. Participants had the sense that the variety of background colours grabbed their attention and required them to pay attention to all of the different boxes and quadrants of information.

Most felt that they could use or look at the at-a-glance tool and there would be no confusion that it was a Government of Canada tool (and a component of Canada's Food Guide). Most described the overall look and feel as professional, modern, minimalist, and timeless.Participants felt that the flow of information was intuitive and that the layout was pleasing to the eye, made good use of the space, and was well organized which gave the impression the digital version would be very easy to navigate and use. And, while it was felt to be modern, no one questioned the credibility of the information.

In terms of the main messages and healthy eating information being communicated, participants felt that this concept very much communicated the importance of healthy eating. Their interpretations can be encapsulated as follows: "eat a variety of healthy foods," "eat healthy," and "eat lots of fruits and vegetables."

One of the most powerful components of this concept (arguably of all those tested) was the image of the plate depicting healthy food options.

The most compelling aspect of this image was the sense of proportion that it conveyed. It was clear to participants that this was supposed to guide Canadians on what to eat. Most really liked that the image displayed real food and there was a sense that the little lines on the plate were helpful in dividing up the proportions of the different food categories (i.e., fruits and vegetables, whole grain foods, protein foods, etc.). In fact, when provided with the print version of the three concepts, participants most often held up this particular image when talking about what they might put up on their fridges, work lunch room or class room walls, or send home with patients and/or students. Participants felt that the image depicted the proportionality of a meal that they could easily recreate and picture themselves preparing at home.

Worth noting, there were some comments about having cutlery represented which felt unnecessarily formal and questions about whether the food on the plate represented a recommended meal size which looked like too much food for one meal.

Participants also found the messaging and the imagery under the caption "Healthy eating is more than the foods you eat" to be very compelling.

***Exhibit B3: Healthy Eating Habits Graphic - Eat well. Live well. Together.***

The reminders about how eating habits correlate with healthy eating were particularly well received, especially by those with adequate health literacy, health professionals and educators.

In terms of the specific imagery used to illustrate these messages, participants very much appreciated the images of foods that were encouraging and inspirational. Reactions to the message and image to "be mindful of your eating habits" were very positive as participants felt the image demonstrated what they should strive for when planning their lunches. Similarly, the image depicting two salads and two forks for "eat meals with others," was clear and understood. Reactions to the other two images were a little less enthusiastic. For example, the image of five apples with "enjoy your food," was a source of some confusion for participants. Similarly, but to a lesser degree, participants questioned the correlation between "cook more often" and food prep given the imagery of a cutting board, knife and vegetables. Most felt that better images could be used for those two messages.

Finally, consistent with the rest of the visual the final section with guidance about limitations and best practices messages was praised with the exception of the last image.

***Exhibit B4: Foods to limit, Labelling and Marketing Graphic - Eat well. Live well. Together.***

Participants found that real images were more helpful coupled with the messages featured above them. The "Be aware of food marketing" image was the only area which participants felt they could not relate to. Many stated they had never seen a candy bar labelled "buy me" thus this image was not effective at supporting the message. The bright red colour was also viewed as undesirable for being too flashy and vibrant.

Tagline

With respect to the tagline, "Eat well. Live well. Together.", reactions were generally very favourable. Most felt it was clear, relevant and to the point. It also fit well with the visual elements of this concept and the message about why healthy eating is important (to live better and longer).

There were some questions around the qualifier "together". Those who liked it felt this tagline might fit better with the For the love of eating well concept given the emphasis on eating with others. Those who did not like it, were often those living alone, arguing it can be challenging to eat with others all the time and that the fact they are single does not mean they do not eat healthy. When asked, the majority were comfortable with "Eat well. Live well.".

Social Media

Reactions to the social media examples for this concept were positive, but slightly less enthusiastic than reactions to the at-a-glance tool. Consistent with the at-a-glance tool, participants described the social media graphics as modern and professional. They were also deemed credible as the Health Canada and Government of Canada logos were visible and clear. However, participants felt that the image of an empty plate in each of the executions lacked colour and vibrancy which they felt was particularly important as an attention-grabbing tactic for social media posts. Without the food, a number of participants were confused about the message of these concepts and many felt these looked more like promotions for a home décor store/magazine or recipe book than they did for Canada's Food Guide. Participants suggested the inclusion of colourful foods on the plate (similar to the plate at the bottom of the at-a-glance tool).

With respect to the messaging on the social media graphics, as mentioned earlier, participants generally appreciated the reminders about healthy eating habits; however, as with the at-a-glance tool, participants struggled to connect the images (of the empty plates) with their respective messages.

Concept 2: FOR THE LOVE OF EATING WELL

***Exhibit B6: At-a-Glance Graphic - For the love of eating well.***

While reactions to this graphic were mixed, there was agreement around the perception that this was an attention-grabbing concept. Participants appreciated the images of people coming together to prepare and enjoy a meal. The photos were described as appealing, attention-grabbing, and representative of Canada's diverse population which was an important distinction for this graphic that resonated across all of the audiences, particularly those of ethnic backgrounds.

In terms of the main messages and healthy eating information being communicated, participants felt that this graphic emphasized the benefits and pleasure derived from preparing and enjoying food with others.

However, the approach of this graphic, to focus on this guidance, was a bit polarizing. Professionals and those with adequate health literacy appreciated the emphasis on lifestyle advice; whereas, those with marginal health literacy questioned its relevance and felt that something was missing. They felt this graphic lacked guidance about specific healthy food choices to make and had trouble understanding what this graphic had to do with healthy eating or Canada's Food Guide.

This polarization was also evident in terms of views toward the design and layout of this graphic. While some enjoyed the unique and colourful circles which they described as fun, modern, and bright, others found them frivolous and overdone. Some participants also felt there was unnecessary empty, blank space that split up the graphic in an awkward fashion. All in all, many participants came away with the impression that this graphic was a bit disorganized and therefore, amateur, especially as compared to Eat Well. Live Well. Together.

***Exhibit B7: Healthy Eating Habits Graphic - For the love of eating well.***

In terms of the images and messages, most participants felt they went well together, although most walked away with the impression that this section was more about the enjoyment of a good meals and good friends than it was about healthy eating. Many felt that food should be featured more prominently in some these images, rather than people. Some participants judged this concept to be less credible for precisely this reason.

In terms of the proportionality graphic, perceptions were varied.

***Exhibit B8: Food Choices Graphic - For the love of eating well.***

The majority of participants were relieved to see food featured more prominently in this image. Presenting food on a table, as one would at home, with the hands of different people involved in preparing and enjoying the meal seemed to strike a better balance in terms of featuring food while communicating the importance of sharing a meal with others.

In terms of portions and proportionality, while a number of participants could infer from the various sizes of plates that they should prioritize vegetables/fruits over whole grain foods and protein foods, because the plate was the largest, the consensus was that this was not as effective as the visual of the plate in Eat Well. Live Well. Together. First, there was some uncertainty about whether this was an example of what an individual should be eating at a given meal or whether this was something one would serve an entire family. Second, in terms of portions, it was a little more difficult to decipher the exact recommended serving sizes of each food category. Third, some questioned the relevance of the person cutting cucumbers and how they should factor the cucumbers into their portion and proportion calculations; although, no one questioned the value in depicting vegetables.

With respect to the quality of the image, the smaller plates were a little more difficult to see and participants had a harder time distinguishing the foods on the protein and whole grain plates.

Reception to the visuals depicting the various food limitations and warnings was felt to be very effective.

>Exhibit B9: Food to Limit, Labelling and Marketing Graphic - For the love of eating well. — ***Exhibit B9: Food to Limit, Labelling and Marketing Graphic - For the love of eating well.***

Of the three at-a-glance tools, participants felt the images were much clearer and strongly correlated with the messages about what to limit and be aware of. In particular, participants felt the image of the cell phone was a much more effective graphic that depicted where they might see food marketing, on their cell phones, which linked very well with the message about being "aware of food marketing." The one suggestion participants made was that the images could be a little larger.

Tagline

The tagline, For the love of eating well, was questioned by participants as to its relevance with Canada's Food Guide. While some found it lighthearted and enjoyable opinions were primarily negative. It was argued that eating for pleasure and eating healthy are not always the same thing.

In addition, many found it sounded awkward and sounded uncomfortably similar to the utterance "for the love of god…". This nuance was felt to be inappropriate for the Government of Canada and ultimately led participants to favour other taglines.

Social Media

The social media examples were arguably the strongest element of this concept; clearly favoured by the vast majority of participants of all three social media examples. The visuals of people laughing and enjoying each other's company were appealing and attention-grabbing. These examples were described as bright, happy, polished, and relatable. And, as compared to the use of some of these same images in Visual 7, participants felt that the food featured more prominently in these larger images.

Participants also really appreciated these examples, again, for the diversity of ethnicities that are featured, which reflect Canada's values. They also really liked that the images looked like they were in people's homes instead of restaurants which made them think of cooking themselves in a social setting. Both of these dimensions were positive and important.

Given the medium, social media, participants felt these would definitely make them stop and pay attention. In fact, a number of participants said they would likely examine the images to see if they recognized anyone, explaining that these resemble images their friends and acquaintances often share in their social media feeds (i.e., photos of meals they are enjoying).

Where the layout was less effective in the overall graphic, on these social media examples, the layout was very effective and pleasing to participants. The circle logo for Canada's Food Guide was seen as friendly and modern for the Government of Canada. In these examples, the use of whitespace, bright colours, and different fonts was attention-grabbing, modern, and professional. Indeed, many participants suggested incorporating the spirit of these social media examples into the Eat Well. Live Well. Together. social media examples.

Concept 3: BRINGING HEALTHY EATING TO LIFE

***Exhibit B11: At-a-Glance Graphic - Bringing healthy eating to life.***

Reactions to the Bringing healthy eating to life at-a-glance tool were neutral to negative. Of the three graphics, it was often described as the most out-of-date, amateur, and confusing.

The illustrative approach was the oft-criticized element of this graphic. First, the illustrations were whimsical which called the credibility of the concept into question. It did not look and feel like a Government of Canada communications tool; and, certainly not how participants want to see the Government communicate the new Food Guide. Second, participants felt the illustrations were especially difficult to interpret and understand.

In terms of the overall look and feel, participants also found the colours to be a little bright and harsh, to the point of distraction.

As a result, the majority of participants did not see themselves making use of this digital version. Of the handful that might, mostly educators, they said they might use it to have conversations with their students (children).

***Exhibit B12: Intro Graphic - Bringing healthy eating to life.***

In terms of the intro graphic, it was evident that this concept was the least favourable of the three. This was mostly due to the jarring use of colour (mentioned above) and the confusing graphics. The illustration that was the most confusing was the knife featured at the top which appeared to be quite sharp and held in an unnatural fashion for food preparation; it appeared sinister and menacing, which most felt was inappropriate for the Government, particularly if this concept was meant for children.

Worth noting, the one positive aspect of this particular graphic was the clarity of the "Explore the guide" instruction. Participants felt that this was the graphic that that reference was the clearest. There was consensus that the "Explore the guide" reference should be much larger on all of the concepts to encourage interaction with the tool.

***Exhibit B13: Healthy Eating Habits Graphic - Bringing healthy eating to life.***

The layout of this graphic was presented in quadrant style which was appreciated by most participants. Similar to the Eat Well. Live Well. Together. graphic, the quadrant style seemed to better fill their smartphone, tablet and laptop screens.

That being said, most of the images in this section were not well received. Participants could not relate to the illustrations mostly because of how unnatural the people's arms and hands appeared. One participant explained: "All I see are thick medical gloves." The two images which received the most criticism were "be mindful of your eating habits," and "eat meals with others," because neither depicted food. Further, participants were confused as to why people were sharing one plate and one fork in the image that accompanied the message "eat meals with others".

***Exhibit B14: Food Choices Graphic - Bringing healthy eating to life.***

Where this at-a-glance tool did meet with more positive reaction was with respect to the proportionality image. Participants really liked the arrangement of food on the plate and could very easily understand the recommended proportions of foods from each of the different food categories. The shading of the different food categories was praised as were the written cues (legend) that appeared on the side of the plate.

Having said all this, participants did still feel the illustrations were difficult to understand. For example, participants had a hard time discerning what the cubes and triangle represented. Interpretations that participants made of these shapes were not helpful (i.e. cookies, a nacho chip, slice of pie, etc.) or likely to be recommended in the Food Guide.

***Exhibit B15: Foods to Limit, Labelling and Marketing Graphic - Bringing healthy eating to life.***

Finally, reactions to the food warning illustrations were much the same as reported above. These are seen as amateur and difficult to understand. The image for "Use food labels," was particularly confusing.

Tagline

Reactions to the tagline, Bringing healthy eating to life, were generally favourable. It fit well with Canada's Food Guide, although, it did not fit well with the look of the at-a-glance tool especially because this tool relied on illustrations, which participants argued are not life-like. Others felt that this tagline lacked the punch of Eat Well. Live Well. Together.

Social Media

Reactions to the social media examples were much like reactions to the at-a-glance tool. While the colours were described as vibrant and attention-grabbing, they were felt to be jarring and harsh. The illustrations were whimsical, confusing and looked like they were for children. As a result, participants felt they would overlook these ads in their social media feeds.

All in all, participants came away feeling this concept was out-of-date, amateur, and inappropriate for the Government of Canada.

Additional Findings Related to the Delivery Method

There was significantly greater interest in a digital version rather than a printed version; although some, especially professionals and educators, could see utility in having both.

Most could see themselves using the digital version of the at-a-glance tool while shopping in the grocery store or for planning grocery lists/menus in advance. While the functionality was not available during the groups, many expected that the interactivity of the tool would be quite helpful while they were planning and/or shopping, as a means of understanding more about healthy eating habits; accessing information about recommended portions, proportions, etc.; suggested options for foods (and new foods to try) that fit certain categories; and, recipes (and ingredient lists) for meals they could prepare themselves, among other things.

Participants' reactions to a downloadable self-print version were mixed. Professionals, especially teachers/educators, mentioned they would hang a paper copy up on their work lunch room or classroom walls or send a copy home with students. The majority of the general population, however, did not see a need to print it out, especially younger tech-savvy participants. There were some participants who thought it would be helpful to tape a printed version to their fridges as visible reminders, or to use to have conversations about healthy eating with their children.

A few participants in each group noted the call to action to visit the Government's website to learn more on the printed versions of each tool. Participants felt this was necessary, particularly for Government of Canada materials and wondered whether the digital version would link to the Government website.

Phase 2

In Phase 2, participants were asked to review a series of different approaches to communicate specific information on amounts and types of food. Participants were advised that the approaches that communicate types and amounts of food represented only a part of the work Health Canada is doing. All of the materials were provided to focus group participants in print during the groups. Policy makers were sent copies of the materials by email in advance.

Overall Reactions

Generally, most participants, regardless of audience, were satisfied with the materials currently being developed and there was a sense that Health Canada was on the right track despite the fact that there were preferences and suggested areas for improvement on most of the materials tested.

Members of the general public with adequate health literacy, health professionals and policy makers tended to prefer language that was more specific and direct such as:

Messages written as directives that start with words like "Eat", "Choose", "Limit", etc.; and,
Those that specified a number to eat at specific intervals, such as: "Eat vegetables and fruits at each meal and snack."

They felt this was appropriate as it correlated with their perception of the importance of conveying healthy eating guidance to Canadians.

Most health professionals and policy makers did express an interest in information related to healthy eating behaviours (habits) which seemed to fit with the advice they provide their constituents and their expectations of Health Canada and the new Food Guide. Their interests were believed when the moderators mentioned that the communications approach under review were but a few examples of options under consideration by Health Canada in support of the Food Guide.

Specific Reactions to the Communication Approaches

The following table outlines the various communication approaches that were explored for each audience. For members of the general public, the objective was to test comprehension; while for health professionals and policy makers, the objective was to understand how they would use the messaging in their work. All of these tools can be found in Appendix B appended to their respective discussion guides.

Communication Approaches	General Population	Health Professional	Policy Maker
Dietary Shift Messaging	✔	✔	✔
Directive Messaging	✔	✔	✔
Directive Messaging Variations	✔	-	-
Portion and Proportionality Images	✔	-	-
Detailed Information by age and sex groups	-	✔	✔

DIETARY SHIFT MESSAGING

The dietary shift messaging was tested with all three audiences (members of the general population, health professionals and policy makers). For members of the general public, the objective was to test comprehension; while for health professionals and policy makers, the objective was to understand how they would use the messaging in their work. As results were consistent across language and audience, the combined results are presented although any important distinctions are highlighted throughout. Please refer to the table on page 57.

Reactions to the dietary shift messaging were generally positive across all of the audiences. It was felt to be clear, concise, relevant, helpful, and easy to remember. The majority of participants also had the impression that the dietary shift messaging fit with their expectations of advice about how to eat healthy (i.e., increase/eat more of this; limit/eat less of this; and, switch to this). The majority of participants described this as high-level, easy to use, guidance for incorporating better eating habits. Some members of the general population suggested they might tape something like this up on their fridges as an easy reference for eating better. Health professionals, particularly those involved in nutrition education, saw this as something to provide to their clients for easy reference on incorporating healthy eating habits.

Given most viewed this messaging as a helpful overview of changes needed to make improvements toward healthier eating choices, most were comfortable with the lack of specificity in terms of frequency, proportions and portions. Having said that, many (across all audiences) did feel it would be helpful to include specific examples of foods for some of the references, such as: "whole grain foods"; "unsaturated fats and oils"; and, "highly processed spreads". In the case of "whole grain foods", participants understood the terminology but had a hard time imagining any food options beyond whole grain bread. Additional examples would help open their minds to new possibilities and choices they had never considered.

In terms of the credibility of the information, participants deemed the information (and guidance provided) to be very credible and generally in line with their understanding of healthy eating, particularly health professionals and policy makers. What was noticed and appreciated by health professionals and policy makers, in particular, was the neutrality of the messaging in that there did not seem to be an industry-bias.

Moreover, most health professionals and policy makers (and some members of the general population) found the dietary shift messaging to be a little more flexible and adaptable (than the directive messaging) for those with dietary restrictions or those who have made specific lifestyle choices (i.e., vegan, vegetarian, etc.). Health professionals involved in nutrition education, in particular, felt that this messaging would be much easier to provide as a take-away for all constituents including those with dietary restrictions or those who have made specific lifestyle choices. This was because the information was not as specific and tended to provide guidance that could be easily adapted which was deemed a more effective way to communicate ways to eat healthier.

All this being said, in terms of improvements, some health professionals questioned whether some of the messages could be expanded with evidence and rationale for why the message was chosen. These health professionals felt that these messages were not informative enough or relatable especially for those working in diabetes or with Indigenous populations.

When members of the general population were asked about their specific wording preferences, there were often a number of participants in each group who did not make any distinction between the wording choices and felt the intended meaning was the same. Those who inferred different meanings explained the following:

"Increase" implied that someone already ate many of these foods and that they should eat more than they do now. Whereas, participants felt "eat more" could apply to those who already eat these foods or encourage those who do not, to start eating these foods. "Eat more" seemed to speak to a greater number of people, to encourage them to make healthy food choices.
"Eat less" was a little too permissive and implied that these less healthy choices could still be eaten, just less. Conversely, the word "limit," conveyed more clearly and directly, that these foods should be avoided.

Ultimately, preference was for "eat more" and "limit", as these were deemed more direct, which participants, especially those with adequate health literacy, health professionals and policy makers, felt was important in the context of the specific food examples mentioned in the Dietary Shift Messaging.

Worth noting, English-speaking participants were generally comfortable with "switch to" although "passez aux" was not well received in French, particularly among health professionals. They were not sure of the intended meaning and questioned the translation of this term. Suggested alternatives to this wording included: "préférez", "essayez", or "changez".

Intended Use of Dietary Shift Messaging for Health Professionals and Policy Makers

Health professionals saw themselves using the dietary shift messaging in a couple of ways:

In consultation with their constituents. Health professionals, especially those in nutrition education, appreciated the simplicity of the dietary shift messaging. They saw this as a general overview document that they could use to communicate changes needed to make improvements toward healthier eating choices (i.e., what to prioritize, what to limit, and what to switch to). Similarly, policy makers, particularly those working closely with local community organizations (i.e., arenas, recreation centres, etc.) also thought it would be a helpful overview document to remind them of the food options to make available in their facilities.
As a take-home. More so than the directive messaging, the dietary shift messaging was something health professionals, in nutrition education in particular, saw themselves sharing with their constituents as a take-home. Other health professionals, thought it would be handy to have posted on bulletin boards, left on waiting room tables, or posted on fridges (for those involved in menu planning).

DIRECTIVE MESSAGING

The directive messaging was tested with all three audiences. The context for health professionals and policy makers was to determine if and how they would use these messages in their work.

Reaction to the directive messaging was mixed. While most came away feeling that the language was plain, and there was widespread appreciation for taking an encouraging, positive approach, there was a sense that the directive messaging was a little vague, especially where amounts of food were concerned.

Read in its entirety as one cohesive document, many participants felt that there was a lot to remember and questioned their own and their constituents' ability to implement the suggested guidance. Some members of the general population, often those with marginal health literacy, came away feeling that it would be difficult to incorporate all of these things into their daily or weekly routines. For example, there were some participants (often younger) who felt it would be difficult to meet these criteria on a budget. Others, often those with adequate health literacy, seemed to come away feeling that the information was helpful and that it was not something that one had to follow to the letter. These participants viewed it as "common sense" and a series of helpful reminders about how to incorporate healthy eating habits into their daily or weekly routines.

When asked how this messaging compared to the dietary shift messaging, the majority (across all audiences) saw this messaging as a compliment to the former. Participants explained that they felt the dietary shift messaging provides a high level, succinct, overview about how to eat healthy; and, for those interested in more detailed guidance, the directive messaging provides specific advice about how to meet those needs across the various food categories. This was particularly the case for health professionals involved in nutrition education who suggested they usually work with their clients on one recommendation at a time. They worried that the totality of the directive messaging might be overwhelming for some of their clients.

Where most participants felt the dietary shift messaging was more effective was in its perceived flexibility in accommodating those with allergies, illnesses, or who have made specific lifestyle choices (i.e., vegan, vegetarian, etc.). There was a sense that the directive messaging was a little more rigid and unforgiving. Participants had a hard time determining how they would make substitutions or replacements for foods they cannot eat based on the directive messaging.

Setting aside the vagueness of some of the language (outlined below), participants appreciated the length and tone of the messages. They were described as short and to the point. The tone was felt to be generally positive and encouraging.

Participants also noticed and appreciated that the guidance was organized by food category. This they felt made it easier for them to envision and plan each meal with foods from each of these food categories. Starting with vegetables and fruits was noticed and appreciated, particularly by health professionals and policy makers; as was, the variety of protein food options. It was interesting to hear members of the general population confirm that the suggestion of beans, peas, lentils, tofu, nuts and seeds as alternative protein sources was helpful.

Finally, the advice about how to improve an eating habit (i.e., the advice on how to cook/prepare foods) was also very well received by all audiences. Specifically, the advice to choose unsaturated fats when cooking or preparing foods, often reminded health professionals and policy makers of their interest in healthy eating habits as part of the new Food Guide.

In terms of the perception that the messaging was vague, the aspects that seemed to contribute most to this sense included:

The general lack of specificity throughout and reliance on words and terms like "several," "at least," "less than," "more of," etc. Some participants, from all audiences, indicated they would have preferred references to a specific frequency, portion (serving), or proportion.
References to foods and terms that were unfamiliar to some participants such as "whole grain foods", "fatty fish", and "unsaturated fats". The majority suggested including examples of such terms.
Similarly, the lack of examples of certain foods such as "dark green", "orange vegetables," "whole grain foods," "fatty fish," "nuts and seeds," and, "shellfish," seemed to discourage participants from thinking of foods they had not considered before or were unfamiliar with. Indeed, as part of the group discussions, when others provided examples of these foods, these terms seemed to make a whole lot more sense.
Finally, with respect to the guidance to "Eat nuts or seeds most days of the week", some participants felt a qualifier would be needed as the state in which these are consumed can be healthier than others (i.e., raw, unsalted vs. salted, flavoured, etc.) as well as how much. For example, many participants were aware of the fact that nuts and seeds could be easily overconsumed.

In terms of the blend of daily and weekly recommendations, participants did not often raise this unprompted which suggests they were generally comfortable with advice provided in either frequency. Interestingly, when asked, those who seemed to prefer the use of one or the other, wanted consistency, and were often those with marginal health literacy. Conversely, those who understood the difference and could see themselves using both (a blend of daily and weekly recommendations) were those with adequate health literacy; some of whom do their own weekly meal planning.

Worth noting, while most generally felt the guidance was in line with their thinking and expectations, there were some recommendations that seemed to contradict what some had heard: 1. That eggs could be eaten most days of the week; and, 2. That lower fat cheese is healthy.

Directive Messaging Variations

Various sample variations of the directive messages were tested among members of the general public. Participants were provided with a handout outlining different wording, tone and approaches for the directive messages.

The findings below summarize participants' comprehension and understanding of each variation, as well as, their thoughts on implementing the guidance (where applicable).

SAMPLE Messages - Vegetables and Fruits:
Eat vegetables and fruits daily. At least half of your choices should be vegetables.
Eat vegetables or fruits at each meal and snack. Choose vegetables more often than fruits.

Variation A: Daily

This wording was succinct
For some, often those with marginal health literacy, daily was a little more attainable, manageable and doable
Others, often those with adequate health literacy, found setting a daily target was a little too forgiving which would make them less accountable; they worried they might easily forget

Variation A: At each meal and snack

For some, this wording was too wordy
For some, often those with marginal health literacy, having to eat a vegetable or fruit at each meal and snack was a little rigid, restrictive and harder to attain
Others, often those with adequate health literacy, thought this would be easier to implement and keep track of

Variation B: At least half

Most found this clear and concise
Is easy to visualize and provides a guideline

Variation B: More often than fruits

While the wording was clear, it often raised more questions than it answered, particularly among those with marginal health literacy
"Why are vegetables better than fruits?"

French variation:

While the results presented above were consistent among French-speaking participants, there was confusion around other wording in these statements worth noting. Participants found the language "La moitié au moins de" from the sentence, "La moitié au moins de ce que vous consommez devrait être constituée de légumes" to be particularly confusing. Many participants had trouble deciphering what that was trying to say and felt it required too much work to make sense of it.

SAMPLE Messages - Dark Green Vegetables:
Eat at least one dark green vegetable every day.
Eat 1 to 2 dark green vegetables daily.
You should eat 1 cup of dark green vegetables every day.
Eat 1 to 2 handfuls of dark green vegetables every day.

Variation A: At least one

Easy to remember
Encouraging
Interpreted to mean there was no maximum to the number of vegetables one can eat; although, some questioned whether that was true (that one could eat a limitless amount of fruit/vegetables daily)
Question about whether you could eat one vegetable (i.e. one brussels sprout) and satisfy this

Variation A: 1 to 2

For some, this was restrictive particularly given it was about vegetables which they felt should not be limited
Many suggested adding "At least"
There was some confusion as to the serving size (i.e., one cup, one vegetable as in one brussels sprout, etc.)
Some wondered what happens if they exceed 2

Variation A: 1 cup

Universally understood
Easy to visualize
Consistent with recipe instructions which is helpful
Some questions about whether this was a measurement of raw or uncooked vegetables

Variation A: 1 to 2 handfuls

Understood
But sense that this is proportional rather than fixed, and therefore not consistent
Easier for in the grocery store; more tactile

Variation B: Every day

The meaning for this and daily were interpreted the same but the tone was different
This was more forceful; seen as a directive, which at times turned off those with marginal health literacy

Variation B: Daily

Easy to remember
Tone was more positive, more a recommendation than a directive

Variation C: Eat

This was more forceful, seen as a command, which was appreciated by those with adequate healthy literacy but a little too direct for those with marginal health literacy
Most were comfortable with this; those who were not as comfortable suggested using a word like "Enjoy"

Variation C: You should eat

This is a little softer, seen as a suggestion
Those with adequate health literacy thought "you should eat" was too permissive; gives readers the option to follow the guidance or not

SAMPLE Messages - Orange Vegetables:
Eat orange vegetables several times per week.
Eat orange vegetables 3 to 5 times per week.

Variation A: Several

Most found this wording vague, although some said 'several' implies 3 or more to them
It was permissive and did not convey enough specificity in terms of how many orange vegetables should be consumed per week

Variation A: 3 to 5

This variation was more precise which most tended to prefer
However, the specificity also raised questions about the repercussions of exceeding this number

SAMPLE Messages - Whole Grains:
Eat 2 to 4 whole grain foods every day.
Switch to whole grain foods.

Variation A: Switch to

This was clear for most; interpretation to cut out white
This also conveyed a lifestyle change rather than something one needed to fit into their meal plan
Some interpreted an implication that they were not already eating enough whole grains

Variation A: 2 to 4

Although participants tended to prefer specific numbers, there was some confusion in this particular instance
Many questioned the serving size in the context of bread
"Is 1 serving two pieces of bread?"; in which case 2 to 4 felt like a lot

SAMPLE Messages - Legumes and Tofu:
Eat beans, peas, lentils or tofu most days of the week.
Eat legumes or tofu almost every day.

Variation A: Beans, peas, lentils or tofu

Participants tended to prefer having examples provided
Was much clearer and easy to understand

Variation A: Legumes

Not all participants were familiar with this term; was confusing for some

Variation B: Most days

The meaning for this and almost every day were interpreted the same, but the tone was different
This was more positive, flexible and attainable
Although, some felt it was a little vague and open to interpretation

Variation B: Almost every day

This was felt to be more specific, direct and not as flexible
Some, particularly those with marginal health literacy, felt this put more pressure on them to eat more of these foods

SAMPLE Message - Nuts and Seeds:
Eat nuts or seeds most days of the week.

Variation A: Most days of the week

Some participants liked the flexibility of 'most days of the week' while others would prefer more specific guidance (i.e., 4 to 5 days a week)
Others suggested something like "Switch to nuts and seeds for your snacks"
There were questions about recommended portion/serving size and concern for overconsumption

SAMPLE Messages - Fish and Shellfish:
Eat fish or shellfish 2 to 3 times per week. Choose fatty fish most often.
A serving size is about the size of a deck of cards.
This includes char, herring, mackerel, salmon, sardines and trout.

Worth Noting

Participants reacted very favourably to this message and all of these variations
They felt these three sentences were complimentary and important; this they felt should be serve as the example to strive for in all communications
It specified the recommended frequency per week and portion size; and, it provided examples for a term that was confusing for most ("fatty fish")

SAMPLE Message - Meats, Poultry and Eggs:
Choose lean meets, poultry and eggs. These can be eaten most days of the week.

Worth Noting

Reactions to this message were generally positive
Some questioned the guidance that eggs could be eaten most days of the week
Suggestion to include examples of lean meats

SAMPLE Messages - Dairy Products:
Choose 1% or skim milk, fortified soy beverage or unsweetened lower fat yogurt with added vitamin D. Have them 2 to 3 times daily.
You need 1% or skim milk, fortified soy beverage or unsweetened lower fat yogurt at least 2 times a day for adequate vitamin D.
Choose a different fortified plant-based beverage if you don't drink milk or soy beverage.

Variation A: Choose

The tone was interpreted as a suggestion

Variation A: You need

In this particular instance, participants questioned the accuracy of this statement arguing that their understanding is that milk is not 'needed'; felt to be inaccurate
The tone is more direct

Variation B: Added vitamin D

This was a source of confusion for many
The requirement of vitamin D was unknown to most
Questions arose about why vitamin D needs to be added

Variation B: Adequate vitamin D

This was preferred
Implied the required amount of vitamin D was already included 'naturally' and not 'added'

Variation C: 2 to 3 times a day

This inferred one's intake should be limited to 2 to 3 times

Variation C: At least 2 times a day

This suggested there was no limit on the amount one could drink every day

SAMPLE Messages - Cheese:
Choose lower sodium and lower fat cheese. Eat it less than once per day.
Cheese can sometimes be included in a healthy eating pattern.
Try to limit your consumption of cheese.
A portion of cheese is the size of 1 or 2 thumbs.

Worth Noting

To a certain extent, these sentences were seen as complimentary
Setting aside the preferences outlined below, participants recommended opening with the sentence that "Cheese can sometimes be included in a healthy eating pattern" or "Try to limit your consumption of cheese" followed by the sentence to "Choose lower sodium and lower fat cheese" and then "A portion of cheese is the size of 1 or 2 thumbs"
Participants would appreciate examples of lower sodium and lower fat cheeses
The portion/serving size of 1 or 2 thumbs was easy to visualize, although, again some raised the point that this is a proportional measure which they felt was less precise and therefore potentially confusing

Variation A: Less than once per day

This was very confusing
Participants questioned how one could eat something less than once per day
Most interpreted this as "just don't eat cheese"

Variation A: Sometimes

This was a little more permissive and therefore positive (most would like to keep eating cheese)

Variation A: Try to limit/Limit

This was easy to understand
Suggested they should eat cheese in moderation
Try to limit was interpreted as more permissive than limit

SAMPLE Messages - Cooking Oils and Fats:
When cooking and preparing foods with oil or fat, choose unsaturated fats.
Choose vegetable oils and margarines instead of butter, lard or shortening.

Worth Noting

Most participants preferred the variation, "When cooking and preparing foods with oil or fat, choose unsaturated fats" primarily because the recommendation to choose margarine instead of butter was widely disputed
Participants suggested adding examples of preferred oils to use for cooking and preparing foods

Intended Use of Directive Messaging for Health Professionals

Perhaps even more so than members of the general population, health professionals came away feeling that presented as one cohesive document, the directive messaging would be overwhelming for members of the general population. For those that work with the general population, they tend to give their constituents suggestions for incremental changes they can make. They felt presented as a whole, the directive messaging was too detailed, prescriptive, difficult to remember, and overwhelming for the general population to understand and implement.

Having said that, they did see themselves using this information in a few key ways:

In consultation with their constituents. In this sense, they would be able to work through the areas the constituent is already doing well, areas for improvement, suggestions for foods to try, what to avoid, etc.
For menu planning purposes. Most thought the directive messaging would be especially helpful for menu planning purposes as a means of ensuring a good variety of foods are represented in menus. The distinction between dark green and orange vegetables and the numerous protein food options were particularly well received as a means of accomplishing this.
As part of their own digital communications. Many came away thinking it would be useful to use these messages individually in messaging about specific topics. In fact, some mentioned using some of these messages as stand-alone excerpts in their own communications such as on their social media feeds as tweets or Facebook posts; on their websites; etc.

PORTION AND PROPORTIONALITY IMAGES

The portion and proportionality images depicting meals were tested among members of the general public.

The portion and proportionality images were met with generally favourable reaction. Images and visual cues were often volunteered as effective ways to communicate portions and proportions; and, in fact, a number of participants suggested displaying food on a plate unaided when reviewing other communication approaches (before these images were shown).

However, while these images were very well received, participants did not feel they could be used as standalone tools. Many participants felt that they wanted to know more about the meals depicted in the images and that they could be improved with labels or written cues detailing exact quantities, portions (serving sizes), and perhaps even recipes they could easily follow.

With respect to the four images tested, some provided more clarity in terms of recommended portions and proportions than others. Participants suggested the salmon dish and omelette (although to a lesser degree) were the most effective at conveying different high-level food categories (i.e., vegetables and fruit, protein foods, whole grain foods) and the desired portions and proportions of each in comparison with the other. Having said that, there was a sense that all of the images could be improved if it were easier to judge the amount of food depicted, particularly in terms of the depth (i.e., the volume the vegetable stew occupies in the bowl or the thickness of the salmon, etc.).

Participants had a harder time identifying the high-level food categories depicted in images of the stir-fry and vegetable stew. A number of participants had a hard time inferring much in terms of proportionality of one food category over another. The stir-fry image, more than any other, also seemed to convey to participants that the portions they currently eat are not recommended because they said they would typically eat a much larger portion of stir-fry than was depicted.

Worth noting, there was some confusion around the images of the glasses of water and milk. In fact, except for the bowl of strawberries, most thought these images depicted empty side bowls (rather than glasses of water or and milk). What participants inferred from the empty side bowls was one of two things: some interpreted that meant dessert with that particular meal was not an option; others interpreted them as empty bowls for bones or other waste.

DETAILED INFORMATION FOR HEALTH PROFESSIONALS AND POLICY MAKERS

The level of information provided by the tables were generally met with positive reaction from health professionals and policy makers. Most felt that it was important to provide guidance for health professionals at this level and that this was an improvement over the current Food Guide. There was a sense that this information would be particularly useful for menu planning.

The aspect that health professionals and policy makers praised most often spontaneously was the provision of guidance at the sub-level food category level. Health professionals and policy makers felt that information at these levels would be especially important for health professionals as a way to help them plan for the unique needs of different audiences and as a way to emphasize the importance of "variety" and "balance" in their advice, menus and education.

The specific food categories that health professionals and policy makers noticed and praised included:

The fact that vegetables were at the top and distinguished in four categories. They argued that most of their constituents need to eat more vegetables and that having the various categories of vegetables makes it easier for them to provide the guidance that not all vegetables are equal. Those involved in menu planning also argued it would make menu planning that much easier to ensure there was adequate variety.
The inclusion and differentiation of legumes and nuts and seeds as their own sub-level categories of protein foods. Those involved in menu planning felt it was a helpful reminder to consider other protein options. Many also reflected on the fact that their constituents do not readily think of these as protein food options and that differentiating these as necessary proteins would help them encourage their constituents to consider a variety of protein food options.

The other element that participants often praised spontaneously was the provision of information specific to a number of age categories. Participants involved in menu planning and those working directly with a variety of age groups (e.g. information for families) were especially receptive to this differentiation. As we will see later in the report, the format of Table 1 was particularly well received by these health professionals because it made important shifts in amounts of food by age much more obvious.

Not all participants, however, felt the number of age categories were reasonable and appropriate. Those who felt there were too many age categories were those who did not often work with families, a variety of age groups, or children. Quite often those who work with these particular audiences were quick to argue why these breaks were important. That being said, the one category that did raise some questions from a number of participants was the 19-50-year-old age category, especially in the context of expectant and nursing mothers. Most felt that this particular segment faces unique dietary requirements. There was a sense that if Health Canada were not able to include tailored guidance for this audience, most could adapt the guidance for this specific audience if and when necessary.

Those with mixed reactions, more often than not, health professionals responsible for nutrition education, felt that the information inferred more rigidity than other messaging approaches in terms of the frequency, proportion and portion of food and likely not necessary to educate their constituents. The information did not seem relevant for application in one-on-one conversations with their constituents. Some also reported they would need more clarity on how to use this information to help those with allergies, illnesses, or those who have made specific lifestyle choices (i.e., vegan, vegetarian, etc.) to include how to remove certain sub-level food categories and to substitute properly with others as required for specific health conditions or preferences.

When asked whether a total (daily and/or weekly) at the high-level food category level would help, many health professionals and policy makers felt rolling up the totals would help them easily adapt the guidance in the tables to help those with unique circumstances. In this way, they felt they could easily use the other recommendations in the sub-level categories to make up the required daily/weekly portions of high-level food categories (by substituting things their constituents cannot eat with things they can at the sub-level category level).

The provision of amounts of food by day and week compounded these views. In fact, reactions to the blend of daily and weekly guidance were mixed overall. Those involved in menu planning were comfortable with the blend of daily and weekly guidance as they felt it would help them ensure adequate variety in their menus which are typically planned on a weekly/monthly basis. Those involved in nutrition education thought that guidance provided at the weekly level might help ensure more variety and help their constituents avoid eating the same thing every day. Others thought it might be more helpful, and less confusing, to provide the guidance either daily or weekly rather than blended. Interestingly, when reminded that this information was intended for health professionals and asked whether they had trouble with the mix of daily and weekly guidance, most indicated they did not.

Other components of the tables that prompted questions or were sources of confusion for participants included:

Some questioned whether these tables would be created for each gender arguing that guidance about frequency, portions and proportions were quite different for women and men. Many mentioned that the current Food Guide provides guidance specific to each gender.
A number questioned whether eggs should be included with protein derived from "red, organ, and game meats, poultry" arguing that they should potentially be categorized separately as their own sub-level food category.
As with the dietary shift messaging and directive messaging, participants suggested the provision of examples for some of the terms used in the format tables. In some cases, this was as a means of providing examples of different food options to consider such as in the case of "whole grain and whole wheat"; while in others it was to help define a confusing term, such as: "refined grain", "legumes", "shellfish", "unsaturated fats and oils", and, "condiments, sauces and lower fat dressings".
Some also raised that there can be constraints to healthy eating due to accessibility and affordability that make some of the guidance difficult or discouraging. For example, they suggested that canned foods and sliced meats may be necessary and healthy options may be available. Health professionals volunteered that they often recommend or substitute reasonable alternatives in order to make the healthiest meal plan within specific contexts.
With respect to "Oils, Fats, Condiments, Sauces & Dressings", more fundamental than helping to define the terminology, participants questioned the inclusion of this food level category in the format tables which seemed to contradict the views of a number of health professionals. Health professionals felt this category was far too broad and offered examples such as hummus and ranch dressing as examples where the nutritional benefit varies considerably and merits separate guidance.

Finally, in terms of the two formats tested, most health professionals and policy makers working across the life span tended to prefer how the information was presented in Table 1. Those developing menus for specific age groups or life stages appreciated the precision of the information in Table 2.

Those who preferred the way the information was organized in Table 1 felt it illustrated more clearly where changes in amounts of foods were required between age groups. This was much clearer and easier to see/understand. This was particularly helpful for health professionals who work with a variety of constituents of different ages (and needs) because they could clearly see where the guidance for a certain sub-level food category was static or changed. They felt this would be much easier to use for menu planning purposes when working across the life span or for those advising families with multiple children of different ages.

Second, most preferred guidance that was provided in whole numbers rather than decimals which participants felt was too finite and difficult to work with; not to mention the fact that it contributed to the sense of clutter of Table 2. Both health professionals and policy makers questioned how to menu plan when a suggested serving is reported as "X.5". The fruit category was raised often with questions such as: "What do I do with the other half of the apple?"

The few who preferred Table 2 primarily worked with one life stage (e.g. menu development in long term care homes) appreciated the clarity of stating frequency, proportions and portions for each age and sub-level food category. They claimed this format removed any doubt or errors of interpretation.

CONCLUSIONS

Phase 1

The concepts that elicited the most enthusiastic and positive reactions featured real photographs and images, rather than drawings and icons. Images of real food in the concepts Eat Well. Live Well. Together. and For the love of eating well made the guidance more relatable, appetizing, and best communicated the importance of eating healthy foods. In contrast, the drawings used in the Bringing Healthy Eating to Life concept seemed juvenile, unprofessional, and unclear. Consequently, participants found the advice less credible.

Across all concepts, participants preferred the digital version over a printed version. Many questioned why the latter was necessary, though professionals, especially teachers/educators, would hang a paper copy up on their classroom walls or send a copy home with students.

Participants welcomed advice about how to eat and viewed it as an improvement from the previous version of the CFG. However, when the concept, namely For the love of eating well, contained more information about how as opposed to what to eat, participants asked for more specific nutritional information. Those with marginal health literacy were also more likely to question the relevance of the lifestyle advice, whereas professionals and those with adequate health literacy appreciated it.

When it came to specific concepts, Eat Well. Live Well. Together. Was the most popular. Of the three, it was often described as the most appealing, attention-grabbing and directly related to food and nutrition. Participants felt the tagline was clear and relevant and fit with the visual elements. The at-a-glance tool was very well received. Participants liked the use of colour and images of real food, particularly the variety and portions sizes displayed on the plate. Participants felt that the social media post was missing this important component and that the image of an empty plate lacked colour and vibrancy.

Reaction to the concept For the love of eating well was more mixed. As mentioned above, participants appreciated the lifestyle advice, but some wished for more information about food. The majority of participants appreciated the photos of happy people coming together around food. The photos were appealing, attention-grabbing, and representative of Canada's diverse populations. However, not all felt these images conveyed the message they would expect to receive from the government about healthy eating. Many came away feeling that this concept was about the enjoyment of food rather than healthy eating (and nutrition). Similarly, the tagline fit with the concept, but participants were not sure it was the appropriate message for Canada's Food Guide.

Finally, Bringing healthy eating to life was deemed the least appropriate. The drawings detracted from the concept's credibility and did not necessarily relate to the messages. The social media examples were attention-grabbing, but most participants felt they caught their attention in an unfavourable way. Participants felt that the colours, while vibrant, were a little jarring. Reactions to the tagline, Bringing healthy eating to life, were generally favourable. It fit well with this concept and Canada's Food Guide, although it lacked the punch of Eat Well. Live Well. Together.

Phase 2

Overall the materials currently being developed by Health Canada to communicate specific information on healthy eating were met with generally positive reaction across all audiences. With the knowledge that these were but a few tools among the various tools that Health Canada was developing, there was a sense that Health Canada was on the right track.

Language proved to be one of the aspects upon which health professionals, policy makers, and those with adequate health literacy differed from those with marginal health literacy. The former felt that more direct and specific guidance (i.e., portion and proportion) was more appropriate as it correlated with their perception of the importance of conveying healthy eating guidance to Canadians. Those with marginal health literacy tended to prefer messaging that was less direct and a little more forgiving.

The dietary shift messaging was particularly well received by all audiences as a high-level overview of changes needed to make improvements toward healthier eating choices. Participants had the impression the guidance could be easily incorporated into daily life and fit with what they know about healthy eating and expected of Health Canada. It was described as clear, concise, helpful, and easy to remember.

The directive messaging, however, was viewed as a compliment to the dietary shift messaging for those interested in more detailed, specific guidance. While the language was described as plain and the tone was felt to be positive and encouraging, while suitably direct, participants thought it was vague and would benefit from more specificity in terms of the amount of food and examples. If presented as a cohesive document, participants (across all audiences) felt it might be overwhelming, a lot to remember and to implement, particularly for those with marginal health literacy. Health professionals and policy makers felt it would be useful to use in one-on-one consultations with their constituents or to use for menu planning purposes in schools, recreation centres, etc. but would not be something they would provide as a take-away for constituents.

In terms of the variations in the descriptive messaging, members of the general population tended to prefer more explicit recommendations such as specific ranges (i.e. "1 to 2 dark green vegetables", "3 to 4 times a week", etc.) over general terms live "several," "more than," "a few times a week", etc. There was also preference for serving size/portion guidance that referred to something that was universally understood, such as "1 cup"; although, examples like "the size of a deck of cards" were also easy to visualize.

Using images of meals was deemed an effective approach to communicating portions and proportions. Images that clearly show the recommended proportions of vegetables and fruits, as compared to whole grain foods and protein foods were more easily interpreted than images of mixed meals (i.e., stew, stir-fry, etc.), although some participants, mostly those with adequate health literacy, were able to understand the recommended proportions. There was a sense that these images could have been improved with messaging outlining a list of ingredients and the quantity of each, or even a recipe, if possible. Worth noting, the images could have been improved with better depictions of the beverages which were often misinterpreted as empty side bowls, which was a source of some confusion.

Finally, reactions of health professionals and policy makers to the detailed information presented in two table variations were mostly positive particularly for menu planning purposes. The information praised most often spontaneously was the provision of guidance by sub-level food category and according to a number of age groups. Participants felt that these were important changes over the current Food Guide that would help ensure more variety in Canadians' diets at a variety of ages. In terms of format preferences, most felt a total (daily and/or weekly) provided for each high-level food category would help them easily adapt the guidance for those with special dietary preferences or limitations. Of the two formats, most preferred Table 1. It was felt to be less cluttered, better for detecting where changes occur across age groups in the healthy eating pattern, and clearer in terms of the use of whole numbers (rather than decimals).

APPENDIX A: DISCUSSION GUIDE

Phase 1

INTRODUCTION 10 min 10 MIN

Moderator introduces herself/himself and her/his role: role of moderator is to ask questions, make sure everyone has a chance to express themselves, keep track of the time, be objective.

Moderator shares the following information with the participants:

The name of the firm the moderator works for, and the type of firm that employs them (i.e. an independent marketing research firm)
The research purpose and research sponsor, described, at a minimum, in the same manner as in recruiting: explain that Canada's Food Guide is changing and is testing concepts for an at-a-glance tool that would be an entry point into the guidance.
Role of participants: speak openly and frankly about opinions, remember that there are no wrong answers and no need to agree with each other
Results are confidential and reported all together/individuals are not identified/participation is voluntary. The length of the session (1.5 hours)
The presence and purpose of any recording being made of the session (audio and video taping of the discussion
The presence of any observers, their role and purpose, and the means of observation (one-way mirror, colleagues viewing in the back room)
Remind participants about the confidential nature of the focus group and not to share its content with others

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

Introduction of participants [GEN POP]: To get started, please give your first name, whether you have any hobbies/pastimes, and who lives in your household (i.e., whether you live with someone including children (number and ages of children).
Introduction of participants [PROFESSIONALS]: Given the topic of our discussion today/tonight, as part of your introduction, please give your first name, tell us what you do and how healthy eating/nutrition is involved in your work.

CONCEPT TESTING: DIGITAL VERSION AND TWO-SIDED PRINT 60 min 70 MIN

TESTING OF DIGITAL VISUAL CONCEPTS

We have heard that Canadians want a tool that provides actionable, succinct, and clear information for Canada's Food Guide. For the first part of our discussion, we will be reviewing digital visual concepts. We will be looking at three options that communicate healthy eating information/dietary guidance at-a-glance as an entry point to Canada's dietary guidance. These would be digital tools that you could access on your smartphone or tablet.

For the purposes of our discussion tonight, I would ask that you use your smartphone or tablet to access the following bitly. You'll notice that the interactivity is not included (working yet) as these are mock-ups that have been created for the purposes of our conversation tonight. The digital concepts you see will be further developed into concepts that will auto-size based on the device you are using (ex: smartphone vs. desktop). I need you to also imagine that the final product would be fully interactive, meaning that you will have the ability to click on an icon or text to reveal additional messages and information.

MODERATOR TO REVIEW THE DIGITAL VISUAL CONCEPTS. CONCEPTS WILL BE PRESENTED IN RANDOMIZED ORDER IN EACH GROUP.

Please take a few minutes to read and review it. Feel free to make notes on your notepaper. I would like to understand what you like, what you don't like, or whether anything is confusing or unclear. Also, think about the colours, the font, the symbols/images/icons/photos used, the presentation and flow of information, the icon messaging etc.

Please do this on an individual basis in silence. We will discuss your thoughts/comments together as a group in a few minutes.

[FOR ALL GROUPS]:

Overall, what is your impression of this concept? (Again, think about the colours, the font, the symbols/images/icons/photos used, presentation and flow of information, icon messaging, etc.)
What did you take away/learn?
Does it make sense to you? Can you relate to what is being communicated? Why or why not?
Does the reading order make sense to you? Why or why not?
Was there anything you found particularly helpful or useful in how the information was presented? Why or why not?
- What do you understand as the main communication messages of this concept? Can you summarize, at a high level? What healthy eating information is being communicated?
Would you use this? How would you use this? Why or why not?
- Would it help and encourage you to make healthy eating decisions?
Does this concept appear to be credible and evidence-based? Why or why not?
- Is it clear that this is an at-a-glance tool delivered by the government that communicates dietary guidance? Why or why not?
Do you feel that the concept communicates a sense of proportionality with respect to the different types of foods (e.g. veg and fruit, whole grains, proteins, etc.)? Why or why not?

[FOR PROFESSIONALS]:

Would you use this with the groups you work with? If so, how would you use it? For what purpose?
Do you think it would resonate with your target audience? Why or why not?
Is this relevant for your target audience? Why or why not?
Do you think this would encourage your audience to take action? What action(s)? Why or why not?
Do you feel the concept is sensitive to the populations you work with? Why or why not?

TAGLINES (e.g. Eat well. Live well. Together; for the love of eating well; Bringing healthy eating to life)

Overall, what did you think of the tagline?
What thoughts/feelings did it evoke for you? How?
Does it fit with the visuals? Why or why not?
Is it appropriate to think about Canada's Food Guide in this context? Why or why not?

QUESTIONS RELATED TO OVERALL LOOK AND FEEL

What did you think of the imagery/icons? Why do you say that?
- Do they relate and make sense against the text they are associated?
- Are they relatable?
- modern and timeless?
- Were they clear and easy to understand? Why or why not?
- Were they sized appropriately? Why or why not?
What about the colours?
Do you like the font? Why or why not?
What do you think of the icons/symbols?
Do you have a preference for photographs vs. icons/symbols? Why do you say that?
Would this meet your needs in an "at a glance" tool for Canada's Food Guide?

[FOR PROFESSIONALS]:

Would you use this visual in your practice/work? Why or why not? How would you use it?

WRAP-UP

Did the concepts meet your expectations for simplified tools/depictions of Canada's Food Guide at-a-glance? Why or why not?

TESTING OF TWO-PAGE PRINT VISUAL CONCEPTS

For the remainder of our discussion, we will be reviewing a 2-paged print visual concept for each of the digital graphics we just looked at. These would be available as a pdf version that you could access online and print.

MODERATOR TO REVIEW THE 2-PAGED PRINT VISUAL CONCEPTS. CONCEPTS WILL BE PRESENTED IN RANDOMIZED ORDER IN EACH GROUP.

Please take a few minutes to read and review it. Feel free to make notes on your notepaper. I would like to understand what resonates with you or whether anything is confusing or unclear. Also, think about the colours, the font, the symbols/images/icons/photos used, the presentation and flow of information, the icon messaging etc.

Please do this on an individual basis in silence. We will discuss your thoughts/comments together as a group in a few minutes.

[FOR EACH PRINT CONCEPT, MODERATOR TO PROBE]

Was there anything you found particularly helpful or useful in how the information was presented? Why or why not?
Does the reading order make sense the print concept? Is there flow to the messages? Why or why not?
- In what order did you read the content? Why?
Would you use this? Why or why not? If yes, how would you use this?
- Do you see this as a useful tool to support the digital version?
Do you see a need for both a digital and a print version? Why or why not?
Would you use it digitally on your phone? Why or why not? When or for what purpose?
Would you print this out? Why? For what purpose?
Are you comfortable with the fact it is two pages? Does this make it any more or less difficult to use? Why do you say that?

CALL-TO-ACTION (Discover more at Canada.ca/foodguide)

Overall, what did you think of the call-to-action?
What thoughts/feelings did it evoke for you? How?
Does it fit with the visuals that were presented to you? Why or why not?

QUESTIONS RELATED TO OVERALL LOOK AND FEEL

What did you think of the overall look and feel of the printed concept after seeing the digital version? (e.g. icons, colour, size of imagery/icons, font?)?

CONCEPT TESTING: SOCIAL MEDIA GRAPHICS 10 min 70 MIN

TESTING OF THE SOCIAL MEDIA GRAPHICS DIGITALLY ON A PROJECTED SCREEN

To begin, I would like to show you a series of visuals. These are visuals you would find in your social media feed, on Facebook for example. I would ask you to focus on the look-and-feel, and, by this I mean, the colours, the font, the symbols/images/icons/photos used, presentation and flow of information, the icon messaging etc. To do so, I would ask you to look at the screen, at the images I have displayed here.

MODERATOR TO REVIEW EACH CONCEPT IN TURN. EACH CONCEPT WILL BE PRESENTED IN RANDOMIZED ORDER IN EACH GROUP. PARTICIPANTS WILL BE ASKED TO REVIEW THE SOCIAL MEDIA GRAPHIC EXAMPLES TO GIVE PARTICIPANTS A FEEL FOR EACH CONCEPT.

MODERATOR TO EXPLAIN: FOR TWO CONCEPTS (THAT USE PHOTOGRAPHIC IMAGES), THESE IMAGES ARE PLACEHOLDERS ONLY AND WILL BE REPLACED WITH IMAGES PRODUCED FOR CANADA'S FOOD GUIDE SPECIFICALLY LATER ON. FOR THE PURPOSE OF THIS FOCUS GROUP, PLEASE FOCUS ON THE CONCEPT RATHER THAN THE SPECIFIC FOODS USED.

Overall, what did you think of this concept? Why do you say that? (Think about the colours, the font, the symbols/images/icons/photos used, the words, etc.)
Does it make sense to you? Can you relate to it? Why or why not?
Is it credible to you? Why or why not?
As far as you're concerned, is it modern/current and timeless (not quickly outdated)? Why or why not?
- [FOR PROFESSIONALS]: Do you think your target audience would find it modern or outdated? Why do you say that?
Would it get your attention? Why or why not?
If you came across this in your social media feed, would you share it? Why or why not?
Would this concept motivate you to do anything? Why or why not?
- If so, what would you do?
- If not, why not?

WRAP-UP [PROJECT ALL 3 OPTIONS ON SCREEN)

After seeing all the concepts, has your initial impression of them changed? How so? Why?
[FOR PROFESSIONALS] Which concept comes closest to what you were expecting in terms of an image that would support the revised Food Guide? Why do you say that?

WRAP-UP 10 min 90 MIN

This concludes what we needed to cover tonight. We really appreciate you taking the time to come down here to share your views. Your input is very important.
I also want to remind you about the confidential nature of these groups. These are all concepts that are very much in the design stage. The feedback received in these groups will be used to inform the revisions and the final design/approach.
And, (reminder for those in the first groups) about reserving comments so as not to influence the next group.

Phase 2: General Population

INTRODUCTION 10 min 10 MIN

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

The name of the firm the moderator works for, and the type of firm that employs them (i.e. an independent marketing research firm)
We are conducting these focus groups on behalf of the Government of Canada, specifically for Health Canada. Health Canada would like to get your views on a series of healthy eating messages.
Role of participants: speak openly and frankly about opinions, remember that there are no wrong answers and no need to agree with each other
Results are confidential and reported all together/individuals are not identified/participation is voluntary. The length of the session (1.5 - 2 hours)
The presence and purpose of any recording being made of the session (audio and video taping of the discussion
The presence of any observers, their role and purpose, and the means of observation (one-way mirror, colleagues viewing in the back room)
Turn off cell phones for the duration of the discussion

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

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

PATTERN HIGHLIGHT MESSAGES 25 min 35 MIN

Health Canada is revising Canada's Food Guide to reflect the latest scientific evidence and to be more modern and relevant. We are conducting this research to help them develop messages that will provide the guidance to Canadians. The messages that you will see are not in their final state or final format of delivery. This will be part of the work that they complete following your input.

They are developing a number of different tools that Canadians will be able to access about the Food Guide and healthy eating. For the purposes of our research tonight, we are going to look at a select series of messages that could be used to communicate amounts of food and how much to eat. The variations we will be exploring focus on different approaches to communicate amounts of food, such as frequency, proportionality and portions. The messages generally convey the same information but are presented in a different way. I say all of this because I want you to remember that this is only a part of the work they are doing. I do not want you to think this is all that they are doing or will be saying.

[MODERATOR TO PROVIDE HANDOUT OF OVERALL PATTERN HIGHLIGHT MESSAGES]

The pattern of healthy eating is not meant to be representative of everyday or meal, it is a pattern. To begin, I would like to share with you some examples of messages that have been drafted. Take some time to read the messages and as you're going along, feel free to mark up your paper. Feel free to put a "√" beside any words/phrases/elements that you like, an "X" beside any word/phrases/elements that you don't like, and, a "?" beside anything that is confusing or unclear; although it is not necessary to do so if you are not moved in one way or another.

Let's take some time to review each message.

The moderator will review the messages overall and then one-by-one:

Overall, in your opinion, do you think these statements are clear? Is the language easy to understand? Why or why not?
Do you believe this advice is practical and helpful? Why or why not?
What about the amount and detail of information? Was it too much, the right amount, or not enough? Why do you say that?
Was it relatable for you? Why or why not?
Would it be easy to remember? Do these messages help you understand and remember recommended amounts of foods to eat? Why or why not?
What did you think of the mixed message approach? For example, some statements provided suggestions for the amount to eat per day, while others were suggestions about the amount to eat per week. Were you comfortable with that? Why or why not?

REACTIONS TO DIFFERENT MESSAGES APPROACHES 55 min 90 MIN

Now I would like to look at each of these messages a little more closely.

[MODERATOR TO PROVIDE HANDOUT OF DIFFERENT MESSAGES APPROACHES (BLACK AND WHITE)]

On this handout, you will notice that the messages we reviewed initially are in the column on the left. On the right, we are providing some variations of that message, as well as messages providing additional information. The variations of the message have the same meaning as the message on the left but are written in a different way. I would like to spend some time exploring these variations and additional messages to understand how these nuances affect your views and understanding.

[MODERATOR TO REVIEW EACH MESSAGE AND VARIATION IN DETAIL, EXPLORING PREFERENCES FOR EACH VARIATION.

As we are reviewing these, I am particularly interested to know whether the variations are clear, practical/helpful, relatable, easy to remember, useful to help apply in your life/for your family, etc. and which aspects you prefer and why.

Let's begin…

Moderator to use the following prompts as applicable:

What did you think of this variation?
Does the variation imply a different meaning? Why or why not?
Do you prefer one over the other? Which one? Why?
Is one more…?
- Clear
- Practical
- Relatable
- Easy to remember
Was there a difference in terms of the tone of the message? Do you prefer a certain tone over another? Why or why not?
Which variation would motivate you to take action? Why or why not?

DIETARY SHIFT MESSAGING 15 min 105 MIN

Now I would like to review dietary shift messaging.

These dietary shift messages are different than the pattern highlight messages. Canadians needs to make the shift in food choices to move toward a healthier pattern of eating. Instead of giving specific information about how much to eat, it recommends what Canadians need to eat more of, less of, or what changes to make.

[MODERATOR TO PROVIDE HANDOUT WITH DIETARY SHIFT MESSAGING]

What is your immediate reaction to these messages?
Overall, how do you feel about this type of message?
Between these shift messages and the highlight messages we saw earlier, which do you prefer? Which is most useful? Why?
Do you find the 2 different sets of messages complement each other? Why or why not?
Does the shift messaging provide enough information by itself? Why or why not?
Do you prefer the terms "increase" or "eat more", "limit" or "eat less"? Is there anything unclear about these terms?
- Are there other terms you think are clearer?

[MODERATOR TO PROVIDE HANDOUT WITH PUBLIC HEALTH MESSAGES THAT COULD ACCOMPANY SHIFT MESSAGING]

Does the addition of this kind of information improve the message? Why or why not?

PORTION AND PROPORTIONALITY IMAGES 10 min 115 MIN

The last few minutes of our conversation, I would like to spend looking at images of meals.

[MODERATOR TO PROVIDE HANDOUT WITH IMAGES]

Does this type of information assist in communicating recommended amounts of food to eat at a meal? Why or why not?
Do these images help you understand the proportions you should eat between food groups? Why or why not?
Do these images help you understand recommended portion sizes? Why or why not?
In the mixed dishes (e.g. the stew and stir fry), do you understand the proportionality between food groups? Why or why not?
Do these images give you enough information on their own about portion or proportion? Why or why not?
- OR, would you rather have this type of visual aid paired with messages? Why do you say that?

WRAP-UP 5 min 120 MIN

This concludes what we needed to cover tonight. We really appreciate you taking the time to come down here to share your views. Your input is very important.
Please remember that this information is confidential and should not be shared outside of the room. If you took notes, please leave them on the table.

DIETARY SHIFT MESSAGING - SAMPLE

To follow Canada's Healthy Eating Patterns:

Increase Or Eat more
- Beans, peas, lentils or tofu
- Nuts and seeds
- Vegetables and fruits, especially dark green and orange
- Fish and shellfish
- 1% and skim milk, fortified soy beverage and lower fat yogurt
Switch to
- Whole grain foods
- Unsaturated fats and oils
Limit Or Eat less
- Sugary drinks
- Candies and chocolate
- Processed meats
- Highly processed spreads and dressings

Sample population health messages that could accompany shift messaging:

Less than 1/4 of Canadians' grain choices are whole grains. Eat more whole grain foods.

Canadians eat less fish and shellfish than recommended for health benefits. Eat fish or shellfish 2 times each week.

Please take a few minutes to review each of the following messages. Feel free to put a "√" beside any words/phrases/elements that you like, an "X" beside any word/phrases/elements that you don't like, and, a "?" beside anything that is confusing or unclear.

SAMPLE

How much to eat

To follow Canada's food guide healthy eating patterns:

Eat vegetables or fruits at each meal and snack. Choose vegetables more often than fruits.
- Eat at least one dark green vegetable every day.
- Eat orange vegetables several times per week.
Eat 2 to 4 whole grain foods every day.
Eat protein foods.
- Eat beans, peas, lentils or tofu most days of the week.
- Eat nuts or seeds most days of the week.
- Eat fish or shellfish 2 to 3 times per week. Choose fatty fish most often.
- Choose lean meats, poultry and eggs. These can be eaten most days of the week.
- Choose 1% or skim milk, fortified soy beverage or unsweetened lower fat yogurt with added vitamin D. Have them 2 to 3 times every day.
- Choose lower sodium and lower fat cheese. Eat it less than once per day.
When cooking and preparing foods with oil or fat, choose unsaturated fats.

How much to eat - SAMPLE message options

Eat vegetables and fruits daily. At least half of your choices should be vegetables.
Eat vegetables or fruits at each meal and snack. Choose vegetables more often than fruits.
Eat at least one dark green vegetable every day.
Eat 1 to 2 dark green vegetables daily.
You should eat 1 cup of dark green vegetables every day.
Eat 1 to 2 handfuls of dark green vegetables every day.
Eat orange vegetables several times per week.
Eat orange vegetables 3 to 5 times per week.
Eat 2 to 4 whole grain foods every day.
Switch to whole grain foods.
Eat beans, peas, lentils or tofu most days of the week.
Eat legumes or tofu almost every day.
Eat nuts or seeds most days of the week.
Eat fish or shellfish 2 to 3 times per week. Choose fatty fish most often.
A serving is about the size of a deck of cards.
This includes char, herring, mackerel, salmon, sardines and trout.
Choose lean meats, poultry and eggs. These can be eaten most days of the week.
Choose 1% or skim milk, fortified soy beverage or unsweetened lower fat yogurt with added vitamin D. Have them 2 to 3 times every day.
You need 1% or skim milk, fortified soy beverage or unsweetened lower fat yogurt at least 2 times a day for adequate vitamin D.
Choose a different fortified plant-based beverage if you don't drink milk or soy beverage.
Choose lower sodium and lower fat cheese. Eat it less than once per day.
Cheese can sometimes be included in a healthy eating pattern.
Try to limit your consumption of cheese.
A portion of cheese is the size of 1 or 2 thumbs.
When cooking and preparing foods with oil or fat, choose unsaturated fats.
Choose vegetable oils and margarine instead of butter, lard or shortening.

**PORTION AND PROPORTIONALITY IMAGES - SAMPLE**

Phase 2: Health Professionals

INTRODUCTION 10 min 10 MIN

Moderator introduces herself/himself and her/his role: role of moderator is to ask questions, make sure everyone has a chance to express themselves, keep track of the time, be objective.

The name of the firm the moderator works for, and the type of firm that employs them (i.e. an independent marketing research firm)
We are conducting these focus groups on behalf of the Government of Canada, specifically for Health Canada. Health Canada would like to get your views on various aspects of communicating recommended amounts and types of foods in a report to health professionals and policy makers.
Role of participants: speak openly and frankly about opinions, remember that there are no wrong answers and no need to agree with each other
Results are confidential and reported all together/individuals are not identified/participation is voluntary. The length of the session (2 hours)
The presence and purpose of any recording being made of the session (audio and video taping of the discussion
The presence of any observers, their role and purpose, and the means of observation (one-way mirror, colleagues viewing in the back room)
Remind participants about the confidential nature of the focus group and not to share its content with others

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

Introduction of participants: Given the topic of our discussion today/tonight, as part of your introduction, please give your first name, tell us what you do, where you work and how healthy eating/nutrition is involved in your work.

CURRENT USE OF CANADA'S FOOD GUIDE PATTERNS 20 min 30 MIN

The focus of our discussion today/tonight will be on healthy eating. Health Canada is revising Canada's Food Guide to: strengthen healthy eating recommendations; and, communicate guidance in ways that better meet the needs of different users such as Canadians, policy makers and health professionals, like you. Health Canada is developing a number of different tools that general consumers, health professionals and policy makers will be able to access about the Food Guide and healthy eating. I say this because I want you to remember that what we are focusing on is only a part of the work they are doing.

It is important to acknowledge that since Health Canada is developing tools with different types of information, they know that some professionals use different information. So as we go through the content tonight, I want to remind you that if you don't think you will use the information presented for a particular part of your job, please share that. It will be important for their work moving forward.

The focus of our discussions tonight/today is on the report to communicate Canada's new Healthy Eating Patterns. The content of this report aims to help health professionals and policy makers in using/applying the Healthy Eating Patterns in their work.

To ensure that we are all on the same page, Canada's Healthy Eating Pattern provides guidance on amounts and types of food, including the quantities, proportions, and the frequency with which they are recommended for Canadians 2 years of age and older. From here on will be referred to as Canada's Healthy Eating Patterns or the recommended amounts and types of food.

In this session, we would like to understand if and how you are using the pattern. Our goal is to use this research to ensure we communicate the Healthy Eating Patterns in ways that are easy to apply, useful and relevant to use in your work.

[HANDS UP] How many of you are aware of Canada's current Food Guide (the rainbow cover) and its supporting Healthy Eating Pattern, which gives the recommended amounts and types of food for Canadians in a table format?

Note to moderator: the current Canada's Healthy Eating Pattern was disseminated in 2007.
Do you use the current Canada's Food Guide Pattern (recommended amounts and types of foods) in your work?
- [IF YES] How?
- [IF NO] Why not?

FORMAT OF DETAILED INFORMATION 60 min 90 MIN

Health Canada would like to explore the format and level of information required by health professionals on amounts and types of food/in communicating Canada's new healthy eating patter. The aim is to ensure the information is communicated to health professionals and policy makers in a way that supports their understanding and implementation of recommended amounts and types of foods.

We will now share two options of the new Canada's Healthy Eating Patterns. We will review them one by one. Please note the selected formats will be professionally designed prior to publication. Also, please don't pay much attention to the values as these are only placeholders and will be replaced by the guidance when available. Our focus is on the level of detail and the organization of the information for our discussion.

[NOTE TO MODERATORS: The below information is included in case you require additional information about the tables]:

The information includes draft results of Canada's healthy eating patterns, which is still being finalized.
In finalizing the Patterns, sub level food categories (left column of the table 1 & 2) may be grouped together where possible in order to provide more flexible (and less prescriptive) recommendations
The amounts refer to Reference Amounts (RAs), which are different units of measure than the one used in the existing 2007 Canada's Food Guide (Food Guide Servings).
It is intended that the information included in tables 1 and 2 would be used in combination with food lists outlining foods in each sub-level food category and their respective Reference Amounts.

Differences between the presentation of recommended amounts and types of food in Tables 1 and 2 are:

Table 1	Table 2
Present ranges of amounts We have converted RA recommendations that are greater than 1 but less than a whole number (e.g. 1.5/day) to a range of whole RAs (e.g. 1-2/day)	Present precise amounts Half Reference Amounts have been left as is (i.e. 1.5/day instead of 1-2/day)
Cells are merged where the recommendations is the same across age groups	Cells are not merged where the recommendation is the same across age groups.

[MODERATOR TO DISTRIBUTE EACH TABLE ONE AT A TIME STARTING WITH THE MERGED TABLE]

The moderator will review each option and probe as follows:

Overall, what are your initial reactions to how the information is organized? Why do you say that?
Overall, would you use the information in these tables in your work?

[IF NO] Why not?

[IF YES]

Thinking about your own use of this information, would this be a useful way to present the details about recommended amounts and types of food? Why or why not?
If you would use them, when, with whom and for what purpose/objective.

Is there anything missing?

[IF YES]

What is it?
Would you expect to see that information included as part of the table or as additional information to be used with the table? Why?

Is there another way the values for amounts and types of foods could be presented that would be more useful or relevant in your work?

[IF YES]

Can you please describe it?

DIRECTIVE & DIETARY SHIFTS MESSAGING 15 min 105 MIN

Now, we are going to look at examples of messages that would communicate the recommended amounts and types of food to the general public. For your information, variations of these messages are currently being tested with the public.

[MODERATOR TO PROVIDE HANDOUT OF EXAMPLES OF DIRECTIVE MESSAGING and DIETARY SHIFT MESSAGING]

The moderator will review examples of the two different types of messages (Directives messaging and Shift messaging) that will be communicated to Canadians. Mention that the wording is subject to change but today we are more interested to know if and how these kinds of messages could be used by a health professional or policy maker:

Overall, would you use messages, like these in your work?
- [IF YES] When, with whom and for what purpose/objective?
- [IF NO] Why not?

NOTE TO MODERATOR: Ensure conversation is around both types (descriptive and shifts) to determine if there are differences in how they would use the two. Reminder, this is not about wording or content but rather the use.

WRAP-UP 15 min 120 MIN

What tools, resources, or references do you currently use in your work to integrate/communicate recommendations on amounts and types of foods? Why?
What do you like or value about these tools/resources/references?
This concludes what we needed to cover today/tonight. We really appreciate you taking the time to come down here to share your views. Your input is very important.
Please remember that this information is confidential and should not be shared outside of the room. If you took notes, please leave them on the table.

**FORMAT - TABLE 2 - SAMPLE**
High-Level Food Categories (grey) Sub-Level Food Categories (white)	2 - 3 YRS	4 - 8 YRS	9 - 13 YRS	14 - 18 YRS	19 - 50 YRS	51 - 70 YRS	71 + YRS
Vegetables and Fruit
Dark green vegetables	1/day	1/day	2/day	2/day	2/day	2/day	2/day
Deep yellow or orange vegetables	3/week	3/week	3/week	3/week	3/week	3/week	3/week
Starchy vegetables	5/week	5/week	5/week	5/week	5/week	5/week	5/week
Other vegetables	1/day	1.5/day	1.5/day	2/day	2.5/day	2/day	2/day
Fruit	1.5/day	1.5/day	1.5/day	1.5/day	1.5/day	1.5/day	1.5/day
Grains
Whole grain and whole wheat	1/day	1.5/day	2/day	2/day	2.5/day	1.5/day	1.5/day
Refined grain	0.5/day	0.5/day	1/day	1/day	1/day	1/day	1/day
Protein Foods
Milks, Fortified soy beverages and Yogurts	2.5/day	2.5/day	2.5/day	2.5/day	2.5/day	2.5/day	2.5/day
Cheeses	1/week	1/week	5/week	4/week	1/week	5/week	5/week
Legumes	3/week	4/week	5/week	1/day	1.5/day	1/day	1/day
Nuts and seeds	5/week	5/week	5/week	5/week	5/week	5/week	5/week
Red, Organ, & Game Meats, Poultry and Eggs	2/week	4/week	5/week	1/day	1/day	1/day	4/week
Fish and shellfish	2/week	2/week	3/week	3/week	3/week	3/week	2/week
Oils, Fats, Condiments, Sauces & Dressings
Unsaturated fats and oils	2/day	1.5/day	1.5/day	1.5/day	1.5/day	1.5/day	1.5/day
Condiments, sauces and lower fat dressings	2/week	2/week	3/week	3/week	3/week	3/week	3/week

**FORMAT - TABLE 1 - SAMPLE**
High-Level Food Categories (grey) Sub level food categories (white)	2-3 YRS	4 - 8 YRS	9 - 13 YRS	14 -18 YRS	19 - 50 YRS	51 -70 YRS	71 + YRS
Vegetables and Fruit
Dark green vegetables	1/day		2/day
Deep yellow or orange vegetables	3/week
Starchy vegetables	5/week
Other vegetables	1/day	1-2/day
Fruit	1-2/day
Grains
Whole grain and whole wheat	1/day	1-2/day	2/day		2-3/day	1-2/day
Refined grain	3-4/week		1/day
Protein Foods
Milks, Fortified soy beverages and Yogurts	2-3/day
Cheeses	1/week		5/week	4/day	1/week	5/week
Legumes	3/week	4/week	5/week	1/day	1-2/day	1/day
Nuts and seeds	5/week
Red, Organ, & Game Meats, Poultry and Eggs	2/week	4/week	5/week	1/day			4/week
Fish and shellfish	2/week		3/week				2/week
Oils, Fats, Condiments, Sauces & Dressings
Unsaturated fats and oils	2/day	1-2/day
Condiments, sauces and lower fat dressings	2/week		3/week

DIRECTIVE MESSAGING - SAMPLE

How much to eat

To follow Canada's food guide healthy eating patterns:

Eat vegetables or fruits at each meal and snack. Choose vegetables more often than fruits.
- Eat at least one dark green vegetable every day.
- Eat orange vegetables several times per week.
Eat 2 to 4 whole grain foods every day.
Eat protein foods.
- Eat beans, peas, lentils or tofu most days of the week.
- Eat nuts or seeds most days of the week.
- Eat fish or shellfish 2 to 3 times per week. Choose fatty fish most often.
- Choose lean meats, poultry and eggs. These can be eaten most days of the week.
- Choose 1% or skim milk, fortified soy beverage or unsweetened lower fat yogurt with added vitamin D. Have them 2 to 3 times every day.
- Choose lower sodium and lower fat cheese. Eat it less than once per day.
When cooking and preparing foods with oil or fat, choose unsaturated fats.

DIETARY SHIFT MESSAGING - SAMPLE

To follow Canada's Healthy Eating Patterns:

Increase Or Eat more
- Beans, peas, lentils and tofu
- Nuts and seeds
- Vegetables and fruits, especially dark green and orange
- Fish and shellfish
- 1% and skim milk, fortified soy beverage and lower fat yogurt
Switch to
- Whole grain foods
- Unsaturated fats and oils
Limit Or Eat less
- Sugary drinks
- Candies and chocolate
- Processed meats
- Highly processed spreads and dressings

Phase 2: Policy Makers

INTRODUCTION

Name:
Position:
Address/Phone number:
Date/Time:
Interview conducted by:

Thank you for agreeing to take part in this research project on behalf of Health Canada. Just as a reminder:

Your anonymity is guaranteed and you will not be directly cited. In this regard, we encourage you to be as frank as possible.
Your input will be compiled into a report that will provide important feedback to Health Canada as they continue to work on the communications aspects around the new Canada's Food Guide.
Your participation will provide important, unvarnished feedback, that they hope will help them communicate recommended amounts and types of foods in a report that is relevant and useful to health professionals and policy makers.
If you don't have any questions, I will go ahead and get started. We will be exploring three key sections as it relates to the development, implementation, and/or evaluation of food and nutrition policies. These sections include:
1. Current use of Canada's Food Guide pattern
2. Format of detailed information on amounts and types of foods
3. Potential use of directive & dietary shift information

CURRENT USE OF CANADA'S FOOD GUIDE PATTERNS

The focus of this interview will be on healthy eating. Health Canada is revising Canada's Food Guide to: strengthen healthy eating recommendations; and, communicate guidance in ways that better meet the needs of different users such as Canadians, health professionals, and policy makers and like you. Health Canada is developing a number of different tools that general consumers, health professionals and policy makers will be able to access about the Food Guide and healthy eating. I say this because I want you to remember that what we are focusing on is only a part of the work they are doing.

It is important to acknowledge that since Health Canada is developing tools with different types of information, they know that some professionals use different information or information in differing levels of detail. So, as we go through the content tonight, I want to remind you that if you don't think you will use the information presented for work on food and nutrition policies, please share that. It will be important for their work moving forward.

The focus of our interview is more specifically on the report to communicate Canada's new Healthy Eating Pattern to health professionals and policy makers.

To ensure that we are all on the same page, Canada's Healthy Eating Patterns provide guidance on amounts and types of food, including the quantities, proportions, and the frequency with which they are recommended for Canadians 2 years of age and older. From here on will be referred to as Canada's Healthy Eating Patterns or the recommended amounts and types of food.

We would like to understand if and how you are using the pattern. Our goal is to use this research to ensure we communicate the Healthy Eating Patterns in ways that are easy to apply, useful and relevant.

To begin, how familiar are you with Canada's current Food Guide (the rainbow cover) and its supporting Healthy Eating Pattern, which gives the recommended amounts and types of food for Canadians in a table format?

Note to interviewer: the current Canada's Healthy Eating Pattern was disseminated in 2007.
Do you feel the current Canada's Food Guide Pattern (recommended amounts and types of foods) is a useful tool to develop, implement, or evaluate food and nutrition policies? An example may be implementing a food and nutrition policy by procuring food in a facility and developing menus.
- [IF YES] From your experience, what types of policies has it been useful for and how?
- [IF NO] Why not?

FORMAT OF DETAILED INFORMATION

Health Canada would like to explore the format and level of information required by policy makers on amounts and types of food/in communicating Canada's new healthy eating patterns.

Before this interview, you should have received different formats to explore that communicate amounts and types of food in a detailed way. We will review them one by one. Please note that these are not professionally designed. Also, note the tables currently include number signs (#). These # will be replaced with actual values once the healthy eating patterns are finalized. Our focus is on the level of detail and the organization of the information for our discussion.

[NOTE TO INTERVIEWER: The below information is included in case you require additional information about the tables]:

The information includes number signs (#) in place of actual values as Canada's healthy eating patterns are still being finalized.
The amounts refer to Reference Amounts (RAs), which are different units of measure than the one used in the existing 2007 Canada's Food Guide (Food Guide Servings). Reference Amounts are regulated quantities of food that represent the amount of food typically consumed by adults in one sitting. The amounts align with those found on Nutrition Facts tables.
It is intended that the information included in tables 1 and 2 would be used in combination with food lists outlining foods in each sub-level food category and their respective Reference Amounts.

Differences between the presentation of recommended amounts and types of food in Tables 1 and 2:

Table 2	Table 1
Present precise amounts Where the result of the pattern is a half Reference Amount ((i.e. 1.5/day instead of 1-2/day) it would be left like that.	Present ranges of amounts Reference Amount recommendations that are greater than 1 but less than a whole number (e.g. 1.5/day) are converted to a range of whole RAs (e.g. 1-2/day)
Cells are not merged where the recommendation is the same across age groups.	Cells are merged where the recommendations is the same across age groups

[ALWAYS START WITH TABLE 2] The interviewer will review each option and ask:

TABLE 2

Overall, what are your initial reactions to how the information is organized? Why do you say that?
Overall, would you use the information in these tables in your work with food and nutrition policies (i.e. development, implementation, evaluation)?

[IF NO] Why not?

[IF YES]

Thinking of your own use of this information, would this be a useful way for details about recommended amounts and types of food to be presented? Why or why not?
When would you use this information and for what purpose/objective?

Is there anything missing?

[IF YES]

What is it?
Would you expect to see that information included as part of the table or as additional information to be used with the table? Why?

PROBE IF NEEDED: For example, would a message such as "choose vegetables more often than fruit" included as a column beside vegetables and fruit, or "choose dark green and deep yellow or orange vegetables every day" associated with those sub food categories. In finalizing the Patterns, sub level food categories (left column of the table 1 & 2) may be grouped together where possible in order to provide more flexible (and less prescriptive) recommendations. Are there any sub level food categories that you would rely for food and nutrition policy? (e.g. amounts on vegetables and fruit only and not the different sub food categories; or combining starch vegetable with another sub-level food category.

Are there any changes you would make to the number of age groups? i.e. would it be more useful to group some together? If so why?

Is there another way you would like to see amounts and types of foods could be presented that would be more useful or relevant?

[IF YES]

Can you please describe it?

TABLE 1

Overall, what are your initial reactions to how the information is organized? Why do you say that?
Overall, would you use the information in these tables in your work with food and nutrition policies (i.e. development, implementation, evaluation)?

[IF NO] Why not?

[IF YES]

Thinking of your own use of this information, would this be a useful way for details about recommended amounts and types of food to be presented? Why or why not?
When would you use this information and for what purpose/objective?

Is there anything missing?

[IF YES]

What is it?
Would you expect to see that information included as part of the table or as additional information to be used with the table? Why?

PROBE IF NEEDED: For example, would a message such as "choose vegetables more often than fruit" included as a column beside vegetables and fruit, or "choose dark green and deep yellow or orange vegetables every day" associated with those sub food categories. In finalizing the Patterns, sub level food categories (left column of the table 1 & 2) may be grouped together where possible in order to provide more flexible (and less prescriptive) recommendations. Are there any sub level food categories that you would rely for food and nutrition policy? (e.g. amounts on vegetables and fruit only and not the different sub food categories; or combining starch vegetable with another sub-level food category.

Are there any changes you would make to the number of age groups? i.e. would it be more useful to group some together? If so why? How would that change help you do your work?
The tables include daily and weekly recommendations, does this cause any confusion? Would grouping foods by daily recommendations and by weekly recommendations be helpful? If yes, why?

NOTE TO MODERATOR: Here we expect we may hear that the following is missing:

Quality messaging - [potential probe] - is there additional information you require about types of foods to eat?
"Foods to Limit" - if this comes up potential probes are:
- How would information on this help you with work on food and nutrition policies?
- Why do you need information on foods that do fit in a healthy eating pattern?
- Is there a need to provide information on foods that fit in a food group but are higher in sodium, sugars, and/or saturated fats?
- Is there a need to provide information on foods that are not part of a food group (e.g. chocolate, sugary drinks) that are higher in sodium, sugars, or saturated fats?
Specific amounts - if this comes up, potential probes are:
- [IF YES]
  - would examples of foods and their associated reference amounts be useful for work on food and nutrition policies? If so, how would you use this information?
- [IF NO]
  - Why not?

Is there another way you would like to see amounts and types of foods presented that would be more useful or relevant?
- [IF YES]
  - Can you please describe it?

DIRECTIVE & DIETARY SHIFTS MESSAGING

Now, we are going to review the examples of "DIRECTIVE MESSAGING" and "DIETARY SHIFT MESSAGING" that would be used to communicate the recommended amounts and types of food to the general public. For your information, variations of these messages are currently being tested with the public.

The interviewer will review each set of messages that will be communicated to Canadians, mentioning that the content and wording is subject to change but today we are more interested to know if and how these kinds of messages could be used by a health professional or policy maker:

NOTE TO INTERVIEWER: Ensure conversation is around both types (descriptive and shifts) to determine if there are differences in how they would use the two. Reminder, this is not about wording or content but rather the use.

How much to eat - SAMPLE

To follow Canada's food guide healthy eating patterns:

Eat vegetables or fruits at each meal and snack. Choose vegetables more often than fruits.
- Eat at least one dark green vegetable every day.
- Eat orange vegetables several times per week.
Eat 2 to 4 whole grain foods every day.
Eat protein foods.
- Eat beans, peas, lentils or tofu most days of the week.
- Eat nuts or seeds most days of the week.
- Eat fish or shellfish 2 to 3 times per week. Choose fatty fish most often.
- Choose lean meats, poultry and eggs. These can be eaten most days of the week.
- Choose 1% or skim milk, fortified soy beverage or unsweetened lower fat yogurt with added vitamin D. Have them 2 to 3 times every day.
- Choose lower sodium and lower fat cheese. Eat it less than once per day.
- When cooking and preparing foods with oil or fat, choose unsaturated fats.

Overall, would you use messages, like these for work on food or nutrition policies?
- [IF YES] When, with whom and for what purpose/objective?
- [IF NO] Why not?

DIETARY SHIFT MESSAGING - SAMPLE

To follow Canada's Healthy Eating Patterns:

Increase OR Eat more
- Beans, peas, lentils and tofu
- Nuts and seeds
- Vegetables and fruits, especially dark green and orange
- Fish and shellfish
- 1% and skim milk, fortified soy beverage and lower fat yogurt
Switch to
- Whole grain foods
- Unsaturated fats and oils
Limit OR Eat less
- Sugary drinks
- Candies and chocolate
- Processed meats
- Highly processed spreads and dressings

Overall, would you use messages, like these for work on food or nutrition policies?
- [IF YES]
  - When, with whom and for what purpose/objective?
  - How would your use of this information be different than the information presented in the tables?
  - Is the level of information useful
  - These messages are directed at the general population. Do they need messages like these directed at health professionals? If yes, why?
- [IF NO] Why not?
- Is anything missing?

NOTE TO MODERATOR: listen to see if they feel they need these messages with the table. Or would they see them replacing some of the information in the table? (e.g. could you have the message about dark green instead of the numbers about dark green vegetables)

WRAP-UP

What tools, resources, or references do you currently use for developing, implementing or evaluation food or nutrition policies that use information on amounts and types of food? Why?
What do you like, use, or value about these tools/resources/references?
This concludes what we needed to cover in the interview. We really appreciate you taking the time to share your views. Your input is very important.
Please remember that this information is confidential and should not be shared. If you took notes, please destroy them.

**FORMAT - TABLE 2 - SAMPLE**
High-Level Food Categories (grey) Sub-Level Food Categories (white)	2 - 3 YRS	4 - 8 YRS	9 - 13 YRS	14 - 18 YRS	19 - 50 YRS	51 - 70 YRS	71 + YRS
Vegetables and Fruit
Dark green vegetables	#/day	#/day	#/day	#/day	#/day	#/day	#/day
Orange vegetables	#/week	#/week	#/week	#/week	#/week	#/week	#/week
Starchy vegetables	#/week	#/week	#/week	#/week	#/week	#/week	#/week
Other vegetables	#/day	#.5/day	#.5/day	#/day	#.5/day	#/day	#/day
Fruit	#.5/day	#.5/day	#.5/day	#.5/day	#.5/day	#.5/day	#.5/day
Grains
Whole grain and whole wheat	#/day	#.5/day	#/day	#/day	#.5/day	#.5/day	#.5/day
Refined grain	#.5/day	#.5/day	#/day	#/day	#/day	#/day	#/day
Protein Foods
Milks, Fortified soy beverages and Yogurts	#.5/day	#.5/day	#.5/day	#.5/day	#.5/day	#.5/day	#.5/day
Cheeses	#/week	#/week	#/week	#/week	#/week	#/week	#/week
Legumes	#/week	#/week	#/week	#/day	#.5/day	#/day	#/day
Nuts and seeds	#/week	#/week	#/week	#/week	#/week	#/week	#/week
Red, Organ, & Game Meats, Poultry and Eggs	#/week	#/week	#/week	#/day	#/day	#/day	#/week
Fish and shellfish	#/week	#/week	#/week	#/week	#/week	#/week	#/week
Oils, Fats, Condiments, Sauces & Dressings
Unsaturated fats and oils	#/day	#.5/day	#.5/day	#.5/day	#.5/day	#.5/day	#.5/day
Condiments, sauces and lower fat dressings	#/week	#/week	#/week	#/week	#/week	#/week	#/week

**FORMAT - TABLE 1 - SAMPLE**
High-Level Food Categories (grey) Sub level food categories (white)	2-3 YRS	4 - 8 YRS	9 - 13 YRS	14 -18 YRS	19 - 50 YRS	51 -70 YRS	71 + YRS
Vegetables and Fruit
Dark green vegetables	X/day		X/day
Deep yellow or orange vegetables	X/week
Starchy vegetables	X/week
Other vegetables	X/day	X-X/day
Fruit	X-X/day
Grains
Whole grain and whole wheat	X/day	X-X/day	X/day		X-X/day	X-X/day
Refined grain	X-X/week		X/day
Protein Foods
Milks, Fortified soy beverages and Yogurts	X-X/day
Cheeses	X/week		X/week	X/day	X/week	X/week
Legumes	X/week	X/week	X/week	X/day	X-X/day	X/day
Nuts and seeds	X/week
Red, Organ, & Game Meats, Poultry and Eggs	X/week	X/week	X/week	X/day			X/week
Fish and shellfish	X/week		X/week				X/week
Oils, Fats, Condiments, Sauces & Dressings
Unsaturated fats and oils	X/day	X-X/day
Condiments, sauces and lower fat dressings	X/week		X/week

DIRECTIVE MESSAGING - SAMPLE

How much to eat

To follow Canada's food guide healthy eating patterns:

Eat vegetables or fruits at each meal and snack. Choose vegetables more often than fruits.
- Eat at least one dark green vegetable every day.
- Eat orange vegetables several times per week.
Eat 2 to 4 whole grain foods every day.
Eat protein foods.
- Eat beans, peas, lentils or tofu most days of the week.
- Eat nuts or seeds most days of the week.
- Eat fish or shellfish 2 to 3 times per week. Choose fatty fish most often.
- Choose lean meats, poultry and eggs. These can be eaten most days of the week.
- Choose 1% or skim milk, fortified soy beverage or unsweetened lower fat yogurt with added vitamin D. Have them 2 to 3 times every day.
- Choose lower sodium and lower fat cheese. Eat it less than once per day.
When cooking and preparing foods with oil or fat, choose unsaturated fats.

DIETARY SHIFT MESSAGING - SAMPLE

To follow Canada's Healthy Eating Patterns:

Increase Or Eat more
- Beans, peas, lentils and tofu
- Nuts and seeds
- Vegetables and fruits, especially dark green and orange
- Fish and shellfish
- 1% and skim milk, fortified soy beverage and lower fat yogurt
Switch to
- Whole grain foods
- Unsaturated fats and oils
Limit Or Eat less
- Sugary drinks
- Candies and chocolate
- Processed meats
- Highly processed spreads and dressings

APPENDIX B: SCREENER

Phase 1: General Population

FOCUS GROUP SUMMARY

GROUP 2 MARGINAL HEALTH LITERACY
- Score 0-3 on health literacy test (Q.S14-Q.S19)
- Good mix of demos (gender, age, income, household situation, ethnicity, etc.)
- Recruit 10 for 8 to show

GROUP 3 ADEQUATE HEALTH LITERACY
- Score 4-6 on health literacy test (Q.S14-Q.S19)
- Good mix of demos (gender, age, income, household situation, ethnicity, etc.)
- Recruit 10 for 8 to show

SASKATOON Wednesday, August 22, 2018
- Group 2: Marginal Health Literacy
- Group 3: Adequate Health Literacy
- Honorarium: $100
- 6:30 pm
- 8:00 pm
OTTAWA Thursday, August 23, 2018
- Group 2: Marginal Health Literacy
- Group 3: Adequate Health Literacy
- Honorarium: $100
- 6:30 pm
- 8:00 pm
KITCHENER Saturday, August 25, 2018
- Group 2: Marginal Health Literacy
- Group 3: Adequate Health Literacy
- Honorarium: $100
- 10:00 am
- 11:30 am

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

Hello/Bonjour, my name is _______________ and I'm calling on behalf of the Earnscliffe Strategy Group, a national public opinion research firm. We are organizing a series of discussion groups on issues of importance to Canadians, on behalf of the Government of Canada, specifically for Health Canada. The purpose of the study and the small group discussion is to hear people's opinions of healthy eating messages, images, icons and symbols. We are looking for people who would be willing to participate in a discussion group that will last up to 90 minutes. These people must be 18 years of age or older. Up to 10 participants will be taking part and for their time, participants will receive an honorarium of $100.00. May I continue?

Yes CONTINUE
No THANK AND TERMINATE

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

Participation is voluntary. We are interested in hearing your opinions; no attempt will be made to sell you anything or change your point of view. The format is a 'round table' discussion led by a research professional. All information collected, used and/or disclosed will be used for research purposes only and the research is entirely confidential. But before we invite you to attend, we need to ask you a few questions to ensure that we get a good mix and variety of people. May I ask you a few questions; this should only take 5 minutes?

Yes CONTINUE
No THANK AND TERMINATE

READ TO ALL: "This call may be monitored or audio taped for quality control and evaluation purposes.

ADDITIONAL CLARIFICATION IF NEEDED:

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

S1. Do you or any member of your household currently work for or have you or has any member of your household ever worked for…

	Yes	No
A marketing research firm or communications or a creative agency	1	2
A magazine or newspaper, online or print	1	2
A radio or television station	1	2
A public relations company	1	2
An advertising agency or graphic design firm	1	2
An online media company or as a blog writer	1	2
The government, whether federal, provincial or municipal	1	2
The medical sector	1	2
Food manufacturing/food industry	1	2
Associations or organization representing the interest of the food and beverage industry	1	2
An organization involved in health promotion or advice on nutrition and healthy eating	1	2
An organization representing a particular type of food and/or beverage	1	2

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

S2. DO NOT ASK - NOTE GENDER

ENSURE GOOD MIX OF GENDER

Male 1
Female 2

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

ENSURE GOOD MIX OF AGE

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

S4. What is your current employment status?

ENSURE GOOD MIX OF EMPLOYMENT STATUS

Working full-time 1
Working part-time 2
Self-employed 3
Retired 4
Unemployed 5
Student 6
Stay at home parent 7
Other (please specify) 8
DK/NR 9 THANK AND TERMINATE

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

ENSURE GOOD MIX OF INCOME

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

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

ENSURE GOOD MIX OF EDUCATION

Elementary school 1
Some high school only 2
Completed high school 3
Some college/university 4
Completed college/university 5
Post-graduate studies 6
DK/NR 9 THANK AND TERMINATE

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

ENSURE GOOD MIX OF HOUSEHOLD SITUATION

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

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

ENSURE GOOD MIX OF ETHNICITY

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

AIM FOR AT LEAST 1 INDIGENOUS AND A MINIMUM OF 2 NON-CAUCASIANS IN EACH GROUP.

S9. Which of the following best describes yourself?

ENSURE GOOD MIX IN ALL GROUPS

I pay close attention to the food and beverages I consume, and I am very interested in health related information 1
I pay some attention to the food and beverages I consume, and I am moderately interested in health-related information 2
I do not pay close attention to the food and beverages I consume, and I am not really interestedin health-related information 3
DK/NR 4 THANK AND TERMINATE

S10. Do you have a personal smartphone including an iPhone, Blackberry, Android, etc. that provides you with access to the Internet either via wifi or your own data?

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

S11. As part of these discussion groups, participants will be required to bring their personal smartphones and asked to access the Internet to view information online and may be asked to download an app for the purposes of the discussion. Would you be willing to bring and use your smartphone during the discussion to review a website and an app in the groups?

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

IF PARTICIPANT ASKS, CONFIRM THAT THE FOCUS GROUP FACILITY WILL HAVE WIFI ACCESS.

S12. Have you participated in a discussion or focus group before? A discussion group brings together a few people in order to know their opinion about a given subject.

Yes 1 (MAX 1/3 PER GROUP, ASK S13, S14, S15)
No 2 SKIP TO S16
DK/NR 9 THANK AND TERMINATE

S13. When was the last time you attended a discussion or focus group?

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

S14. How many of these sessions have you attended in the last five years?

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

S15. And what was/were the main topic(s) of discussion in those groups?

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

S16. We are asking participants about nutrition information that appears on all pre-packaged foods. To do that, I need to email you a sample nutrition label and ask you some questions about it. I would like to do that now so we can continue with the questions. Do you have immediate access to your email?

Yes 1 SEE INTERVIEWER INSTRUCTIONS
No 2 SEE INTERVIEWER INSTRUCTIONS

INTERVIEWER INSTRUCTIONS:

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

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

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

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

NOTE TO INTERVIEWER:

The questions must be asked in order. Continue even if the respondent gets the first few questions wrong. However, if Q.S21 is answered incorrectly, do not ask Q.S22.
Do not in any way prompt a respondent who is unable to answer a question. You can repeat the question if asked or if you think it might help the respondent. Prompting may jeopardize the accuracy of the test. Just say, "Well then, let's go on to the next question."
The respondent is to be given as much time as needed to answer the questions.
Note: The average time needed to complete all 6 questions is approximately 3 minutes. Do not tell respondents if they have answered correctly or incorrectly. If asked, say something like: "I can't tell you at the moment, but for now, you are doing fine. Now let's go on to the next question."
Scoring the answers: Score by giving 1 point to each correct answer for a maximum of 6 points

SCORE OF 0-3 QUALIFIES FOR MARGINAL HEALTH LITERACY GROUP - GROUP 1

SCORE OF 4-6 QUALIFIES FOR ADEQUATE HEALTH LITERACY GROUP - GROUP 2

**ICE CREAM CONTAINER LABEL TO BE EMAILED**

Amount per serving	% Daily value*
Calories 250	-
Fat 13g	20 %
Saturated 9.0 g + Trans 0 g	45 %
Cholesterol 28 mg	-
Sodium 55 mg	2 %
Carbohydrate 30 mg	10 %
Fibre 2 g	1 %
Sugars 23 g	-
Protein 4g	-
Vitamin A	10 %
Vitamin C	0 %
Calcium	15 %
Iron	4 %

S17. 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

S18. 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:

250 ml or 1 cup (or any amount up to 250 ml or 1 cup), or
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.

S19. 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

S20. 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

S21. 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

S22. [ASK ONLY IF ANSWER TO Q.S21 IS "NO"] Why not?

RECORD ANSWER:

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

**SCORING SHEET**
Answer	Correct	Not Correct	Correct response should be
Q.S17			1,000
Q.S18			250 ml or 1 cup (or any amount up to 250 ml or 1 cup), OR half the container
Q.S19			33
Q.S20			10%
Q.S21			No
Q.S22			Because it has peanuts/peanut oil
TOTAL SCORE

PARTICIPANT GETS 1 POINT FOR EACH CORRECT ANSWER

TOTAL SCORE OF 0-3 QUALIFIES FOR MARGINAL HEALTH LITERACY GROUP - GROUP 1

TOTAL SCORE OF 4-6 QUALIFIES FOR ADEQUATE HEALTH LITERACY GROUP - GROUP 2

INVITATION

S23. Participants in discussion groups are asked to voice their opinions and thoughts. How comfortable are you in voicing your opinions in front of others? Are you… (READ LIST)

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

S24. Sometimes participants are asked to read text and/or review images during the discussion. Is there any reason why you could not participate?

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

S25. Based on your responses, it looks like you have the profile we are looking for. I would like to invite you to participate in a small group discussion, called a focus group, we are conducting at [TIME], on [DATE].

As you may know, focus groups are used to gather information on a particular subject matter; in this case, the discussion will touch on the food choices you make. The discussion will consist of 8 to 10 people and will be very informal. It will last up to 90 minutes, refreshments will be served and you will receive $100.00 as a thank you for your time. Would you be willing to attend?

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

PRIVACY QUESTIONS

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

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

Yes 1 GO TO P2
No 2 GO TO P1A

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

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

Yes 1 GO TO P2
No 2 THANK & TERMINATE

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

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

Yes 1 THANK & GO TO P3
No 2 READ RESPONDENT INFO BELOW & GO TO P2A

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

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

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

P3) Employees from Health Canada and/or the Government of Canada may be onsite to observe the groups in-person from behind a one-way mirror.

Do you agree to be observed by Government of Canada employees?

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

P3a) It is standard qualitative procedure to invite clients, in this case, Government of Canada employees, to observe the groups in person. They will be seated in a separate room and observe from behind a one-way mirror. They will be there simply to hear your opinions first hand although they may take their own notes and confer with the moderator on occasion to discuss whether there are any additional questions to ask the group.

Do you agree to be observed by Government of Canada employees?

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

Invitation:
Wonderful, you qualify to participate in one of our discussion sessions. As I mentioned earlier, the group discussion will take place the evening of [Day, Month, Date] @ [Time] for up to 90 minutes.

Do you have a pen handy so that I can give you the address where the group will be held? It will be held at:

SASKATOON Wednesday, August 22, 2018
- Insightrix
  1-3223 Millar Avenue
  Saskatoon, SK S7K 5Y3
  Tel: 306-657-5640
- Honorarium: $100
- 6:30 pm
- 8:00 pm
OTTAWA Thursday, August 23, 2018
- Stratcom
  100 Sparks Street, Suite 802
  Ottawa, ON K1P 5B7
  Tel: 613-916-6215
- Honorarium: $100
- 6:30 pm
- 8:00 pm
KITCHENER Saturday, August 25, 2018
- Metroline Research Group
  7 Duke Street West, Suite 301
  Kitchener, ON N2H 6N7
  Tel: 519-584-7700
- Honorarium: $100
- 10:00 am
- 11:30 am

We ask that you arrive fifteen minutes early to be sure you find parking, locate the facility and have time to check-in with the hosts. The hosts may be checking respondents' identification prior to the group, so please be sure to bring some personal identification with you (for example, a driver's license). If you require glasses for reading make sure you bring them with you as well. And, please, don't forget to bring your smartphone as you will not be able to participate without one.

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

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

First name
Last Name
email
Daytime phone number
Evening phone number

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

Phase 1: General Health Professionals/Educators

FOCUS GROUP SUMMARY

Group 1 is a mix of the following three professions
Recruit 8 with a mix from each of the three professions

ELEMENTARY SCHOOL TEACHERS

Teach children in JK, SK and up to Grade 6 (ages 4 to 12)
Ensure that all have first-hand experience educating on healthy eating (QS6)

COMMUNITY LEVEL EDUCATORS

Work in areas such as YMCA, recreations centres, community kitchens, libraries, community centres, Girl Guides, Scouts, senior centres, family resource centres, etc.
Ensure that all have first-hand experience with educating on and/or communicating about healthy eating (QS6)

REGISTERED NURSES WORKING IN PUBLIC HEALTH OR COMMUNITY

Work in public health clinics/units/offices, community health centres/CLSC
Ensure that all have first-hand experience with educating on and/or communicating about healthy eating (QS6)

SASKATOON Wednesday, August 22, 2018
- Group 1: Mix of:
  - Primary Level Teachers
  - Community Level Educators
  - Registered Nurses working in Public Health or Community
- Honorarium: $250
- 5:00 pm
OTTAWA Thursday, August 23, 2018
- Group 1: Mix of:
  - Primary Level Teachers
  - Community Level Educators
  - Registered Nurses working in Public Health or Community
- Honorarium: $250
- 5:00 pm

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

Hello/Bonjour, my name is _______________ and I'm calling on behalf of the Earnscliffe Strategy Group, a national public opinion research firm. We are organizing a series of discussion groups on issues of importance to Canadians, on behalf of the Government of Canada, specifically for Health Canada. The purpose of the study and the small group discussion is to hear people's opinions of healthy eating messages, images, icons and symbols. We are looking for people who would be willing to participate in a discussion group that will last up to 90 minutes. These people must be professionals in the health and/or education fields. Up to 8 participants will be taking part and for their time, participants will receive an honorarium of $250.00. May I continue?

Yes CONTINUE
No THANK AND TERMINATE

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

Yes CONTINUE
No THANK AND TERMINATE

READ TO ALL: "This call may be monitored or audio taped for quality control and evaluation purposes.

ADDITIONAL CLARIFICATION IF NEEDED:

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

S1. Do you or any member of your household currently work for or have you or has any member of your household ever worked for…

	Yes	No
A marketing research firm or communications or a creative agency	1	2
A magazine or newspaper, online or print	1	2
A radio or television station	1	2
A public relations company	1	2
An advertising agency or graphic design firm	1	2
The federal government	1	2
Food manufacturing/food industry	1	2
An organization representing the interest of the food and beverage industry	1	2
An organization representing a particular type of food and/or beverage	1	2

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

S2. DO NOT ASK - NOTE GENDER (ATTEMPT TO ENSURE A GOOD MIX)

Male 1
Female 2

S3. What is your current employment status?

Working full-time 1 CONTINUE
Working part-time 2 CONTINUE
Self-employed 3 CONTINUE
Retired 4 THANK AND TERMINATE
Unemployed 5 THANK AND TERMINATE
Student 6 THANK AND TERMINATE
Stay at home parent 7 THANK AND TERMINATE
Other (PLEASE SPECIFY, CONTINUE IF "VOLUNTEER") 8
DK/NR 9 THANK AND TERMINATE

IF SAYS "OTHER" AND "OTHER" INCLUDES "VOLUNTEER", CONTINUE; OTHERWISE THANK AND TERMINATE.

S4. Are you a…?

Elementary school teacher (JK, SK, up to Grade 6) 1
Community level educator working/volunteering at a YMCA, recreation centre, community centre, community kitchen, library, Girl Guides, Scouts, senior centre, family resource centre, or something similar (SPECIFY) 2
Registered nurse working in community or public health (so NOT in clinical/hospital or long-term care, etc.) 3

MUST SAY "YES" TO AT LEAST ONE, OTHERWISE THANK AND TERMINATE. ENSURE GOOD MIX OF ALL THREE IN EACH GROUP.

S5. Does part of your role include educating on and/or communicating healthy eating information (including the food guide)?

Yes 1 CONTINUE
No 2 THANK AND TERMINATE

S6. Do you have a tablet and/or laptop that you use for work?

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

S7. [IF NO AT QS6] In that case, do you have a personal smartphone including an iPhone, Blackberry, Android, etc. or tablet that provides you with access to the Internet either via wifi or your own data?

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

S8. As part of these discussion groups, participants will be required to bring their tablets, laptops and/or personal smartphone and asked to access the Internet to view information online and may be asked to download an app for the purposes of the discussion. Would you be willing to bring and use your tablet, laptop and/or personal smartphone or tablet during the discussion to review a website and an app in the groups?

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

IF PARTICIPANT ASKS, CONFIRM THAT THE FOCUS GROUP FACILITY WILL HAVE WIFI ACCESS.

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

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

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

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

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

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

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

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

INVITATION

S13. Participants in discussion groups are asked to voice their opinions and thoughts. How comfortable are you in voicing your opinions in front of others? Are you… (READ LIST)

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

S14. Sometimes participants are asked to read text and/or review images during the discussion. Is there any reason why you could not participate?

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

S15. Based on your responses, it looks like you have the profile we are looking for. I would like to invite you to participate in a small group discussion, called a focus group, we are conducting at [TIME], on [DATE].

As you may know, focus groups are used to gather information on a particular subject matter; in this case, the discussion will touch on the food choices you make. The discussion will consist of approximately 8 people and will be very informal. It will last approximately 90 minutes, refreshments will be served and you will receive $250.00 as a thank you for your time.

Would you be willing to attend?

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

Please remember that all information discussed in this group will be confidential and should not be shared outside the room in which the discussion will be held. If you takes notes, you will have to leave them at the end of the session. We also ask in advance that you refrain from using your cell phone during the session.

PRIVACY QUESTIONS

Yes 1 GO TO P2
No 2 READ RESPONDENT INFO BELOW

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

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

Yes 1 GO TO P2
No 2 THANK & TERMINATE

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

Yes 1 THANK & GO TO P3
No 2 GO TO P2A

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

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

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

P3) Employees from Health Canada and/or the Government of Canada may be onsite to observe the groups in-person from behind a one-way mirror.

Do you agree to be observed by Government of Canada employees?

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

Do you agree to be observed by Government of Canada employees?

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

Do you have a pen handy so that I can give you the address where the group will be held? It will be held at:

SASKATOON Wednesday, August 22, 2018
- Insightrix
  1-3223 Millar Avenue
  Saskatoon, SK S7K 5Y3
  Tel: 306.657.5640
- Honorarium: $250
- 5:00 pm
OTTAWA Thursday, August 23, 2018
- Stratcom
  100 Sparks Street, Suite 802
  Ottawa, ON K1P 5B7
  Tel: 613.916.6215
- Honorarium: $250
- 5:00 pm

We ask that you arrive fifteen minutes early to be sure you find parking, locate the facility and have time to check-in with the hosts. The hosts may be checking respondents' identification prior to the group, so please be sure to bring some personal identification with you (for example, a driver's license). If you require glasses for reading make sure you bring them with you as well. And, please do not forget to bring your tablet or laptop as you will not be able to participate without one.

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

First name
Last Name
email
Daytime phone number
Evening phone number

Phase 2: General Population

FOCUS GROUP SUMMARY

GROUP 3 MARGINAL HEALTH LITERACY

Score 0-3 on health literacy test (Q.S15-Q.S20)
Good mix of demos (gender, age, income, household situation, ethnicity, etc.)
Recruit 10 for 8 to show

GROUP 4 ADEQUATE HEALTH LITERACY

Score 4-6 on health literacy test (Q.S15-Q.S20)
Good mix of demos (gender, age, income, household situation, ethnicity, etc.)
Recruit 10 for 8 to show

TORONTO TUESDAY, DECEMBER 11, 2018
- Group 3: Marginal Health Literacy
- Group 4: Adequate Health Literacy
- Honorarium: $100
- 5:30 pm
- 7:30 pm
HALIFAX WEDNESDAY, DECEMBER 12, 2018
- Group 3: Marginal Health Literacy
- Group 4: Adequate Health Literacy
- Honorarium: $100
- 5:30 pm
- 7:30 pm
EDMONTON THURSDAY, DECEMBER 13, 2018
- Group 3: Marginal Health Literacy
- Group 4: Adequate Health Literacy
- Honorarium: $100
- 5:30 pm
- 7:30 pm
MONTREAL SATURDAY, DECEMBER 15, 2018
- Group 3: Marginal Health Literacy
- Group 4: Adequate Health Literacy
- Honorarium: $100
- 10:00 am
- 12:00 pm

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

Hello/Bonjour, my name is _______________ and I'm calling on behalf of the Earnscliffe Strategy Group, a national public opinion research firm. We are organizing a series of discussion groups on issues of importance to Canadians, on behalf of the Government of Canada, specifically for Health Canada. The purpose of the study and the small group discussion is to hear people's opinions of a series of healthy eating messages. We are looking for people who would be willing to participate in a discussion group that will last up to 2 hours. These people must be 18 years of age or older. Up to 10 participants will be taking part and for their time, participants will receive an honorarium of $100.00. May I continue?

Yes CONTINUE
No THANK AND TERMINATE

Yes CONTINUE
No THANK AND TERMINATE

READ TO ALL: "This call may be monitored or audio taped for quality control and evaluation purposes.

ADDITIONAL CLARIFICATION IF NEEDED:

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

S1. Do you or any member of your household currently work for or have you or has any member of your household ever worked for…

	Yes	No
A marketing research firm or communications or a creative agency	1	2
A magazine or newspaper, online or print	1	2
A radio or television station	1	2
A public relations company	1	2
An advertising agency or graphic design firm	1	2
An online media company or as a blog writer	1	2
The government, whether federal, provincial or municipal	1	2
The medical sector	1	2
Food manufacturing/food industry	1	2
Associations or organization representing the interest of the food and beverage industry	1	2
An organization involved in health promotion or advice on nutrition and healthy eating	1	2
An organization representing a particular type of food and/or beverage	1	2

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

S2. DO NOT ASK - NOTE GENDER

ENSURE GOOD MIX OF GENDER

Male 1
Female 2

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

ENSURE GOOD MIX OF AGE

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

S4. What is your current employment status?

ENSURE GOOD MIX OF EMPLOYMENT STATUS

Working full-time 1
Working part-time 2
Self-employed 3
Retired 4
Unemployed 5
Student 6
Stay at home parent 7
Other (please specify) 8
DK/NR 9 THANK AND TERMINATE

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

ENSURE GOOD MIX OF INCOME

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

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

ENSURE GOOD MIX OF EDUCATION

Elementary school 1
Some high school only 2
Completed high school 3
Some college/university 4
Completed college/university 5
Post-graduate studies 6
DK/NR 9 THANK AND TERMINATE

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

ENSURE GOOD MIX OF HOUSEHOLD SITUATION

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

ENSURE AT LEAST 3 PARTICIPANTS ARE PARENTS WITH CHILDREN LIVING WITH THEM AT LEAST SOME OF THE TIME (2, 4, OR 5).

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

ENSURE GOOD MIX OF ETHNICITY

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

AIM FOR AT LEAST 1 INDIGENOUS AND A MINIMUM OF 2 NON-CAUCASIANS IN EACH GROUP.

S9. Which of the following best describes yourself?

ENSURE GOOD MIX IN ALL GROUPS

I pay close attention to the food and beverages I consume, and I am very interested in health related information 1
I pay some attention to the food and beverages I consume, and I am moderately interested in health-related information 2
I do not pay close attention to the food and beverages I consume, and I am not really interested in health-related information 3
DK/NR 4 THANK AND TERMINATE

S10. Have you participated in a discussion or focus group before? A discussion group brings together a few people in order to know their opinion about a given subject.

Yes 1 (MAX 1/3 PER GROUP, ASK S11, S12, S13)
No 2 SKIP TO S14
DK/NR 9 THANK AND TERMINATE

S11. When was the last time you attended a discussion or focus group?

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

S12. How many of these sessions have you attended in the last five years?

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

S13. And what was/were the main topic(s) of discussion in those groups?

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

S14. We are asking participants about nutrition information that appears on all pre-packaged foods. To do that, I need to email you a sample nutrition label and ask you some questions about it. I would like to do that now so we can continue with the questions. Do you have immediate access to your email?

Yes 1 SEE INTERVIEWER INSTRUCTIONS
No 2 SEE INTERVIEWER INSTRUCTIONS

INTERVIEWER INSTRUCTIONS:

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

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

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

NOTE TO INTERVIEWER:

The questions must be asked in order. Continue even if the respondent gets the first few questions wrong. However, if Q.S19 is answered incorrectly, do not ask Q.S20.
Do not in any way prompt a respondent who is unable to answer a question. You can repeat the question if asked or if you think it might help the respondent. Prompting may jeopardize the accuracy of the test. Just say, "Well then, let's go on to the next question."
The respondent is to be given as much time as needed to answer the questions.
Note: The average time needed to complete all 6 questions is approximately 3 minutes. Do not tell respondents if they have answered correctly or incorrectly. If asked, say something like: "I can't tell you at the moment, but for now, you are doing fine. Now let's go on to the next question."
Scoring the answers: Score by giving 1 point to each correct answer for a maximum of 6 points

SCORE OF 0-3 QUALIFIES FOR MARGINAL HEALTH LITERACY GROUP - GROUP 1

SCORE OF 4-6 QUALIFIES FOR ADEQUATE HEALTH LITERACY GROUP - GROUP 2

Amount per serving	% Daily value*
Calories 250	-
Fat 13g	20 %
Saturated 9.0 g + Trans 0 g	45 %
Cholesterol 28 mg	-
Sodium 55 mg	2 %
Carbohydrate 30 mg	10 %
Fibre 2 g	1 %
Sugars 23 g	-
Protein 4g	-
Vitamin A	10 %
Vitamin C	0 %
Calcium	15 %
Iron	4 %

S15. 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

S16. 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:

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

S17. 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

S18. 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

S19. 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

S20. [ASK ONLY IF ANSWER TO Q.S19 IS "NO"] Why not?

RECORD ANSWER:

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

**SCORING SHEET**
Answer	Correct	Not Correct	Correct response should be
Q.S15			1,000
Q.S16			250 ml or 1 cup (or any amount up to 250 ml or 1 cup), OR half the container
Q.S17			33
Q.S18			10%
Q.S19			No
Q.S20			Because it has peanuts/peanut oil
TOTAL SCORE

PARTICIPANT GETS 1 POINT FOR EACH CORRECT ANSWER

TOTAL SCORE OF 0-3 QUALIFIES FOR MARGINAL HEALTH LITERACY GROUP - GROUP 1

TOTAL SCORE OF 4-6 QUALIFIES FOR ADEQUATE HEALTH LITERACY GROUP - GROUP 2

INVITATION

S21. Participants in discussion groups are asked to voice their opinions and thoughts. How comfortable are you in voicing your opinions in front of others? Are you… (READ LIST)

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

S22. Sometimes participants are asked to read text and/or review images during the discussion. Is there any reason why you could not participate?

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

S23. Based on your responses, it looks like you have the profile we are looking for. I would like to invite you to participate in a small group discussion, called a focus group, we are conducting at [TIME], on [DATE].

As you may know, focus groups are used to gather information on a particular subject matter; in this case, the discussion will touch on the food choices you make. The discussion will consist of 8 to 10 people and will be very informal. It will last up to 2 hours, refreshments will be served and you will receive $100.00 as a thank you for your time. Would you be willing to attend?

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

PRIVACY QUESTIONS

Yes 1 GO TO P2
No 2 GO TO P1A

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

Yes 1 GO TO P2
No 2 THANK & TERMINATE

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

Yes 1 THANK & GO TO P3
No 2 READ RESPONDENT INFO BELOW & GO TO P2A

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

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

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

P3) Employees from Health Canada and/or the Government of Canada may be onsite to observe the groups in-person from behind a one-way mirror.

Do you agree to be observed by Government of Canada employees?

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

Do you agree to be observed by Government of Canada employees?

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

Do you have a pen handy so that I can give you the address where the group will be held? It will be held at:

TORONTO Monday, December 10, 2018
- Consumer Vision
  2 Bloor Street West, Third Floor
  Toronto, ON M4W 3E2
  Tel: 416.967.1596
- Honorarium: $100
- 5:30 pm
- 7:30 pm
HALIFAX Wednesday, December 12, 2018
- MQO
  1883 Upper Water Street, Fourth Floor
  Halifax, NS B3J 1S9
  Tel: 902.465.3034
- Honorarium: $100
- 5:30 pm
- 7:30 pm
EDMONTON Thursday, December 13, 2018
- Leger Marketing
  10080 Jasper Avenue, Suite 801
  Edmonton, AB T5J 1V9
  Tel: 780.423.0708
- Honorarium: $100
- 5:30 pm
- 7:30 pm
MONTREAL Saturday, December 15, 2018
- CRC Research
  1610 Saint-Catherine Street West, Suite 411
  Montreal, QC H3H 2S2
  Tel: 514.932.7511
- Honorarium: $100
- 10:00 am
- 12:00 pm

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

First name
Last Name
email
Daytime phone number
Evening phone number

Phase 2: Health Professionals

FOCUS GROUP SUMMARY

Recruit 10 for each group
Groups are segregated by their use of the content to communicate the healthy eating pattern/messages (S5)
- Group 1 includes professionals responsible for nutrition assessment, screening and intervention
  - Mix of registered dietitians and potentially some public health nurses and food service managers
- Group 2 includes professionals responsible for nutrition education
  - Mix of registered dietitians, registered nurses working in public health, and professionals who work in health, wellness or education.

PROFESSIONALS WHO WORK IN HEALTH, WELLNESS OR EDUCATION

Assess, promote, or provide education on healthy eating to groups, individuals or other health professionals.
Examples of these types of professionals include family physicians, allied health professionals such as osteopaths, exercise physiologists, health promoters or health promotion managers, school health coordinators.
Work in areas like health, wellness or medical centers, hospitals, Ministry of Education or school boards,

ADMINISTRATIVE REGISTERED DIETITIANS OR FOOD SERVICE MANAGERS

Involved in the development or implementation of menus or food procurement policies and/or programming
Develop tools or resources for menu development or implementation
Work in administrative/public food service
Work in facilities such as childcare, recreation, schools, hospitals, long-term care, retirement residences, corrections, and/or workplaces

REGISTERED DIETITIANS IN PUBLIC HEALTH OR COMMUNITY NUTRITION

Assess, promote, or provide education on healthy eating to groups, individuals or other health professionals.
May complete nutrition screening, assessment or intervention
Develop or implement food or nutrition policies, programs, tools, resources, or education materials.
Work in the public sector, such as health authorities, Ministries of Health or Education, public health units, school boards, not for profit organizations.

REGISTERED DIETITIANS IN CLINICAL/PRIVATE PRACTICE

Work in childcare facilities, recreational facilities, schools, hospitals, long-term care facilities, correctional facilities, and/or workplaces OR
Work in private practice providing expertise on healthy eating and disease prevention for individuals, public groups, or other health professionals

REGISTERED NURSES WORKING IN PUBLIC HEALTH

Assess, promote, or provide education on healthy eating to groups, individuals or other health professionals.
May complete nutrition screening, assessment or intervention
Implement food or nutrition policies, programs, tools, resources, or education materials.
Work in public health clinics/units/offices, community health centres/CLSC

TORONTO MONDAY, DECEMBER 10, 2018
- Group 1: Nutrition assessment, screening and intervention
- Group 2: Nutrition education
- Honorarium: $285
- 5:30 pm
- 7:30 pm
HALIFAX TUESDAY, DECEMBER 11, 2018
- Group 1: Nutrition assessment, screening and intervention
- Group 2: Nutrition education
- Honorarium: $285
- 5:30 pm
- 7:30 pm
EDMONTON WEDNESDAY, DECEMBER 12, 2018
- Group 1: Nutrition assessment, screening and intervention
- Group 2: Nutrition education
- Honorarium: $285
- 5:30 pm
- 7:30 pm
MONTREAL THURSDAY, DECEMBER 13, 2018
- Group 1: Nutrition assessment, screening and intervention
- Group 2: Nutrition education
- Honorarium: $285
- 5:30 pm
- 7:30 pm

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

Hello/Bonjour, my name is _______________ and I'm calling on behalf of the Earnscliffe Strategy Group, a national public opinion research firm. We are organizing a series of discussion groups on issues of importance to Canadians, on behalf of the Government of Canada, specifically for Health Canada. The purpose of the study and the small group discussion is to hear people's opinions of a series of healthy eating messages. We are looking for people who would be willing to participate in a discussion group that will last up to 2 hours. These people must be professionals in the health and/or education fields. Up to 8 participants will be taking part and for their time, participants will receive an honorarium of $285.00. May I continue?

Yes CONTINUE
No THANK AND TERMINATE

May I ask you a few questions; this should only take 5 minutes?

Yes CONTINUE
No THANK AND TERMINATE

READ TO ALL: "This call may be monitored or audio taped for quality control and evaluation purposes.

ADDITIONAL CLARIFICATION IF NEEDED:

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

S1. Do you or any member of your household currently work for or have you or has any member of your household ever worked for…

	Yes	No
A marketing research firm or communications or a creative agency	1	2
A magazine or newspaper, online or print	1	2
A radio or television station	1	2
A public relations company	1	2
An advertising agency or graphic design firm	1	2
The federal government	1	2
Food manufacturing/food industry	1	2
An organization representing the interest of the food and beverage industry	1	2
An organization representing a particular type of food and/or beverage	1	2

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

S2. DO NOT ASK - NOTE GENDER (ATTEMPT TO ENSURE A GOOD MIX)

Male 1
Female 2

S3. What is your current employment status?

Working full-time 1 CONTINUE
Working part-time 2 CONTINUE
Self-employed 3 CONTINUE
Retired 4 THANK AND TERMINATE
Unemployed 5 THANK AND TERMINATE
Student 6 THANK AND TERMINATE
Stay at home parent 7 THANK AND TERMINATE
Other (PLEASE SPECIFY, CONTINUE IF "VOLUNTEER") 8
DK/NR 9 THANK AND TERMINATE

S4. Are you a…?

MUST SAY "YES" TO AT LEAST ONE, OTHERWISE THANK AND TERMINATE. ENSURE GOOD MIX OF ALL FIVE IN EACH GROUP.

Registered dietitian SEE SECTION A QUESTIONS BELOW TO CLARIFY.
Registered nurse working in community or public health(NOT in clinical/hospital or long-term care, etc.) SEE SECTION B QUESTIONS BELOW TO CLARIFY.
Professional who works in health, wellness, or education E.g. family physician, allied health professionals such as an osteopath, exercise physiologist, health promoter or health promotion manager, school health coordinators. SEE SECTION C QUESTIONS BELOW TO CLARIFY.
Food Service Manager Working in childcare facilities, recreational facilities, schools, hospitals, long-term care facilities, retirement residences, correctional facilities, and/or workplaces CONTINUE TO S4a.

S4a. How long have you worked in that capacity?

Less than a year THANK & TERMINATE; ASK FOR REFERRAL
One year or more CONTINUE TO S5

SECTION A. IF REGISTERED DIETITIAN (ASK FOLLOWING QUESTIONS)

A1. Are you working or involved in…?

Public health or community nutrition CLARIFY (SEE BELOW), THEN CONTINUE TO A2
Clinical or private practice CLARIFY (SEE BELOW), THEN CONTINUE TO A2
Administrative/public food service; or CLARIFY (SEE BELOW), THEN CONTINUE TO A2
Something else THANK & TERMINATE; ASK FOR REFERRAL

A2. How long have you worked in that capacity?

Less than a year THANK & TERMINATE; ASK FOR REFERRAL
One year or more CONTINUE TO S5

NOTE TO INTERVIEWER - FOR RESPONSE ABOVE, CLARIFY THAT THEY MEET THE FOLLOWING CRITERIA:

HEALTH, WELLNESS OR EDUCATION:

If you work in health or wellness, please confirm that a major component of your work is in areas that assess, promote or provide education on healthy eating to groups, individuals or other health professionals. Examples of this type of work may include delivering group or individual nutrition education or counselling; developing or implementing: food or nutrition policies; food laws and regulations; food, nutrition, or healthy eating programs; tools, resources, or education materials.

If you work in education, please confirm that your work focuses on assessing, promoting or educating on healthy eating and nutrition-related disease prevention. Examples of work may be developing school curriculum or nutrition programs.

PUBLIC HEALTH OR COMMUNITY NUTRITION:

Please confirm that a major component of your work is in areas that assess, promote, or provide education on healthy eating to groups, individuals or other health professionals. Examples of this type of work may include developing or implementing: food or nutrition policies, food laws and regulations, or food, nutrition, or healthy eating programs; tools, resources, or education materials. This may include working for health authorities, Government Ministries or municipalities, public health units, not for profit organizations, or school boards as examples.

CLINICAL OR PRIVATE PRACTICE:

If you are a clinical dietitian, please confirm that you work in child care facilities, hospitals, long-term care, retirement residences, or other health care facilities. If you are a consulting dietitian, please confirm that you work in private practice, providing expertise on healthy eating and disease prevention for individuals, public groups, or other health professionals.

ADMINISTRATIVE/PUBLIC FOOD SERVICE:

Please confirm that you develop or implement policies or menus to provide food in public facilities such as child care, recreation, schools, universities, hospitals; workplaces, long-term care, retirement residences.

SECTION B. IF REGISTERED NURSE (ASK FOLLOWING QUESTIONS)

B1. Are you working in…?

Public health (public health clinics/units/offices, community health centres/CLSC) 1 CONTINUE TO S5
Hospital (clinical) 2 THANK & TERMINATE; ASK FOR REFERRAL
Private practice 2 THANK & TERMINATE; ASK FOR REFERRAL

B2. How long have you worked in that capacity?

Less than a year THANK & TERMINATE; ASK FOR REFERRAL
One year or more CONTINUE TO S5

SECTION C. IF PROFESSIONAL WHO WORKS IN HEALTH, WELLNESS OR EDUCATION (ASK FOLLOWING QUESTIONS)

C1. What is your current occupation?

C2. For what type of organizations do you perform this type of work?

(ATTEMPT TO ENSURE A GOOD MIX)

Health, Wellness or Medical Unit or Center
Health Authority or Public Health Unit
Government Municipality or Government Ministry
Not for Profit Organization
Other: specify CHECK FOR VALIDITY

C3. How long have you worked in that capacity?

Less than a year THANK & TERMINATE; ASK FOR REFERRAL
One year or more CONTINUE TO S5

S5. Does part of your role include…?

Nutrition assessment or screening for individuals, groups or sub-populations. Examples of groups or sub-populations might include pregnant or breastfeeding women, older adults, newcomers to Canada, other populations that may be at high risk for poor dietary intakes such as low income. Examples of nutrition screening or assessment may include assessing behaviors of a group or individual against a standard to identify their nutrition risk.

Yes 1 CONTINUE FOR GROUP 1

Nutrition Intervention Specifically regarding quantity (e.g. proportionality, frequency, measured amounts), quality (e.g. meeting specific nutrient standards), grouping of food or food categories. Examples of interventions of interest include:

Developing or implementing healthy eating standards, programs, tools and/or resources
Developing or implementing a nutrition care plan for a population, group or individual
Customizing healthy eating information, programming or services to meet specific group or individual needs. For example, menu plans.
Menu planning or implementation within a facility

Yes 1 CONTINUE FOR GROUP 1

Educating on and/or communicating healthy eating information on quantity (e.g. proportionality, frequency, measured amounts), quality (e.g. meeting specific nutrient standards), grouping of food or food categories.Examples include: using or developing tools or resources to complete nutrition education around amounts or types of foods to other health professionals, small groups or individuals.

Yes 2 CONTINUE FOR GROUP 2
None of the above 3 THANK AND TERMINATE
DK/NR 4 THANK AND TERMINATE

S6. Do you work with any of the following population groups:

PARTICIPANTS NEED NOT WORK WITH ALL OF THE FOLLOWING POPULATION GROUPS BUT WE WANT A GOOD MIX OF DIFFERENT CLIENT GROUPS REPRESENTED.

People with a low income
People from diverse cultures
Indigenous populations
Pregnant or breastfeeding women
Seniors
Children and adolescents
People living in rural areas
None of the above
DK/NR THANK AND TERMINATE

S7. Do you work in any of the following settings:

PARTICIPANTS NEED NOT WORK IN ALL SETTINGS BUT WE WANT A GOOD MIX OF DIFFERENT SETTINGS REPRESENTED.

Childcare facilities
Recreational facilities
Schools
Hospitals or long-term care facilities
Health Authority
Public Health Unit
Health or wellness center
Government municipality or ministry
Correctional facilities, and/or Workplaces or something similar
DK/NR THANK AND TERMINATE

S8. Have you participated in a discussion or focus group before? A discussion group brings together a few people in order to know their opinion about a given subject.

Yes
No
DK/NR THANK AND TERMINATE

S9. When was the last time you attended a discussion or focus group?

If within the last 6 months THANK AND TERMINATE
If not within the last 6 months CONTINUE
DK/NR THANK AND TERMINATE

S10. How many of these sessions have you attended in the last five years?

If 4 or less CONTINUE
If 5 or more THANK AND TERMINATE
DK/NR THANK AND TERMINATE

S11. And what was/were the main topic(s) of discussion in those groups?

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

INVITATION

S12. Participants in discussion groups are asked to voice their opinions and thoughts. How comfortable are you in voicing your opinions in front of others? Are you… (READ LIST)

Very comfortable MINIMUM 4 PER GROUP
Fairly comfortable CONTINUE
Comfortable CONTINUE
Not very comfortable THANK AND TERMINATE
Very uncomfortable THANK AND TERMINATE
DK/NR THANK AND TERMINATE

S13. Sometimes participants are asked to read text and/or review images during the discussion. Is there any reason why you could not participate?

Yes THANK AND TERMINATE
No CONTINUE
DK/NR THANK AND TERMINATE

S14. Based on your responses, it looks like you have the profile we are looking for. I would like to invite you to participate in a small group discussion, called a focus group, we are conducting at [TIME], on [DATE].

As you may know, focus groups are used to gather information on a particular subject matter. The discussion will consist of approximately 10 people and will be very informal. It will last approximately 2 hours, refreshments will be served and you will receive $285.00 as a thank you for your time.

Would you be willing to attend?

Yes RECRUIT
No THANK AND TERMINATE
DK/NR THANK AND TERMINATE

Please remember that all information discussed in this group will be confidential and should not be shared outside the room in which the discussion will be held. If you take notes, you will have to leave them at the end of the session. We also ask in advance that you refrain from using your cell phone during the session.

PRIVACY QUESTIONS

Yes GO TO P2
No READ RESPONDENT INFO BELOW

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

Yes GO TO P2
No THANK & TERMINATE

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

Yes THANK & GO TO P3
No GO TO P2A

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

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

Yes THANK & GO TO P3
No THANK & TERMINATE

P3) Employees from Health Canada and/or the Government of Canada may be onsite to observe the groups in-person from behind a one-way mirror.

Do you agree to be observed by Government of Canada employees?

Yes THANK & GO TO INVITATION
No GO TO P3A

Do you agree to be observed by Government of Canada employees?

Yes THANK & GO TO INVITATION
No THANK & TERMINATE

Do you have a pen handy so that I can give you the address where the group will be held? It will be held at:

TORONTO Monday, December 10, 2018
- Consumer Vision
  2 Bloor Street West, Third Floor
  Toronto, ON M4W 3E2
  Tel: 416.967.1596
- Honorarium: $285
- 5:30 pm
- 7:30 pm
HALIFAX Tuesday, December 11, 2018
- MQO
  1883 Upper Water Street, Fourth Floor
  Halifax, NS B3J 1S9
  Tel: 902.465.3034
- Honorarium: $285
- 5:30 pm
- 7:30 pm
EDMONTON Wednesday, December 12, 2018
- Leger Marketing
  10080 Jasper Avenue, Suite 801
  Edmonton, AB T5J 1V9
  Tel: 780.423.0708
- Honorarium: $285
- 5:30 pm
- 7:30 pm
MONTREAL Thursday, December 13, 2018
- CRC Research
  1610 Saint-Catherine Street West, Suite 411
  Montreal, QC H3H 2S2
  Tel: 514.932.7511
- Honorarium: $285
- 5:30 pm
- 7:30 pm

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

First name
Last Name
email
Daytime phone number
Evening phone number

Phase 2: Policy Makers

Good morning/Good afternoon,

Thank you for your indicating your interest to participate in the revision of Canada's Food Guide by providing Health Canada permission to share your name and contact information with us. We are writing to ask you for your participation in a research study being undertaken by Earnscliffe on behalf of Health Canada.

Over the next few weeks, we will be conducting one-on-one interviews with a number of health professionals who develop, implement, and/or evaluate food and/or nutrition policies. The intent of these interviews is to gather your feedback and reactions to the use of Canada's healthy eating patterns for health professionals and policy.

The interview would take approximately 30 to 40 minutes of your time and would be scheduled at a time convenient to you. As is customary with this type of research, results will be anonymous and reported on an aggregate basis only, rather than attributed to an individual. Please be assured that the responses of individual participants will be treated with complete confidentiality and not be revealed to Health Canada by Earnscliffe.

We very much hope that you will find the time and be willing to share your thoughts. Over the next few days, one of our staff will be contacting you to inquire about your willingness to participate, and ideally to arrange a time for the interview to take place.

If you require any further information, please do not hesitate to contact me directly. The attached consent form will need to be signed

Warmest regards,

Stephanie Constable
Principal

Healthy Eating Strategy - Dietary Guidance Transformation - Focus Groups to inform approach for communicating healthy eating information - Final Report

TABLE OF CONTENTS

EXECUTIVE SUMMARY

Phase 1

Specific Reactions to the Concepts

Phase 2

DIETARY SHIFT MESSAGING

Exhibit A4: SAMPLE - Dietary Shift Messaging

DIRECTIVE MESSAGING

Exhibit A5: SAMPLE - Directive Messaging

Exhibit A6: SAMPLE - Specific Message Variations

PORTION AND PROPORTIONALITY IMAGES

DETAILED INFORMATION FOR HEALTH PROFESSIONALS AND POLICY MAKERS

INTRODUCTION

RESEARCH APPROACH

Phase 1

Phase 2

TARGET AUDIENCE

Phase 1

Phase 2

DETAILED FINDINGS

Phase 1

Overall Reactions to the At-a-Glance Tools

Specific Reactions to the Digital Graphics

Concept 1: EAT WELL. LIVE WELL. TOGETHER.

Concept 2: FOR THE LOVE OF EATING WELL

Concept 3: BRINGING HEALTHY EATING TO LIFE

Additional Findings Related to the Delivery Method

Phase 2

Overall Reactions

Specific Reactions to the Communication Approaches

DIETARY SHIFT MESSAGING

DIRECTIVE MESSAGING

Directive Messaging Variations

Intended Use of Directive Messaging for Health Professionals

PORTION AND PROPORTIONALITY IMAGES

DETAILED INFORMATION FOR HEALTH PROFESSIONALS AND POLICY MAKERS

CONCLUSIONS

Phase 1

Phase 2

APPENDIX A: DISCUSSION GUIDE

Phase 1

INTRODUCTION 10 min 10 MIN

CONCEPT TESTING: DIGITAL VERSION AND TWO-SIDED PRINT 60 min 70 MIN

TESTING OF DIGITAL VISUAL CONCEPTS

TESTING OF TWO-PAGE PRINT VISUAL CONCEPTS

CONCEPT TESTING: SOCIAL MEDIA GRAPHICS 10 min 70 MIN

WRAP-UP 10 min 90 MIN

Phase 2: General Population

INTRODUCTION 10 min 10 MIN

PATTERN HIGHLIGHT MESSAGES 25 min 35 MIN

REACTIONS TO DIFFERENT MESSAGES APPROACHES 55 min 90 MIN

DIETARY SHIFT MESSAGING 15 min 105 MIN

PORTION AND PROPORTIONALITY IMAGES 10 min 115 MIN

WRAP-UP 5 min 120 MIN

Phase 2: Health Professionals

INTRODUCTION 10 min 10 MIN

CURRENT USE OF CANADA'S FOOD GUIDE PATTERNS 20 min 30 MIN

FORMAT OF DETAILED INFORMATION 60 min 90 MIN

DIRECTIVE & DIETARY SHIFTS MESSAGING 15 min 105 MIN

WRAP-UP 15 min 120 MIN

Phase 2: Policy Makers

INTRODUCTION

CURRENT USE OF CANADA'S FOOD GUIDE PATTERNS

FORMAT OF DETAILED INFORMATION

DIRECTIVE & DIETARY SHIFTS MESSAGING

WRAP-UP

APPENDIX B: SCREENER

Phase 1: General Population

Phase 1: General Health Professionals/Educators

Phase 2: General Population

Phase 2: Health Professionals

Phase 2: Policy Makers