Despite improvements in the level

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1 Proximal Impact of Canada on the Move The Relationship of Campaign Awareness to Pedometer Ownership and Use Cora L. Craig, MSc 1 Sue E. Cragg, MBA 1 Catrine Tudor-Locke, PhD 1,2 Adrian Bauman, PhD 3 ABSTRACT Objective: Despite increased participation in leisure-time physical activity, inactivity remains an important public health problem. This study examines the immediate impact of the Canada on the Move initiative to promote walking through pedometer use among adult Canadians. Methods: Data from a rolling monthly sample were collected via the Canadian Fitness and Lifestyle Research Institute s Physical Activity Monitor between November 2003 and September Prevalence rates were compared using Bonferroni-adjusted confidence intervals. Correlates of campaign recall and pedometer ownership were estimated using odds ratios adjusted for age, sex, income and education. Results: Message recall and awareness as well as ownership and use of pedometers increased over the campaign and coincided with promotional activity. There was some evidence of a dose response between the number of messages recalled and pedometer use. Discussion: The increased awareness and usage of pedometers among adult Canadians is encouraging; it indicates that these proximal targets are realistic and achievable for health promotion campaigns and contribute to opportunities for increasing physical activity behaviours. MeSH terms: Walking; behavior; social marketing; evaluation 1. Canadian Fitness and Lifestyle Research Institute, Ottawa, ON 2. Walking Research Laboratory, Department of Exercise and Wellness, Arizona State University, Mesa, AZ 3. School of Public Health, University of Sydney, New South Wales, Australia Correspondence: C.L. Craig, Canadian Fitness and Lifestyle Research Institute, Somerset Street West, Ottawa, ON, K2P 0J2, Tel: (613) , Fax: (613) , ccraig@cflri.ca Despite improvements in the level of physical activity participation among adult Canadians in recent years, 1 inactivity remains an important public health problem. Population monitoring data suggest that approximately 60% of adults are still insufficiently active for health, which is a problem more than twice as prevalent as hypertension or tobacco use. There is an urgent and likely continual need to motivate adults who are insufficiently active to become more active, as that is where substantial gains in population health could be realized. 2 The most plausible mass physical activity message is to encourage regular walking, as this activity is feasible and accessible for all population groups. 3 It is also beneficial for health, independently of other forms of physical activity. 4-6 One method to assess and motivate walking is to encourage the use of step counters/pedometers, which enable individuals to set goals for walking, and to obtain feedback on the number of steps they actually take in a day. 7,8 Pedometers can be especially useful for sedentary or low-active people to monitor their progress towards meeting the recommended population levels of physical activity for health 8,9 The 2004 Canada on the Move (COTM) initiative was a co-operative campaign (promoting both pedometers and walking) between the Canadian Institutes of Health Research (CIHR) and Kellogg Canada. COTM was comprised of two separate yet complementary components: research and promotion. The research component was a web-based research platform intended for use in subsequent observational and intervention projects. It was designed under the auspices of CIHR to collect and warehouse information on determinants of physical activity and the number of daily steps taken. Specifically, Canada on the Move s launch in December 2003 was to link people to the CIHR website, enabling them to register and monitor their step counts, effectively donating their steps for health research. The focus on encouraging pedometer usage and walking was reinforced through a public-private partnership with Kellogg Canada. Kellogg Canada independently planned to distribute pedometers via cereal boxes 10 beginning in January 2004; the public-private partnership included an educational message on CANADIAN JOURNAL OF PUBLIC HEALTH S21

2 the cereal boxes directing consumers to the CIHR website. Press releases were independently produced by both partners to introduce the project and encourage Canadians to walk more. Mass media advertisements were disseminated exclusively by Kellogg Canada. Together, publicity surrounding the CIHR platform and Kellogg s campaign promoted walking and pedometer use. Partnerships such as this are often referred to in the prevention literature and in government-planning processes, but are relatively rare. 11 Although the long-term goals of such partnerships should include public health outcomes, more realistic proximal impacts include raising awareness and salience (or personal relevance) of physical activity. 12 In COTM s partnership, successful endpoints would include campaign and pedometer awareness as well as pedometer ownership and usage. The Canadian Fitness and Lifestyle Research Institute (CFLRI) 13 has conducted the Physical Activity Monitor (PAM) surveys 14 since 1995 to track physical activity in the Canadian population. This monitor offered a unique mechanism to evaluate the impact of the COTM initiative upon the Canadian general population. PAM s monthly rollout permitted measurement of baseline levels to the campaign by including questions during November and December 2003 and then tracking post-launch awareness throughout Therefore, the primary purpose of this study was to evaluate the proximal impact of the COTM initiative. Specifically, we set out to answer the following questions: 1) Who recalled the campaign and how was it associated with campaign timing? 2) Who owned pedometers and how was ownership associated with campaign timing and pedometer acquisition? 3) Was campaign recall associated with pedometer awareness, ownership and use? A secondary purpose was to describe pedometer ownership and use among adult Canadians who were the non-selective target population for the COTM initiative. METHODS November 2003 December January 2004 February- May 2004 June 2004 July-September 2004 Figure 1. Timeline of Canada on the Move (COTM) and Physical Activity Monitor (PAM) activities COTM Kellogg s first mass marketing messages to encourage walking were aired the last week of December on completion of the Canada on the Move website (2003 December 19). Messages included walk more, use pedometers, Keep it simple. First official press release appeared January 8, 2004 ( Kellogg Canada Steps Up Efforts to Help Fight Obesity and Get Canadians Moving with Industry- Government Program, Donate your steps to health research, Canada on the Move, add 2000 steps and tips for how to walk more). Cereal boxes containing pedometers (n=800,000 according to Kellogg Canada s press release) appeared on shelves during the week of January 8, 2004 in specially marked boxes of Special K* and Special K* Red Berries. Cereal box messages cited Canada on the Move, the tag lines Donate your steps to health research and add 2000 steps, and Kellogg Canada s tag line Keep it simple. Second press release launching the Canada on the Move website January 26 by CIHR. Messages included Canada on the Move, Donate your steps to health research, visit website, goal of 10,000 steps. Although not in the official release, the tag line add 2000 steps was included in media interviews. The second mass marketing campaign was released by Kellogg Canada on June 10. In addition to repeating the message add 2000 steps, a challenge was issued to Step up Canada and Walk across Canada. A second mass release of pedometers (n=1,500,000) through cereal boxes began the week of June 10. The list of brands offering direct or indirect promotion of pedometers was expanded to include Special K*, Special K* Red Berries, Vive*, Just Right*, Muslix* Almond-Raisin, Muslix* Banana Nut, Vector* and Kellogg s Corn Flakes* brands. As per the earlier release, the boxes cited Canada on the Move, Donate your steps to health research, and add 2000 steps. PAM Baseline data Post-launch data Post-second wave data Study design CFLRI s PAM provided a monthly rolling sample of 750 Canadians aged 15 years and older, selected with probability proportional to the size of the population of Canada s provinces and territories and a minimum monthly sample of 20 individuals per jurisdiction. Individuals were selected using a two-step design, which began with a random digit dialling to select an eligible household telephone number. The individual within the household with the closest birth date was then selected. To enable comparisons with the CIHR website participants, only adults aged 18 and older were included in this study of the COTM campaign, yielding a total of 7,217 individuals between November 2003 and September In order to assess the impact of the campaign by month, we provide a timeline of COTM and PAM activities in Figure 1. Baseline data were collected in November prior to the release of the campaign. S22 CANADIAN JOURNAL OF PUBLIC HEALTH VOLUME 97, SUPPLEMENT 1

3 40% 35% 30% 25% 20% 15% 10% 5% 0% Figure 2. Monthly tracking continued in December 2003 and spanned the initial launch in January 2004, the first post-launch phase (February to May 2004), the second promotional campaign in June 2004, and the second post-launch phase (July to September 2004). Interviews were conducted by the Institute for Social Research at York University, Toronto, using computer-assisted telephone interviews. Participants provided verbal consent according to the procedures approved by the Ethics Review Board of York University. Despite the response rate of 50%, previous studies of the methods used by the PAM have found minimal response bias. 1 Measures Priority research questions were initially identified collectively by a group of researchers who were invited to the COTM meeting in Toronto in September 2003, and refined by the listed investigators prior to baseline measurements in November Recall of the campaign and its tag lines was assessed by asking respondents if they had heard of Canada on the Move, add 2,000 steps, and donate your steps to health research in the previous month (yes/no/don t know). Two other unrelated campaign tag lines were included for comparison purposes. One was ParticipACTION s walk a block campaign from the early 1980s, whose slogan is still in popular usage. 15,16 The other was Stairway to Health, a poster-based workplace campaign to cue taking the stairs over the elevator. 17 Awareness of pedometers was gauged by Recall of COTM and other messages over the period November 2003 to September 2004 asking, Have you ever heard of a pedometer or step counter? (yes/no/don t know). Those aware of pedometers were asked if they owned one (yes/no) and if so, where they had acquired it (bought it/from a cereal box/from friends or family/other) and On how many days in the last seven days did you wear a pedometer? Analysis Differences in prevalence rates were estimated by weighting responses to the population and compared using Bonferroniadjusted 95% confidence intervals. Correlates of campaign recall and pedometer awareness, ownership and use were examined using adjusted odds ratios obtained from forced entry logistic regression models. SPSS version 12 was used for the analyses. RESULTS Who recalls the campaign and how is it associated with campaign timing? Figure 2 depicts the recall of the COTM and other messages over the period November 2003 to September Overall, 29.3% of adults 18 years and older reported that they had heard of Canada on the Move over this period. In November and December, about one quarter of adults reported hearing about Canada on the Move in the previous month. Coincidental to the launch of Kellogg s media campaign, recall of Canada on the Move increased to 32.1% in January (difference 6.3%; 95% CI %) and then returned to its baseline level in February. Recall of Canada on the Move subsequently increased in June (May-June difference 6.0%; 95% CI %) coinciding with Kellogg s second media campaign. Overall, recall of Canada on the Move was 6 percentage points higher (difference 5.6%; 95% CI %) 9 months after the launch of the campaign than at baseline. Recall of the more specific messages, add 2,000 steps and donate your steps to health research both increased, from 3.8% in November 2003 to 11.9% in January 2004 (difference 8.1%; 95% CI %) for the former and from 4.5% to 14.5% (difference 10.0%; 95% CI %) for the latter. As with Canada on the Move, recall of add 2,000 steps increased after the second campaign (difference 3.7%; 95% CI %). However, this increase was observed in July. Finally, recall of both specific messages was higher in September 2004 than at baseline in November 2003 (absolute difference for add 2,000 steps was 8.8%; 95% CI %; and for donate your steps to health research was 10.3%; 95% CI %). In summary, there was a positive overall gradient for awareness of the COTM initiative and its specific subcomponent messages over the period November 2003 to September 2004 (p<0.001). This differs from the recall of both the stairway to health and the walk a block messages, for which no gradient by month was observed (p=0.15 and p=0.30, respectively). Table I summarizes the recall of the COTM initiative, its specific subcomponent messages, and how it varies by population segment. Women were 37% more likely than men to report hearing about Canada on the Move in the previous month. Although the percentage recalling Canada on the Move decreased slightly across age groups, this association with age disappeared after controlling for sex, education and income. Whereas hearing about the campaign was unrelated to education, an inverted u-shaped relationship was observed with income levels. However, after adjusting for age, sex and education, all groups above the lowest income were 17-30% more likely to recall the campaign than the lowest income group. Fewer adults recalled the more specific messages of the campaign: 10.2% (95% CI CANADIAN JOURNAL OF PUBLIC HEALTH S23

4 TABLE I Awareness of the Campaign by Socio-demographic Groups Heard of Canada on the Move Heard of Donate your Steps Heard of Add 2000 Steps N Prevalence Adjusted 95% CI Prevalence Adjusted 95% CI Prevalence Adjusted 95% CI % Odds % Odds % Odds Ratios* Ratios* Ratios* All Adults, Gender Male Female Age Group Education <Secondary College University Income (per annum) <$20, $20,000-39, $40,000-69, $70, * Adjusted for age, gender, education and income %) recalled add 2,000 steps a day and 10.4% (95% CI %) recalled donate your steps to health research. Women were 1.9 times more likely than men to recall the add 2,000 steps message and higher-income earners ($40,000+) were 37-46% more likely to recall the message than their lower-income counterparts. By contrast, higher-income earners and university graduates were less likely to recall the donate your steps message, as were those between 25 and 44 years of age. How is pedometer ownership associated with campaign timing and where pedometers were obtained? Prevalence of pedometer awareness and ownership by month is depicted in Figure 3 and the method of acquisition (purchased vs. from a cereal box) is shown in Figure 4. In November 2003, 39.8% of adults were aware of pedometers and 3.3% owned one. The percentage of adults who had heard of a pedometer increased significantly between December and January (difference 18.6%; 95% CI %) and between May (55.4%) and July (64.6%) (difference 9.2%; 95% CI %). The prevalence of pedometer ownership increased significantly between January and February (difference 6.3%; 95% CI %) and between May and July (difference 4.9%; 95% CI %). In November 2003, 1.5% of adults reported that they had bought a pedometer (Figure 4). This increased to 4.3% by February Figure 3. Figure 4. Prevalence of pedometer awareness and ownership over the period November 2003 to September 2004 Cereal box How pedometer was obtained (purchased vs. from cereal box) over the period November 2003 to September 2004 S24 CANADIAN JOURNAL OF PUBLIC HEALTH VOLUME 97, SUPPLEMENT 1

5 TABLE II Pedometer Awareness, Ownership and Source Aware of Pedometer Own a Pedometer Bought a Pedometer Obtained Pedometer in Cereal Box Prevalence Adj 95% CI Prevalence Adj 95% CI Prevalence Adj 95% CI Prevalence Adj 95% CI % OR* % OR* % OR* % OR* N All Adults, Gender Male Female Age Group Education <Secondary College University Income <$20, $20,000-39, $40,000-69, $70, Not aware COTM Recall COTM Recall COTM & 1 specific Recall COTM & both specific * Adjusted for age, sex, education and income (difference 2.8%; 95 % CI %) and remained at that level through September. In February, 3.2% of adults reported that they had obtained pedometers from a cereal box, a significant increase from zero at baseline (difference 3.2%; 95% CI %). The percentage obtaining pedometers from cereal boxes further increased between June (3.6%) and July (7.4%) (difference 3.8%; 95% CI %) and then declined between July and September (difference 2.0%; 95% CI %). Overall, 57.1% of Canadian adults had heard of a pedometer or step counter. Table II indicates greatest awareness of pedometers among women, adults aged between 45 and 64 years, college and university graduates and high-income earners. There were socioeconomic gradients in the data: more educated and more affluent adults were more likely to be aware of pedometers than the leasteducated group or the lower two income groups. Just over 1 in 10 Canadians reported owning a pedometer. Pedometer ownership was more prevalent among women, college and university graduates and high-income earners and was less prevalent among those aged 18 to 24. Moreover, these associations remained after adjusting for age, sex, income and education. Similar proportions of Canadians bought their pedometer (3.6%) as obtained it from a cereal box (3.7%). Compared to those between 18 and 24, adults 25 years and older were 3 to 6 times more likely to have purchased the pedometer and were much less likely to have obtained it from a cereal box. Was campaign recall associated with pedometer awareness, ownership and use? The lower panel of Table II shows that awareness of the COTM campaign was associated with having heard of a pedometer. Those who recalled Canada on the Move were more likely to be aware of a pedometer, compared to those unaware of the tag phrase. Furthermore, recalling one of the other specific campaign submessages in addition to Canada on the Move increased the likelihood of being aware of a pedometer. Adults who recalled one or both specific messages were 1.6 to 2.2 times as likely to own a pedometer as those who were unaware of Canada on the Move. In addition, adults who heard one specific message were twice as likely to have obtained a pedometer from a cereal box as those unaware of Canada on the Move ; those recalling both specific messages were more than twice as likely to have bought a pedometer. Figure 5 describes the association between using a pedometer at least once in the previous week and awareness of the campaign. Only 2.4% of Canadian adults (95% CI %) reported using a pedometer in the previous week. Pedometer use was more likely among women (AOR=1.81, 95% CI= ) and 44- to 64-yearolds (AOR=1.73, 95% CI= ). Moreover, pedometer use was related to awareness of the COTM campaign, in that those aware of Canada on the Move and both of its specific messages were almost four times as likely to have worn a pedometer in the last week as those unaware of the campaign. DISCUSSION The 2004 Canada on the Move initiative represents a unique and interesting example of a public-private partnership between CIHR and Kellogg Canada, and of a social marketing effort to increase CANADIAN JOURNAL OF PUBLIC HEALTH S25

6 Canadians physical activity through marketing and distribution of pedometers. By distributing pedometers through cereal boxes, Kellogg Canada was acting to provide broad access to a potentially motivational tool believed to be supportive of physically active lifestyles. 8 We have little documented evidence for pedometers as a community-wide intervention to promote physical activity. The research has not been conducted and, in controlled studies, may never be available at the population level. However, some attributes of the pedometer suggest that it is suitable for this kind of population-change-oriented intervention. Specifically, they are simple to use, unobtrusive, provide immediate user feedback and fit easily within accepted selfmonitoring theories of behaviour change. In addition, they are affordable and therefore feasible for individual trialing within a social marketing campaign. Kellogg previously partnered with the U.S. National Cancer Institute (NCI) in the mid-1980s to promote All-Bran* cereal. 18 Specifically, Kellogg carried NCI cancer prevention messages in their advertisements and on the boxes for All-Bran* cereal. The campaign increased Kellogg s market share and spilled over to increased consumption of other bran products. Data collected on the impact of the campaign on consumers support a significant impact on consumers knowledge, attitude and practices with regard to overall fibre consumption. 18 Although we do not have direct information about the impact on sales of cereal tied to the COTM campaign, this study provides evidence of influencing consumer awareness. Since such examples of public-private partnership are simultaneously seductive and uncomfortable, impact evaluation is necessary to consider advantages versus disadvantages of these potentially controversial ventures. This impact evaluation capitalized on an existing nationwide monitoring system and focussed on proximal impacts of campaign recall and pedometer awareness, ownership and trialing of the proposed solution or resource (i.e., use of a pedometer). Such proximal impacts are more realistic targets of health promotion campaigns 12,19 and are congruent with public health aims to demonstrate change relevant to, or antecedent to, changes in physical activity Figure 5. Association (adjusted odds ratio) between using a pedometer at least once in the previous week and awareness of the campaign behaviour of populations. Canada on the Move resulted in increased awareness of the campaign and of pedometers and pedometer ownership immediately following the initial campaign in January 2004 and again following the second wave in June The large increase in awareness was probably due to the social advertising component, indicating the larger resources required to penetrate community-wide consciousness. The impact of message recall flowed on to sustained effects on pedometer ownership, but the modes of obtaining pedometers showed two patterns. Some obtained pedometers through cereal box promotions, demonstrating an acute response to in-package placements in January (followed by a decay function through March to May), and another response to phase two of the Kellogg s marketing in June. Rates of pedometer ownership through purchasing were also higher after the launch of Canada on the Move compared to before it. This suggests two modes of campaign effect: one through messaging and package insert, and the other through messaging and independent pedometer purchase. In fact, the impressive sensitivity of the Physical Activity Monitor for documenting variability in awareness related to campaign timing (refer to Figure 2) is a reminder of the need for continuous and repeated social marketing efforts if sustained social and behavioural change is sought. Previous work in skin protection behaviours shows serial learning by the population with each successive campaign, followed by reductions almost to previous levels this sequential build may be required to get innovations accepted at the whole community level. 20 Although the percentage points might seem of questionable import on first glance, the 3.3 and 3.8 percentage point increases observed in February and July resulted in pedometer uptake by 759,000 adult Canadians attributable to the launch and by a further 874,000 adult Canadians attributable to the second campaign wave. The campaign effect here was similar to other effective campaigns in increasing community awareness of health-related issues, with reasonably similar rates of awareness-raising across population segments. 12,21 Women generally responded slightly more than males, but this is consistent with females being early adopters of innovative behaviours, and also being receptive to motivational messages regarding walking. It is important to emphasize that message recall was specific to the COTM initiative and its specific subcomponent messages. The fact that neither of the competing decoy messages displayed the same positive gradient by month provides further evidence to support a true causal relationship between campaign timing and awareness. This study also demonstrates some evidence of a dose response between relevant message recall and pedometer use. Those S26 CANADIAN JOURNAL OF PUBLIC HEALTH VOLUME 97, SUPPLEMENT 1

7 who were aware of Canada on the Move and both specific campaign messages about donating steps and increasing steps by 2,000 were most likely to have been aware of a pedometer, to own one, and to have used the pedometer in the previous week. In summary, the Canada on the Move initiative appears to have increased awareness and usage of pedometers in the Canadian population, even producing an effect in the initial campaign launched in midwinter. The repeated effects seen after phase 2, and the apparent dose-response relationship observed, point to the need to continue delivering the message to the population. Overall, there are no targets for message awareness or pedometer ownership, but, if sustained, effects on the population prevalence of walking could be sought; if that occurred, then the initiative would be contributing to health gain among adult Canadians. REFERENCES 1. Craig CL, Russell SJ, Cameron C, Bauman A. Twenty-year trends in physical activity among Canadian adults. Can J Public Health 2004;95(1): Bauman AE. Updating the evidence that physical activity is good for health: An epidemiological review J Sci Med Sport 2004;7(Suppl 1): Craig CL, Cameron C, Russell SJ, Beaulieu A. Increasing Physical Activity: Building a Supportive Recreation and Sport System. Ottawa, ON: Canadian Fitness and Lifestyle Research Institute, 2001; pp. 94, Oguma Y, Shinoda-Tagawa T. Physical activity decreases cardiovascular disease risk in women: Review and meta-analysis. Am J Prev Med 2004;26(5): Kelley GA, Kelley KS, Tran ZV. Walking and resting blood pressure in adults: A meta-analysis. Prev Med 2001;33(2 Pt 1): Kelley GA, Kelley KS, Tran ZV. Walking, lipids, and lipoproteins: A meta-analysis of randomized controlled trials. Prev Med 2004;38(5): Tudor-Locke C. Taking steps toward increased physical activity: Using pedometers to measure and motivate. Research Digest 2002;3(7): Tudor-Locke C, Bassett Jr. DR. How many steps/day are enough? Preliminary pedometer indices for public health. Sports Med 2004;34(1): Canadian Society for Exercise Physiology. Canada s Physical Activity Guide to Healthy Living. Health Canada, Tudor-Locke C, Sisson SB, Lee SM, Craig CL, Plotnikoff RC, Bauman A. Evaluation of quality of commercial pedometers. Can J Public Health 2006;97(Suppl 1):S10-S Buse K, Waxman A. Public-private health partnerships: A strategy for WHO. Bull World Health Organ 2001;79(8): Cavill N, Bauman A. Changing the way people think about health-enhancing physical activity: Do mass media campaigns have a role? J Sports Sci 2004;22(8): See Canadian Fitness and Lifestyle Research Institute at For more information about the Physical Activity Monitor, see See Walk a Block for Lupus campaign at html. 16. See Walk a Block zones created as part of Green Communities Active & Safe Routes to School program at index.php?page=iwalkclub. 17. Health Canada, Canadian Council for Health and Active Living at Work. Stairway to Health, Freimuth VS, Hammond SL, Stein JA. Health advertising: Prevention for profit. Am J Public Health 1998;78(5): Cavill N. National campaigns to promote physical activity: Can they make a difference? Int J Obes Relat Metab Disord 1998;22(Suppl 2):S Smith BJ, Ferguson C, McKenzie J, Bauman AE, Vita P. Impacts from repeated mass media campaigns to promote sun protection in Australia. Health Promot Int 2002;17(1): Bauman AE, Bellew B, Owen N, Vita P. Impact of an Australian mass media campaign targeting physical activity in Am J Prev Med 2001;21: CANADIAN JOURNAL OF PUBLIC HEALTH S27