8

Promotion, Evaluation, and Monitoring for Front-of-Package Symbol Systems

INTRODUCTION

The burden of nutrition-related diseases including type 2 diabetes, cancer, and cardiovascular disease on the health of the American population is high, and the prevalence of certain diseases such as diabetes have dramatically increased over the past few decades because of obesity (Lopez et al., 2006). In an effort to improve public health nutrition, national and international efforts have focused on developing health promotion initiatives and policies to raise public awareness about the relationships between nutrition, health, and food choices (WHO, 2002). For the past two decades in the United States, federally mandated nutrition labeling, i.e., the Nutrition Facts panel (NFP), has been a source of standardized information about the nutritional content of food products at the point of purchase. Front-of-package (FOP) nutrition rating symbol systems are another tool that provide consumers with information and guidance on food choices, and a variety of such systems have been developed by food manufacturers and retailers, as well as by nonprofit organizations such as the American Heart Association (Nestle and Jacobson, 2000). As described in Chapter 4, a proliferation of FOP nutrition labeling and claims followed inauguration of the NFP on the back of food product packages in the early 1990s. Although a variety of FOP systems have been developed since that time, the public health impact of various formats for an effective system has been robustly debated, but little evaluation has been done (Lobstein et al., 2007).

Despite the limitations and uncertainty in relevant fields of research, the committee’s review of available evidence (discussed in Chapters 4 through 6) revealed that, in addition to time constraints when shopping, concerns about price, and taste preferences, many consumers have difficulty understanding and using the nutrition information provided on FOP nutrition labeling, as well as on the NFP. As a result, the committee concluded that a simplified FOP symbol system that provides readily accessible and understandable nutrition information and is linked to the NFP would be a preferable option to the current package environment. The specific goals of an effective FOP symbol system include simplifying consumers’ purchase decisions, encouraging food and beverage manufacturers to develop healthier products, and encouraging food retailers to promote purchase of healthier options among food products.

This chapter examines ways in which social marketing techniques and principles can be applied to inform promotion, monitoring, and evaluation of FOP symbol systems to enhance their effectiveness in guiding food choice and purchase behaviors. Specifically, the committee introduces the tenets and processes of social marketing, briefly highlights evidence supporting the effectiveness of social marketing in changing health behaviors, and describes the application of social marketing techniques to FOP symbol systems. The committee’s recommendations for a



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8 Promotion, Evaluation, and Monitoring for Front-of-Package Symbol Systems INTRODUCTION The burden of nutrition-related diseases including type 2 diabetes, cancer, and cardiovascular disease on the health of the American population is high, and the prevalence of certain diseases such as diabetes have dramatically increased over the past few decades because of obesity (Lopez et al., 2006). In an effort to improve public health nutrition, national and international efforts have focused on developing health promotion initiatives and policies to raise public awareness about the relationships between nutrition, health, and food choices (WHO, 2002). For the past two decades in the United States, federally mandated nutrition labeling, i.e., the Nutrition Facts panel (NFP), has been a source of standardized information about the nutritional content of food products at the point of purchase. Front-of-package (FOP) nutrition rating symbol systems are another tool that provide consumers with informa - tion and guidance on food choices, and a variety of such systems have been developed by food manufacturers and retailers, as well as by nonprofit organizations such as the American Heart Association (Nestle and Jacobson, 2000). As described in Chapter 4, a proliferation of FOP nutrition labeling and claims followed inauguration of the NFP on the back of food product packages in the early 1990s. Although a variety of FOP systems have been developed since that time, the public health impact of various formats for an effective system has been robustly debated, but little evaluation has been done (Lobstein et al., 2007). Despite the limitations and uncertainty in relevant fields of research, the committee’s review of available evidence (discussed in Chapters 4 through 6) revealed that, in addition to time constraints when shopping, con - cerns about price, and taste preferences, many consumers have difficulty understanding and using the nutrition information provided on FOP nutrition labeling, as well as on the NFP. As a result, the committee concluded that a simplified FOP symbol system that provides readily accessible and understandable nutrition information and is linked to the NFP would be a preferable option to the current package environment. The specific goals of an effective FOP symbol system include simplifying consumers’ purchase decisions, encouraging food and bever- age manufacturers to develop healthier products, and encouraging food retailers to promote purchase of healthier options among food products. This chapter examines ways in which social marketing techniques and principles can be applied to inform promotion, monitoring, and evaluation of FOP symbol systems to enhance their effectiveness in guiding food choice and purchase behaviors. Specifically, the committee introduces the tenets and processes of social marketing, briefly highlights evidence supporting the effectiveness of social marketing in changing health behaviors, and describes the application of social marketing techniques to FOP symbol systems. The committee’s recommendations for a 97

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98 FRONT-OF-PACKAGE NUTRITION RATING SYSTEMS AND SYMBOLS simplified FOP symbol system include extensive testing and consumer evaluation prior to implementation. The committee did not examine questions specific to implementation of an FOP symbol system, including responsibili - ties for its cost, management, and enforcement. SOCIAL MARKETING APPROACH TO CHANGING HEALTH BEHAVIOR Principles of Social Marketing Social marketing, the application of commercial marketing techniques to the development, implementation, evaluation, and dissemination of programs designed to influence health-relevant behaviors in target audiences, offers a systematic approach to guide the promotion of health behavior in defined populations (Andreasen, 1995). In addition, an effective marketing mix yields an opportune interchange that minimizes barriers and maximizes benefits to promote a given behavior among a target audience. The process of social marketing involves identifica - tion of an optimal “marketing mix” of the four Ps of marketing: product, price, place, and promotion (NCI, 2004). Details of the marketing mix are shown in Table 8-1. The four Ps of social marketing are substantively grounded in behavior change theory, which guides assessment of the behavior of target audience members and offers insight into factors that might influence behavior change (NCI, 2004). Thus, this approach is ideally suited to the goal of a single, simplified FOP symbol system, i.e., maximizing the opportunity to encourage consumers to make healthier food choice and purchase decisions while minimizing barriers. Rationale for a Social Marketing Approach Considerable evidence supports the effectiveness of social marketing in modifying health behavior at the population level (Hogan et al., 2002; Snyder, 2007). A recent review of evidence of the effectiveness of health communication campaigns, drawing upon meta-analyses and other literature, revealed that health communica - tion campaigns, on average, influence relevant community behavior by approximately 5 percentage points with somewhat greater impact shown for nutrition campaigns (Snyder, 2007). One such social marketing campaign that resulted in behavior change is VERB: It’s What You Do. This campaign, administered by the Centers for Disease Control and Prevention (CDC) from 2002 to 2006, promoted physical activity among youth ages 9-13 years (Caville and Maibach, 2008). The campaign used a combination of paid advertising, marketing strategies, and partnership efforts and employed branding and message strategy grounded in behavioral theory that was developed and inte - grated into campaign planning and implementation (Bandura, 1986; Ajzen, 1991; Huhman et al., 2004). Through development of messages derived from consumer research, and dissemination through multiple media and market - ing efforts, the VERB campaign achieved significant population impact (Banspach, 2008; Huhman et al., 2010). TABLE 8-1 The Marketing Mix of the Four Ps Marketing Mix Component Definition Examples Product The promoted behavior and attendant benefits Choose a healthier food product while grocery shopping Price The barriers or costs associated with adoption of Time the promoted behavior Money Taste Place A convenient location to deliver the product and Point of purchase its benefits Promotion The process of delivering the product and its Communication campaigns benefits to the target market Branding strategies

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99 PROMOTION, EVALUATION, AND MONITORING Branding and Communication Social marketing through public health branding utilizes commercial branding practices, including modeling of desired behaviors and imagery (e.g., attractive, energetic people eating fruits and vegetables), to promote healthy behaviors (Evans et al., 2008). Social marketing through mass communication and branding around nutrition has increased dramatically during the past decade and shows considerable promise as a tool for behavior change (Grilli et al., 2000; Bauman et al., 2006; Snyder, 2007; Evans et al., 2008; Hornick et al., 2008). The committee’s review of evidence acknowledges the increasingly cluttered food package environment (see Chapter 6) and highlights the need for FOP symbol systems to be distinctive, readily assessable, and consistent across all food packages in order to be recognized and used by consumers. The committee identified four attributes that are common to successful FOP symbol systems: • simple, understanding does not require specific or sophisticated nutritional knowledge; • interpretive, nutrition information is provided as guidance rather than as specific facts; • ordinal, nutritional guidance is offered through a scaled or ranked approach; and • supported by communication with readily remembered names or identifiable symbols. Application of Social Marketing Campaigns to FOP Systems As discussed above, social marketing provides a useful framework to guide the promotion and evaluation of FOP nutrition rating systems and symbols. The committee identified potential stages in successful social marketing campaigns that could be applied to the promotion of an FOP system. Figure 8-1 summarizes the stages that are common to successful campaigns; their application to FOP labeling systems is discussed below. Phase I of the study, Examination of Front-of-Package Nutrition Rating Systems and Symbols (IOM, 2010), involved preliminary activities designated in Stage 1 of the social marketing process, Campaign Planning and Strategy Development. These activities included conducting a review of 20 representative FOP labeling systems; characterizing the strengths and limitations of existing systems; designing key objectives to encourage consumers to choose foods and beverages that are lower in calories, sodium, and saturated and trans fats; and identifying the market audience as the general U.S. population. The aim of Phase II is to expand upon these planning and strategy development activities to develop a set of recommendations and a research agenda that will optimize the impact and support promotion of an FOP symbol system on consumer food choice and purchase behavior. While Stages 2 through 4 outlined in Figure 8-1 are essential components for comprehensive implementation strategy, specific recommendations for those areas are beyond the scope of the committee’s task. Special consideration should be given to audience segmentation (e.g., parents with young children, adoles - cents, families living on tight budgets) and to integrating promotion and education efforts around FOP package labeling in food and nutrition assistance programs such as Supplemental Nutrition Assistance Program (SNAP) and SNAP Nutrition Education (SNAP-ED), Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), the U.S. Department of Agriculture (USDA) commodities program, and the National School Lunch and School Breakfast programs (NSLP/SBP). Effective FOP symbol systems could serve to inform and unify federal and local nutrition assistance programs and education efforts around shared public health nutrition goals and standards. Finally, promotion of FOP symbol systems is encouraged with branding and media campaigns to increase awareness, use of compelling images and sources, development of a related slogan, and distribution through multiple channels. A promotion and implementation campaign will need to include information and messages that complement, and in some cases, further describe an FOP symbol system. For example, messaging around calorie content in terms of overall calorie needs and anchoring statements—such as those used or proposed in menu labeling efforts across the country—will be important to help consumers put calorie content information into perspective. In addi - tion, messaging around saturated and trans fats, added sugar, and sodium will be essential to help consumers better understand the simplified icon with the zero, one, two, or three symbols depicting nutrients of concern.

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100 FRONT-OF-PACKAGE NUTRITION RATING SYSTEMS AND SYMBOLS Four Ps of Social Marketing • Product: the FOP symbol system • Price: financial, time, effort, and cost of selecting healthier food, and time and effort of interpreting FOP labels • Place: FOP systems are recommended to appear on all food and beverage products, at point of purchase, and integrated with food and nutrition assistance programs, such as WIC and SNAP • Promotion: branding and media campaigns around the FOP system; use of compelling images and sources, develop related slogan; and distribute through multiple channels Stage 1: Campaign Planning and Strategy Development • Review representative FOP symbol systems • Characterize strengths and limitations of existing FOP systems • Designate key communication objectives of FOP campaign • Identification of the market audience • Develop a research agenda to evaluate FOP symbol systems • Suggest social marketing strategies to promote FOP labeling systems Step 2: Formative Research to Develop and Pretest Concepts, Messages, and Material • Develop consistent, clear, relevant, and appealing messages; • Select and define target populations; • Conduct formative research on diet-related awareness, knowledge, attitudes, and behaviors of target population; • Test impact of messages on intended behavior change; • Create awareness of FOP labels and develop favorable associations with consumer behavior through branding and social modeling; and • Employ multiple communication channels to maximize population reach and effectiveness of FOP labels. Step 3: Implementation • Program launch with a kick-off event or media event to create awareness of FOP campaign; and • Engage in process evaluation to assess dissemination efforts and evaluate campaign reach. Step 4: Evaluate Effectiveness and Make Refinements • Implement measures to assess consumer awareness, knowledge, attitudes, and behavior relevant to FOP symbol systems; • Establish and implement techniques for monitoring and evaluation of campaign relevant outcomes; and • Modify campaign to reflect findings from results and outcomes of monitoring and evaluation. FIGURE 8-1 Application of social marketing to a front-of-package symbol system. Figure 8-1 R02048 editable vectors

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101 PROMOTION, EVALUATION, AND MONITORING PROMOTION, MONITORING, EVALUATION, AND RESEARCH Promotion The committee identified a number of ways in which social marketing strategies can be applied to FOP symbol systems to guide food choice and purchase behaviors. Based on its review of existing public health campaigns, the committee concluded that in order to be effective, promotion of FOP symbol systems must be a well-funded, sustained effort and must be dynamic, refreshed on a regular basis, and carried out by multiple stakeholders rep - resenting both public and private interests. Further, campaigns that focus on behavioral goals that are effective and actionable have a greater chance for success. Comprehensive, multi-level approaches that speak to environmental and policy constraints, socio-cultural influences, and individual-level factors that affect dietary behavior change are encouraged. Monitoring, Evaluation, and Research Monitoring, evaluation, and research are essential components of an FOP symbol system. Addressing these components includes: • Identifying the steps toward reaching the goal of making healthier choices; • Conducting research designed to assess success in reaching each step; and • Enhancing system components and taking corrective action where necessary. Research should be conducted by governmental and nongovernmental organizations as well as by academic and industry stakeholders to assess the needs and preferences of target audiences to better understand the factors that influence consumer food choice and purchase behavior. For example, research could examine whether differ- entiating between fat, sodium, and added sugar points on the FOP has any impact on food choices and purchasing decisions. In addition, research should determine if consumers see nutrition information on the FOP as marketing materials or as credible health or government statements. In addition formative research is necessary to test and refine messages and to determine the best approaches and channels to promote an FOP system. Monitoring through both process and outcome evaluation is needed to assess effectiveness and impact and to refine and strengthen program components. Assessment of the impact of an FOP symbol system on product reformulation is also neces - sary. Placing special emphasis to nutritionally at-risk subpopulations such as those with low incomes, low literacy/ numeracy skills, or low levels of education, is an important component of these processes. Ongoing research will also help to guide and strengthen implementation efforts and help inform any corrective action where necessary. Table 8-2 illustrates the process necessary to monitor, evaluate, and improve an FOP symbol system. FINDINGS AND CONCLUSIONS Findings Social marketing campaigns have been effectively implemented to modify a diversity of health behaviors, including behaviors relevant to diet and nutrition (Grilli et al., 2000; Hogan et al., 2002; Snyder and Hamilton, 2002; Bauman et al., 2006; Evans et al., 2008). With careful development and implementation, a social market - ing campaign to promote FOP symbol systems has considerable potential to change nutrition-related behaviors in the population. Review of existing public health campaigns suggests that to be effective, FOP symbol system implementation must be well-funded, sustained, refreshed, and carried out by multi-sector collaborations including stakeholders from public health, medical, education, science, industry, and government. The committee’s review of relevant campaigns organized by the social marketing framework suggests that FOP symbol systems should focus on actionable behaviors. In addition, comprehensive, multi-level approaches that address a combination of factors

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102 FRONT-OF-PACKAGE NUTRITION RATING SYSTEMS AND SYMBOLS TABLE 8-2 Ongoing Monitoring, Evaluation, and Improvement of the New Front-of-Package System Process Toward Healthier Choices Evaluation/Research Revision of FOP System Consumers encounter the FOP Recognition of the FOP symbol Examine message delivery by each medium symbol system in national, local, system across demographic groups across demographic groups and bolster social, and/or in-store media shortcomings Consumers understand that products Perceptions of the healthfulness Revise symbol design or sharpen receiving FOP symbols with more of products receiving more or less communication of the symbol’s meaning nutritional points are healthier nutritional points versus perceptions choices of the same products without the FOP symbol system Consumers perceive purchases of Perceptions of the purchasers of Improve communications’ ability to products with the FOP symbol products with the FOP symbol stimulate the desired inference system displaying more nutritional system displaying more nutritional points more positively, compared points compared to perceptions of to purchases of products with FOP the purchasers of products with an symbols displaying fewer nutritional FOP symbol system displaying fewer points nutritional points Consumers make healthier choices at • etail activity behind healthier R • olicit possible adaptations of the S the point of purchase options before and after the program in keeping with consumer and introduction of the FOP symbol retailer needs system • olicit possible adaptations of the S • nterviews with retail managers I program in keeping with consumer and • hare of shelf space accounted S manufacturer needs for by healthier options before and after the introduction of the FOP symbol system • nterviews with manufacturers I • ales of healthier options before S and after the introduction of the FOP symbol system • conometric modeling of the E impact of price, promotion, retail presence, and FOP symbol system to understand what may account for the sales pattern such as environmental and policy constraints as well as individual-level factors are important areas to encourage (Grilli et al., 2000; Hogan et al., 2002; Snyder and Hamilton, 2002; Bauman et al., 2006; Evans et al., 2008). A robust monitoring and evaluation approach is essential to ascertain the mechanisms underlying consumer purchasing behaviors relevant to FOP symbol systems. Such an approach will help inform campaign implemen - tation and refinement. Integration of promotion of FOP symbol systems informed by basic communication and social marketing science into existing and relevant social marketing campaigns, such as Fruits and Veggies—More Matters and food and nutrition assistance programs and education efforts, can lead to widespread adoption and promotion of FOP symbol systems. Such coordinated and complementary efforts will also help to maximize use of limited public health resources, provide consistent messages in different venues, and capitalize upon the shared public health goal of promoting healthy behaviors and ultimately reducing obesity and diet-related chronic diseases.

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103 PROMOTION, EVALUATION, AND MONITORING Conclusions Implementation of an FOP symbol system must include a multi-stakeholder, multi-faceted, ongoing awareness and promotion campaign. The characteristics of a successful campaign are as follows: • Include a combination of the four key tenets of marketing: product, price, place, and promotion; • Involve the four stages of the social marketing process including o Planning and strategy development; o Development of pretesting concepts, messages, and materials; o Implementation; and o Evaluation of in-market effectiveness and refinement; and • Be integrated into existing and relevant social marketing campaigns, as well as food and nutrition assistance programs and education efforts such as SNAP and SNAP-ED, WIC, and the USDA NSLP/SBP. Additionally, in order to be successful, federal agencies and interested stakeholders, including private and nongovernmental organizations, should support the FOP symbol system, emphasizing its impact on consumer purchases and consumption behaviors. Monitoring and evaluation are essential components of the process to ensure that the needs, values, and pref - erences of the targeted audiences are assessed and integrated into campaign components. A variety of monitoring and evaluation efforts should be used to capture key campaign components and to continually refine, strengthen, and refresh efforts. Formative evaluation, qualitative and quantitative research, and process and outcome evalu - ation are all important to consider and employ to best assess program effectiveness and continued refinement of an FOP symbol system. REFERENCES Ajzen, I. 1991. The theory of planned behavior. Organizational Behavior and Human Decision Processes 50:179-211. Andreasen, A. 1995. Marketing Social Change. San Francisco, CA: Jossey-Bass. Bandura, A. 1986. Social Foundations of Thought and Action: A Social Cognitive Theory. Englewood Cliffs, NJ: Prentice Hall. Banspach, S. 2008. The VERBTM campaign. American Journal of Preventive Medicine 34:S275. Bauman, A., B. Smith, E. Maibach, and B. Reger-Nash. 2006. Evaluation of mass media campaigns for physical activity. Evaluation and Program Planning 29:312-322. Caville, N., and E. Maibach. 2008. VERB™ demonstrating a viable national option for promoting physical activity among our children. American Journal of Preventive Medicine 34:S173-S174. Evans, W. D., J. Blitstein, J. C. Hersey, J. Renaud, and A. Yaroch. 2008. Systematic review of branded public health campaigns. Journal of Communications 13:721-741. Grilli, R. N., S. Freemantle, and S. Minozzi. 2000. Mass media interventions: Effects on health services utilization. In Cochrane Database of Systematic Reviews. Oxford: Cochrane Library. Hogan, E. H., B. A. Hornick, and A. Bouchoux. 2002. Communicating the message: Clarifying the controversies about caf - feine. Nutrition Today 37(1):28-35. Hornick, B. A., A. J. Krester, and T. A. Nicklas. 2008. Menu modeling with MyPyramid food patterns: Incremental dietary changes lead to dramatic improvements in diet quality of menus. Journal of the American Dietetic Association 108:2077-2083. Huhman, M., C. Heitzler, and F. Wong. 2004. The VERB™ campaign logic model: A tool for planning and evaluation. Preven- tion of Chronic Diseases 1:A11. Huhman, M. E., L. D. Potter, M. J. Nolin, A. Piesse, D. R. Judkins, S. W. Banspach, and F. L. Wong. 2010. The influence of the VERB™ campaign on children’s physical activity in 2002 to 2006. American Journal of Public Health 100:638-645. IOM (Institute of Medicine). 2010. Examination of Front-of-Package Nutrition Rating Systems and Symbols: Phase I Report . Washington, DC: The National Academies Press. Lobstein, T., J. Landon, and P. Lincoln. 2007. Misconceptions and Misinformation: The Problems with Guideline Daily Amounts (GDA). London: National Heart Forum. Lopez, A. D., C. D. Mathers, M. Ezzati, D. T. Jamison, and C. J. L. Murray. 2006. Global Burden of Disease and Risk Factors. London: Oxford University Press and the World Bank.

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104 FRONT-OF-PACKAGE NUTRITION RATING SYSTEMS AND SYMBOLS NCI (National Cancer Institute). 2004. Making Health Communications Programs Work. Washington, DC: U.S. Department of Health and Human Services. Nestle, M., and M. F. Jacobson. 2000. Halting the obesity epidemic: A public health policy approach. Public Health Report 115:12-24. Snyder, L. 2007. Health communication campaigns and their impact on behavior. Journal of Nutrition Education and Behavior 39:S32-S40. Snyder, L. B., and M. A. Hamilton. 2002. Meta-analysis of U.S. health campaign effects on behavior: Emphasize enforcement, exposure, and new information, and beware the secular trend. In Public Health Communication: Evidence for Behavior Change, edited by R. Hornik. Hillsdale, NJ: Erlbaum. Pp. 357-383. WHO (World Health Organization). 2002. Reducing Risks, Promoting Healthy Life. Geneva: World Health Organization.