Respondent characteristics
The total number of respondents to the survey was 342. Table1 presents the demographic and socioeconomic characteristics of the survey respondents. Not all respondents completed the demographic questions as they were kept optional in the survey. Most respondents were mothers (n=288, 91.9%), with a mean age of 38years (SD, 6.1, range 2257years). A large proportion of the sample had at least two children (n=219, 70.1%). The mean age of the respondents youngest child was 5.1years old (SD 3.0, range 011years). The majority of respondents were born in the United Kingdom (n=272, 90%), and around three-quarters of the sample were living in Leeds (n=223, 77.2%). The majority were from White British backgrounds (n=283, 93.7%); this is higher than the White-British population in Leeds (73.9%) [31] and the national average (86.0%) [32]. Over 70% of the sample had at least a level 4 qualification (degree, higher degree or professional qualification). This is much higher than the Leeds average (40.1%) and the national average (40.0%) [33]. Over a quarter of the sample were from the 20% most deprived areas (IMD quintile 1) in the UK (28%), similar to the average of 31% of the population for the Leeds area and 20% nationally [31].
Just over half of respondents who answered the question, stated that they had come across the C4L 100 calorie snacks, two a day max campaign (54.7%, n=187). Therefore, only these respondents were able to answer subsequent questions about the campaign, giving a smaller number of respondents to each question. When asked where they had seen or heard the phrase look for 100 calorie snacks, two a day max, 310 options were selected (respondents could choose as many as appropriate). Table2 demonstrates that the most common responses were a C4L leaflet (n=85, 27.4%) or a television advert (n=61, 19.7%), followed by a social media advert (n=48, 15.5%) and the C4Lwebsite (n=45, 14.5%).
When asked how many times they saw the campaign in total (could only select one answer), 183 respondents provided an answer. Table 2 indicates that most saw it 23 times (n=76, 41.5%). Some reported seeing the campaign 6 or more times (n=36, 19.6%), whilst 9.8% (n=18) reported that they had never seen the campaign. When asked if they had seen or received a leaflet about the campaign (could only select one answer), just over half of the 184 respondents to the question stated that they had seen a leaflet (n=109, 59.2%). When asked where they had seen or received the leaflet (could select as many options as appropriate), the most common response was from primary school (n=86, 62.8%), followed by GP surgery/health centre (n=13, 9.5%) or health professional (n=10, 7.3%), as indicated in Table 2.
The respondents were asked about their perceptions of the campaign through their agreement with a series of statements (summarised in Fig.1). Number of respondents to each question varied as questions were optional and again, only those who had seen the campaign could answer. Over two-thirds of the 191 respondents to the question agreed or strongly agreed that the campaign caught their attention (n=126, 69.6%). A similar proportion agreed or strongly agreed that the campaign informed them about 100cal snacks (n=117, 66.0%,), and just over a half thought it was memorable (n=102, 54.4%). Of the 179 respondents who completed the following questions, just under a third agreed or disagreed that the campaign was appealing (looked good) (n=114, 63.7%). A small majority agreed or strongly agreed that it was convincing (n=104, 58.5%). Over half of the respondents agreed or strongly agreed that the campaign made them think about limiting high sugar and high fat snack foods for their child (n=106, 59.2%), and just under a half of respondents agreed or strongly agreed that it made them think about dental decay in their child (n=87, 48.6%).
Respondents agreement with a series of statements about the campaign
When the respondents were asked. please tell us what you thought about the C4L 100cal snack campaign overall? 132 respondents (who had seen the campaign) provided a written response. Figure2 highlights these perceptions. The following themes emerged from their feedback; positive views on the campaign (overall good acceptance and positive impact); negative views on the campaign (poor acceptance of campaign messages); recommendations for improvements to the campaign.
Word clouds highlighting parent perceptions of the C4L 100cal snack campaign
Just over half of these respondents used positive language to describe the campaign; describing it as good, very good, effective, useful, helpful or informative/interesting (n=77, 58.3%). For example: It was a brilliant help with snack ideas to give my children. It gave me a different variety of snack ideas which were very healthy for them; This campaign is a very good idea. It can help parents to care more about what their children eat.
A few respondents believed it was eye-catching, memorable and easy to remember. For example: The brightly coloured leaflet and posters draws peoples attention to it, so people are more willing to learn about the campaign and read the information. Others stated that they would like to have seen more examples of actual recommended snacks.
Furthermore, a few respondents reported a positive impact of the campaign, with improved awareness of healthier nutrition and making healthier snack choices. For example: made me really think about what I can give as snacks and trying new things. Some also reported that their children were receptive to the campaign. For instance: It was appealing to my daughter as she was able to make healthy choices in the supermarket. Conversely, some respondents indicated their disagreement with the campaign messages focussing predominantly on calorific content of snack foods, as well as perceiving poor suitability of snack examples. This is illustrated by the following examples:
"It is short sighted and unhelpful to suggest that low calorie snacks are the best snacks, or that processed snack foods full of sweeteners are a good alternative to proper full foods"
"I do not agree with the campaign. I give my child nutritious snacks. The calorific value is not important. I do not want to teach my children to count calories, but to eat intuitively"
Some respondents also suggested recommendations for improvements to the campaign, for example, increased promotion and more information on healthy snack choices, or for an alternative focus. This is illustrated with the following quotations from respondents:
More information needs to be available on snack types and portion sizes
"We should be promoting only fruit and veg as snacks"
"A low sugar campaign would be more apt as this is what causes obesity"
The survey asked, did the campaign encourage you to search for 100 calorie snack information on the website?, to which 78.3% (n=141,) reported that it did not. The survey also asked what did you think about the 100 calorie snack information on the website? Twenty-seven people commented, with a majority describing the website as good, informative or just okay (as highlighted in Fig.2). Moreover, a few parents indicated that the information on the website was helpful:
Good ideas for healthy snacks.
Really like recipe ideas for lunchboxes.
Respondents were asked for their agreement with a series of statements about the information available on the C4L 100cal snack website (only 39 respondents reported actually seeing the website). Of the respondents who completed these statements three quarters agreed or strongly agreed that the website informed them about 100cal snacks (n=30, 77%). The majority agreed that the examples of snacks were useful (n=34, 87%), but less than half agreed that the examples of snacks were easy to make at home (n=18, 47%). Just over half agreed that the snacks were affordable (n=19, 51%) and that their children liked the examples of snacks (n=19, 51%). Most agreed or strongly agreed that the 100cal snack information was easy to understand (n=34, 85%) and nearly three quarters agreed or strongly agreed that it helped them to understand what a healthy snack looked like (n=28, 74%). Around two-thirds reported agreeing or strongly agreeing that the information helped them to find calorie information on packaging (n=25, 64%).
There was no clear consensus of a perceived positive impact on healthier snack purchasing nor preparing more 100cal snacks at home. However, some respondents reported making positive changes:
It made a huge difference to my familys eating habits.
Of the 40 respondents to complete the question, a similar number of respondents agreed (n=10, 25%), disagreed (n=11, 28%) or neither agreed nor disagreed (n=13, 33%) that they now buy more 100cal snacks when shopping. Of the 39 respondents who responded to the question about whether they now prepare more 100cal snacks at home, a similar number of respondents agreed (n=11, 28%), disagreed (n=9, 23%) or neither agreed nor disagreed (n=14, 36%). Respondents did, however, report that they looked at the nutritional information on packaging more frequently due to the campaign, for around a half (n=24, 52%) agreed or strongly agreed that they now look for calorie information on packaging and just under two thirds (n=24, 63%) agreed or strongly agreed that they now look at traffic labelling on packaging.
Respondents were then asked about their childs frequency of snack consumption. A greater number of respondents were able to answer the questions that were not directly related to the campaign. When asked how many times in 1 day respondents give their child a snack (not including fruit and vegetables), of the 318 respondents to the question, a mean of 1.7 (SD, 1.0) times per day was given. When asked how many times in 1 day respondents give their child fruit and/or vegetables as a snack, of the 319 respondents to the question, a higher mean of 2.0 (SD, 1.2) times per day was given. The following questions related to changes in snack consumption since the campaign specifically. A much lower number of respondents completed these questions (N=65), as many had not seen the campaign. Nearly two thirds reported no change in number of times their child consumed a snack per day (not including fruit and/or vegetables) since seeing the campaign (n=41, 63%), with only 11% (n=7) reporting that it had decreased. Most reported that the number of times their child consumed fruit and/or vegetables as a snack per day since seeing the campaign, had stayed the same (62%, n=40), with only 15% reporting an increase in fruit and vegetable consumption (n=10).
When asked about their perceptions around improvements to the 100cal snack information (for example type of information, how it looks, where you find it), 89 respondents provided a written response. The following themes emerged from the feedback: promotion of the campaign, recommended snack examples and nutritional labelling.
For example, around half of the comments related to better advertising and publicity around the campaign. Some examples were provided and included mainly delivering through educational settings (school, nurseries), social media, television/radio and at supermarkets. Figure 2 highlights these perceptions.
Around a quarter of respondents suggested improvements to snack products. Some comments related to improved healthiness of snack food ideas, with a handful of respondents disliking artificial sweeteners in low sugar and low fat examples, with a preference for real whole foods. For example:
Sugar free items that are sweet are full of other chemicals which I prefer not to give my child. It would be better to suggest snacks that are made from non 'snack foods' already in the house, like a small peanut butter sandwich on wholemeal bread, which I suppose might be more than 100 calories depending on how its made, so advice on this type of snack would be useful"
Several wanted more specific ideas for healthier snacks, with examples being more visible in the campaign. A few comments related to improved labelling of products, to make it clearer which products meet the 100cal guidelines, for example:
"It might be helpfulif there was something indicating snacks that are under 100 calories on the shelves. It would possibly lead to people making more informed choices for snacks and lunchbox fillers"
Several respondents disliked the target message of calories, occasionally perceiving calorie counting to be ill-advised for children, preferring an alternative focus on overall healthiness of diet, for example:
Don't focus on calories - it's not health would it not be better to have categorieswe have allergy children (dairy and egg so focus on healthy snacks for calcium, iron, iodine, zinc, etc). We need to step away from quantifying the item and look at the quality"
Some thought focussing on sugar content or portion sizes could be more suitable. A few comments also related to making the campaign more appealing to children, through use of apps, games, posters with tick boxes for when a snack is eaten, for example:
Top trump cards for children to play with categories such as 'sugar content, calories, dental health' values
Respondents were asked how they would like to be supported to provide healthier snacks for their children. One hundred and twenty four respondents commented. The following themes emerged from the discussion: improved access to, availability of and display of healthier snack items; clearer nutritional labelling; creating more opportunities for children to eat more healthily and more information and guidance around healthy eating.
Around a quarter of comments related to strategies for improved access to healthier snacks in supermarkets/shops. These included more availability and choice of healthier snack products (low sugar, low salt, low fat) and improved display of healthier products (less visibility of high sugar high fat options), for example:
Create aisle ends - dedicated areas for healthier snacks in supermarkets Supermarket to make a specially selected snack items corner with free tasting samples
Respondents desired better promotion of and more information on low sugar, low fat, low salt options in supermarkets and shops, as well as increased availability of healthier options at other venues such as cafes, leisure centres, vending machines, cinemas, theme parks etc. Others desired increased availability of cheaper, low sugar and low-fat snack options and fruits and vegetables and money-off vouchers for healthy foods made available. For example:
"I can easily find whole isles of chocolate and crisps, but healthy crackers for example are hard to find and expensive"
"Should be more fresh fruit and healthy snacks on offer at cinemas, theme parks, child friendly outings"
Some wanted clearer nutritional information labelling on the packaging, particularly calories and sugar, portion sizes and allergen information. Others discussed the need for tighter restrictions on marketing of high sugar high fat items to children, with television characters used for promoting healthier snack items, for example:
Child friendly packaging and more obvious sugar warning signs
Ban food manufacturers from promotions with toy/tv/film characters/companies unless its a healthy snack
Some respondents perceived that schools or nurseries would be useful environments for targeting children, by improving packed lunches (for example with prizes for best lunchbox), providing healthier meals, and restricting sales and provision of high sugar, high fat items on site and creating more opportunities for children to try new healthier foods. For example:
"Schools should take on board the information as my child is given high calorie snacks in the form of cupcakes/sweets provided as a reward for good behaviour or volunteering"
Schools to follow their healthy campaigns through by looking at the sugar/fat content of their school dinners better. Nurseries to have better training/guidelines on healthy options for children
Around a quarter of respondents wanted improved guidance and information on healthier snack provision for their children. Many of which related to more information on healthy snack choices (low sugar mainly), for example, healthy carbohydrate based snacks, suitable easy ideas and recipes for children, such as sugar free treat recipes, and also ideas that can be prepared and stored in advance. Providing information (for example a list of healthy snacks ideas) by emails, leaflets, Apps, or on a snack chart was recommended. A few wanted reminders around eating healthily as well. Several wanted ideas on how to encourage fussy eaters to eat more healthily with filling low sugar tasty options. For example:
"Sometimes it is hard as a parent to encourage your child to eat healthier - my youngest would choose a sugary treat over something healthier although does try"
Hints and tips on how to encourage children to try healthy foods
"A campaign that shows me the products so it is quick and easy to identify when shopping or ordering online
The survey then asked how they would like information about healthy snacking to be provided. Ninety three respondents provided a written response. Themes related to improved delivery and promotion of information and strategies for better nutritional labelling. Many comments related to preferred methods for delivery of information, with through school being the most popular. Other suggestions included TV advertising (or radio for older generations), emails and websites, social media, applications on mobile phones, in supermarkets or stores and leaflets. Some also commented on the need for clearer nutritional labelling on product packaging, regarding the healthiness of products, for example, clear labelling at the front of the package showing important nutritional information that can be easily and quickly interpreted, e.g. through traffic light labelling.
"Make it statutory for price labelling as well as packaging to be given the same green light logo to make it stand out more".
"Traffic lights easy to view at a glance to make quick decision. Not much reading done by colour"
There was also a suggestion for traffic light labelling to extend to take-away packaging and for artificial sweeteners to be clearly labelled on the packaging. A few expressed the difficulty with knowing what healthy snacks to give to children and thus wanted ideas for healthy snacks, easy to follow and easily accessible recipes (e.g via an App), that children can also follow as well.
The survey presented a list of strategies for providing more 100cal snacks for children and respondents were asked to select which ones were most acceptable to them (see the full survey in the supplementary materials). Respondents were able to select as many strategies as they wished. Of the 550 statements selected, the most popular strategy was a sticker or logo that states the following product meets the 100cal guidelines (n=192, 34.9%), followed by more products in 100-cal portions (n=164, 29.8%) and easier labelling on which products are 100cal (n=161, 29.2%). A few comments related to focussing less on calorie content of pre-packaged snacks, but rather providing ideas for healthier snacks made from real whole foods (as opposed to processed items), appropriate portion sizes, and other alternative ideas to just fruit and vegetables for snacks. For example:
I have seen snacks advertising that they have less than 100 calories but they arent necessarily healthy e.g. crisps or iced gems But I wish there were more easy, low sugar, healthy options.
Ideas above seem to be focussed on pre-packaged / processed foods which I would prefer to avoid, so more ideas about home-prepared snacks or portion sizes eg of crackers, breadsticks, hummus etc.
Respondents could also select from lists of initiatives to help parents provide healthier choices for their children, which would be most acceptable to them (they could select as many options as they wished, 822 statements were selected). The most popular strategies were healthy snack ideas that are easy to prepare (n=241, 29.3%) and making healthier products cheaper than less healthy ones (n=231, 28.1%); followed by providing fruit and vegetables that are more affordable (n=190, 23.1%) and all packaged products using traffic light labelling (n=146, 17.8%). Of a list of further strategies presented (300 statements selected), the most popular strategy was replacing unhealthy products near the checkouts with healthier ones (n=87, 29.0%). Similar lower proportions of respondents preferred the following strategies: changing ingredients in food gradually so people dont notice a change in taste (n=53, 17.7%), changing ingredients in food to reduce the calories or amount of sugar, though this may change the taste of the product (n=52, 17.3%), reducing the size of the unhealthy products and keeping the same price (n=48, 16.0%) and reducing the size of unhealthy products and reducing the price (n=47,15.7%).
Other recommendations (n=27) included the following: cheaper, healthier, age-appropriate options for children; greater availability of healthier snacks; snacks that stay in date for longer; more affordable fruit and vegetables in good condition; make foods more natural and less sweet; sugar free snacks not full of additives or sweeteners; make healthier products taste good for children, including more kid friendly vegetable foods; grab and go ideas that do not need preparation; suggestions for filling meals to prevent snacking; fruit and vegetable snacks beside tills; Change4Life tuck shop in schools; more recyclable packaging. Ideas for other more top-down approaches included: limit snack calorie sizes by legislation; regulate advertising of HFSS foods aimed at children and advertising aimed at grandparents about healthy eating/snacking.
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Parents' awareness and perceptions of the Change4Life 100 cal snack campaign, and perceived impact on snack consumption by children under 11 years -...