applying theories and models …to community nutrition programs and strategies
TRANSCRIPT
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Applying Theories and Models
…to Community Nutrition Programs and
Strategies
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Theories & Models of Health Behaviour
We will explore:
Factors that influences our food choice behaviours
Theories & models of health behaviour Community & System level change
strategies (Community Development, Social Marketing, Policy)
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Food Choice Behaiours
READ Raine, K. (2005). Determinants
of healthy eating in Canada. An overview and synthesis. Can. J. Public Health, 96, suppl 3, S8-S14.
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Personal Food Choices
Physiological factors
Food Preferences Nutritional
Knowledge Perceptions of
Healthy Eating Psychological
Factors
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Personal Food Choices?
Environmental Factors Interpersonal influences Physical environment Economic environment Social environment
Creating Supportive Environments - Policy
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Food Choices Food choices, eating behaviours and
resulting nutrional health are influenced by a number of complex and inter-related individual, collective and policy-related determinants.
A growing body of research is supporting the relationship between food preparation and cooking skills and food choices of children and adolescents within the family context.
Health Canada, Improving Cooking and Food Preparation Skills, 2011
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Food Choices Diet quality of youth related to
frequency of family meals AND involvement in food prep
Taste, nutritional value, cost and time Main factors behind food choice & prep
decisions ACROSS SES groups Low SES report cooking from
‘scratch’ more often AND use of fewer convenience foods
Health Canada, 2011
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Best Practices for Interventions
Theoretical basis clear Or minimally based on set of
“defendable community-relevant assumptions”
Experiential/hands-on learning Promotes self confidence through
skill development Include self-assessment of
eating patterns & behaviour change tracking
Health Canada, 2011
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Best Practices
Tailored for specific population group
Based on measurable, specific goals
Longer vs. shorter duration programs Provide reinforcement & motivation
Health Canada, 2011
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What are food skills? Knowledge
Food safety, label reading, ingredient substitution
Planning Organizing menu, food prep within budget,
teaching children food skills Conceptualizing food
Creative use of leftovers, adjusting recipes Mechanical techniques
Following recipe, chopping, mixing, etc. Food Perception
Using senses, when foods are cooked
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Rural Restaurant Customers Preferences
Options most likely to order if available Broiled or baked
meat WW bread Fresh fruit Steamed veg Regular salad
dsg on side
Options least likely to order if available Low-fat sour cream Low-fat salad dsg Low-fat milk Low-calorie dessert Request to hold
high fat ingredients
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Income & supplement use Lower income adults less likely to
consume vit/min supplements Higher education linked to greater
supplement use Lower income
Food insecure & poorer diet quality May need supplements most
Findings suggest need for improved access to supplements for lower income
Whiting, Adolphe, & Vatanparast, Oct 2009, DC Current Issues
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Food Choice Behaviours
Knowledge behaviour
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Food Choice Behaviours Values
Permeate our lives; define who we are & where we stand; learned from socialization (Vanden Heede, et al., 2006)
conception of what is desirable & undesirable Beliefs
conceptions of reality & propositions about how the universe works
Norms principles, rules or standards for behavior - they are
people’s conception of what should occur in a given situation
Culture a guide for behaviour a mental map
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Theory
a set of interrelated concepts, definitions, and propositions presents a systematic view of events
or situations by specifying relationships among
variables in order to explain or predict the
events of the situations.
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Theory Used as a guide:
WHY people are/are not following health advice
WHAT you need to know before developing or organizing an intervention program
HOW you shape program strategies to reach population and make an impact
WHAT should be monitored, measured, and/or compared in the program evaluation
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Theory
Helps us understand behavior Explains dynamics of behavior Explains process for change of behavior Identifies target for programs Identifies methods for accomplishing
change Theories and models EXPLAIN behavior
and SUGGEST ways to achieve behavior change
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Theory
Keep in mind that more than one theory may be used to address an issue
No single theory dominates community nutrition activities
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Theory Designing interventions for eating
pattern changes can best be done with understanding of relevant theories and of dietary behaviors change and an ability to put them into practice
(Glanz & Eriksen, 1993)
Theories therefore: Guide program development Provide foundation for evaluation
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Model
Vehicle for applying theories Provides plan for investigating
or addressing a phenomenon Only represents processes;
does not attempt to explain them
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Two models linking theory to practice Scientific model
Theory defined to deduce hypotheses that are tested with experimental research design
Requires replication by practitioners of exact process to find the ‘truth’
Humanistic model Theory define to seek to clarify social values Practitioners use theory to stimulate
dialogue about “eating habits in living the kind of life that community members find most valuable.”
Buchanan, 2004, JNEB, 36, 146-154.
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Theories and models
Intrapersonal level (Individual) Stages of Change (TTM) The Health Belief Model Theory of Reasoned Action
Interpersonal level Social Cognitive Theory
Community and group level Diffusion of innovations
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Transtheoretical Model (TTM) – Intrapersonal Developed by Prochaska &
Diclemente Stages of Change Model
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Transtheoretical Model (TTM)
Focus Person’s readiness to change or
attempt to change toward healthy behaviour
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Transtheoretical Model (TTM) Assumptions
Behaviour change involves series of stages or steps
Common stages across variety of health behaviours
Tailor interventions to be most effective
Encourages us to think about client’s readiness to change
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Transtheoretical Model (TTM) Precontemplation – unaware or not
interested in making change Contemplation – thinking about taking
action - next 6 mths Preparation – active decision to change
and planning Action – trying to make change for
<6mths Maintenance -has sustained change for
>6mths Termination – no temptation and 100%
self-efficacy
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TTM
Self Efficacy confidence in ability to change
behaviour & to withstand temptations to relapse
Decisional Balance pros and cons of change how an individual perceives these
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Decisional Balance
Pros of Change
Cons of Change
Pros of No Change
Cons of No Change
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TTM Applications
Intervention strategies should be matched with processes commonly used in particular stage of change cognitive processes used in pre-action
stages Seeking information
behavioral processes used in Prep, Action and Maintenance
Seeking ways to strengthen behaviour
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TTM Applications
TTM originated with addictive behaviours research e.g., smoking cessation
Dietary change involves complex combination of removal of one set of behaviours & acquisition of new set of behaviours
Measurement of definite stage of change is more difficult
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TTM – use to increase V/F intake in preschool children
Low-income parents & primary caregivers (N=238)
Incorporates staging algorithm for increasing V/F accessibility to PS children, decisional balance, self-efficacy
Hildebrand, & Betts, 2009; JNEB, 41(2), 110-119
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TTM – use to increase V/F intake in preschool children Precontemplation/Contemplation (43%)
Best to use methods to share ideas for planning meals and snacks to include V/F
Preparation (29%) Aim to build skills in making quick &
economical V/F Stress parent role-modeling Encourage goal setting
Action/Maintenance To prevent relapse, build in social support
in all learning formatsHildebrand, & Betts, 2009; JNEB, 41(2), 110-119
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TTM with low income parents & caregivers Caregivers assessed for stage of
change for increasing V/F access for PS children
43% precontemplation/contemplation 29% preparation Those in action & maintenance
Showed higher self efficacy u Used more behavioral processes
Interventions should be tailored to stage of change Cognitive vs. behavioural
Hildebrand, & Betts, 2009
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Health Belief Model - Intrapersonal
Hochbaum, Rosenstock and Kegel - 1950s
to explain why people would/would not use health services
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Health Belief Model - Intrapersonal
Focus Person’s perception of a health
problem & appraisal of recommended behaviour to manage or prevent the problem
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Health Belief Model – Three Components1. Perception of threat to health
personal threat to health concerned that ‘disease’ carries serious
personal consequences2. Outcome expectations
perceived benefits and barriers to taking specific action
3. Self-efficacy belief that one can make a behaviour change
Other factors affect perceived threat, outcome expectations & efficacy expectations
Thus, factors influence health behaviour indirectly
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Using Health Belief Model
Include skill-building components increase self-efficacy
Be aware of times of increased threat perception ↑ likelihood of change
Identify barriers to action develop strategies for helping
clients overcome barriers
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Theory of Reasoned Action – Intrapersonal Ajzen and
Fishbein
Behaviour determined directly by intention to perform the behaviour
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Theory of Reasoned Action Intention
Instructions given to self to behave in certain way
Consider behaviour outcomes & opinion of significant others when forming opinions
Intentions influenced by attitudes and social pressures to perform (subjective norms) Perceived social pressure to perform or
not perform a behaviour
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Theory of Trying - Intrapersonal Developed by
Bagozzi Modified Theory
of Reasoned Action
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Theory of Trying
Added components that influence intention to try behaviour: past experience (success or
failure) with behaviour mechanisms for coping with
behaviour outcome emotional responses to process
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Application of Theories to Practice
Self-assurance seems linked to successful behaviour change self-esteem self-efficacy
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Application of Theories to Practice
Could screen clients upon program entry degree of readiness to change degree of past success degree of confidence in ability to
change level of commitment to program
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Social Cognitive Theory Developed by
Bandura to explain how
people acquire & maintain behaviours
SLT = Social Learning Theory
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Interpersonal Model – Social Cognitive Theory
EnvironmentalFactors
Internal/PersonalFactors
Behavior
(Bandura, (Bandura, 1972)1972)
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Social Cognitive Theory
Strength focus on target behaviours rather
than attitudes & knowledge Key concepts and their
implications Table 15-3, page 487
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Interpersonal level applications Small Groups
Supplement or substitute individual counseling
Social Support Interacting with positive role models and
problem solving through discussions with people with shared problems
Peer Education Effective at enhancing observational learning
through role models Youth and cultural minority groups
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Interpersonal level applications
Point-of-purchase nutrition information Guide food selections in food
establishments, i.e., supermarkets, cafeterias, restaurants
Information during decision making increase awareness and serve as reminder
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Community & Group – Diffusion of Innovation
Rogers and Shoemaker, 1970s to explain how
product/idea becomes accepted by majority of consumers
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Diffusion of Innovation
Focus Addresses how new ideas,
products & social practices spread within a society or from one society to another
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Diffusion of Innovation
Consists of 4 stages Knowledge Persuasion Decision Confirmation
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Diffusion of Innovation
Spread of innovations largely by word-of-mouth
Speed of diffusion is a function of number of people adopting
Consumers classified by readiness to adopt new innovation
innovators, early adopters, early majority, late majority, late adopters, laggards
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Application of Diffusion of Innovation
Diffusion process facilitated by actions of different sectors
Barriers to adoption occur due to disruption of habitual routines
The greater the disruption, the slower the adoption
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Knowledge-Attitude-Behaviour
Health Information
Calorie per calorie, whole fruit has more dietary fibre than fruit juice.
ADA position paper, Total diet approach to communicating food and nutrition information, 2007.
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Health Belief Model Perceived benefits, threats, barriers
Whole fruits have fibre that helps me feel full. If I drink juice instead of eating whole fruit, I
would get less fibre and have a harder time managing my calorie intake.
That could lead to gaining excess weight which would make me feel less attractive.
However, I may not be able to eat whole fruit as often as I want to because it is easier to find fruit juice when I need something that’s fast and easy from a vending machine or a convenience store.
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Social Learning TheoryTTM, & Health Belief Model
Self-efficacy I know that I can eat more fruit
and less juice by learning which fruits are in season and putting those fruits on my weekly shopping list.
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Social Learning Theory
Reciprocal Determinism If the vending machines at my
office have fruit, I will be more likely to select it as a snack.
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TTM Stages and Processes of Change
I realize that eating whole fruit is a good way to help me increase my intake of fruits & vegetables each day.
I also realize that I have been getting most of my fruit in the form of juice.
I will start buying more whole fruit and less juice the next time I go to the supermarket.
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Community-level models
Frameworks for understanding how social systems function and change, and how communities and organizations can be activated
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Community-level models
Essential for comprehensive community education
individuals, groups, institutions, and communities
Embody an ecological perspective Complement individually oriented behaviour
change goals with broad aims that include advocacy and policy development
Suggest strategies and initiatives that are planned and led by organizations and institutions,
i.e., schools, worksites, health care settings, community groups, and government agencies
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Ecological Perspective Multiple
dimensions of influence on behavior
Interactions across dimensions
Multiple levels of environmental influences
Environments directly influence behaviors
Intra-personalfactors
Inter-personal processes and groups
Institutionalfactors
Communityfactors
Public policy
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Community-level models
Community Organization Theories
Organizational Change Theory
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Community-level models
Organizational Change theory Focus
Processes and strategies for increasing the chances that healthy policies & program will be adopted & maintained in formal organizations
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Community-level models
Community Organization Theories
roots in theories of social networks and support.
Emphasizes active participation & development of communities that can better evaluate and solve health and social problems
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Community Change: Key Concepts
Empowerment process by which individuals,
communities or organization obtain mastery over their lives to produce change
Community Competence Community sectors able to
collaborate effectively to engage in problem solving
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Community Change: Key Concepts
Participation involvement of all community
members in planning, development, & implementation of programs in the community
Relevance starting where the people are;
beginning with the community’s felt needs
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Community Change: Key Concepts
Issue Selection community’s ability to identify &
prioritize issues Critical Consciousness
Developing understanding of the root causes of a problem
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Community Level Strategies
Community Development Community Capacity Building
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Community Based vs. Community Development
Community based programming is the process of health professionals and/or health agencies Defining the health problem Developing strategies to remedy the
problem Involving local community members and
groups to assist in problem solving Working to transfer major responsibility for
ongoing program to local community members and groups
Labonte, 1993
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Community Based vs. Community Development
Community development is the process of organizing and/or supporting community groups in their identification of important concerns and issues, and in their ability to plan and implement strategies to mitigate their concerns and resolve their issues.
Labonte, 1993
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Characteristics of community-based
The problem name is given by the professional/institution
There are defined program timelines
Changes in specific behaviours or knowledge levels are the desired outcome
Decision-making rests principally with the professional/institution
Labonte, 1993
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Characteristics of community development
The naming of the problem starts with the community group
Work is long term, requiring many hours
A general increase in the group’s capacity is the desired outcome
Power relations are constantly negotiated
Labonte, 1993
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Capacity Building “the strengthening of the ability of
people, communities and systems to plan, develop, implement and maintain effective health and social approaches.” (PPHB Atlantic, Health Canada 2001)
“an approach to the development of skills, organizational structures, resources, and commitment to improvement in health and other sectors, to prolong and multiply health gains many times over.” (Hawe, 1999)
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Capacity Building
Individual/Personal
Community
Organization
Systems
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Society Level Strategies
Social Marketing Policy Change
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Social Marketing
“ the use of marketing principles and techniques to advance a social cause, idea, or behaviour”
Vanden Heede & Pelican, 1995
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Social Marketing
“…combines the best elements of traditional approaches to social change in an integrated planning and action framework, and utilizes advances in communications technology and marketing skills. It uses marketing techniques to generate discussion and promote information, attitudes, values and behaviors. By doing so, it helps to create a climate conducive to social and behavioral change.”(Health Canada, 2004)
Social Marketing Network http://www.hc-sc.gc.ca/english/socialmarketing/
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Social Marketing Aim: to influence the voluntary
adoption of behavior change of the target audience
Uses consumer research i.e. demographics
Focus on conferring benefits & reducing barriers
Primary beneficiaries are the target audience, not the marketing body
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The Marketing Mix
The 4 P’s of marketing: Product - the “bundle of benefits” Price - “cost” of the behavior change Place – benefits must be available at
the right place and the right time i.e., “the how” and “the where”
Promotion – methods used to raise awareness and provide education i.e., “the what”
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The role of research…
Market research Developing demographic, behavioral and
lifestyle profiles Identifying existing behaviors, actions,
needs, perceptions, attitudes and perceived benefits/barriers of the target audience
Competitive analysis Identifying organizational and
environmental considerations that influence behavior change
Health Canada, 2004
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Social Marketing CDC recommends social marketing to
achieve targeted public health goals Self-guided Web course (free)
Social Marketing for Nutrition and Physical Activity
http://www.cdc.gov/nccdphp/dnpa/socialmarketing/training/basics
Basics, problem description, Formative research, Strategy development, Intervention design, Evaluation, Implementation PLUS tips, worksheets, glossary and resources
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Social Marketing Examples
Evidence that providing coupons for nutritious food to university students, low-income seniors, WIC participants (US) improved long term nutrition status
Linking communities with local farms & encouraging pick-your-own intitiatives increased V/F intake ? Reduced obesity risk
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FOP Label Understanding Low-CHO claim FOP Only FOP claim seen
Rated low-CHO claim as more helpful to wt management AND lower in calories than same product without claim
Bread with low-cho claim rated more healthful
FOP claim with Nutrition facts panel Rated products with the same nt profile the
same with or without FOP claim Consumers who do not use the NF
panel may misinterpret FOP claims Labiner-Wolfe, Lin, & Verrill, 2010
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Online Social Marketing Projects
Social Marketing: Nutrition and Physical Activity http://www.cdc.gov/nccdphp/dnpa/
socialmarketing/training/basics/ Self-guided web course in social
marketing of health Modules take about 15-30 minutes
to complete Tips, worksheets, resources, glossary
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Ecological theory and social marketing
Behavior is influenced by a variety of factors. If…
They believe it will reduce risk (intrapersonal)
Their family requests it (interpersonal) Their employers offer a nutrition education
program (organizational) There is an availability of foods that can
reduce risk (community) There is improved product labeling (policy)
Lefebvre, 1995
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Milk - some facts… Children main consumers but by teens
consumption reduced Nearly 90% teen girls and 70% teen boys don’t
get the calcium they need Osteoporosis affects 1.4 million Canadians
1 in 4 women and 1 in 8 men over the age of 50 $1.3 billion in health care costs
Milk viewed as high fat & associated with high fat foods
Low fat milk perceived as lower in nutrients
Goeree 1996, Hanley and Josse 1996, NIH Consensus statements 2000
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The got milk? program
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History of got milk?
In 1993: California Milk Processor Board (CMPB) formed Aim: to make milk more competitive
& to increase consumption in California
Initial target: women aged 25-44 Initial position: skim milk was
healthy for adults
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1994: milk consumption in California increased 1%
1995: the got milk? campaign was licensed to the National Dairy Board
1996: billboard ads 1998: Birth of the milk mustache 1999: gotmilk.com born
History of got milk?
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2000: ads promote chocolate milk 2002: California milk sales
increase 1.6% since 2001 Californians used 746 million
gallons of milk in 2002, the highest since 1992
2003: McDonalds McHappy Meals include milk
History of got milk?
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History of got milk? By 10th anniversary: Over 95% of Americans recall campaign Spawned hundreds of got milk? rip-offs Has become a multi-million dollar licensing
property Helped defend milk’s share of beverage
consumption in California & the US Dairy industry spends $150 million annually to
support campaign Industry worth $2 billion in California & $20 billion
nationally Competition: products such as Coke and Pepsi and
more recently calcium enriched beverages
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4P’s of got milk?
Product: e.g., milk provides vitamins and minerals to aid in the prevention of osteoporosis
Price: resources needed to drink milk Place: magazines, billboards, TV
actual milk: stores, schools, fast food
Promotion: via ads, media campaign, web site
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Why television ads?
To reach people in their homes Less than 5% of all milk is
consumed outside the home Aim to get people to “reach for
cookies and milk instead of chips and soda”
Started in 1994 and in 2 years there was a 91% awareness rating
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Evidence its reaching the public (Evaluation)
In July 2002 press release: Milk intake increased for the first time in 6
years Soft drink still number one for those 13-17 y Flavored milk big hit Per capita milk consumption among teens in
2001 was 22 gallons, 3% increase increased to 23.5 in 2002
Teens that drink milk get 34.6% of their beverage intake from soft drinks and 29.7% from milk
Non-milk drinkers: soft drink-54.8%
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Evidence its reaching the public (Evaluation) Milk Mustache Survey
36% women said the campaign would make them drink more milk
70% who viewed the entire campaign now consider milk cool and contemporary
86% thought milk was delicious after seeing the campaign
1% and skim milk consumption has increased, while 2% and whole has decreased
The campaign got over 60% awareness in just 3 months