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

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 s 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

©Her Majesty the Queen in Right of Canada, as represented by the Minister of Health, 2018

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:

1. To assess pubic and stakeholder views and acceptance of the draft Canada Food Guide visual and brand concepts to ensure understanding and usefulness.
2. 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 - Text Description

The first concept has three distinct sections. The first section shows a place setting on a split background. The left side of the background is beige and shows a fancy white plate with gold flecks and a blue design with two different sized forks to the left. The right side of the background is a dark blue with designs throughout and a plain whitish-grey plate. There is a set of chopsticks to the right of the plate. The words "Canada's food guide" show on the top left hand side with a green background and the words "Eat well. Live well. Together." are in dark blue to the left of the forks. Underneath all this is a white section with the words "Healthy eating is more than the foods you eat" in dark blue.

The second section is a set of four squares. The first square in the upper left is a light turquoise blue with the words "Be mindful of your eating habits" in orangey-red. There is a container of food below the words with three sections: a sandwich, a bunch of baby carrots and blueberries. The next square in the top left hand corner is a light green with the words "Eat meals with others" in a darker green. There are two plates below with a salad on a bed of lettuce. The third square on the bottom left is a brownish-green and has the words "Cook more often" in darker green. There is a lime green cutting board and knife with asparagus and Brussels sprouts below. The fourth square is a light pink with the words "Enjoy your food" in red. There is a row of apples below.

The third section has a beige background. The top of the section shows the words "Eat a variety of healthy foods each day: Eat plenty of fruits and vegetables; Consume protein foods; Choose whole grain foods; Make water your drink of choice. There is a white plate with gold specs on it. There are two different sized fancy forks to the left and one fancy knife to the right. The plate has food on it with half the plate vegetables and fruit (left); one quarter grain (top right); and one quarter protein (bottom right).

Underneath this beige part of the section, there is another section split in three parts from left to right. The first section has a purple background and has the words "Limit foods high in sodium, sugars or saturated fat" with an image of a cookie below. To the right of that section is a second section that has a grey background with the words "use food labels" and an image of a jar showing the label. The third section has a red background with the words "Be aware of food marketing" and an image of a chocolate bar.

• 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 - Text Description

The second concept has two distinct sections. The first section is in three parts. The first part shows an image of a culturally diverse group of people sharing a meal at a table. To the right of the image are the words "Canada's food guide" within a blue circle. Underneath the circle are the words "For the love of eating well". The second part has a purple-pink background with the words "Healthy eating is more than the foods you eat." The third part has four circles. The top circle shows an image of a woman cooking with the words "cook more often". The second circle shows the same people from the picture above with the words "eat meals with others". The third circle shows three happy people eating together with the words "Enjoy your food". The fourth circle shows a mother and daughter looking at a food label with the words "Be mindful of your eating habits".

The second section has three parts. The first part has a purple-pink background with the words "Eat a variety of healthy foods each day." The second part shows a picture below shows a birds-eye view of a dark wooden table. On the table is a pitcher of water with the words "Make water your drink of choice." There is also someone holding a bowl of salad with the words "eat plenty of fruits and vegetables." On the table is a plate of protein foods with the words "Consume protein foods." There is also a bowl of rice pilaf with the words "Choose whole grain foods." The third part shows three circles. The first shows a saltshaker with the words "Limit foods high in sodium, sugars or saturated fat". The second circle shows a food label with the words "Use food labels." The third circle shows an image of someone looking at his or her phone with the words "Be aware of food marketing."

• 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 - Text Description

The third concept has two distinct sections and is cartoon-like. The first section is broken up in two parts. The first part has a blue background with cartoon images of a cutting board and a person holding a knife and a pot with a person holding a spoon. To the left of the images are the words "Canada's Food Guide" in a yellow square with the words "Bringing healthy eating to life" underneath. The second part has a white background. At the top are the words "Healthy eating is more than the foods you eat". Underneath the words are four birds-eye images: 1. a place setting with a plate and drink and two hands, one hand holding a spoon - the words "Be mindful of your eating habits" underneath; 2. a pot with two hands, one holding a spoon with the words "Cook more often" underneath; 3. A set of hands making a heart shape and a rolling pin in the background; 4. a place setting with two different people's hands with the words "Eat meals with others".

The second section has three parts. The first part has a purple-pink background with the words "Eat a variety of healthy foods each day." The second part shows a cartoon-like plate of foods with half the plate showing vegetables and fruit (left hand side), quarter whole grains (top right) and quarter protein foods (bottom right). There is a fork and knife to the left of the plate and a glass of water on the top right of plate. The third part has a white background with three images. The first image is a bag of chips with the words "Limit foods high in sodium, sugars or saturated fat." The second image shows a hand holding a canned good with the words "Use food labels". The third image shows an image of a person looking at their phone with the words "Be aware of food marketing".

• 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 - Text Description

This image has four different photos. The photo in the top left quadrant shows a plate of food with wild rice, salmon and broccoli and carrots with a glass of water. The photo in the top right quadrant shows a plate of food with rice and a Moroccan stew (Harira) and a glass of milk. The third photo in the bottom left quadrant shows a stir-fry and a glass of water. The fourth photo shows an omelette for two pieces of whole grain toast. There is a side bowl of strawberries.

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.

• 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