COMMUNICATING HEALTHY EATING TO ADOLESCENTS Kara Chan (Corresponding author) Professor Department of Communication Studies Hong Kong Baptist University Tel: (852) 3411 7836 Fax: (852) 3411 7890 Email: [email protected] Gerard Prendergast Professor Department of Marketing Hong Kong Baptist University Tel: (852) 3411 7570 Fax: (852) 3411 5586 Email: [email protected] Alice Grønhøj Assistant Professor Department of Marketing and Statistics Aarhus School of Business, University of Aarhus Denmark Tel: (45) 8949 6471 Email: [email protected] Tino Bech-Larsen Associate Professor Department of Marketing and Statistics Aarhus School of Business, University of Aarhus Denmark Tel: (45) 8948 6448 Email: [email protected] Paper submitted to Journal of Consumer Marketing Acknowledgement: The study was fully supported by a Faculty Research Grant from the Hong Kong Baptist University (Project No. FRG/05-06/II-48). JCM healthy eating May 23, 2007

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COMMUNICATING HEALTHY EATING TO ADOLESCENTS Abstract This study explores perceptions of healthy/unhealthy eating, and perceptions of various socializing agents encouraging healthy eating, amongst Chinese adolescents. A survey was conducted of 152 seven, eighth and ninth grade Hong Kong students. Results showed that respondents frequently ate out with friends and frequently consumed a range of relatively unhealthy food (candies, chips, and soft drinks). They perceived that a balanced diet and eating at a regular time were the most important attributes of healthy eating. In terms of situational influences on their consumption, respondents most likely ate unhealthy food at parties, when eating out or with friends. They most likely ate healthy food at home and when they were sick. Looking at socializing agents, respondents claimed that parents and government publicity asked them to eat healthy food more often than teachers or friends. Parents were also perceived as being the most effective source in encouraging them to eat healthy food. In terms of alternative adverting appeals discouraging unhealthy eating, respondents considered news and fear appeals the most effective, while popularity and achievement appeals were considered relatively less effective. Practical implications and suggestions for future research are discussed.

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COMMUNICATING HEALTHY EATING TO ADOLESCENTS Keywords:

adolescents – health education – China – advertising execution

Structured abstract Research paper Purpose This study explores perceptions of healthy/unhealthy eating, and perceptions of various socializing agents encouraging healthy eating, amongst Chinese adolescents. Design/methodology/approach A survey was conducted of 152 seven, eighth and ninth grade Hong Kong students. A structured questionnaire with closed-ended questions was distributed in four public secondary schools. Findings Results showed that respondents frequently ate out with friends and frequently consumed a range of relatively unhealthy food (candies, chips, and soft drinks). They perceived that a balanced diet and eating at a regular time were the most important attributes of healthy eating. In terms of situational influences on their consumption, respondents most likely ate unhealthy food at parties, when eating out or with friends. They most likely ate healthy food at home and when they were sick. Looking at socializing agents, respondents claimed that parents and government publicity asked them to eat healthy food more often than teachers or friends. Parents were 3

also perceived as being the most effective source in encouraging them to eat healthy food. In terms of alternative adverting appeals discouraging unhealthy eating, respondents considered news and fear appeals the most effective, while popularity and achievement appeals were considered relatively less effective. Research limitations/implications The respondents were chosen from three secondary schools (two co-ed schools and one school for boys). These three schools may not be representative of all schools in Hong Kong or elsewhere, thus limiting the generalizabilty of the findings. Practical implications The study can serve as a guideline for social services marketing professionals targeting adolescents. Looking at the findings in relation to socializing agents, social services marketers can consider influencing the adolescents eating habits through the parents. As government publicity was perceived as a relatively weak socializing agent, there is a need to review health education materials targeting adolescents. Looking at the findings in relation to different advertising appeals discouraging unhealthy eating, news and fear appeals should be considered, as these were considered relatively more likable and effective than other types of appeals.

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Originality/value This paper offers insights into designing communication strategies for adolescents. It is original in that it focuses on adolescents, and explores the perceptions of various socializing agents influencing healthy eating. (360 words)

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COMMUNICATING HEALTHY EATING TO ADOLESCENTS

Introduction Obesity is a global problem afflicting all countries and age groups, bringing social and economic burdens. The direct economic costs of obesity assessed in several developed countries are in the range of 2 to 7 percent of total health care costs (Department of Health, 2005). Overweight and obesity do not only bring about physical problems, but are also associated with a number of psycho-social problems including body shape dissatisfaction and eating disorders. People with obesity are often confronted with social bias, prejudice and discrimination. Studies indicate the importance of developing healthy eating habits among people at a young age. Yet, there is steadily increasing obesity among young people. Indeed it is estimated that at the turn of the 21st century, there were over 155 million overweight children and youth in the world (Lobstein, Baur and Uauy, 2004). This obesity problem in children is especially prevalent in Hong Kong, where the Department of Health reported an increasing trend of obesity among primary school students, from 16 percent in 1997/98 to 19 percent in 2004/05. In other words, almost one in five school children in Hong Kong is obese. These statistics are also reflected in survey research. For instance, a survey of 2115 secondary school students aged 11 to 18 in Hong Kong found that 42 percent of them reported health problems with excessive body weight, high blood pressure, high blood sugar or abnormal 6

blood fat levels. The study concluded that adolescent obesity in Hong Kong is now reaching epidemic proportions (Information Services Department, 2006). Given that obesity is becoming an increasingly serious problem globally, there has in recent times been an increase in research studying the issue of how to communicate healthy eating habits to people, and the role of various socializing agents (such as parents, government publicity, teachers, and peer groups). For instance, Livingstone (2005) identified that food advertising (especially those for unhealthy food) affects food preference and behaviors of children directly and indirectly, although establishing a direct causal link between food advertising and food eating behaviors is contested in the literature (Young, 2003). Social services marketers try to promote good eating habits, directly to the children and indirectly through the children’s parents. Effective health communication to young people should be based on a sound knowledge of their perceptions of healthy and unhealthy eating habits, their perceptions of the various socializing agents/sources communicating healthy eating habits to them, and their perceptions of different communication appeals regarding healthy eating. While these issues have been researched in the context of younger children, the perceptions of adolescents have not been explored. This would seem to be an important area to research, since more often adolescents are away from the home and watchful eyes of their parents. What are adolescents’ perceptions of healthy eating? Which socializing agents do adolescents perceive

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as being important and effective in communicating healthy eating messages? If advertisements are used to promote healthy diet among adolescents, what types of appeals should be used? In order to fill these research gaps, this paper explores these important issues. Background Socialization agents Scholars generally agree that healthy eating habits are developed through a process of socialization, in which families, schools, the community, the government, and international health organizations all play an active role (Kelly, Turner and McKenna, 2006; McGinnis, Gootman and Kraak, 2006; Raiha, Tossavainen and Turunen, 2006). Parents serve as role models and influence children’s purchase behavior through direct communication (McNeal and Ji, 1999). Empirical data supports the notion that parental support for healthy meals and nutrition skills have a positive association with adolescents’ healthy food choices and healthy eating habits (Raiha, Tossavainen and Turunen, 2006; Young and Fors, 2001). Schools also disseminate nutrition health information through formal curriculum as well as extracurricular activities. Schools can support healthy eating by monitoring the nutrition values of the food supplies in lunch orders and snack shops (Nutbeam, 2000). Interestingly, peer influence is perceived to be negative in healthy eating (Kelly, Turner and McKenna, 2006). Conflict between parental influence and peer influence may occur when young consumers refuse to

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bring healthy food to school as their friends may bring or buy junk food. Governments and international health organizations also play a role in health promotion by advocating balanced diets and design health related publicity campaigns. Apart from parents, teachers, peers and government, young consumers may also be attracted by food advertisements which sometimes put pressure on their parents to purchase those foods that are unhealthy (Kelly, Turner and McKenna, 2006). In 2004, an estimated US$15 billion was spent on all advertising and marketing directed at children and youth in U.S., of which a major share was designated to food and beverage marketing (Schor, 2004). Through the use of cartoon figures, jingles, and animations, food advertisements aimed at children associate the consumption of foods with fun, enjoyment and peer acceptance (Center for Science in the Public Interest, 2003). To conclude, healthy eating is an important issue for the well-being of the young consumers. Socializing agents including parents, schools, governments, friends, and food advertisers are competing with one another in influencing children’s health perceptions and food choices. Previous studies have examined the role of various socializing agents in influencing the eating habits and behaviors of children. Yet the all important adolescent group has been ignored. It would seem that this group needs to be studied, since these teenagers are gradually becoming independent in both thinking and behavior. In the light of the previous research, and the absence of any research on adolescents, this

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paper represents an exploratory study. We aim to seek relationships rather than predict relationships. With this in mind, the following research questions are posed: RQ1.

What are adolescents’ perceptions of healthy/unhealthy eating?

RQ2.

What are adolescents’ perceptions of various social influences (i.e. parents, teachers, friends, and government publicity) that encourage healthy eating?

RQ3.

How do adolescents respond to different advertising appeals (i.e. popularity, love, achievement, news and fear appeals) discouraging unhealthy eating?

Method The Hong Kong context Hong Kong was chosen as the context of this study for a number of reasons. First, the educational system in Hong Kong has been criticized for being examination-oriented (Children Council Working Committee, 2005). With the high pressures of studies, Hong Kong children enjoy very little leisure time and exercise, and are considered to be extremely inactive (Hui, 2001). Most elementary schools offer only two physical education classes a week (compared to at least five a week in the U.S.). The lack of physical exercise was considered as a contributing factor of still more obese children in the society (Hui, 2001). The second reason for choosing Hong Kong as the study location is that the Government has placed renewed emphasis on promoting healthy eating since 2005.

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Altogether three television commercials titled ‘2+3 is the way’ about healthy eating and balanced diet were broadcast in recent years. The main message of the three commercials was that a balanced diet should compose of two portions of fruit and three portions of vegetables everyday. In July 2006, the Department of Health joined hands with elementary schools, food traders, teachers and school-parents association in launching the “[email protected]” Campaign. The target audience is families with elementary school children, and the objectives are to promote consumption of healthy lunch boxes and snacks at elementary schools. Out-of-home posters and guidebooks are also targeted at children, while training and workshops have been organized for elementary school principals and teachers, parents and food suppliers to foster support from various stakeholders. Yet an analysis of all these government publicity materials reveals that they were targeted at younger children, with no publicity targeted at adolescents in secondary schools and higher educational institutes.

Data collection Data was collected from end February to March 2007. Respondents were 152 grades 7 to 9 students aged 12 to 16 years. Two classes of students were from grade 8 while one class each was from grade 7 and 9. Altogether 160 questionnaires were distributed and 152 were collected. The response rate was 95 percent. Questionnaires were self-administered in classroom settings in three secondary schools (two co-ed schools and one school for boys).

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All the schools were situated in low to middle income residential zones. Permission was obtained from school principals to conduct the study. All aspects of the research procedure were conducted in Chinese. Fifty seven percent of the respondents were male and 43 percent were female. The mean age of the respondents was 13.4 years. Fifty-four percent of the respondents were living in public or rental housing and the remaining 46 percent were living in private housing. Eighty percent of the respondents received a regular allowance. For those with regular allowance, they received on average 5 to 900 Hong Kong dollars (equivalent to one to 115 U.S. dollars) each week. The average weekly allowance was 111 Hong Kong dollars (equivalent to 14 U.S. dollars).

Questionnaire development A draft questionnaire in Chinese was constructed for the study based on focus group sessions. Altogether four focus group sessions were conducted and 22 interviewees in grades 7 to 9 were interviewed in November 2006. Interviewees were asked open questions including “What do you think about healthy/unhealthy eating?”, “In what situations will you consume healthy/unhealthy food?”, and “Can you tell me who ask you to eat healthy/unhealthy foods?” The answers obtained from the focus group interviews were used in designing the answers in the structured questionnaire. The questionnaire was tested by personally interviewing seven young persons aged 12 to 14.

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The final questionnaire had two parts and all the questions were close-ended. The first part collected information about eating habits, perception about healthy and unhealthy eating, contexts of consuming healthy and unhealthy foods, and perceived influence of healthy eating from four socializing agents. Eating habits were measured in a four-point scale (1=never, 4=five or more days a week). Perceived social influence was measured by how frequently a socializing agent asks the respondents to eat more healthy food (1=never, 5=very often) and the perceived effectiveness (1=very ineffective, 5=very effective). Perception of healthy and unhealthy eating, as well as the contexts of consuming healthy or unhealthy food, was measured using a nominal scale. Respondents were given six choices and they were asked to check as many answers as they thought appropriate. The second part of the questionnaire collected respondents’ perception of five de-marketing print advertisements about consuming less soft drink (see Figure 1 for the English versions of the ads). Each ad represented a different appeal type: popularity, love, achievement, news, and fear. Respondents were asked to evaluate their liking and the perceived effectiveness of the advertisements using a five-point scale (1=dislike very much, 5=like very much; 1=very ineffective, 5=very effective). Soft drink was selected as the focus of the de-marketing campaign for three reasons: first, soft drinks are identified as unhealthy food in government’s publicity campaigns against unhealthy snacks at schools. Second, soft drinks have aggressive advertising campaigns targeted toward young consumers, often employing youth idols as spokespersons.

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Third, young consumers are familiar with soft drinks. [Insert Figure 1 about here] FINDINGS Respondents’ eating habits are summarized in Table 1. Most of the respondents did not bring lunch boxes to the school. Over eighty percent of them bought food during a school day at least once a week. The consumptions of candies/chips/soft-drinks were popular among respondents. They seldom bought food for the family. Sixty percent of respondents had experience of eating out with friends at least once a week. [Insert Table 1 about here] Respondents’ perception of healthy and unhealthy eating is summarized in Table 2. Having a balanced diet and consuming food at regular time was perceived as healthy eating. Eating a narrow range of food and consuming food at irregular time was perceived as unhealthy eating. While consuming food with preservatives/additives and eating fast food was perceived as unhealthy by over two-third of the respondents, eating natural food was perceived as healthy by only 46 percent of the respondents. Respondents did not perceive that the quantity of food intake had any relationship with healthy or unhealthy eating. [Insert Table 2 about here] Situations in which respondents consumed healthy or unhealthy food is shown in Table 3. A majority of the respondents reported that they would consume healthy food at home or

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when they were sick. A majority of the respondents reported that they would consume unhealthy food in parties, eating out, in gatherings with friends, and in special festivals. A small proportion of respondents reported that they consumed healthy foods at school. Eating healthy or unhealthy food was not related with mood. [Insert Table 3 about here] Perceived social influences in healthy eating Respondents were asked how often various socializing agents ask them to eat healthy food. Table 4 summarizes the results. Parents and the government publicity scored the highest means, and both means were significantly higher than the mid-point of 3.0 (t=4.5 for parents, p