Project 2: Literature Review

[Review]

The effect of media campaigns on intention to reduce consumption of sugar-sweetened beverages Samuel Bosch Department of Biology, Northeastern University, Boston, Massachusetts 02115 Contact address: Samuel Darren Bosch, 62 Day Street, Jamaica Plain, MA, 02130.

Email: bosch.s@husky.neu.edu.

Editorial group: ENGW 3307 Publication status and date: published in NEJM citation style, 3/3/2016 Review content assessed as up-to-date: 3/3/2016 Citation: Bosch SD. The effect of media campaigns on intention to reduce consumption of sugar-sweetened beverages. Advanced Writing in the Disciplines 2016;ENGW 3307;wordcount(2823).

ABSTRACT To combat obesity, public health interventions have recently focused on the consumption of sugar-sweetened beverages (SSBs). Inspired by successes in the smoking cessation interventions of the recent past, many interventions use mass media campaigns to educate large populations and influence voters on policy proposals.

This review examined the recent literature on the effects of media campaigns to influence the intentions of people to reduce their consumption of SSBs. Six studies matched criteria to be included in the study. Data from the selected studies indicate that media interventions have mostly small to moderate effects on intention to reduce consumption of SSBs. Although these results are promising, these campaigns can be modified by focusing on the emotional appeals of the message, and the content of the message itself. In addition, it’s clear that intention doesn’t necessarily lead to behavior change. Future research should focus on bridging the intention-behavior gap.

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PLAIN LANGUAGE SUMMARY The effect of media campaigns on intention to reduce consumption of sugar-sweetened beverages.

This review shows the effects of various media-based interventions on the intention to consume less sugar-sweetened beverages. Results show small to moderate intention changes in most studies.

Table 1 – Summary of Findings

Study

Description

Participants (n)

Results

Study Type

Conclusions

Barragan 2014

Street-intercept interviews analyzed efficacy of health marketing campaign

438 people who drink SSBs and saw the campaign

Of the n = 438 who both saw the campaign and drink SSBs, 62.6% said they were likely or very likely to reduce consumption of SSBs

Case (crosssectional) study

Expansive and expensive health marketing campaigns may be effective at increasing intentions to decrease consumption of SSBs

Bleakley 2015

Participants were assigned to PSAs with either 1) humor, 2) fear, or 3) nuruturance, or to a control group.

805, 13-17 year olds

Fear: M = 5.09, CI [4.75, 5.43] Humor: M = 4.55, CI [4.20, 4.91] Nurturance: M = 4.54 CI [4.14, 4.95] Control: M = 4.40, CI [4.02, 4.78]

Randomized controlled trial

A fear based campaign among adolescents that uses strong reasoning and plays on the negative beliefs about SSBs may be more effective than other methods

Boles 2014

Telephone interviews measured awareness of a mass-media campaign covering web, television, billboards and transit.

219 adults heard or saw any part of the campaign

51.4% reported an intention to change their behavior

Case (crosssectional) study

With roughly half the respondents reporting intention to cut back, a mass media campaign of this size may be effective

Jordan 2012

Online surverys measured intention change after viewing of health marketing messages

507 urban caregivers with children between 3-16

MPre=5.27, SD=1.78 MPost=5.74, SD=1.63 t = –6.99, p < .05, ES r = .30

Case (crosssectional) study

Although all messages increased intention, messages that appeal to diabetes prevention in children, and doing good for the family are highly useful.

Jordan 2015

Participants were assigned to PSAs with either 1) humor, 2) fear, or 3) nuruturance, or to a control group.

807 parents with children between 3-17 years

Humor: b = 0.26 (.25), ns Fear: b = 0.46 (.25), ns Nurturance: b = 0.32 (.28), ns

Randomized controlled trial

The efficacy of PSAs on parents’ intention to cut back on SSBs is largely due to emotional appeal, but no direct experimental effects were determined

Lilienthal 2015

Students viewed antisugary beverage ads with/without a friend, and either discussed/didn't discuss after viewing.

109 undergrad students aged 18+

Significant increases in attitude scores from pre- to postassessment for both groups With Friend group remained higher at follow up

Randomized controlled trial

Viewing ads with peers/friends and discussing the ads may be of help in increasing intention and retention

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BACKGROUND The obesity epidemic Obesity, clinically diagnosed by having a body-mass index greater than 301, is considered one of the largest epidemics in the United States, afflicting 1 in 3 people nationally2. Obesity is comorbid with other diseases, such as heart disease, diabetes mellitus, rheumatoid arthritis, and cancer2, 3. Because of the scale of the epidemic, and the variety of comorbidities, four of twenty-six leading health indicators targeted by the US governmental health promotion initiative, Healthy People 2020, are aimed at reducing rates of obesity and improving nutrition2. Examples of public health interventions looking to reduce obesity include attempts to increase workplace physical activity4, increase access to water in schools5, and create policy that restricts access to nutritionally deficient food6, 7. Recently, much attention has been brought to the role of sugar-sweetened beverages (SSBs) in climbing obesity rates, and public health interventions have largely aimed to reduce consumption of such beverages2, 6, 7.

What are sugar-sweetened beverages?

The Center for Disease Control defines SSBs as those beverages that contain caloric sweeteners8. Examples of SSBs include soft drinks, soda pop, fruit drinks, sports drinks, energy drinks, and tea/coffee/milk products with added caloric sweeteners8. Though this definition is broadly applicable, policy usually aims to reduce consumption of just a few of these types of SSBs6, 9.

Why reduce consumption of sugary beverages?

The association between SSBs and obesity is examined in numerous studies3, 10, 11. Mechanisms that might explain this association include failure of SSBs to fulfill satiety signals12, increasing hunger due to insulin mechanisms, the innate human desire for sweet foods, and lack of caloric compensation by those that consume SSBs13. Given national focus on the broader topics of healthy-eating and obesity, conversations center on reducing consumption of various foods are easily accessible for much of the population. Finally, focusing on reduction of a single, high-impact food, is simpler in terms of policy work, and less restrictive in terms of personal liberty.

Description of media awareness campaigns One of the methods used to educate populations and influence voters on policy changes are media awareness campaigns. Media awareness campaigns traditionally include advertisements and public service announcements on television, radio, billboards, brochures, and banners on mass transportation that attempt to educate a population on a certain topic14. These campaigns use diverse means of spreading their message in order to a) reach a wide base of consumers and b) reinforce the message as much as possible14. For example, some families may not own TVs or watch the local news, so hopefully they would hear the message through either the radio or billboard messages (or both to maximize information intake).

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Why is it important to do this review?

The first and most important reason to do this review is to analyze whether current tactics to reduce intentions to consume sugar-sweetened beverages are sufficient. Public health concerns itself with the wellbeing of the population, and convincing people that it’s better for their health to reduce their consumption of SSBs is of tantamount importance. Although media campaigns are largely considered effective in small to moderate changes in intention to change behavior among certain behaviors15, no review has yet looked at the efficacy of such campaigns on intention to reduce sugar-sweetened beverages. Secondly, these media awareness campaigns are aired in tandem with a policy proposal (i.e. a tax on SSBs); in the fight against SSBs, these proposals have overwhelmingly failed at the ballot box6.

Examining media awareness campaigns efficacy in changing intentions might reveal how to better tailor future campaigns to generate support for these policy proposals.

OBJECTIVE The objective of this study is to determine which methods of mass media interventions are the most effective at increasing intention to cut back on consumption of sugar-sweetened beverages.

METHODS Criteria for considering studies for this review Due to the limited number of studies on the topic, the types of studies used in this review were not defined.

However, the studies fall into the following categories: randomized controlled trial, case study, and cross-sectional study. These studies were limited to the continental United States, but did not limit participant characteristics.

Studies must have included some use of a mass media, public service announcement, or health marketing campaign.

The primary, and only outcome of interest, was intention to cut back on consumption of sugar-sweetened beverages.

Search methods for identification of studies Studies were found from the following databases: Medline, Pubmed, Social Sciences Premium Collection (Proquest) and Google Scholar. The following words and their permutations were used in non-systematic format to find possible studies: •

Sugar-sweetened beverage*, soda*, soft drink*

•

Health market*, public service announce*, advert*, mass media*, media awareness*, public health intervention*

•

Intent*

•

Consum*

Studies that resulted from non-systematic search were screened by title and abstract and selected by subjective appropriateness.

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Determining Efficacy Efficacy of intervention (Table 3, p. 7) was determined subjectively by reading author’s opinion and weighing evidence on objective data.

RESULTS Description of the studies Results of the search The results of the non-systematic search resulted in 6 appropriate studies. Two of the studies stemmed from the same research group, but produced two papers that analyzed two different populations (adolescents vs. adults).

Table 2 - Characteristics of Included Studies Study

Characteristics of study methods

Characteristics of study participants

Characteristics of interventions

Intervention costs and resources

Barragan 2014 16

Street-intercept survey style

Age: 18-24 20.9% / 25-44 39.1% /45-64 33% / 65+ 6.1% / Missing 1% Sex: Male 50.6% / Female 45.7% / Other 3.7% Race/ethnicity: Hispanic, Latino 39.8% / African American, Black 26.8% / White 14.2% / Asian, Pacific Islander 11% / Other 6.7% / Missing 1.5%

Public transport media campaign Choose Health LA social media Sugar calculator

Total costs estimated at $920,000

Bleakley 2015 17

Pre-intervention, PostPSA and Postintervention questionnaire

Sex: Male 48% (unreported) / Female 52% Race/ethnicity: White 55.8% / African American 13.9% / Hispanic 21.7% / Other 5.5% / Two or more 3.1%

PSAs with either humor, fear, nurturance, or control

No mention of costs

Boles 2014 18

Telephone questionnaire

Age: 18–44, 41.1% / 45–64, 38.6% / 65+, 20.4% Gender: Male 47.2% / Female 52.8% Race/ethnicity: White (non-Hispanic) 83.6% /All other races/ethnicities 16.4%

Paid and unpaid media campaign

No mention of costs

Jordan 2012 19

Online questionnaire

Age: 41 (mean) Race/ethnicity: White (non-Hispanic) 51% / African American 46% / Hispanic 9% / Other 3%

Three messages: TV, radio and transit ad

No mention of costs

Jordan 2015 20

Pre-intervention, PostPSA and Postintervention questionnaire

Age: 39.8 (mean) Gender: Female 55.8% / Male 44.2% Race/ethnicity: White, non-Hispanic 63.8% / Black, non-Hispanic 11.6% / Hispanic 17.0% / Other 7.6%

PSAs with either humor, fear, nurturance, or control

No mention of costs

Lilienthal 2015 21

Post-assessment survey

Gender: Female 73% / Male 27% Race/ethnicity: White 89% / Other (not listed in paper) 11%

View five anti-sugary beverage ads in one of four groups (all combinations of with/out friend and with/out discussion)

No mention of costs

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Included studies The various characteristics of the included studies can be found in Table 2 (p. 5). Perceived and reported gender of participants across most studies tended to be evenly distributed (with the exception of the Lilienthal et al. 2015, which had more than 2/3rds of participants reporting as female). Besides gender, participants varied widely in terms of ethnicity (from majority Hispanic/Latino in Barragan et al. 2014, to majority White in Boles et al. 2014), geographic location (from Los Angeles, CA in Barragan et al. 2014 to nationwide in Bleakley et al. 2015), and age (adolescents only in Bleakley et al. 2015, to parents only in Jordan et al. 2015). Mass media campaigns used billboards, public transport, social media, website advertisements, television and radio advertisements16, 18, 19, fliers in facilities18, and innovative web tools16. Public service announcement studies tested various emotional inputs17, 20, and influence of friend groups.21 Survey methods ranged from street-intercept styles16 to telephone interviews18 to online questionnaires17, 19, 20 to in person questionnaires21. The most expensive intervention (that reported costs) was the LA Sugar packet campaign, spending an estimated $920,000 to reach its broad population16, however the other studies did not report costs of interventions17-21.

Risk of bias in selected studies Because the studies varied widely in intervention and assessment, it was difficult to apply biases. Studies that used mass media interventions were not subject to allocation or blinding biases, as they did not specifically prescribe the interventions to people; the populations encountered the ads in their everyday lives, by way of commute, television and radio, and community living16, 18, 19. Of the three studies that recruited specific populations, none of the studies transgressed allocation bias17, 20, 21. Those three studies, however were biased in that the researchers were not blind to the type of intervention received17, 20, 21. That said, this type of bias is unimportant in the studies described, and would not cause any difference in reporting. None of the studies had incomplete data, and none reported select data16-21.

Effects of interventions on intention The effects of interventions on intention can be found in Table 3 (p. 7). Five out of six studies reported that intervention was effective in changing intention. The three studies that used mass media campaign messages reported over half of the interviewed populations reporting a change in intention16, 18, 19. Bleakley et al. (2015) and Lilienthal et al. (2015) also reported changes in intention from direct experimental effects of intervention. Only one study reported that there were no significant, direct experimental effects on intention to cut back due to intervention20.

7 Table 3 - Effects of interventions on intention Study

Results

Efficacy

Barragan 2014

Of the n = 438 who both saw the campaign and drink SSBs, 62.6% said they were likely or very likely to reduce consumption of SSBs

Effective (over 50% reported intention change)

Bleakley 2015

Adolescentsâ&#x20AC;&#x2122; intention to cut back on sugary drinks was highest in the fear condition (M = 5.09, CI [4.75, 5.43]), followed by humor (M = 4.55, CI [4.20, 4.91]), nurturance (M = 4.54 CI [4.14, 4.95]) and the control group (M = 4.40, CI [4.02, 4.78]).

Fear was effective

Boles 2014

Of those who saw or heard any part of the campaign (n = 219) 51.4% reported an intention to change their behavior

Effective (over 50% reported intention change)

Jordan 2012

All three messages significantly increased intention to reduce consumption MPre=5.27, SD=1.78 MPost=5.74, SD=1.63 t = â&#x20AC;&#x201C;6.99, p < .05, ES r = .30

Effective, messages about diabetes and involving family good were especially effective

Jordan 2015

Direct experimental effects on intention to cut back; humor, b = 0.26 (.25), ns; fear, b = 0.46 (.25), ns; nurturance, b = 0.32 (.28), ns

Not significant, not effective

Lilienthal 2015

Significant increases in attitude scores from pre- to postassessment for both groups

Effective (significant immediate increase in intention after intervention)

DISCUSSION Summary of main results The small number of studies makes it difficult to draw conclusions about the effects of media campaigns on intentions to reduce consumption of sugar-sweetened beverages. The wide variety of intervention and assessment types makes it even more challenging to draw conclusions. However, the studies within seem to show that media campaigns and health marketing advertisements have a small to moderate effect on those intentions. The two studies that use mass media awareness campaigns show over half of the population surveyed plans to reduce their consumption of SSBs as a direct result of the campaigns16, 18 with the other mass media study showing three types of messages all statistically significantly increasing intention to reduce consumption19. The other studies show mixed results in changing intention based on emotional appeal and social factors17, 20, 21.

Quality of evidence Several issues about the quality of evidence arise in terms of the types of studies, the types of assessments, and the number of participants/respondents. The two studies that used mass media campaigns and the Philadelphia study were cross-sectional studies. These types of studies are generally considered weaker evidence, when compared to controlled trials22. Barragan et al. (2014) used street-intercept interviews, which can be unreliable, given that people will answer questions untruthfully to get out of a conversation, or to avoid being embarrassed in public. Most studies had

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a fair number of respondents, but the study by Lilienthal et al. (2015) had only 109 participants. While this seems a low number, they used G power analysis and determined that they only needed a sample of 98 participants to create a significant, medium power dataset21.

Potential biases in the review process Some studies may have been missed due to subjective screening of titles and abstracts.

Agreements/Disagreements with other studies and reviews Reviews on the effects of media campaigns in combatting tobacco use agree with the small/moderate effects on intention to reduce use seen in this review.8 AUTHORâ&#x20AC;&#x2122;S CONCLUSIONS Implications for practice Future media campaigns should target specific populations, and cater emotional appeals and focus of ad to those specific groups. For example, results from Bleakley et al. (2015) suggest that fear was the biggest emotional mediator in adolescents. The same study and its sister study suggest that argument strength was one of the most important mediators in changing intention to consume SSBs, for both adolescents and adults17, 20. The results from Jordan et al.

(2012) suggest that caregivers respond to messages that focus on childhood diabetes and framing reduction of SSBs as â&#x20AC;&#x153;good for the familyâ&#x20AC;?19. Framing messages using these studies as guides may produce better results.

Implications for research More robust research and case studies need to be performed to get a better understanding of the efficacy of these types of campaigns. Including study costs in future research would be helpful too, so other public health officials can assess the viability of implementing such a program in their own city. Research would be best focused on clearly outlining the effects on intention. But changing intention is only half the battle; although most of these studies affected intention, none affected behavior change. Thus, future research could benefit from bridging the intentionbehavior gap23. One method for bridging this gap is by passing policies that limit access to such beverages (i.e. SSB taxes). These proposals have largely failed at the ballot box, because of failure to connect with constituents through media routes6. Future research could also look at more effective ways of combating pro-soda industry focus groups in health marketing24.

ACKNOWLEDGEMENTS I would like to thank Rebecca Sorrell, Brandon Nguyen and Cecelia Musselman for their review of my initial paper.

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CONTRIBUTIONS OF AUTHORS Samuel Bosch – completed research, wrote and compiled manuscript.

DECLARATIONS OF INTEREST There are no special interests to disclose.