Focus Testing of Opioids Public Education Campaign on Stigma
Final Report

Health Canada is planning a national public education campaign to help address stigma, to prevent opioid overdoses and related deaths, and reduce harm related to problematic opioid use. The total cost to conduct this research was $74,992.45, including HST.

The objectives of the research were to test the creative concepts for the opioid paid advertising campaign, gather insight from the target audiences, elicit suggestions for potential changes and identify preferred sources and methods of receiving information. Feedback from the research will help Health Canada ensure that the public education campaign will be supported by robust and sustainable messaging, creatives and concepts, and that funding allocated towards public education activities will be spent responsibly and effectively.

To meet the objectives, Earnscliffe conducted qualitative research. The research included a series of ten focus groups across five cities – Toronto (September 11); Halifax (September 12); Edmonton (September 12); Montreal (September 13); and, Vancouver (September 13). In each city, the first group was conducted with men aged 20-39, and the second was conducted with members of the general population. All groups in Montreal were conducted in French. In each city, focus groups began at 5:30 pm and 7:30 pm. The sessions were approximately two hours in length.

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.

• Awareness of the term ‘opioids’ was fairly high although familiarity/knowledge about the subject was low and those who had heard the term before did not seem to have a single common understanding.
  • Men 20-39 and those in Western Canada (Edmonton and Vancouver) were more familiar with the term.
  • Those who were more knowledgeable mentioned specific drugs/prescription medicine, while those less knowledgeable often associated the term with street drugs.
• Participants accepted that there is an opioid crisis in Canada, but their understanding of what that entails, its severity and relevance varied.
  • There was a sense that the issue is more prevalent in Western Canada, particularly Vancouver.
  • Many often had the sense that the people suffering from problematic opioid use tended to be people in the worst situations already – descriptions or adjectives included “homeless”, “drug users”, struggling, etc. Ironically, this stereotyping is part of the reason why stigma is a barrier.
• While there was unanimous agreement that the Government of Canada should address the opioid crisis, many felt that talking about stigma was not the primary message to tell Canadians.
  • Again, this was more acute among men 20-39.
  • Many felt the public needed to hear first what the Government of Canada is doing to reduce harm and help people recover.
  • Some felt the messages shifted blame to the general population, which was off-putting for those who felt they have actually done nothing wrong and can do little to alleviate the crisis.
• Participants were reluctant to self-identify as stigmatizing, including those who used stereotypes that are stigmatizing. The discussions demonstrated both the existence of stigma and the barrier to communicating effectively to reduce the stigmatizing behaviour.
  • This disconnect appeared to be rooted in their understanding of who needs help. Participants tended to be fairly sympathetic of people at risk (e.g. homeless populations, drug users, etc.), and therefore did not feel they were stigmatizing those people. They did not immediately think of the people within their social circle who may develop problematic opioid use as a result of using a prescription drug.
  • At the same time, there was widespread acknowledgement that it is, or would be difficult, to tell people you have an opioid use disorder, precisely because of the stigmatizing reactions that would likely be caused.
• The concepts generated mixed reactions. All appealed to different people, which suggests this might not be a one-size-fits-all campaign.
• Concept 1 proved compelling to some based on the statistic used prominently in the ad (4,000 deaths). The statistic clearly conveyed the breadth of the problem and participants appreciated the direct call to action.
  • Participants were confused about the main message: that this could happen to anyone was being communicated before messages about treatment and harm reduction.
  • A few understood and appreciated the artistic portrayal of the dots, others found them distracting to the point that they were concentrating so hard on the dots that they missed the oral cues (including the reference to 4,000 opioid deaths).
  • Finally, the majority felt the concept was aimed at an “older” audience – neither youth nor young adults.
• Concept 2 generally received positive ratings, although reactions were somewhat polarized. Those who liked it appreciated the testimonial approach, which was more personal and conveyed the message that “this story could be yours.” This concept also more clearly demonstrated a path to problematic use that might justify telling all Canadians to stay vigilant and make sure they are not helping anyone form an emotional barrier to seeking help. Those who did not like this concept found the testimonials too dramatic/overdone, and felt they preyed too heavily on viewers’ emotions to make them feel guilty when it was not necessary to do so.
• The pace and clarity of Concept 3 were its strongest elements. Participants very clearly understood the main message – a person in your life may inadvertently develop problematic opioid use. The tempo, music, and announcer’s voice contributed to the sense that this concept was short and to the point. Participants pointed out the diversity of people shown in the concept but felt even more diversity could be shown.
  • Despite the positive reactions to this concept, some remained resistant to the notion of their own responsibility and still did not accept the message that this really could happen to anyone.
• Many participants, particularly men under 39, preferred shorter taglines, irrespective of the message. There was also a sense that mentioning stigma was not necessary and that leaving it out might help avoid a judgmental tone.
• The following taglines were the most popular: Know More. Get the facts about opioids. Together we can stop stigma.; and, This story could be yours. Stop stigma. Make a difference.
  • Those who would rather the government communicate about the severity of the crisis and what they are doing to address it tended to prefer Know More. Get the facts about opioids. Together we can stop stigma. Those who did not feel mentioning stigma was appropriate also proposed removing the last sentence.
  • Participants who preferred This story could be yours. Stop stigma. Make a difference. appreciated that the message implied this could happen to anyone, and felt the tagline fit well with Concept 2.
  • Many were not comfortable with the use of a hashtag in the tagline.
• Participants expressed that ads would be most likely to reach them on social media. Some men 20-39 mentioned that television ads, particularly on sports channels, could also be effective.

Research Firm:

Earnscliffe Strategy Group Inc. (Earnscliffe)
Contract Number: HT372-183031/001/CY
Contract award date: August 17, 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.

Health Canada is planning a public education campaign to help address stigma and to prevent opioid overdoses and related deaths and reduce harm related to problematic opioid use. Feedback from the research will help Health Canada ensure that the national public education campaign will be supported by robust and sustainable messaging, creatives and concepts, and that funding allocated towards public education will be spent responsibly and effectively.

The objectives of the research were to:

• Gather target audience insights into current or prospective opioid campaign messages and products;
• Evaluate each of the creative concepts and determine if the content is:
  • Clearly understood by the audience;
  • Credible, relevant and of value to the audience;
  • Appealing and appropriate to the audience;
  • Memorable in the minds of the audience;
  • Utilizing the right tone; and,
  • Able to motivate the audience to take personal action(s).
• Elicit suggestions for potential changes to ensure the messages and products resonate with the target audience.
• Identify preferred sources and methods of receiving information on the subject of opioids from the Government of Canada.

To meet these objectives, Earnscliffe conducted qualitative research. The research included a series of ten focus groups with two segments of the Canadian population: men aged 20-39 and the general population. Two sessions were conducted in each of: Toronto (September 11); Halifax (September 12); Edmonton (September 12); Montreal (September 13); and, Vancouver (September 13). All groups in Montreal were conducted in French. Please refer to the Recruitment Screener in the Appendix of this report for all relevant screening and qualifications criteria.

In each city, the groups with men aged 20-39 began at 5:30 pm and the groups with the general population began at 7:30 pm. The sessions were approximately two hours in length. Focus group participants were given an honorarium of $100 as a token of appreciation for their time.

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.

Detailed Findings

This qualitative report is divided into three sections. The first explores participants’ understanding of opioids and their level of concern, if any, related to the crisis. The second section presents participants’ reactions to three video concepts aimed educating the public about opioids and the stigma related to problematic opioid use. The third section explores reactions to a variety of proposed taglines.

For the most part, participants claimed to be familiar with the term opioids and believe they have at least a functional understanding of the meaning of the term. However, over the course of the discussions, it became clear that there were often wildly differing assumptions over what qualifies as an opioid. In every group, there were some who demonstrated knowledge of a variety of drugs, both prescription and illegal drugs, that are opioids. At the same time, there were others in the same group who were thinking far more narrowly, with a tendency to focus exclusively on illegal drugs without consideration of legal drugs, like prescribed medication, as being within the scope of the discussion or crisis.

In most groups, a number of participants claimed to have seen, read or heard something about opioids in the media recently but what it was they had heard varied widely from city to city. Participants in Toronto and Montreal tended to have heard very little, particularly in comparison to participants in Edmonton and Vancouver.

When prompted, virtually all claimed to have heard that there is an opioid crisis in Canada right now, but when placed in the context of their specific city, opinions of the local presence and severity of the crisis varied widely. While those in Edmonton and Vancouver were well aware that the crisis was present in their cities, and tended to see it as a major crisis, those in other cities had divided opinions of whether opioids were a local problem. In those cities, the tendency was to lump opioids in with problematic drug use, particularly among people at risk (i.e., homeless populations).

Participants’ level of concern varied widely and when asked to explain their level of concern, the responses suggested that concern was closely related to their understanding of the nature of the opioid crisis. Those most knowledgeable tended to be quite concerned due to how easy they felt it was for people to advance from responsibly taking a medication as prescribed to developing an opioid use disorder (always described as “an addiction”). In some groups, there were participants who shared stories of people they knew who had developed dependence or opioid use disorder through behaviour that no one would consider risky or would assume could lead to problematic opioid use. Indeed, in Edmonton, many participants relayed a personal story – in many cases, it was about their own challenges.

However, it was more often the case that people were less knowledgeable about opioids and these people appeared to have a different sort, and degree, of concern than the more knowledgeable participants. The concern among these participants tended to be focused on one of two distinct types of people at risk:

• Those, typically youth, who might inadvertently experiment with a recreational drug that was laced with an opioid (often specifically identified as fentanyl); or,
• People at risk, often described as homeless, who sought out an illegal opioid to satisfy their existing substance use disorder to provide escape.

With respect to stigma, the research demonstrated both the existence of stigma and the challenge to communicating effectively to reduce stigma. This disconnect appeared to be rooted in participants’ understanding of the types of people who need help (as outlined above). There was also widespread acknowledgement that it is, or would be difficult, to tell people that you have a problem with opioid use, precisely because of the stigmatizing reactions that would likely be caused.

Reactions to the three concepts demonstrated that these preconceptions heavily influenced how participants reacted to the concepts and, in particular, to the call to action to address (and remove) stigma. For example, some of those who felt that the opioid crisis was primarily about youth engaging in risky recreational substance use, pointed out that stigmatizing that kind of behaviour was actually an important thing to help deter it. For those who see the opioid crisis as one that is primarily harming people at risk (e.g. homeless populations), there was a sense that stigma relates more to how people feel about these populations. Many participants ended up feeling like they were being blamed for holding a stigmatizing view that they neither agreed they held nor felt was germane to how the crisis needs to be addressed.

Ironically, these narrow assumptions about the opioid crisis and the people being affected were evidence of the stereotyping that is part of the problem that the government is trying to address – stigma. Only those more knowledgeable about just how easy it is for any Canadian to potentially find themselves dealing with a substance use disorder readily appreciated what the concepts were trying to accomplish and accepted that communicating that kind of message should be a priority for addressing the crisis.

Approach

In terms of testing, participants were shown three concepts in animatic (a 30-second video advertisement using drawings and images) format. The order in which the concepts were presented was rotated in each group. Each animatic was played twice. After reviewing each concept, participants were asked to complete a handout in which they were asked to rate each concept on a 0-10 scale where “0” signified a very negative reaction and “10” signified a very positive reaction, with “5” being neutral. The ratings outlined in the tables below represent the mean scores of these ratings. Participants were also asked to articulate the main message of each ad. Please refer to Appendix B for the handout used in the groups.

• This concept proved compelling to some based on the statistic used prominently in the ad (4,000 deaths). The statistic clearly conveyed the breadth of the opioid crisis, although some participants, particularly in the East, questioned the significance of that number and a desire for some context about whether this was increasing or decreasing.
• Many participants also appreciated the more obvious direct call to action to visit the website to learn more. In fact, when asked whether the ad would motivate them to take action, this was the only concept that seemed to motivate people to do anything; in this case, go to the website to learn more.
• However, participants were a little confused about the main message of the ad. Many understood the message, “this could happen to anyone,” but were confused as to why viewers were being asked to “stop the stigma.” Those who were most critical of the message were a little disappointed that the Government of Canada appeared to be transferring responsibility to viewers; accusing them of holding unhelpful opinions, rather than describing what actions the Government was taking to reduce harm to those dealing with problematic opioid use and end the crisis.
• With respect to the artistic portrayal of the dots, reactions were mixed. A few understood and appreciated the dots as depicting the isolation (one dot) someone dealing with problematic opioid use might experience and stopping the stigma to welcome them (multiple dots). Others found them distracting to the point that they were concentrating so hard on the dots that they missed the oral cues (including the reference to 4,000 opioid deaths). Some suggested the dots may be more compelling and more easily interpreted if they were photos of individuals.
• As a result, in most groups, participants were divided over whether the concept would capture their attention.
• The majority felt the concept was aimed at an “older” audience – neither youth, nor young adults.
• While the use of the closing image was well received as it helped explain the use of the dots, the selected still image represented a discord for many as they assumed the message was intended for people who use opioids and people interacting with them. The people represented in the image did not fit with their expectations of someone at risk of substance use disorder. Again, the assumption for many was that a younger segment of society was more at risk than the individuals depicted. Moreover, they felt this concept did not do a good job to clarify those assumptions.
• Finally, participants felt the information presented was credible and that it was appropriate for the Government of Canada to communicate on this topic. However, many had specific questions they felt were left unanswered on the nature, size, scope, and seriousness of the crisis; and, more importantly, what the Government was doing to address the crisis.

• While ratings for this concept tended to be generally positive, there was some polarization of opinion. The general population groups tended to connect more emotionally to this concept than the groups with men 20-39.
• Those who liked this concept reacted very positively to the testimonial approach, which was more personal, stimulated empathy and effectively conveyed the message that “this could be your story.” This concept also more clearly demonstrated a path to problematic opioid use that might justify telling all Canadians to stay vigilant and make sure they are not helping anyone form an emotional barrier to seeking help.
• Indeed, in terms of the visuals, participants noticed and appreciated the diversity of images, showing people of different ethnicities, ages, socio-economic status, etc., which reinforced the message that this can happen to anyone.
• Those who did not like the concept found the testimonial approach too dramatic and a little overdone, and felt they preyed too heavily on viewers’ emotions to make them feel guilty, when it was not necessary to do so.
• In terms of the script, a few sentences were particularly effective. “Someone so full of life and potential” was cited by some for being relatable. For those with more knowledge of the pathways to problematic opioid use, the sentence “someone who just needed some relief from pain” resonated and reminded them of how they or people they knew had innocently begun a journey that resulted in opioid use disorder. The sentences about how a person is treated and how they feel ashamed were mentioned by some as being credible and compelling. As a result, the combination of speakers and dialogue reinforced the notion of loss and that stigma is often a tragic aspect faced by those who develop problematic substance use.
• Where this concept fell a little short, was that most assumed these were stories of loss told by the survivors and not by the individuals who had developed a substance use disorder. As a result, a few offered that they would like to see individuals who had received treatment and had recovered to demonstrate that there are solutions and there is hope.
• As with the first concept, participants felt this ad was credible and that it was appropriate for the Government of Canada to communicate on this topic.

• Overall, reactions to this concept were mixed, leaning toward mildly positive. Participants in Montreal and Halifax tended to offer slightly more favourable impressions than participants in the other cities.
• The pace and clarity of this concept seemed to be the strongest elements. The tempo, music, and announcer’s voice reinforced that the message was short and to the point.
• Most offered positive comments about the use of real people and some participants particularly appreciated the diversity of people shown in this concept. That said, most tended to agree that even more diversity could be shown, particularly in terms of showing younger people, especially given most assume they are most at risk.
• Participants felt they very clearly understood the main message – a person in your life may inadvertently develop problematic opioid use. However, it was clear that not all participants were interpreting that the individuals depicted on screen were people dealing with, or recovered from, problematic opioid use.
• Despite the clarity of the message, some remained resistant to the notion of their own responsibility and some still did not accept the message that it really can happen to anyone.
• While a few in every group interpreted the red circle (that blocked the faces) as the artistic representation of the lens of stigma, this facet was lost on many and the coloured shape was often regarded as distracting.
• The red colour was deemed appropriate for representing stigma in the sense that it was attention-grabbing. However, in most groups, at least one person mentioned the red dot made them think of blood or donating blood. In some groups, some mentioned it being reminiscent of CBC marketing.
• As with all of the concepts tested, participants had no trouble with the credibility of the concept and all felt it was appropriate for the Government of Canada to be communicating on this topic.

At the end of the discussion about Concept 3, participants were asked to react to an alternative version of Concept 3 in which the circles were replaced with squares.

• Exposing participants to both the circle and square versions of this concept had no real impact on overall impressions, even as some preferred one approach over the other.
• The square seemed to cover the face in an interesting way and create a helpful blurry effect that conveyed a sense that the opioid user was lost (blurred) but then recognized and getting the help they needed (panning out to clear). Participants also appreciated that the ad did not begin with the multiple moving circles and began more directly with the spotlight on the opioid user.
• The circle mimicked a lens, which participants extrapolated as the lens through which participants viewed the opioid user.

In summary, while the concepts effectively conveyed the need to remove stigma and the fact that the opioid crisis could affect anyone, the results suggest that many participants were not convinced this was the most important message to communicate about the opioid crisis at this time. Educating the public on the nature of the crisis (e.g., providing facts on the number of people being affected) and what the Government is doing to address the crisis were felt to be more important elements to address.

Tagline testing

After testing the concepts, participants were led through an exercise testing a variety of potential taglines for the campaign. In total, thirteen taglines were tested, and discussions elicited a few valuable findings:

• Messages of positive encouragement and empowerment tended to be better received than messages that were taken as criticizing or implying blame. Encouraging people to become better informed, to join in the cause or make a difference were among the most positively received. At the other extreme, reactions were often negative when the message was “stop” one’s own behaviour or the behaviour of others.
• Placing the problem in a personal context, such as “this story could be yours” was a compelling context that participants felt could pull them in.
• There was also a sense that the word stigma does not need to be used to communicate the message to not judge or be judgmental. Indeed, a number of participants (in every group) reacted unfavourably to the word and felt that it conveyed a sense of guilt, that again many were not convinced was appropriate. Others did not understand the meaning of the word.
• Shorter taglines were generally preferred to longer taglines; especially among men 20-39.
• The use of hashtags was met with mixed reactions. Younger participants questioned the appropriateness of using a hashtag in a medium other than social media. Older participants tended to find it appropriate given they viewed it as part of the younger generation’s lexicon, which coincided with their sense this was a crisis more readily faced by younger people.

The tables below depict the total number of participants who ranked each slogan in their top three choices.

These two taglines proved to be the most compelling overall.

Those who felt that the Government should be communicating the extent of the crisis, and the work that they are doing to support those affected by the crisis, often preferred Know More. Get the facts about opioids. Together we can stop stigma. It was an invitation to get more information and went very well with Concept 1 which provided information about the severity of the crisis and displayed the Government’s website address very prominently. Those who did not feel mentioning stigma was all that important felt that this message would be improved if it was shortened to remove the last sentence (Together we can stop stigma).

With respect to This story could be yours. Stop stigma. Make a difference., participants very much appreciated the implication that this could happen to anybody. It also connected with participants on a personal level by bringing them into the message. Most felt that this tagline went very well with Concept 2.

With respect to these taglines the discussions elicited a few helpful findings:

• Concepts that addressed the power of one’s words and actions were well received and viewed as a helpful reminder generally; not just a reminder about how to be sensitive of those with problematic opioid use.
• Most preferred language that referred to changing lives as opposed to saving lives. The concept of changing lives implied a sense of hope that it could be possible, whereas participants felt saving lives might set unreal expectations; particularly among those who know (and have tried to help) someone with an opioid use disorder.
• In addition to the comments made above about reactions to hashtags, with respect to the language StopOverdoses, participants felt that it emphasized the outcome rather than the root cause. Participants argued that the bigger problem to address was the problematic use (“addiction” in their words).
• Finally, the concept of understanding stigma implied a certain responsibility to do more work to learn more about opioids than many were prepared to commit.

Communications

To wrap-up the conversation about the public education campaign elements, participants were asked about their communications preferences. While focus group timing preclude us from doing this in all of the groups, what we learned was that social media was deemed to be the most effective way to reach participants. YouTube, Facebook, and Instagram were mentioned most often when asked for specific examples of social media. Some suggested television ads, although most argued that they rely more heavily on the internet for television content; although, men 20-39 did suggest playing ads on television sports channels. Beyond these communications channels, some indicated that ads displayed on public transportation could be effective. A handful also volunteered advertising at movie theatres and concert venues.

Conclusions and Recommendations

Generally, participants were aware of the term opioids and the ongoing crisis in Canada, though their understanding of, and reaction, to the term varied. There was also resistance to the proposed campaign’s call to reduce stigma in order to help those suffering feel comfortable seeking help. For both these reasons, there was no clear preference among the target audiences when it came to the three concepts tested.

Familiarity and understanding of the term opioid varied by region – those in Western Canada were more knowledgeable. These participants were more likely to understand that the crisis is linked to the problematic use of prescription medication, rather than just illegal drugs. Across all groups, most also had the sense the crisis is most severe in Western Canada.

While there was unanimous agreement that the Government of Canada should act to address the opioid crisis, many felt that talking about stigma was not the most important message to communicate to Canadians. Men aged 20-39 were the most likely to agree that the government’s focus should be to show Canadians how they are helping to reduce harm, and that including messaging about stigma shifted blame to Canadians who, in their view, have not done anything to worsen the crisis. Of note, a related attitude emerged that the people suffering from problematic opioid use tended to be people in the worst situations already – descriptions or adjectives included “homeless”, “drug users”, struggling, etc. Ironically, this stereotyping, more prevalent among the men aged 20-39, is part of the reason why stigma is a barrier. Reluctance to self-identify as stigmatizing may also have contributed to participants’ confusion around the term’s inclusion in the campaign. The discussions demonstrated both the existence of the problem of stigma and the barrier to communicating effectively to reduce the stigmatizing behaviour.

As discussed earlier, each of the concepts tested were met with mixed reaction. Some elements of Concept 1 were compelling, particularly the statistic about 4,000 deaths related to opioids and the direct call to action. However, the main message was not always clear and the design (i.e. the red dots) was distracting to some. Concept 2 was polarizing - some liked the testimonial approach, and felt it clearly conveyed the message that “this could happen to anyone”. Others felt it unfairly preyed on viewers’ emotions. The latter group found the approach too dramatic and did not appreciate being made to feel anxious and guilty. The pace and clarity of Concept 3’s message was well received, though some were still resistant to the notion of their own responsibility and did not accept the message that it really can happen to anyone.

The most popular taglines were: Know More. Get the facts about opioids. Together we can stop stigma.; and, This story could be yours. Stop stigma. Make a difference. Those who would rather the government communicate about the severity of the crisis and what they are doing to address it tended to prefer Know More. Get the facts about opioids. Together we can stop stigma. Those who did not feel mentioning stigma was appropriate also proposed removing the last sentence. Participants who preferred This story could be yours. Stop stigma. Make a difference. appreciated that the message implied this could happen to anyone, and felt the tagline fit well with Concept 2.

There may be no one-size-fits-all campaign that conveys the appropriate messages to Canadians in a way that will be clearly understood and well received. Varying degrees of understanding about the crisis – particularly from region to region – and resistance to the notion of prioritizing stigma as the message people first hear about the Government of Canada’s approach to countering the crisis suggest a more nuanced approach may be necessary in order to achieve both increased understanding of the crisis and reduced stigmatizing behaviour.

Many participants indicated that the people who are in crisis are people who are far from living a “normal life”. Some describe them as “homeless drug users” and others envision their path to problematic opioid use as beginning with a choice to try a drug recreationally and/or having a predisposition to substance use disorder and tendency to make poor choices. Thus, when discussing how people with substance use disorder are stigmatized, the individuals that come to mind are not the people closest to them, but rather, they are “troubled individuals one might come across on the street.”

This context matters. And, while the scripts of the messages included phrases that were intended to ensure viewers understood that “this could happen to anyone,” the signal was not received as intended. Participants easily accepted that one should not judge the troubled individuals who are obviously suffering from opioid use disorder and could notionally accept that it is at least theoretically possible that anyone could end up in that situation. However, many, if not most, clearly discounted the probability of that really occurring. It appeared these participants could easily discount the probability because they were not usually considering that the path can easily begin with a behaviour that they see as responsible and risk-free: taking pain medications as prescribed.

Individuals with the most personal exposure to, or education about, this path were much more readily accepting and appreciative of the messages as presented in these concepts and were more able to identify where stigma is a problem and why. For most others, these concepts were much more difficult to appreciate at face value.

As a result, if the Government of Canada is to pursue a communications strategy designed to remove barriers caused by stigma, this research suggests it is essential to ensure all Canadians understand that the risk of opioid use disorder is not restricted to those who make “irresponsible choices,” but is a risk faced regularly by a much broader range of Canadians – people like themselves and their loved ones who are reasonably prescribed medicine and who take it in a responsible manner.

In addition to this explanation, the findings suggest that any communications campaign is likely to be more effective if it begins with an introduction about the nature, size and scope of the opioid crisis. Addressing stigma can be among a variety of messages communicated but should not be the only message.

Appendix A: Discussion Guide

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

• The name of the firm the moderator works for, and the type of firm that employs them (i.e. an independent marketing research firm)
• The research purpose and research sponsor, described, at a minimum. The Government of Canada, Health Canada, specifically, is developing ad concepts that will be used for public education purposes.
• 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 of any observers, their role and purpose, and the means of observation (one-way mirror, teleconference/webstreaming; colleagues viewing in the back room and listening in remotely)
• The presence and purpose of any recording being made of the session (audio and video taping of the discussion
• Turn off cell phones for the duration of the discussion

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

• [HANDS UP] How many of you are familiar with the term opioids?
• [HANDS UP] Have you recently seen, heard or read anything in the media or elsewhere about opioids? If so, what did you see, hear or read? Anything else?
• To the best of your knowledge, is there currently an opioid crisis in Canada? If so, how serious do think the situation is?
• To the best of your knowledge, how serious would you say the opioid crisis is here in [insert city]? Why do you say that? How would you characterize your level of concern? Why do you say that?

Tonight, we’re going to be reviewing creative concepts that are being proposed by the Government of Canada. We have three creative concepts to show you in animatic format.

An animatic is basically a 30-second video advertisement. However, it is not the version you would see on television or in other media (like YouTube or social media) but rather a draft version using drawings and images. The music and voice overs you will hear are simply there for effect but will not be the final sounds of the ad. The videos will feature real people (not animation).

We will look at each of the three concepts one-by-one. Before we discuss each concept, I will have you fill out a short rating sheet for each one.

[DISTRIBUTE HANDOUT / ASK PARTICIPANTS TO WRITE DOWN]

• Please rate each concept on a 0-10 scale where “0” means very negative and “10” means very positive, with “5” being neutral.
• What is the main message of the ad?

We will do this for each concept.

[MODERATOR TO PLAY EACH CONCEPT AND AFTER EACH, PARTICIPANTS WILL BE ASKED TO COMPLETE THE HANDOUT. NO DISCUSSION UNTIL EACH OF THE CONCEPTS IS SHOWN AND RESPONDENTS FILL OUT THE HANDOUT. ORDER OF CONCEPTS WILL BE SHOWN IN RANDOMIZED ORDER.]

• What did this concept say to you? What was the key message(s) or idea(s) conveyed by the concept?
• What did you like/dislike?
• What about the approach taken/tone of the ad? Was it appropriate? Why or why not?
• Was it credible/believable? Why or why not?
• Is it appropriate for the Government of Canada to provide this kind of information? Why or why not?
• Who is the ad aimed at? Why do you say that?
• If you saw this ad, would it motivate you to take action? Why or why not?
  • What type of actions? Probe: talk to someone, look for more information, etc.?
• What, if anything, would you say to your friends if you saw this ad? Why is that?
• [FOR CONCEPT 1] Did you notice the facts or statistics? How do they strike you?
• [FOR CONCEPT 2] What do you think of the testimonials?
• [FOR CONCEPT 3] What did the square/circle over the faces mean to you?
  • How do you feel about the colour used for this shape?
  • Which colour do you think works best to represent stigma (probe: yellow, purple, green, etc.)? Why do you feel that way?

CONCEPT WRAP-UP

• Which would be most likely to motivate you to take action? Why?
• Which do you feel is most appropriate for the Government of Canada? Why?
• Has anything you’ve seen here today/tonight changed the way you feel about opioids? Why or why not?

Now, I would like to spend a few minutes exploring tagline options for this campaign.

[MODERATOR TO PROBE]:

• Overall, what do you think of these taglines?
• Which are your top three? Why?
  • What did you like? Dislike? Find confusing? Why do you say that?
• Is it appropriate to think about people dealing with problematic opioid use in this context? Why or why not?

You have the power to change lives. Stop the stigma.
YOU can make a difference. Stand up to stigma. #StopOverdoses
Your words and actions matter. Stop stigma. Change lives.
Your voice makes a difference. Stop stigma. Save lives.
Know More. Get the facts about opioids. Together we can stop stigma.
Understand stigma. Stop overdoses.
Understanding the impact of stigma can save lives.
This story could be yours. Stop Stigma. Make a difference.
See past stigma. Save lives.
See past your stigma. Change lives.
Help end stigma. Help save lives.
Stand up to stigma. Save lives. #StopOverdoses
Change your words and actions. Change lives.

• How best would you like to receive this kind of information from the Government? What is the best way for them to reach you?
• What are your preferred sources of information? Probe: specific sources if respondents mention general categories such as newspaper, radio, television, social media, etc.

MODERATOR TO CHECK IN THE BACK ROOM AND PROBE ON ANY ADDITIONAL AREAS OF INTEREST.

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

Appendix B: Handout

Concept 1:

Please rate the concept on a 0-10 scale where “0” means very negative and “10” means very positive, with “5” being neutral.

What is the main message of the ad?

Concept 2:

Please rate the concept on a 0-10 scale where “0” means very negative and “10” means very positive, with “5” being neutral.

What is the main message of the ad?

Concept 3:

Please rate the concept on a 0-10 scale where “0” means very negative and “10” means very positive, with “5” being neutral.

What is the main message of the ad?

Appendix C: Screener

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. 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

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

• Yes Continue
• No Thank and terminate

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.

Invitation:

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

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

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 health card, a student card, or a driver’s license). If you require glasses for reading make sure you bring them with you as well.

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

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

• First name
• Last Name
• email
• Daytime 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.