1.3.1 Global programs aiming to improve vegetable intake
In Australia, the last fruit and vegetable specific social marketing campaign was titled ―Go for 2&5‖. It was managed by the Commonwealth Department of Health in 2005 and targeted adults, encouraging increased fruit and vegetable intake (63). Although multiple strategies such as mass media (radio, television, point-of-sale), school and community activities and press and publications were used for promotion, it is unknown whether younger adults engaged with the messages. The key goal of this program was to support intention formation for the consumption of two servings of fruit and five servings of vegetables daily among adults. The Western Australian ―Go for 2&5‖ campaign, used short positive and motivational messages targeted the primary caregiver within the household who was responsible for shopping and meal preparation (64). Key messages aimed to educate on the recommended daily servings of fruit and vegetables, and address barriers to intake by framing the ease of the process of preparing and eating vegetables. Evaluation revealed a significant increase in vegetable intake by 0.6 serves over a three year period (64).
Page | 46 The United States have also targeted caregivers in their latest campaign launched in 2007, titled ―Fruits & Veggies – More Matters‖ (12). Rather than focusing on promoting the consumption of five servings a day, this campaign promoted small steps to help increase consumption such as adding beans to salads and soups, or processing vegetables to be added to pasta sauces. The messages also focused on inspiring consumers by promoting the benefits of fruit and vegetable intake, including their role in improving health and energy levels. The latest evaluation has revealed that consumption levels have not improved, however, the campaign has been successful in increasing motivation with close to 50% of mothers surveyed very/extremely motivated by the messages promoted (double the percentage since 2007) (12).
A national Danish campaign called ―6 Om Dagen‖ which translates to ―6 a day‖ has been very successful in increasing fruit and vegetable intakes. The number six, which in Danish is pronounced as ―sex‖, was selected as it was predicted to be a notable and effective way to engage consumers, particularly men. The campaign commenced in 1995 and in the period between its launch and 2004, consumption of vegetables increased by 41% in 11-75 year olds (21). The campaign remains effective more than two decades later, with vegetable intakes increasing by 29% between 2008-2011. The most recent national data from Denmark (2011-2013) indicates that vegetable intake has increased from a mean daily intake of 162 g per day to 191 g among 18-75 year olds (21, 65). Given the positive impact ―6 Om Dagen‖ has had on population consumption levels, the campaign continues to be promoted in Denmark and suggests that catchy messages which make the process of eating more vegetables appear
―sexy‖ may be a successful approach to behaviour change.
Page | 47 Aside from population wide marketing campaigns, there have been research-based
interventions for improving fruit and vegetable intake in the general population. A review of 34 studies concluded an average increase in fruit and vegetable intake by +0.8 servings per day. The proportion of this change as vegetables alone was not reported. This review found that among the effective studies, self-efficacy generally promoted greater intake (66).
In 2016, a review of programs solely targeting vegetable intake found a total of 140
interventions (60). However, 81% were conducted with children and only three with young adults. The authors noted that while strategies which may be successful in one population group might also be effective in others, a ―one size fits all‖ approach should not be employed (60). This is particularly important when addressing the underlying motivators of young adults who, as discussed in section 1.2.6, have unique challenges that should be considered.
1.3.2 Interventions for young adults
There are a number of interventions in young adults to improve their lifestyle habits which date back to 1976 (67). A large proportion of the literature in this area is related to weight management for 18-25 year olds, where fruit and vegetable intake is targeted as one lifestyle behaviour for improvement. While the literature has revealed that providing support,
encouragement and feedback are important components for health behaviour change in young adults (67), the evidence from interventions which target fruit and vegetable intake as the primary outcome are limited (68-72). Furthermore, the majority have been delivered within university/college courses within the United States (US) using regular face-to-face contact with facilitators. Living arrangements of college students in the US and Australia differ. Most US students live on campus with meal provisions from the college food service provider. In
Page | 48 Australia, only a minority of students have pre-prepared meals supplied. This limits the
applicability of the US programs within the Australian population and in settings beyond the university/college environment. Furthermore, as these interventions are designed for
individual behaviour change, there is a need for the development of interventions that appeal to individuals but are applicable to young adults within the wider population.
Researchers have suggested testing modern approaches to program delivery such as use of social marketing strategies and technology-based modes of communication to deliver individualized theory-based interventions but at scale to the community-at-large (66). This approach may be particularly useful for younger generations where modern platforms including apps and social media are their primary information sharing resources.
The technological advancements which have occurred in the last couple of decades have encouraged greater interconnectedness and information sharing, particularly through smartphones and social media platforms. While these technologies have been shown to enhance maintenance of behavioural changes (73), little is known about the effectiveness of digital platforms such as social media and smartphones for improving vegetable intake in young adults specifically. Therefore, the research in this thesis aims to explore the impact of using these platforms to deliver a theory-based behavioural intervention in a controlled setting.
1.3.2 Mobile technologies and their use among young adults
The current generation of young adults (GEN Y) are technologically savvy, using platforms such as social media and smartphones for communication more than any other age group
Page | 49 (74). In 2016 95% of Australian young adults aged 18-34 years owned a smartphone and 91%
used their device for social networking (74, 75). In 2015 it was reported that 75% of this age group also used their smartphone to obtain health-related information (76).
This high penetration of smartphone ownership and usage increases accessibility to
smartphone applications (apps) and digital media which have been harnessed by researchers for the delivery of behaviour change interventions. The WHO has termed the use of
smartphones in the public health setting as ‗mobile health‘ (mHealth) (73). ‗Electronic Health‘ or eHealth describes use of the internet to aid with public health practice. It is proposed that capitalising on e/mHealth for interventions can increase efficiency and expand delivery beyond the conventional boundaries (77). The functionalities of smartphone
communication technologies such as dietary assessment and tracking apps (78), short messaging service (SMS), and access to the internet and social networking platforms would likely be more appealing to young adults than traditional modes of intervention such as face-to-face or group education.
Another modern approach for behaviour change is the use of gaming elements such as points and rewards in a non-game context to enhance motivation. This has formally been defined as gamification (79, 80). Gamification has been shown to have implications on the degree of engagement in digital behaviour change interventions (81). Gamification elements serve as affordances to increase intrinsic motivation. Particular elements such as rewards can generate excitement and satisfaction when engaging in the target behaviour (82). This investment of emotion and value towards the activity can result in greater cognitive absorption of the required behaviour and may support ―immersion‖ with the task or goal (81). Furthermore,
Page | 50 rewards can reinforce positive behaviours enabling change (83), habit formation and
maintenance of new behaviours (84).
The effectiveness of e/mHealth interventions for improving the vegetable intake of young adults and the impact of gamification and social networks on nutrition behaviours of this age group have not yet been documented. As such, Chapters Four and Five aimed to review the existing literature and determine directions for future research in this area.