Preferred Child Obesity Message Frames and Their Perceived Strength among State Policymakers

Abstract

Background:

Health message framing, including gain or loss frames, can influence perceptions of child health messaging. It is unknown how characteristics such as political party and education may impact policymakers' message frame preference and perceived strength of child obesity messages. The purpose of this study was to examine preferred child obesity message frame, perceived strength of child obesity messages, and group differences among state policymakers.

Methods:

A cross-sectional online survey was administered in-person to state representatives and senators via electronic tablet between February and May, 2019, at a midwest State Capitol building. Participants were asked their message frame preference and perceived strength of child obesity messages related to long-term health, school, geographic region, military readiness, cost-savings, and the workforce. They were also asked who was responsible for preventing child obesity and strategies to prevent it. Data were analyzed descriptively and via chi-square tests for group differences.

Results:

One hundred fifteen state policymakers completed the survey. Participants overall favored gain-framed messages, which were perceived as stronger than loss-framed. Parents were viewed as most responsible overall for preventing child obesity, with Republicans (vs. Democrats; χ² = 8.54; p = 0.008) and those with less education (vs. more; χ² = 5.97; p = 0.029) perceiving them as more responsible (χ² = 8.54; p = 0.008). Democrats viewed the food industry as more responsible (χ² = 11.4; p = 0.001) than Republicans. Increasing physical activity, nutrition education, and fresh fruits and vegetables in schools were the most preferred prevention strategies.

Conclusions:

Child health advocates should consider using gain-framed messages related to child obesity when communicating with policymakers, and targeting their preferred strategies may enhance policy development.

Introduction

Child obesity is a rampant and complex issue, and addressing it requires strategies and partnerships from a variety of systems, including individuals, organizations, the private sector, and government.¹ Policy change is one potential strategy to influence the health of populations and target reductions in and prevention of child obesity.² For example, the Safe Routes to School program was developed to encourage and enable children to walk and bicycle to school at the state level.³ These policies should include promotion of nutrition education and physical activity messages, which can influence the curriculum and available foods in schools, likely affecting the health of the students. Evidence suggests specific policies related to food or physical activity can be effective,^4,5 yet, less is known regarding more comprehensive obesity prevention policies, and there is a paucity of data on how important policymakers view these comprehensive policies and their language. Further, there is a dearth of evidence to apply messaging data to policymaking in conservative, rural states. Individual states have considerable legislative power to enact and regulate public health policies.⁶ In addition, while local health departments have much of the same policy responsibility as state departments, they typically do not have the same reach as state departments and are limited to powers delegated to them by the state.⁷

To help establish effective child obesity prevention state policies, such as improved requirements regarding school nutrition or physical education, effective messages are needed to inform or educate state policymakers. Policymakers do not have time to be experts in every field, and clear messages from lobbyists or constituents consistent with their wants and needs are crucial to the development of effective policies. Message framing attempts to understand and influence human behavior in the policy process,⁸ which includes advocacy campaigns and policy adoption. Health messages framed as a “gain” are more effective than “loss-framed” messages at promoting prevention behaviors (e.g., exercising to prevent obesity).⁹ Gain-framed messages emphasize what can be gained from following a recommendation, and conversely, loss-framed messages emphasize what can be lost.¹⁰ For example, a gain-framed message might state that exercising regularly would increase weight loss and improved health; whereas, a loss-framed message would state that not exercising regularly would lead to less weight loss and worse health.

Successful health campaigns must identify when to use gain- versus loss-framed messages.¹⁰ However, policymakers seldom use health messages or child obesity research evidence,^11,12 and no studies have examined the preferred message framing of child obesity prevention messages among this group at the state level. In addition, political party and personal characteristics (e.g., senate vs. representative, education level) may influence a policymaker's support of obesity prevention policy,^6,10,13 and understanding these group differences more locally as they relate to child obesity can inform future research and assist in effective policy development at the state level.

The prevalence of child obesity nationally is 18.5%, which has been increasing for the past two decades.¹⁴ More specifically, although the prevalence of child obesity in Missouri (16.3%) is lower than the national average, rates are increasing in youths and high school students.¹⁵ Thus, there is a critical need to address this issue and determine what evidence-based child obesity messaging is most appropriate and relevant to Missouri state policymakers from a prevention standpoint. This will inform advocacy efforts and child obesity laws and policies, as well as identify any group differences among policymakers' preferred message frame. Further, there is a need to determine how important specific child obesity policies are to state policymakers, and what their preferred strategies are to create action.

This study was guided by Prospect Theory, which proposes that decision-making related to external assessments involves trade-offs and explains a pattern of choice based on the framing effects and manner in which choices are presented.¹⁶ The purpose of this study was therefore to identify (1) preferred language and strength of child obesity prevention messages among Missouri state policymakers; (2) the association between message frame and strength; (3) group differences for the preferred messages; (4) who policymakers assign as responsible for preventing child obesity; and (5) preferred prevention strategies among these policymakers.

Methods

Participants and Data Collection

Investigators developed a cross-sectional, electronic survey and administered it to Missouri state policymakers. Missouri was chosen due to its historic role as a bellwether state (i.e., a state that may predict how other areas will vote). The 2019 Missouri General Assembly consisted of 197 members (163 Representatives and 34 Senators). Before commencing data collection, a recruitment email was sent to all 197 policymakers and their legislative assistants, and flyers advertising the study were posted around the Missouri State Capitol building. The survey was administered in-person to state policymakers by each member of the research team at the Capitol building during the months of February to May, 2019. These dates were chosen to maximize recruitment as the 2019 Missouri legislative session ran from January 9 to May 17.

Policymakers were approached in their offices or common areas in the Capitol by a member of the research team and asked to complete the survey on an iPad. When policymakers were unavailable or absent, researchers approached legislative aides to schedule a time for the policymaker to complete the survey with a member of the research team present. Up to four attempts were made to contact the policymakers or their legislative aides. If policymakers declined participation, or their aides declined on their behalf, they were no longer contacted. This information was tracked via electronic spreadsheet that was accessible to all research team members. For the policymakers who agreed to participate, surveys were completed in their offices to ensure privacy and confidentiality. As an incentive, policymakers who completed the survey were provided with an option to have $25 donated to Honor Flight, a charitable organization serving veterans, in their name or anonymously.

Survey Instrument

The survey instrument was first pretested by seven individuals with backgrounds in survey design, policymaking, and lobbying to examine completion time, suggestions for improvement, and comprehension. Suggestions to improve the survey included reducing Likert Scale responses from a 7-point to 5-point scale to reduce time spent on the survey. The final instrument included 21 total questions. The main questions of interest were related to the preferred message frame (see Table 1 showing the message preference questions for each of the following categories: long-term health, schools, geographic area affected, military readiness, cost-saving, and workforce effects).

Table 1.

Questionnaire Questions and Message Frame Responses for the Six Categories Provided to State Policymakers

Question category	Gain frame	Loss frame
Which of the following obesity prevention messages would you prefer to use, as it relates to long-term health:	Taking action to help children grow up at a healthy weight will improve long-term health in Missouri	Not taking action to help children grow up at a healthy weight will damage long-term health in Missouri.
Which of the following obesity prevention messages would you prefer to use, as it relates to schools:	Making changes in schools will help children grow up at a healthy weight.	Not making any changes in schools will increase the number of unhealthy weight children in Missouri.
Which of the following obesity prevention messages would you prefer to use, as it relates to geographic area where your constituents live:	Taking action to help children grow up at a healthy weight will improve the lives of rural children.	Not taking action to help children grow up at a healthy weight will harm rural children.
Which of the following obesity prevention messages would you prefer to use, as it relates to national security and the military:	Taking action to help children grow up at a healthy weight will ensure Missouri children will be fit and ready to join the military.	Not taking action to help children grow up at a healthy weight means too few Missouri children will be eligible to serve in the military.
Which of the following obesity prevention messages would you prefer to use, as it relates to cost savings:	Missouri could save $3 billion in health care costs each year by taking action to help children grow up at a healthy weight.	Missouri spends an extra $3 billion in health care costs each year by not taking action to help children grow up at a healthy weight.
Which of the following obesity prevention messages would you prefer to use, as it relates to industry and the workforce:	Taking action to help children grow up at a healthy weight is good for Missouri's small businesses.	Not taking action to help Missouri children grow up at a healthy weight is bad for Missouri's small businesses.

Participants answered message frame questions one at a time, which was followed by rating the perceived strength of their response on a 5-point Likert scale.

Participants were asked whether they preferred a gain or loss frame, then asked to rank the perceived strength of their choice to create action on a 5-point Likert scale (very weak to very strong). There were also questions on demographics (five questions on house and district, highest education completed, marital status, and number of children); two questions on who is responsible for preventing child obesity (5-point Likert scale from Not at all responsible to Completely responsible) and preferred strategies to prevent it (choose top 3 from a list of nine choices). Two final questions assessed preferred ways to provide child health messaging to the policymakers (e.g., email, phone, etc.) and whether they wanted to receive the incentive.

Participants answered a single question at a time. For all six message frame questions, the order of a gain- or loss-frame answer option was randomized to prevent an ordering effect. The six message frame categories used here were the result of previous work.¹⁷

Data Analyses

Data were analyzed using SPSS (version 26; IBM Corp., Armonk, NY). Frequencies and proportions were examined for all variables and missing data were examined for patterns. Spearman correlations were used to examine the association between preferred message frame and perceived strength. Based on data distributions, Likert responses regarding who is responsible for preventing obesity were combined into two categories (completely/very responsible, and moderately/slightly/not at all responsible) and analyzed using chi-square tests. The Institutional Review Board (at the University of Missouri-Kansas City) approved the study procedures.

Results

A total of 115 policymakers (107 representatives and 8 senators) completed the survey. After accounting for 19 policymakers who declined to participate, 1 unfilled seat, and 2 representatives who resigned their seat during the legislative session, the response rate of all completed surveys was 65.7%, including a 74.3% and 25.0% response rate among the representatives and senators, respectively. The survey took on average 10 minutes to complete. A total of 57 (52.3%) participants accepted the incentive donation, with 29 of those (51.0%) doing so anonymously. Participants in this study were slightly less likely to be male or Republican, and slightly more likely to be a representative, compared to the entire Missouri legislature, the nonresponders, and those who declined to participate (Table 2). The demographics of the sample overall, and for senators and representatives separately, are shown in Table 3.

Table 2.

Study Participants Compared to the Overall State Legislature, Nonresponders, and Those Who Declined to Participate

	State legislature (N = 197)	Study sample (n = 115)	Nonresponders (n = 63)	Declined to participate (n = 19)
Male, n (%)	148 (75.1)	85 (74.0)	48 (76.2)	15 (79.0)
Republican, n (%)	140 (71.0)	74 (64.3)	51 (81.0)	16 (84.2)
Representatives, n (%)	163 (82.7)^a	107 (93.0)^a	39 (62.0)^a	17 (90.0)

Fisher's exact p < 0.05 between study sample and Missouri legislature/nonresponders.

Table 3.

Demographics of State Policymaker Participants

	Overall (n = 115)	House (n = 107)	Senate (n = 8)
Gender, n (%)
Male	85 (73.9)	79 (73.8)	6 (75.0)
Female	30 (26.1)	28 (26.2)	2 (25.0)
Age, years
Mean (SD)	52.4 (13.2)	51.9 (12.9)	57.4 (16.6)
Party, n (%)
Republican	74 (63.2)	68 (63.6)	6 (75.0)
Democrat	41 (35.0)	39 (36.4)	2 (25.0)
Marital status, n (%)
Married	92 (80.0)	85 (79.4)	7 (87.5)
Not married	21 (18.3)	20 (18.7)	1 (12.5)
Number of children, n (%)
0	22 (19.1)	21 (19.6)	1 (12.5)
1	10 (8.7)	8 (7.5)	2 (25.0)
2	40 (34.8)	38 (35.5)	2 (25.0)
3	22 (19.1)	21 (19.6)	1 (12.5)
4	14 (12.2)	12 (11.2)	2 (25.0)
5 or more	7 (6.1)	7 (6.5)	0
Education, n (%)
Bachelor degree or less	59 (51.3)	55 (51.4)	4 (50.0)
Some graduate college or more	56 (48.7)	52 (48.6)	4 (50.0)

Preferred Frame and Perceived Strength of Child Health Messages

Regarding the preferred message frame among the policymakers, for all six categories and across all groups, the gain-framed message was preferred. Two significant within-group differences were noted. Those who were not married (vs. married) were more likely to prefer the loss-framed long-term health message (χ² = 4.73; p = 0.045), and Republicans (vs. Democrats) were more likely to favor the gain-framed military readiness message (χ² = 5.29; p = 0.03).

When examining the association between preferred frame and perceived strength of that frame, all six categories had positive correlations, indicating that those who chose gain-framed messages perceived them as stronger than those who chose loss-framed messages. Long-term health (Spearman ρ = 0.30; Fisher's p < 0.01), geographic region (Spearman ρ = 0.07; Fisher's p = 0.03), cost savings (Spearman ρ = 0.21; Fisher's p < 0.01), and the workforce (Spearman ρ = 0.28; Fisher's p = 0.01) had significant associations between preferred frame and perceived strength. Democrats viewed the strength of the cost savings message stronger than Republicans (Fisher's p-value = 0.002).

Preventing Child Obesity

In terms of ranking those perceived as responsible for preventing child obesity, the policymakers viewed parents of overweight children as most responsible overall (n = 100; 89.3%) and by each of the following: branch, party, gender, marital status, and education level. Further, policymakers who had one or more children, compared to those who had no children, were more likely to perceive parents as responsible (χ² = 13.8; p = 0.001). The policymakers viewed the food industry (n = 50; 45%) and overweight children themselves (n = 40; 36%) as the next most responsible for preventing child obesity. Most of the differences in who was viewed as responsible occurred between political parties, with Republicans viewing overweight children themselves (χ² = 10.1; p = 0.02) and their parents as more responsible (χ² = 8.54; p = 0.008), and Democrats viewing the food industry as more responsible (χ² = 11.4; p = 0.001). Other differences included males (vs. females) perceiving overweight children as more responsible (χ² = 7.69; p = 0.006), and those with less education (vs. more) perceiving parents as more responsible (χ² = 5.97; p = 0.029).

The most frequently reported preferred strategies for preventing child obesity (Table 4) were increasing physical activity in schools (n = 89; 77.4%); increasing nutrition education in schools (n = 62; 53.9%); and increasing the amount of fresh fruits and vegetables in schools (n = 55; 47.8%). The least reported strategies were healthier options at park concession stands (n = 7, 6.1%), advertising bans for unhealthy foods (n = 11, 9.6%), and making it easier for moms to breastfeed (n = 13, 11.3%).

Table 4.

Top Preferred Strategies for Preventing Child Obesity by Missouri State Policymakers (N = 115), from Most to Least Frequently Preferred

Prevention strategy	n (%)
Increasing physical activity in schools	89 (77.4)
Increasing nutrition education in schools	62 (53.9)
Increasing the amount of fresh fruits and vegetables available in schools	55 (47.8)
Healthier options in school vending and concessions	24 (20.9)
Improving the health of food available at food pantries	22 (19.1)
Sidewalks and crosswalks that make it safer to walk to school and other locations	17 (14.8)
Making it easier for moms to breastfeed at work and in public locations	13 (11.3)
Banning advertising for unhealthy foods aimed at children	11 (9.6)
Healthier options at park concession stands	7 (6.1)

Discussion

This study found that state policymakers preferred gain-framed messages related to child obesity, compared to loss-framed, and gain-framed messages were perceived as stronger than loss-framed. The policymakers viewed parents as most responsible for preventing child obesity, and their most preferred strategies for preventing this issue were via schools increasing physical activity, nutrition education, and amounts of fresh fruits and vegetables.

Knowing that these policymakers prefer gain-framed messages that can assist in the process of advocating for tailored child obesity policies, in particular, targeting child obesity messages to the policymakers, rather than the health advocates producing the messages, can improve communication between these groups while creating positive feelings and/or motivated attitudes toward the issue at hand.¹⁸ It is important to note that first steps in the process of adopting and implementing evidence-based decisions include successfully framing and prioritizing a child obesity message.¹⁹

Few group differences were found among the preferred message frame; those that were found included marital status and political party. These findings support the notion that party affiliation serves as an important moderator in determining the success of a message.¹⁰ In this study, a greater percentage of Republicans favored the gain-framed message related to military readiness, supporting other evidence that conservative political views rate this issue highly.²⁰ Of the six message categories used here, four were tested in a national, population-based study (long-term health, health costs, workforce, and military readiness),²⁰ indicating that study findings may be relevant in other states and regions of the country. Another category in this study tested a message around rural child obesity, which could translate to other rural states, and the final category tested a message around schools that may have broad applicability to all states. Future research is needed to determine comparable evidence of these categories in other states.

In terms of perceived strength of preferred messages, those who chose gain-framed messages perceived them as stronger than those who chose loss-framed messages. The only difference by political party included Democrats perceiving the cost savings question as stronger than Republicans, emphasizing that cost savings is one potential strategy to promote societal efforts for reducing child obesity. Some researchers have found that those with conservative political views tend to resist societal causes of health issues,²¹ while others have called for research identifying message strategies that enhance societal rather than individual causal attributions for obesity.¹⁰ However, it is important to note that the policymakers here viewed parents as the most responsible for preventing child obesity, followed by the food industry. The gap between parents and the food industry is very wide as twice as many policymakers viewed parents as the most responsible compared to the food industry. Few policymakers viewed local, state, or federal leaders as responsible, indicating that they may provide little support for public health approaches to prevent obesity. This indicates that more messaging research is needed about the positive role of health policy and the substantial, detrimental role of the food industry in child obesity. One encouraging finding is that those with more reported education were less likely to view parents as responsible, and perhaps those with more education would be more amenable to policy approaches for preventing child obesity.

Policymakers in this study mostly preferred child obesity prevention strategies that involve schools, including increasing physical activity, nutrition education, and fresh fruit and vegetable access. School programs for increasing availability of healthier foods and beverages, plus similar approaches combined with physical activity interventions are recommended obesity prevention strategies from the Community Preventive Services Task Force.²² In addition, federal regulation gives control of school wellness to each local education agency,²³ and, school-based policies may be inexpensive, easy to implement, and might be better supported by policymakers and the food industry.²⁴ However, this also represents an opportunity to educate policymakers on effectiveness of school policies compared to policies supporting community-based prevention strategies outside the school. Evidence suggests that multicomponent, community-based interventions involving local leaders and social structures are more likely to be successful,²⁵ and some promising strategies include involving primary care²⁶ and community parks and recreation centers.²⁷

The response rate in our study was higher than what others have reported when surveying policymakers,^28,29 likely owing to our chosen strategy of collecting data at the Capitol building and in policymakers' offices, rather than mailing or emailing surveys. This supports evidence for collecting information from legislators in person.³⁰ In fact, one important lesson learned from this study was that policymakers are willing and often prefer to meet in person, and that their legislative aides serve as important gatekeepers for facilitating communication.

Limitations

The study was limited by the cross-sectional nature of the data, preventing causal inferences. Findings may not be generalizable to all state policymakers although they are consistent with other states' and national data. Further, the response rate among senators was low and results here may not be representative of that group overall. It is feasible that participants in this study were more interested in health in general, child health specifically, and/or children's education; however, reviewing the legislative committees that participants served on revealed numerous participants with no ties to those areas. Finally, all policymakers were provided with both gain- and loss-frame messages and other designs, such as randomizing policymakers to receive only gain- or loss-frame and then assessing their agreement could enhance understanding of how to persuade them to take action based on the message.

Implications for Practice and Research

How a health message is framed is an important early consideration in the policymaking process, as supported by the findings here. In-person communication using gain-framed messages are preferred by state policymakers, and research is needed to confirm these findings in other states. Findings offer support for using Prospect Theory to guide the study of patterns of choice. Future research could examine whether gain-framed messages impact policy revisions or adoption in Missouri and other states where child obesity is a problem, and whether training based on the knowledge of preferred messages and their perceived strength could improve communication between policymakers and child obesity advocates.

Footnotes

Acknowledgments

The authors are grateful for the assistance and hard work of Jason Rush, Stephanie Hamann, and Andria Caruthers, as well as the participating policymakers and their respective legislative aides.

Funding Information

This study received financial support from the Funding for Excellence Program at the University of Missouri-Kansas City.

Author Disclosure Statement

No competing financial interests exist.

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