Overview

 

Snack Right was a targeted intervention for the parents and carers of preschool children from deprived neighbourhoods of Cheshire and Merseyside. It aimed for children to replace at least one unhealthy snack each day with a healthy one, ideally with a fruit or vegetable.

Commissioned by ChaMPs, the public health network for Cheshire and Merseyside, and designed by the ChaMPs social marketing group, the project used a mix of fun activity days, competitions and rewards to encourage and maintain healthy snacking behaviours.

Results:

  • 64 Snack Right events held across 8 primary care trusts, in conjunction with 14 local authorities
  • 3,788 parents, carers and children attended 64 Snack Right events
  • 1,003 children signed up to the Phase Two direct mail programme
  • 41 per cent of families attending Phase Two events entered the Snack Right competition and continued to replace an unhealthy snack with a healthy snack for 4 weeks after attending an event
  • 84 per cent of families attending Phase Two events felt they had picked up new ideas about healthy snacking
  • A minimum of 46 new families signed up to the Healthy Start scheme as a direct result of the project

Getting Started

 

ChaMPs, the public health network for Cheshire and Merseyside, set up a social marketing group in response to the 2004 Choosing Health White Paper. The group began by looking at where social marketing might have the most impact and what aspect of health needed addressing most urgently.

In 2002, England’s Chief Medical Officer had described obesity as ‘a health time bomb’, and by 2004 the House of Commons Select Committee published a report which stated that ‘an epidemic of obesity has swept over England’. Against this backdrop of growing public concern over healthy weight, the newly set up ChaMPs Social Marketing group decided on obesity as the topic for its first social marketing programme, with a particular focus on food and diet.

The development (and later implementation) of the project was informed by key national policy drivers, including:

  • The English Government’s target, set in 2004, to halt the year-on-year increase in obesity among children under 11 by 2010, which was later replaced in 2007 by the target to reduce the prevalence of childhood obesity and overweight to the 2000 levels by 2020
  • Maternal and Child Nutrition Guidelines – Improving the nutrition of pregnant and breastfeeding mothers and children in low-income households (NICE, 2008)

Leadership and governance

A steering group was set up to guide the programme and reported to the Cheshire and Merseyside directors of public health group.

This group was made up of representatives from:

  • Public health – from NHS Knowsley, NHS Warrington, Liverpool Primary Care Trust (PCT), NHS Western Cheshire, NHS Sefton, and North West Public Health Team
  • Marketing, communications and social marketing – from Knowlsey Health and Wellbeing, Liverpool PCT, NHS Halton and St Helens, and ChaMPs Public Health Network
  • Heart of Mersey
  • North West Food Taskforce
  • Dingle Lane Children’s Centre
  • Liverpool John Moore’s University
  • University of Liverpool

ChaMPs logo

Further partners were brought on board as the project developed.

Frontline delivery of Snack Right, while facilitated by the project team, was put in the hands of local ‘ambassadors’ to encourage ownership of the intervention.

Finance

The project was pump-primed with £50,000 by Cheshire and Merseyside's directors of public health in 2005 to 2006. Principal funding was subsequently secured through the Department of Health (DH) Communities for Health Fund to the value of £263,000. This funding covered the total cost of the intervention, including two academic evaluations and the project manager’s salary in the first full year (this was subsequently funded separately).

Scoping

 

Segmenting and target audiences

The scoping phase began with a review of evidence and extensive desk research by Murray Consultancy, which identified amongst other key issues that the dietary intake of many English preschool children was inadequate. Snacking and snack foods had been recognised as major contributors to dietary problems. However, snacks (frequent small intakes of food) are essential to many preschool children to enable them to consume the necessary volume of food, and hence nutrients, for normal growth and development.

Further research was undertaken through workshops with nutritionists, public health, communications and marketing leads. Based on this initial research, the parents and carers of preschool children aged three to five from deprived communities were chosen as the project’s primary target audience for Phase One. This was because:

  • To influence the eating behaviour of preschool children the project would need to influence the behaviour of their parents and carers
  • Fewer health initiatives were available to this age group (compared to babies and school-aged children)
  • Food tastes are formed for life at this age
  • Cheshire and Merseyside have some of the worst health inequalities in England

For Phase Two of the project, the age range was expanded to include children from six months (weaning) to four years.

It was also concluded that the secondary audience would be health visitors and children’s centres, because of the influence they could have on parents and carers of this age group.

For Phase One, a mapping exercise was carried out to identify where these children lived. This used census data and Indices of Multiple Deprivation to identify Lower Super Output Areas in Cheshire and Merseyside. These are among the quintile with the highest proportion of three- to five-year-olds and the quintile with the highest proportion of people who have never worked or are long-term unemployed. The results were tested by mapping value supermarket chains (like Aldi and Lidl). A statistically significant correlation was established and Aldi was approached to become a partner of the project.

Primary research

Fifteen focus groups (one per borough) were held at a variety of venues across Cheshire and Merseyside identified in the mapping work. Each focus group was conducted with a specific cohort with responsibilities for caring for preschool children, like single mothers, grandparents, first-time parents, non-white ethnic groups and Sure Start Children’s Centre nursery workers. The aim of these groups was to form an understanding of the target group’s lives and to identify factors affecting the problem behaviour (unhealthy eating). Questions about shopping and media consumption were also asked.

Actionable insights

Day care workers observed that while children were fed healthily during the day at care, some parents presented them with fatty or sugary snacks as soon as they picked them up. This was for a range of reasons – reward, comfort, behavioural control, guilt. This observation formed the foundation of the project’s actionable insight.

A focus on the health benefits of healthy eating alone would not be enough. Parents and carers knew the health messages but did not engage with them. There was also a belief that some junk foods led to hyperactivity.

“If I’m leaving my kids at 7:30 in the morning and picking them up at 5:30, they’re tired, they’re hungry, you get the worst hour possible with them before they go to bed.” (Parent)

“I’ve had to cut fizzy pop out…when he drank fizzy pop and ate chocolate I noticed his behaviour became aggressive…low attention span…now he’s calmed down…” (Parent)

Girl with banana

Barriers

The key barriers to healthy eating included:

  • Conviction that children would not eat fruit and vegetables – “Mine won’t eat vegetables…only thing I know she’ll definitely eat is from McDonalds”
  • Lack of cooking skills and a ‘can’t cook, won’t cook’ attitude
  • Lack of basic nutritional knowledge
  • Belief that healthy food was expensive – “You’d go in to Tesco’s and fill your basket with fruit and vegetables, and it would cost you £20”
  • Belief that preparing healthy food was time-consuming, inconvenient and of limited availability – “Where can you get a fresh pineapple in Speke?”
  • Reluctance to waste healthy food because children would not like it

Competition

  • Internal competition from parents and carers who believed that good parenting required giving children snacks and treats
  • External competition, including retailers (like fast food chains and in-store promotion) and media (like TV adverts and ‘advergames’)

During the research, given a free choice of what their 3- to 5-year-old children would eat as a special treat, McDonalds, KFC and Pizza Hut were mentioned by 8 out of 10 respondents. Parents and children also found it easy to recall specific adverts and their associated cartoon characters when interviewed:

“Anything with the Tweenies and my [child] will eat it.” (Parent)

Motivators

The research identified the following potential motivators for healthier eating:

  • Retail offers (voucher promotions, product placement, positive messages at point of sale)
  • Pester power of children

The research also showed that negative behaviour could be challenged if an intervention captured the following:

  • Demonstrate children liked fruit and vegetables as snacks
  • Healthy snacks benefit long- and short-term health
  • Fruit and vegetables are not expensive
  • Healthy snacks can be quick and easy to prepare
  • Early food preferences stay with you for life
  • Healthy snacks can improve childrens’ behaviour
  • Slow release snacks keep children energised longer

Behavioural goals

Based on this research it was decided that the programme’s aim would be to promote the consumption of fruit and vegetables as acceptable snack foods and as alternatives to common, highly marketed but less desirable snacks, such as crisps and chocolate. The key behavioural goal would be for children aged three to five (later six months to four years) from deprived neighbourhoods to replace at least one unhealthy snack each day with a healthy snack (ideally fruit or vegetables).

Six secondary goals were also agreed:

  1. Parents and carers would attend an event with their children under the branding Snack Right
  2. Parents and carers attending Snack Right events would overcome negative perceptions of fruit and vegetables as a snack food for children
  3. Every child would have the opportunity to try fruit and vegetable snacks at the events
  4. Children would continue to ‘snack right’ through the work of ambassadors, PCTs, local authorities (LAs), communities, etc
  5. Ambassadors were engaged in the process and attended Snack Right events
  6. Ambassadors delivered their own events

Development

 

The steering group decided that the campaign – branded ‘Snack Right’ – would consist of two phases. Phase One would be developed based on the findings of the scoping work conducted. An evaluation of this phase would then lead to development of a second phase, which would incorporate key lessons learnt.

Snack Right events

Fifteen fun, interactive events were targeted at children’s centres that correlated with the segmentation work. The events were aimed at children but, crucially, were an opportunity to engage with the parents or carers who accompanied them. Advertising agency McCann Erickson was commissioned to support delivery of the events, design support materials and engage the media.

At each event, children could try different fruit and vegetables and parents and carers were shown fun ways of creating healthy snacks for their children. A health worker was on hand to sign parents up for Healthy Start (the national welfare voucher scheme) and parents were told where they could use the vouchers locally.

Snack Right boy

Parents and carers were also provided with information about the short- and long-term health benefits of replacing an unhealthy snack with a healthy one. The events were designed to be fun and informal, with a visit from a Banana character, and each child would take home a piece of fruit. They were held in easy-to-access locations (children’s centres within the community) and run by staff who the parents and children already knew. In addition, by signing parents up to the Healthy Start voucher scheme, the events offered a financial incentive that made achieving the positive behaviour possible. The immediate benefits of participating in the event were thus clear and appealing to the target audience. Providing each parent with information on a one-to-one basis was essential because of low literacy and numeracy in the target families.

The Snack Right events aimed to overcome the barriers to the consumption of fruit and vegetables as identified in the research, giving parents and carers information as well as practical tips, to demonstrate that:

  • Healthy snacks can be quick, fun and easy to prepare
  • Children will eat and enjoy healthy snacks
  • Fruit and vegetables do not have to be expensive and Healthy Start vouchers are available
  • Healthy snacks can improve children’s behaviour
  • Healthy snacks benefit long- and short-term health
  • Early food preferences stay with you for life
  • Slow release snacks keep children energised longer 

Snack Right incorporated ‘good competitors’ under the campaign, by inviting them to attend the Snack Right events to ensure co-promotion of shared objectives and avoid mixed or repeated messages being sent to parents and carers. Good competitors included:

  • Breastfeeding support groups
  • Ready…steady…eat
  • Cook and taste programmes
  • Self-esteem programmes
  • Parents ‘n’ Tots groups
  • Foundation Year dental programme
  • Community gardens
  • Breakfast clubs
  • Sure Start cookery courses
  • Redeemable voucher schemes
  • Local veggie vans

Snack Right ambassadors

Representatives from the steering group recommended key people from within their organisation and geographical area to become Snack Right ambassadors, who could also recommend others to become involved. These were strategic and operational professionals from Cheshire and Merseyside’s PCTs, LAs and third sector, including obesity leads, children’s centre managers, health visitors, health promotion workers, health trainers and community cooks.

  • Strategic ambassadors supported local plans for the delivery of the Snack Right campaign and provided staff to support the implementation, including events and passing on messages to target groups. They also worked to embed the Snack Right model through local strategic plans or work plans, and create a legacy for the project
  • Tactical ambassadors delivered Snack Right messages, promoted and supported delivery of events, and sustained messages with the families they worked with

Ambassador days were run in the development stage of Phase One (and of Phase Two) to test the quality and effectiveness of the Snack Right intervention and materials.

By spring 2008, 150 ambassadors were registered, of whom a third were strategic.

Snack Right ambassadors

Partnerships

McCann Erickson brokered a partnership with Aldi to supply fruit and vegetables to the events. The company also hosted the launch of Snack Right in 2007 at a store in Liverpool.

While the partnership with Aldi contributed a number of elements to the campaign, this was not to the extent anticipated by the Snack Right team.

“We hoped for quite a good relationship with them and to do quite a bit of promotion in their 35 stores in the Cheshire and Merseyside area, but we weren’t able to get as much out of that relationship as we’d hoped. They did do some things for us, like put leaflets on desks, had a launch event, and they provided some fruit and vegetables for us for free. But we weren’t able to get as much coverage in the stores as we wanted to get. We would have liked to get posters over the fruit and vegetable aisles and things like that.” (Carol Johnson-Eyre, Social Marketing Project Manager)

Snack Right partnered with Healthy Start for the duration of the project. The project became an accredited promoter of the scheme and Healthy Start provided some metrics to support the evaluation.

Learning from Phase One

An evaluation of Phase One was conducted by Liverpool John Moores University. Their findings and observations in the field of how Phase One was received were key in re-scoping and developing Phase Two.

This additional insight led the social marketing group to:

  1. Extend the target age range to include children aged six months to four because tastes and preferences, and parental choice, were apparent in the under-twos. These children also attended children’s centres and were eligible for Healthy Start
  2. Revise and improve the marketing materials. Professional advice suggested the Snack Right leaflet was too detailed for the audience and that retainable items distributed at events (and through direct marketing) would remind families about snacking more healthily when they got home
  3. Develop a direct marketing intervention based around each child being professionally photographed at the events. Mailing the photograph to the child’s home would reinforce Snack Right messages and encourage behavioural change at home. This would be supported by creating additional retainable items 

Snack Right poster

“Between Phases One and Two there was a lot of learning around sustaining the behaviour change. We took photographs at the events in stage one and parents were asking the centres if they could have copies of those photographs. We were doing it for PR purposes, but they had high value for the families, so we embedded that into the delivery of Phase Two where we actually sent a photographer in to do mini professional photography for individual children, which enabled us to gather the families’ details to sustain the relationship for a longer period of time. So we were able to get the messages out to them not just through events but through the direct mail programme as well.” (Carol Johnson-Eyre, Social Marketing Project Manager)

Implementation

 

Phase Two was commissioned from three agencies, which were responsible for: the creatives and managing the direct marketing (Corporate Culture); delivering and supporting events at the children’s centres (Squash Nutrition); and media relations (Webber Shandwick).

The Snack Right 5, a cartoon group of fruit and vegetables, was developed as the creative platform for all the Phase Two materials. These included a:

  • Storybook about the Snack Right 5
  • Snacking sticker calendar
  • Branded stationery
  • Plastic snack bowl
  • Wipe-clean table mat
  • New leaflet describing the benefits of snacking right
  • Professional photo of the child, mailed to the parent’s home

Snack Right characters

To ensure the materials, event format and competition prizes were appealing to the target audience, they were pretested through 3 focus groups held in Crewe, Liverpool and Sefton children’s centres, involving a total of 23 parents, carers and grandparents. Amendments were made to materials and suggestions were fed into the event planning process. These consultations ensured that the end-user was the person who ultimate decided which products would be used.

Forty-nine events were held at children’s centres, of which eight (one for each PCT area in Cheshire and Merseyside) were designated as exemplar events. These were an opportunity for ambassadors to see a 'live' event and learn how to deliver one themselves. The events were similar to those in Phase One, but with more interactive games using fruit and vegetables.

Competition winners

The key difference was professionally photographing each child who attended, with parental consent. The photograph was later mailed to their home with a letter and snacking sticker calendar. Children who completed the calendar, by replacing an unhealthy snack with a healthy one each day, were mailed a wipe-clean table mat as a reward. Their parents or carers were also entered into 2 prize draws (top prize £1,000 Co-op travel vouchers and a fruit hamper). They also received other communications, such as a recipe for a fruit snack. Each family received a ‘goodie bag’ as they left the event, which included the book and plastic snack bowl, a Healthy Start leaflet, a piece of fruit, a Snack Right leaflet and any relevant local information from the children’s centre or PCT.

There were some logistical problems with posting the photos and calendar – for instance the calendars were quite big and some were returned to sender for being too large to be posted in certain letter boxes. The team overcame this by calling recipients to let them know when it would be posted so they could collect it from the postman, or organise for them to collect it from their local children’s centre. Despite these issues, the calendar and competition were very successful in trying to encourage children to sustain the habit of replacing one unhealthy snack with a healthy one.

Webber Shandwick sourced press and radio coverage for the events. Two of the exemplar events were designated Phase Two launches – one for Merseyside and one for Cheshire. Basketball players from Cheshire Jets and Everton Tigers came along to encourage parents and carers to put fruit and vegetable snacks in their shopping baskets. Life-size versions of two of the Snack Right characters – Pip the Apple and Narna the Banana – were also commissioned to bring the brand to life and interact with children at the events.

Nana and Pip

Webber Shandwick sourced press and radio coverage for the events. Two of the exemplar events were designated Phase Two launches – one for Merseyside and one for Cheshire. Basketball players from Cheshire Jets and Everton Tigers came along to encourage parents and carers to put fruit and vegetable snacks in their shopping baskets. Life-size versions of two of the Snack Right characters – Pip the Apple and Narna the Banana – were also commissioned to bring the brand to life and interact with children at the events. 

Evaluation

 

The biggest challenge was demonstrating Snack Right had achieved its behavioural goal amid all the background noise of other health messages. This was recognised as a challenge in the Phase One evaluation and partly addressed in Phase Two by using direct marketing. This allowed the use of self-reporting (such as completing the snacking calendar) as a proxy for behaviour change.

A full evaluation of Phase Two was published by Liverpool Public Health Observatory in summer 2009. This involved a baseline and follow-up questionnaire survey, which were conducted in children’s centres with parents or carers of preschool children four years or younger (with both a Snack Right intervention group and a control group). In addition, 23 interviews and 2 focus groups were conducted with a total of 33 parents or carers to provide feedback from the Snack Right events and views on snacking. This showed the secondary behavioural goals had been largely fulfilled and indicated the families Snack Right engaged had moved into Prochaska and DiClemente’s ‘contemplation stage’ in relation to giving more fruit and vegetables to their children.

  • Snacking behaviour – 41 per cent of children who signed up to the direct marketing programme at an event reported they continued snacking healthily 4 weeks later by returning the tear-off slip on their snacking calendar. Significantly, very few arrived before the calendar could have been reasonably completed, suggesting families took healthy snacking seriously
  • Participation – 3,788 children, parents and carers attended 64 Snack Right events from the targeted families
  • Direct marketing – 1,003 children, made up of 824 families, signed up to the direct mail programme
  • Healthy Start – Applications for Healthy Start vouchers in the Merseyside area increased by 25 per cent during Phase One. Forty-six families were signed up at Phase Two events with many others eligible but signing up afterwards
  • Families’ views – 84 per cent of families attending Phase Two events felt they had picked up new ideas about healthy snacking
  • Effect on children’s centres – The Phase Two evaluation reported Snack Right had given children’s centres staff new ideas around promoting healthy snacking. Practice had changed thanks to Snack Right – staff had stopped serving biscuits at one centre; another stopped crisps and cake at parties; many others were using learning from the project to develop existing practice or use the Snack Right format for future events

A further evaluation for autumn 2011 was planned to assess longer-term impacts, but that had to be withdrawn due to reductions in public sector finances.

Follow Up

 

In May 2009 a celebration event was held at Aintree Racecourse, entitled Healthy Lives for Under Fives. This event was a ‘thank you’ to those who had been involved in the Snack Right campaign and was a way to disseminate results and share learning. In addition, it enabled discussions of other research and campaign areas related to Snack Right, such as the role that breastfeeding and the diets of preschool children can have on obesity later in life.

A sub-regional approach allowed PCTs to participate in a project at a scale and quality most could not have delivered alone. By working together, effort and expertise were pooled to secure funding and economy of scale, which created a readily transferable intervention.

The ambassador network created to support delivery of Snack Right is the mechanism that continues to sustain the project. It encouraged a partnership approach that ensured events were delivered locally with the Snack Right project team’s expertise on tap.

“The children’s centres themselves have continued to do a variety of different things around healthy snacking. One of the centres continues to have fruit and vegetables as a snack for all parent and children groups, reinforcing the messaging that children do like fruit and vegetables as a snack.” (Carol Johnson-Eyre, Social Marketing Project Manager)

The Cheshire and Merseyside PCTs have committed to developing Snack Right through children’s centres. Their plans include:

  • Annual Snack Right events in all children’s centres
  • Commissioning new products to support the brand, like snack boxes
  • Top tips for parents on snacking
  • Examining the practicality of texting families with snacking ideas after events

To help in this process, the Snack Right project team has:

  • Produced a toolkit to help with organisation of events and delivery of messages, which includes a DVD showing an event in action
  • Provided training on the concepts underlying Snack Right as well as how to run events and disseminate messages effectively
  • Published brand guidelines to enable partners (within and outside Cheshire and Merseyside) to develop their own Snack Right materials

Snack Right was deemed a success by the directors of public health involved and subsequently raised the profile of social marketing, which has now been endorsed as a successful and useful approach to use for public health campaigns by the ChaMPs network. Consequently, further funding was put forward for the second ChaMPs Social Marketing Group project – ‘Drink a little less, see a better you’ – which aims to reduce the levels of hazardous drinking in 35- to 55-year-old males. This campaign has won a number of awards, including a North West Public Health Award in 2010.

Drink a little less

Lessons learned

 

Following Phase Two and the completion of the campaign, a number of key lessons were identified:

Measuring behaviour change over a short period can be difficult – ensure from the start your behavioural goals are SMART and data sharing is agreed

A particularly problematic aspect was establishing a baseline from which to demonstrate swapping an unhealthy snack for a healthy one. Application and voucher redemption statistics from Healthy Start vouchers were initially going to be a key indicator of behaviour change. However, access to this data was far more limited than the Snack Right team anticipated and thus could not form a key element of the evaluation.

Managing commercial partners can be difficult and time consuming – negotiate and clearly establish from the start what is expected from them

ChaMPs learnt that commercial partners will want to work with you on the basis of perceived business benefit. Subsequently, from the onset you also need to be clear what you want from them and to negotiate hard. In addition, brokering commercial relationships can be very time consuming, which can sometimes be difficult for public sector organisations. Walk away from a deal if what they offer will not add value to the work and if negotiations are not yielding reasonably quick results.

Working in partnership is invaluable – but ensure you get senior level buy-in

The work with the children’s centres was a key element of the success of Snack Right. However, in retrospect more work should have been done to gain senior level buy-in from within the children’s centres and from the associated councils, to ensure the work could be embedded thoroughly.

“I think we could have got more senior buy-in, higher up the children’s centres systems, so within the councils and higher up in the Sure Start system. I think we could have got more buy-in from them because I think some staff were getting involved, but not necessarily their managers, and higher up didn’t necessarily actually know what the frontline staff were getting involved in.” (Carol Johnson-Eyre, Social Marketing Project Manager)

Key facts

Topics

 

Target audience

 

Location

 

Date

 
Phase 1 - Summer 2007; Phase 2 - Summer 2008

Organisation

 
ChaMPs Public Health Network

Budget

 
£313,000