Network for a Healthy California 2008 Conference Breakout Session One – Room 204

1. Opting In: A Pioneering Direct Marketing Campaign Designed to Empower Low-Income Women to Become Champions for Change. Network for a Healthy California 2008 Conference Breakout Session One – Room 204 Presented by RS&E, Field Research and handshake Marketing, January 23, 2008

2. Agenda • Formative research (10 minutes) • Implementation (15 minutes) • Results (40 minutes) • Discussion (25 minutes)

3. 1. FORMATIVE RESEARCH Discovering a highly motivating context for the direct mail campaign

4. Discovering a highly motivating context for the direct mail campaign • “Discovering” = listening to intended recipients • 8 consumer panels in California • Spanish-dominant, African American, Multicultural • really varied stimulus and approaches

5. Discovering a highly motivating context for the direct mail campaign • “Motivating context” = an execution theme that encourages • opening the mail piece

6. Discovering a highly motivating context for the direct mail campaign • “Motivating context” = an execution theme that encourages • opening the mail piece • reading, valuing and using the information

7. Discovering a highly motivating context for the direct mail campaign • “Motivating context” = an execution theme that encourages • opening the mail piece • reading, valuing and using the information • perceptions of norms (“women like me are doing this”)

8. Discovering a highly motivating context for the direct mail campaign • “Motivating context” = an execution theme that encourages • opening the mail piece • reading, valuing and using the information • perceptions of norms (“women like me are doing this”) • feelings of self-efficacy (“I can do this”)

9. Discovering a highly motivating context for the direct mail campaign • “Motivating context” = an execution theme that encourages • opening the mail piece • reading, valuing and using the information • perceptions of norms (“women like me are doing this”) • feelings of self-efficacy (“I can do this”) • appreciation of the brand

10. Discovering a highly motivating context for the direct mail campaign • “Motivating context” = an execution theme that encourages • opening the mail piece • reading, valuing and using the information • perceptions of norms (“women like me are doing this”) • feelings of self-efficacy (“I can do this”) • appreciation of the brand • taking action

11. Discovering a highly motivating context for the direct mail campaign • Opening the mail piece – Low-income mothers described what’s typically in their mailbox, and what’s not: Typical: retail, credit, insurance offers Atypical: health information, DVDs

12. Discovering a highly motivating context for the direct mail campaign • Opening the mail piece – Spanish-dominant and African American moms chose support to lower their family’s health risks as the mail piece topic they would open first. DVD Case Title Ratings (% “4” or “5” on a 5-point scale) Spanish African TotalDominantAmerican “The help you need to lower your chances of obesity, high blood pressure and Type II diabetes in your family.” 80% 91% 87% “Healthy food. Healthy kids. Moms make it happen.” 81% 82% 83% “The next 30 minutes could make a lifetime of difference 76% 61% 82% for your kids.” “You’re holding the answer to healthier children.” 75% 78% 71% “Be a hero mom. Find out how, inside.” 63% 64% 53%

13. Discovering a highly motivating context for the direct mail campaign • Reading, valuing and using the information – Low-income mothers showed very high interest in a broad range of prevention-related topics … • - the key role, power of mothers in prevention … individually at home and collectively in the community • - recommendations and goal-setting • - benefits of eating more fruits & vegetables, being more physically active • - range of 1st-person stories from mothers like themselves • - variety of tips, recipes focused on overcoming barriers

14. Discovering a highly motivating context for the direct mail campaign • Reading, valuing and using the information – Materials scored very high on a range of diagnostic measures … Brochure and DVD Ratings (% “4” or “5” on a 5-point scale) BrochureDVD Clarity 94% 91% Character Believability 87% 86% Content Believability 94% 89% Utility 94% 86% Relevance 91% 78% Attraction 92% 79% Persuasiveness 87% 65% Motivation – eat more fruits & vegetables 97% 87% Motivation – get more physical activity 94% 83%

15. Discovering a highly motivating context for the direct mail campaign • Perceptions of norms (“women like me are doing this”) – Of greatest appeal, overall, was the depiction of multiple, diverse and very real mothers sharing their experiences and serving as believable role models …

16. Discovering a highly motivating context for the direct mail campaign • Perceptions of norms (“women like me are doing this”) – Of greatest appeal, overall, was the depiction of multiple, diverse and very real mothers sharing their experiences and serving as believable role models … • “I’m busy, and what I see is that these people are busy too, but they still • have the time to cook.” • (African American mother, Oakland) • “I could relate to them all. They are all moms … just to read what they are • going through.” • (African American mother, Oakland)

17. Discovering a highly motivating context for the direct mail campaign • Perceptions of norms (“women like me are doing this”) – Of greatest appeal, overall, was the depiction of multiple, diverse and very real mothers sharing their experiences and serving as believable role models … • “To me they looked like real women, they looked like average women • I see everyday.” • (Mother in Multicultural Panel, Fresno) • “They are all moms. And that, in itself, catches you because it’s like ‘Oh, • finally from our point of view’ … It’s all moms that know what we are going • through and they are doing it too.” • (Mother in Multicultural panel, Fresno)

18. Discovering a highly motivating context for the direct mail campaign • Feelings of self-efficacy (“I can do this”) – The depiction of believable role models gave behavior change a realistic, practical, achievable aura …

19. Discovering a highly motivating context for the direct mail campaign • Feelings of self-efficacy (“I can do this”) – The depiction of believable role models gave behavior change a realistic, practical, achievable aura … • “(The tip regarding) ‘How I got my kids to love fruits and vegetables.’ I • thought maybe I could get (my daughter) to help me cook and maybe she • would like more things. She might even eat something green!” • (African American Mother, Oakland) • “They are realistic things, if you are motivated and want this for your family. • The little hints are short, brief and to the point. I thought this was really • helpful. I really enjoyed this.” • (Mother in Multicultural panel, Fresno)

20. Discovering a highly motivating context for the direct mail campaign • Feelings of self-efficacy (“I can do this”) – The depiction of believable role models gave behavior change a realistic, practical, achievable aura … • “It had suggestions, like planting a garden, growing your own food. That’s • something kids can get involved with, or taking them to a place where you • can pick the vegetables. And preparing food, getting them involved in that.” • (Mother in Multicultural Panel, Fresno) • “When I shop, I get what I like. So the kids end up eating what I like to eat. • Maybe I should try taking the kids shopping with me so they can try new • things … pick out what they like.” • (African American mother, Oakland)

21. Discovering a highly motivating context for the direct mail campaign • Appreciation of the brand – moms saw themselves as the “Champions for Change” • Champions within their own families • Collective champions for the community • Inspirational, empowering ideas

22. Discovering a highly motivating context for the direct mail campaign • Taking action – Mothers indicated a genuine interest in acting upon this intervention in a variety of ways … • Keeping the information – e.g. posting it on the fridge • Sharing materials with friends and family members • - Requesting more tips and recipes in the mail • - Nominating women they know as future role models

23. Discovering a highly motivating context for the direct mail campaign • MOTIVATING CONTEXT • Realistic role models playing vital roles as mothers.

24. 2. IMPLEMENTATION Executing the intervention to be both in-depth and scalable

25. Low-income mothers are hungry for in-depth nutrition information: - Knowledge about health risks and prevention - Specific nutrition and physical activity guidelines - New skills in the form of tips and recipes to try - Personal accounts from other moms - The collective power of mothers to speak up in their community for environmental change Executing the intervention to be both in-depth and scalable

26. DM mailer helps achieve a greater level of direct intervention than mass media can achieve on its own. Cost investment versus the cost impact of obesity. DM campaign reflects higher level of investment in the health and well-being of low-income moms and their families. Executing the intervention to be both in-depth and scalable

27. Real Moms Healthy Kids DM mailer delivered to six target counties: - Los Angeles - Orange - Ventura - Fresno - Western San Bernardino - Western Riverside Executing the intervention to be both in-depth and scalable

28. A complete, multimedia and easy-to-use format. Executing the intervention to be both in-depth and scalable

29. Champions for Change DVD

30. Nutrition Support Materials – Mini Magazine Executing the intervention to be both in-depth and scalable

31. Executing the intervention to be both in-depth and scalable Nutrition Support Materials – Mini Magazine

32. Nutrition Support Materials – Success Cards Executing the intervention to be both in-depth and scalable

33. Executing the intervention to be both in-depth and scalable Nutrition Support Materials – Success Cards

34. Assessment Tool – Fruit & Vegetable Slide Guide Executing the intervention to be both in-depth and scalable

35. Ongoing Nutrition Support – Reply Card Executing the intervention to be both in-depth and scalable

36. 3. RESULTS Evaluating the intervention for statewide expansion

37. Evaluating the intervention for statewide expansion State of the Art Evaluation Design

38. Study Objectives This study sought to assess the effectiveness of the initiative. Specific objectives were to assess: Recall of the mail/DVD package, Extent to which it was actually read and used, How consumers rated it in terms of interest, relevance and utility, Effectiveness of package in increasing the saliency of healthy eating and physical activity issues as well as knowledge about recommended behaviors, Effectiveness of package in changing social normative and efficacy beliefs, health behavior and information and support seeking. Evaluating the intervention for statewide expansion

39. Methodology The evaluation design was quasi-experimental; before and after surveys were conducted within a sample of households that received the mailing (treatment households) and a sample of similar households that did not receive the mailing (control households). The data were collected using a longitudinal design. Treatment households were randomly selected from the mailing list devised by handshake Marketing. Control households were randomly selected from the same media markets using the same household database of handshake Marketing. Evaluating the intervention for statewide expansion

40. Methodology (continued) Although the L.A. mailing went to Los Angeles, Orange, San Bernardino and Riverside Counties, control households were selected randomly from eligible households and tracts in L.A. County only. Control households for the Fresno market were selected from same types of households and tracts in Merced and Madera counties, two counties contiguous to Fresno County, the only county mailed to. The counties are all similar in terms of socio-economic status and race/ethnic composition. Evaluating the intervention for statewide expansion

41. Methodology (continued) Although the L.A. mailing went to Los Angeles, Orange, San Bernardino and Riverside Counties, control households were selected randomly from eligible households and tracts in L.A. County only. Control households for the Fresno market were selected from same types of households and tracts in Merced and Madera counties, two counties contiguous to Fresno County, the only county mailed to. The counties are all similar in terms of socio-economic status and race/ethnic composition. All treatment and control households were exposed to Network paid advertising that emphasized the same messages as those contained in the mailer/DVD. Evaluating the intervention for statewide expansion

42. Methodology (continued) The before- and after-surveys were conducted by telephone in English and Spanish; interviews lasted approximately 15 minutes. The before-interviews were conducted just before the mailing, May 15 - June 15. The after-interviews were conducted immediately following the mailing, July 31 - August 31. The before-survey consisted of approximately 400 interviews with treatment households and 400 with control households. Evaluating the intervention for statewide expansion

43. Methodology (continued) In the after-survey we were able to complete interviews with 248 treatment households and 237 control households for a total of 485, a response rate of 61%. Of these, 238 completed the interview in English; 247 completed it in Spanish. In order to minimize reporting bias and sensitization effects, the questionnaires used in both waves of data collection covered multiple health and safety issues. Evaluating the intervention for statewide expansion

44. Network Mailer, DVD & Recall In the study, we assessed recall, use and how recipients rated the effectiveness of the mailer and DVD. In general, recipients reacted very favorably. Evaluating the intervention for statewide expansion

45. Evaluating the intervention for statewide expansion Recall • English speakers (24%) were more likely to recall receiving the package than Spanish speakers (14%).

46. Evaluating the intervention for statewide expansion Recall Rate & Date of Interview • The data suggest that "week after recall" for the Network mailing may have been in the 25%-30% range.

47. Evaluating the intervention for statewide expansion Recall Rate & Date of Interview • English speakers (67%) were more likely to report that they read the info/played the DVD than Spanish speakers (47%).

48. Evaluating the intervention for statewide expansion

49. Evaluating the intervention for statewide expansion • The majority of English speakers (67%) read the printed information only, while the majority of Spanish speakers (56%) only played the DVD. • We found no significant differences in outcomes between those who watched the DVD and those who did not watch the DVD.

50. Evaluating the intervention for statewide expansion