Change4Life is England’s first ever national social marketing campaign to reduce obesity. In designing it, the Department of Health and its agencies drew on academic and commercial sector expertise, behaviour change theory and evidence from other successful behaviour change campaigns, and commissioned a substantial and ongoing programme of research among the target audiences.
This led to the creation of a three-year marketing strategy to drive, coax, encourage and support people through each stage of the behaviour change journey. Launched in January 2009, Change4Life focuses on prevention and aims to change the behaviours and circumstances that lead to weight gain, rather than being a weight-loss programme for the already obese. In its first year, Change4Life focused on families, particularly those with children under 11. In years two and three, the campaign has expanded to address other at-risk groups.
Change4Life exceeded all of its first year targets, including:
- The campaign reached 99 per cent of targeted families
- 413,466 families joined Change4Life in the first 12 months
- Over 44,833 families were believed to still be involved with Change4Life after 6 months
- Over 1.9 million responses (postal, online, face-to-face, telephone) were received in year one
The prevalence of obesity in the UK has trebled since the 1980s. Already, around one-third of children and two-thirds of adults in England are overweight or obese. If trends continue as forecast, by 2050 only 1 in 10 of the adult population will be a healthy weight. This could mean a doubling in the direct healthcare costs of overweight and obesity, with the wider costs to society reaching £49.9 billion by 2050.
In response to the rise in obesity, the Government set out its ambition that, in future, all individuals will be able to maintain a healthy weight. To meet this commitment, it is necessary not only to encourage individuals and families to desire, seek and make healthier choices but also to create an environment in which those choices become easier.
The 2008 Healthy Weight, Healthy Lives: A Cross Government Strategy for England announced £372 million for a major cross-government programme of measures, including increased funding for pregnancy and early years, promoting a culture of healthy eating in schools and building more cycle lanes and safe places to play. Fundamentally a prevention strategy, it sets out to change the behaviours and circumstances that lead to weight gain, rather than a weight-loss programme for the already obese.
The initial focus has been on childhood obesity, where the Government’s target is to reduce the percentage of overweight and obese children to 2000 levels by 2020. The strategy sets out a framework for action in five main areas: children, healthy growth and healthy weight; promoting healthier food choices; building physical activity into our lives; creating incentives for better health; and personalised advice and support.
Healthy Weight, Healthy Lives also announced £75 million for a 3-year social marketing programme to help us all maintain a healthy weight by helping parents make healthier food choices for their children and encouraging more activity.
Aims and objectives
The social marketing programme aims to:
- Create a societal movement in which everyone plays their part, helping to create fundamental changes to those behaviours that can lead to people becoming overweight and obese
- Create a segmentation model that would allow resources to be targeted to those individuals most in need of help (i.e. whose attitudes and behaviours place their children most at risk of excess weight gain)
- Provide insight into why those individuals hold the attitudes and behave as they do
- Create a communications campaign to change those attitudes
- Provide ‘products’ (such as handbooks, questionnaires, wall charts and web content) that people could use to help them change their behaviours
- Signpost people to services (such as breastfeeding cafés, accompanied walks, free swimming and cookery classes)
- Bring together a coalition of local, non-governmental and commercial sector organisations to use their influence to change behaviour
To have an impact on long-term behaviour, the programme’s targets were to generate 1.5 million responses from at-risk families, with 200,000 of those respondents converting into a customer relationship management (CRM) programme to support behaviour change.
The focus of the social marketing programme is on:
- The 1.4 million families who have children aged under 2
- The 1.6 million families with children aged 2 to 10 whose children are most at risk of weight gain
- Pregnant women
- Those ethnic minority communities (particularly Black African, Bangladeshi and Pakistani) where levels of childhood obesity are particularly high
The Healthy Weight, Healthy Lives research programme was developed to provide insights into the attitudes and behaviours of families with children under the age of 11 in relation to diet and physical activity. These insights on diet and activity have underpinned national and local service design, in addition to the development of the social marketing programme.
The research sought to develop a rounded picture of the role food and activity currently play in family life, the attitudes driving behaviour relating to diet and activity, and which families exhibit behaviours and attitudes that could put their children at risk of obesity. The research also looked at what activities and communications might start to shift attitudes and therefore change behaviour.
The research programme consisted of five phases:
- Review of the existing evidence base in both academic and market research
- Quantitative segmentation of 883 families of children aged 2 to 10 using the TNS Family Food Panel and bespoke surveys
- Qualitative research by 2CV into current behaviours and attitudes and opportunities for intervention focusing on those families identified as a priority in the segmentation
- Proposition research by 2CV to identify the most effective ways of tackling the issue of family diet and activity levels and promoting behaviour change
- Qualitative research with six ethnic minority communities – Pakistani, Bangladeshi, Black African, Gujarati Hindu, Punjabi Sikh and Black Caribbean communities
Analysis of the quantitative data showed that participating families could be grouped into six clusters according to their attitudes and behaviours relating to diet and physical activity. TNS drew on additional data to add information on each cluster’s demographic make-up, levels of food consumption and levels of obesity and overweight. Subsequently, 2CV used observational research techniques to identify the actual food habits and activity levels that lie behind families’ perceived and claimed behaviours.
Three clusters of families were prioritised, as the data suggested their children were at risk of becoming obese. Within the family, the focus would usually be the mother, who is more often the gatekeeper of diet and activity, although the programme would ensure all materials were accessible for those fathers and carers who want to be involved.
Due to differing cultural drivers, the six ethnic minority communities surveyed did not fit neatly into the mainstream segmentation. Instead, mothers within the six communities fell into four broad groups.
Health and weight
- While people know obesity is an issue (93 per cent of UK parents agree that ‘childhood obesity is an issue of national importance’) they do not realise that it is their issue (only 5 per cent of parents believe their child is overweight or obese)
- Parents routinely under-estimate the amount of food they and their children eat and over-estimate the amount of activity they undertake
- A host of behaviours the research suggests are unhealthy (such as spending a lot of time participating in sedentary activities) have no perceived risk for parents
- Healthy living is perceived as a middle-class aspiration
- Parents prioritise their children’s immediate happiness over their long-term health, the link between poor diet and sedentary behaviour today and future health outcomes is not understood
- Many parents have surrendered control over food choices to their children –allowing children to decide what goes in the supermarket trolley, what they eat and when they eat it – in order to avoid rows
- Parents often prioritise filling children up over feeding them the right foods
- Snacking has become a way of life in many households and is used in emotionally complex ways, for example as a reward for good behaviour and as appeasement
- Many parents lack the knowledge, skills and confidence to cook from scratch and rely on convenience food
- Coping strategies to deal with fussiness can create chaotic, unhealthy family mealtimes
- Most parents believe their children are already active (confusing ‘being boisterous’ with ‘being active’) and believe that schools are already doing enough to make sure children are active
- Sedentary activity (for example watching television and playing computer games) is encouraged by parents because it frees up their own time and they may lack the inspiration or motivation to be more active
- Parents often believe it is too unsafe for their children to play outside
- Some mothers lack the confidence to take part in physical activity with their children
- Parents habitually use cars for short journeys because they believe it is more convenient and they attach status to car usage
Since there was no universally accepted model for behaviour change with regard to obesity and since this was the first time any government had implemented a programme of this nature, scale and ambition, the team derived a set of assumptions from existing literature on behaviour change for diet and activity, which it used to drive its marketing campaign.
The team believed the programme would need two stages:
1. Creating the right preconditions for behaviour change
Before behaviour change could be achieved on any significant scale, people would need to:
- Be concerned that weight gain has health consequences
- Recognise their families are at risk and take responsibility for reducing that risk
- Know what they need to do to change
- Believe that change is possible
2. Supporting people on a behaviour change journey
Consultation and dialogue would need to play a central role and include the following elements:
- Ask – Use a variety of mechanisms to ask as many families as possible about their own behaviours
- Benchmark – Use mass media to bring results to life and tell people how they and their neighbours stand in relation to the nation
- Create practical goals – Allow families to select a behaviour to change, based on their own needs and aspirations
- Record – Provide a mechanism for individuals to record their own behaviour
- Report back – Tell the nation how we are doing
The scoping work resulted in the development of a marketing strategy, which set out what the campaign would say and what tools, techniques and products would be provided at each stage.
Pre-stage: Mobilising the network
Rather than taking a top-down approach, the campaign set out to use marketing as a catalyst for a broader societal movement in which everyone who had an interest in preventing obesity could play a part. The programme began with over six months of engagement with partners and workforces, local service providers, potential local supporters and (non-governmental organisations (NGOs), so that when national marketing started, the public would encounter an informed and supportive local environment. It also enabled those organisations that provide services and commission marketing of their own to join up their activities with the national effort. Other government departments took part by aligning their communications. This phase included social marketing training (including briefing on the research findings), face-to-face presentations and direct marketing.
The programme also set out to recruit ‘local supporters’ – someone from the community whose job it is to promote healthy lifestyles, or an individual who has influence with the target audience (such as a member of a community-minded voluntary group, club or registered charity). What distinguished them was that they would be willing to do more than help their own families.
The potential competition from food retailers was also anticipated and a network of commercial sector organisations was developed to ensure that many of the biggest companies in the UK pledge to support the programme, including Asda, PepsiCo, Kellogg’s and Tesco.
Phase one: Reframing the issue
The campaign would launch with advertising explaining the link between weight gain and illness and reduced life expectancy, positioning this as an issue that could affect the majority of families in the future. It would also tell people where to go for more help and advice.
The team consciously decided to avoid government branding, since research indicated that people were keener to be part of a movement owned by all, rather than prescribed by the Government. Accordingly, agency partner M&C Saatchi created the Change4Life brand, along with a suite of sub-brands (Cook4Life, Play4Life, Swim4Life, etc.) and toolkits for partners to use.
The word ‘obesity’ was avoided, since evidence suggests that focusing on positive messages about healthy lifestyles, rather than directly on weight or obesity, is more likely to create effective behaviour change.
Phase two: Personalising the issue
The next phase would help people recognise that their own families may be at risk of developing obesity because of their current behaviours. The main marketing mechanic for this phase is a ‘How are the kids?’ questionnaire on children’s health and activity, constructed around eight desired behaviours. Respondents would receive a review of their score, along with recommended behaviours they should focus on changing, helpful tips and information about other available resources.
Phase three: Rooting the behaviours
In consultation with the Healthy Weight, Healthy Lives Expert Advisory Group and policy team, the Chief Medical Officer (CMO) and key stakeholders (including the Food Standards Agency), the campaign team defined the behaviours that parents should encourage their children to adopt if they are to achieve and maintain a healthy weight:
To make the behaviours real for people, partner agencies created user-friendly, memorable language for describing them, supplied tips that translated each behaviour into real situations to which target audiences could relate, and created a mechanism for promoting the behaviours as a set. The desired behaviours promoted are:
- Reducing sugar intake (‘Sugar Swaps’)
- Increasing consumption of fruit and vegetables (‘5 A Day’)
- Having structured meals, especially breakfast (‘Meal Time’)
- Reducing unhealthy snacking (‘Snack Check’)
- Reducing portion size (‘Me Size Meals’)
- Reducing fat consumption (‘Cut Back Fat’)
- 60 minutes of moderate intensity activity (‘60 Active Minutes’)
- Reducing sedentary behaviour (‘Up & About’)
Phase four: Inspiring people to change
For people to move from an intent to actual change, they need to be convinced that change is possible and normal. This stage would seek to inspire people to believe that change is possible and convince them that change is already happening. This would include editorials in local press and radio advertising, detailing local services and events, and local people telling stories of how they managed to change their families’ behaviours.
Phase five: Supporting people as they change
All campaign materials would give at-risk families the opportunity to sign up to an ongoing CRM programme that supports behaviour change. Delivered online and by post, this programme would provide encouragement, information and support for families to get their children eating better and moving more. Through a locally searchable database of services provided by partner organisations, people can find activities they can undertake locally.
In conjunction with communications partners and the Central Office of Information (COI), using its Artemis forecasting tool, the following targets were developed for the first year of the campaign:
- To reach 99 per cent of families living in England (defined as an opportunity to see the campaign)
- For 82 per cent of all mothers with children under 11 to recall the advertising campaign (as measured by the tracking study)
- For 44 per cent of mothers with children under 11 to recognise the Change4Life logo (as measured by the tracking study)
- For 100,000 families to complete ‘How are the kids?’ questionnaires
- For 200,000 families to join Change4Life (defined as registering their details with the programme)
- For 33,333 families to still be involved with Change4Life after 6 months
- To generate 1.5 million responses (calls, web visits or paper responses)
Pre-stage: Mobilising the network
‘Mobilising the network’ started in 2008, before any direct communication to the public. An enormous amount of work was done by local authorities (LAs), primary care trusts (PCTs), strategic health authorities (SHAs), regional government offices and commercial and NGO partners to prepare for the public launch. This phase is ongoing and has grown as the campaign has developed.
At the stakeholder launch, seven commercial organisations had signed the Change4life terms of engagement and made pledges to support the campaign. Activity has included:
- Providing lower-cost fruit and vegetables (Tesco)
- Selling 70,000 family bikes at cost (Asda)
- Sponsoring the London Marathon as the Flora Change4Life London Marathon (Unilever)
- Funding breakfast clubs (Kellogg’s)
- Funding free swimming for all customers (British Gas)
At launch there were about 8,000 individuals signed up as local supporters, growing to a current number of 50,000 people. Contrary to initial expectation that local supporters would come primarily from the voluntary sector and community-minded individuals (many parents themselves), 70 per cent are LA public sector workers.
To tell workforces that Change4Life was coming, the CMO and Chief Nursing Officer wrote to every general practitioner and nurse, and the Secretary of State for Children, School and Families wrote to every headteacher, urging them to lend their support to the movement.
Phase one: Reframing the issue
In January 2009, Change4Life was launched officially to the public with television and print advertising, an information line and a campaign website. Three of the main health charities – Cancer Research UK (CRUK), British Heart Foundation and Diabetes UK – also collaborated on a campaign to support Change4Life in women’s magazines.
Phase two: Personalising the issue
The ‘How are the kids?’ questionnaire was distributed to over five million at-risk households. The survey was available online and on paper and was ‘door-dropped’ directly to high-risk cluster areas, delivered face-to-face via field marketing, supported with direct response television, made available in doctors’ surgeries, pharmacies and post offices, and distributed in women’s magazines.
Phase three: Rooting the behaviours
People who responded to the campaign were sent a welcome pack of materials, including a handbook for Healthy Happy Kids, a wall chart detailing target behaviours and stickers for their children.
In addition, three television commercials were made. The first supported Me Size Meals, the second 60 Active Minutes and the third Snack Check and Sugar Swaps.
Phase four: Inspiring change
From June to September 2009, Amra (which represents over 190 regional newspapers) used locally sourced case study material to showcase local activity and reported on upcoming and relevant events that fitted the Change4Life movement.
To improve integration of local marketing activity with the national effort, the Department of Health (DH) created a bid fund to allow SHAs to fund localised activity from the central budget of £1 million – eight awards were made. In addition, it funded advertising space in those publications that have good coverage among at-risk target audiences and invited obesity leads in PCTs and LAs to nominate local services and initiatives for inclusion.
Phase five: Supporting change
200,000 at-risk families who joined Change4Life were entered into a CRM programme, which comprised 4 separate packs of information and resources, designed around the calendar of family life and delivered to their homes. These included items like an activity book, information booklets, snakes and ladders game or a pedometer. A further 90,000 people received a lower-cost electronic version of the CRM programme.
Outside the CRM programme, the team realised there was considerable appetite among the public for interactive products and tools that would stimulate behaviour change and help them track the changes they were making. For this reason, Change4Life agencies were tasked with creating an integrated communications package around the Snack Check and Sugar Swaps behaviours. This involved the creation of a product (Snack Swapper), television advertising, public relations, partnership activity (including free distribution through schools and the NHS) and an online version. Over 2.5 million Snack Swappers were distributed to the public, supplies were exhausted and Snack Swappers gained their own online following through blogs, Facebook and Twitter posts.
A Change4Life Board was created to review progress against campaign objectives, advise on future direction and adjudicate on any disputes arising under the partnership terms of engagement. The board is jointly chaired by the DH Director General of Communications and Director of Health and Wellbeing, with membership from NHS North West, Marks & Spencer, Medical Research Council, The Advertising Association and CRUK.
Before any national partner can work with Change4Life, they must sign the campaign Terms of Engagement. Among other things, the Terms require the organisation to support healthy diet and activity behaviours and the goals of the campaign. Local supporters are required to accept the campaign terms and conditions. All national partners are also required to complete and submit activity application forms for approval by the DH.
In order to create a robust evidence base, 7 per cent of the total marketing budget is being spent on research, monitoring and evaluation of campaign activity, and national partners are required to demonstrate how they will evaluate their own activity and to share any results with Change4Life.
There are three high-level themes to the evaluation programme:
- Monitoring campaign exposure and visibility to the target audience
- Investigating the impact on families
- Tracking the development of a social movement
- Tracker study – Conducted by the British Market Research Bureau (BMRB), this study aims to measure campaign awareness and track intent to change and self-reported behaviour. Every month 300 mothers with children aged 0 to 11 are interviewed face-to-face in their homes. Fieldwork began in December 2008 to provide a baseline.
- Academic study – University College London is using a combination of quantitative and qualitative approaches and a randomised design and control group to gauge the impact of Change4Life marketing materials on family behaviour.
- Artemis database – COI’s Artemis database holds response data for all government campaigns and enables the team to assess the cost-effectiveness of the marketing activity in terms of the volume and nature of responses generated.
- Proxy data – Over time, routine survey data (such as Health Survey for England, National Travel Survey and National Diet and Nutrition Survey) will support tracking of behaviour change, body mass index (BMI) change and other longer-term health outcomes.
- Basket analysis – To understand whether Change4Life might be beginning to have a measurable impact on the food that at-risk audiences were buying, retail media group dunnhumby was commissioned to analyse data from the Tesco Clubcard database to track actual shopping behaviour.
In February 2010, the Government published a full evaluation report of the first year of Change4Life.
|Year 1 target||Year 1 achievement|
|Reach (% of all mothers with children under 11 who had an opportunity to see the advertising campaign)||99%||99%|
|Awareness (% of all mothers with children under 1 who recalled seeing the Change4Life advertising)||82%||87%|
|Logo recognition (% of all mothers with children under 11 who recognised the Change4Life logo)||44%||88%|
|Response to How are the Kids? (total number of questionnaires returned electronically, by post or from face-to-face marketing)||100,000||346,609|
|Total responses (including website visits, telephone calls, returned questionnaires)||1,500,000||1,992,456|
|Sign-up (total number of families who joined Change4Life)||200,000||413,466|
|Sustained interest (total number of families who were proven to still be interacting with Change4Life six months after joining)||33,333||44,833|
- Three in 10 mothers who were aware of Change4Life claim to have made a change to their children’s behaviours as a direct result of the campaign. This equates to over one million mothers claiming to have made changes in response to the campaign
- The number of mothers claiming their children do all 8 behaviours increased from 16 per cent at the baseline to 20 per cent by quarter 4
- The proportion of families having adopted at least four of the behaviours has increased, suggesting the campaign has persuaded people with much less healthy lifestyles to make an effort to improve their health
- Basket analysis found differences in the purchasing behaviour of 10,000 families who were most engaged with Change4Life relative to a control group. In particular, there were changes in the purchases of beverages among Change4Life families, who favoured low-fat milks and low-sugar drinks
- 44 per cent of primary schools, hospitals, general practices, town and village halls, children’s centres, pharmacies, nurseries, libraries and leisure centres displayed Change4Life materials
- Over 25,000 local supporters used Change4Life materials to help them start conversations regarding lifestyles, with over 1 million people
- NHS staff ordered over 6 million items of Change4Life material to distribute to the public
- Primary schools generated over 50,000 sign-ups to Change4Life
- LAs and PCTs joined up their own activities and created new ones, such as street parties and roadshows
Value for money
Independent audits by COI concluded that Change4Life had the fastest awareness build of any government campaign they had ever monitored, and the ‘How are the kids?’ questionnaire was the most cost-effective response mechanism in government.
The government investment in Change4Life attracted:
- £1.5 million in spend from other government departments
- A further £7.5 million of national partner activity
- £12,457,572 in free media space for the launch
- £532,393 in free media around the sponsorship of Channel 4’s The Simpsons
- £200 million in commitments by the Advertising Association consortium
An independent review of the media buying for Change4Life highlighted that over £6 million worth of media savings were made across the year, the equivalent of 40 per cent of the actual spend.
Evolving the campaign
The evaluation from the first year’s activity made it clear that more targeted approaches would be needed for specific subsections of the community. It also revealed that it was significantly more cost-effective to recruit people into the programme via peers and by using public sector institutions, such as schools, than via mass media advertising or on-street promotions. Going forward, therefore, the team plan to focus more on government channels and de-prioritise paid-for distribution channels, making the campaign more cost-effective.
During the second phase of the programme (2010 to 2012), more effort has been put into providing materials for schools to encourage children to make pledges to change their diet and/or activity levels, and developing a clearer role for the Change4Life sub-brands and ambassadors.
The programme has produced targeted interventions and materials for pregnant women and parents of children under the age of two (under the Start4Life sister brand, which launched to the public in January 2010), for ethnic minority communities (a bespoke campaign launched in late 2009) and for middle-aged adults (a campaign targeting 45- to 65-year-olds launched in February 2010).
Although Change4Life was developed for England, meetings have been held with devolved administrations and, in February 2010, Wales launched its version of Change4Life, including a Welsh-language version of ‘How are the kids?’
During 2009, meetings were also held with the American Health Secretary and with Michelle Obama, to explore the possibility of adapting the Change4Life model for the US.
With the change in government in summer 2010, the new coalition government has progressively scaled back Labour’s £75 million marketing budget for Change4Life in its plans to cut its ad spending by up to 50 per cent. Controversially, Health Secretary Andrew Lansley has been asking the food and drink industry to take greater responsibility for funding the anti-obesity initiative in exchange for no new regulation.
"We have to make Change4Life less a government campaign, more a social movement. Less paid for by government, more backed by business. Less about costly advertising, more about supporting family and individual responses." Andrew Lansley, Health Secretary
As part of this new approach, the Great Swapathon campaign was launched in January 2011, which aims to urge families to swap at least one unhealthy habit for a healthier one. Partnering with News of the World and Asda, Change4Life is giving away 5 million voucher booklets, worth over £50 each, with money off healthier foods, drinks and activities.
What worked well
- Embedding Change4Life within the broader policy context. The programme is not an add-on – it is an integral part of Healthy Weight, Healthy Lives. It has helped to bind the policy together and explain it to the public
- Basing the programme on the latest evidence, including evidence generated through ongoing campaign research and monitoring, sharing that evidence base widely and seeking expert opinion to guide decisions where the evidence base was limited
- Engaging specialist suppliers, all of whom, while outstanding in their own field, are also capable of working together in a spirit of cooperation
- ‘Open source’ marketing – The creation of sub-brands and allowing partners to create their own sub-brands, content and programmes, encouraging them to feel that they are part of a bigger initiative
- Building a coalition of partners, including commercial sector, NGOs and other government departments
- Working to engage the local NHS and the schools. Pre-existing networks, such as regional obesity leads, regional physical activity leads and healthy schools coordinators have all worked hard to promote the movement in their areas
- The Change4Life brand identity captured the imagination of the public and made it possible to land some hard-hitting messages in an engaging and charming way. It has also provided a rallying call for those already working in the area
- The ‘How are the kids?’ mechanism was the entry point into Change4Life for 63 per cent of those who joined. Without it, the campaign would have ended the year with a database of only 149,458 families, about 50,000 short of its target. In addition, families who joined Change4Life through ‘How are the kids?’ engaged more frequently with other aspects of the programme
What worked less well
The campaign was developed (and is being delivered) at great speed. The team would advise others contemplating such a programme to:
- Spend more time on the ‘Mobilising the network’ phase: On reflection, there was an under-estimation of the amount of time it would take to engage properly
- Start the CRM programme sooner – Many families waited months for their first CRM pack. The CRM programme should have been ready to go out to families as soon as they joined Change4Life
- Develop more products for professionals, such as teachers and doctors, who have a professional interest in combating obesity