Doctoral thesis

Understanding the effects of communication and engagement in a social marketing intervention on children’s eating behavior : design, measurement and evaluation


262 p.

Thèse de doctorat: Università della Svizzera italiana, 2017 (jury note: Summa cum laude)

English The prevalence of overweight and obesity represents a serious health problem, and is a risk factor for several non- communicable diseases. Poor nutrition and lack of regular physical activity are among the primary determinants of overweight and obesity. Data show that overweight and obesity rates are high in, and that the Swiss population does not adhere to the nutritional guidelines provided by the Swiss Society for Nutrition, nor to the physical activity guidelines provided by the Swiss Federal Office of Public Health. To address and counteract the issue of overweight and obesity, effective interventions are needed. Social Marketing is a framework grounded on Marketing concepts that focuses on behavior and aims at benefiting society by enhancing the social good. The evidence shows that the Social Marketing framework has been widely and effectively used in interventions aiming at changing different health behaviors, with different populations, including overweight and obesity in children. However, it is imperative to understand what makes interventions work, and what, on the contrary, impedes their success. In particular, there is need to improve knowledge and build up the evidence base on Social Marketing use in Europe. Hence it is critical to develop and implement Social Marketing interventions and to share consistently methodologies and results, in particular by operationalizing the Social Marketing benchmark criteria, and by reporting behavioral outcomes. “Famiglia, Attività fisica, Nutrizione” (FAN) was one of the interventions developed by the Department of Health and Social Affairs of Canton Ticino to address the issue of overweight and obese children. It was developed in collaboration with the BeCHANGE Research Group at the Università della Svizzera italiana, following the Social Marketing framework. FAN was addressed to families with school-aged children, and delivered to parents via Web, e-mail, SMS and via print letters to children, with the ultimate goal to help children and their parents eat healthy and practice regular physical activity. Since no validated tool existed to collect children’s food consumption data in Switzerland, a new instrument was developed and tested. This dissertation includes five complementary articles about measuring and improving children’s eating behaviors, each published in, or submitted to, a relevant scientific peer-reviewed journal in the field of Social Marketing or Public Health research. Each article presents the examination and discussion of one of the following four aspects related to the promotion of healthy nutrition in the FAN Social Marketing intervention: 1) The operationalization and implementation of Social Marketing; 2) The measurement of children’s food consumption; 3) The role of different communication channel bundles; 4) The role of engagement. To address the first aspect, the FAN intervention with the operationalization of the Social Marketing benchmark Criteria is described. Rates of participation and satisfaction with the intervention are also presented (Chapter II). To examine the second aspect, agreement between parents and their children in reporting the child’s food consumption was assessed, using two different instruments (7-day food diary vs. 2-day food record). These were then compared, to assess which one was more reliable with this population (Chapter III and Chapter IV). The third aspect examined the role of Web plus e-mail and Web plus SMS communication compared to Web-only communication using a Randomized Controlled Trial design. The study assessed children’s food consumption at pre- and post-intervention, by group assignment in the FAN intervention (Chapter V). Finally, to examine the fourth aspect, the role of online versus offline engagement in FAN was assessed using data from a self-reported questionnaire and data from a log of the FAN Website (Chapter VI). The description of the FAN intervention with the operationalization of the Social Marketing benchmark criteria helps to build the evidence on Social Marketing, defining how each benchmark was operationalized and allowing comparisons across studies. The analyses conducted in the second study, demonstrate that children are accurate reporters of their food consumption. The effects of the communication channels show that FAN had an overall positive effect on food consumption behavior, and in particular on that of fruit and sweets. The analyses of the role of engagement in intervention outcomes suggest that improved consumption of fruit, sweets and sugar drinks was associated with engagement. The world is facing a variety of health-related challenges that result from choices on nutrition, physical activity, smoking, alcohol consumption and other behaviors, and that negatively impact populations’ health, as well as health, social and economic systems and welfare. Among those, the prevalence of overweight and obesity needs urgent attention. Indeed, despite some efforts to decrease them, the rates of overweight and obesity are still high. Hence, cost-effective and urgent solutions are required. Social Marketing offers a systematic and detailed guide for developing, implementing, managing, and evaluating health behavior interventions. Evidence so far shows that Social Marketing has been effectively used in different settings, with different populations and for different health behaviors (including nutrition). This framework is also recommended in policy documents. However, the evidence on its use and effectiveness, in particular in Europe, still needs to be built up. Adhering to the eight benchmark criteria resulted in an intervention that was appropriate and relevant to the participants, and that had a positive effect on participation, retention, satisfaction rates, and behavior change. Future online interventions promoting healthy food consumption should adhere to the Social Marketing framework. The research described above tested two different food consumption measurement tools designed for children, to address the issue of gathering data about children’s food consumption, which is particularly difficult. The results suggest that children can provide accurate and useful data. The research also emphasizes the need to incorporate different complementary communication channels and that promoting engagement in a social marketing campaign can make a positive contribution to behavior change. All things considered, this research contributes to building knowledge and evidence about Social Marketing’s use and the promotion and measurement of healthy food consumption in children. The results provide an optimistic foundation that can be used and extended to other populations, behaviors and settings.
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