Evaluating the effectiveness of an Australian obesity mass-media campaign: how did the Measure-Up campaign measure up in New South Wales?

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1 HEALTH EDUCATION RESEARCH Vol.28 no Pages Advance Access published 20 August 2013 Evaluating the effectiveness of an Australian obesity mass-media campaign: how did the Measure-Up campaign measure up in New South Wales? E. L. King 1, A. C. Grunseit 2 *, B. J. O Hara 2 and A. E. Bauman 2 1 Cancer Australia, Level 14, 300 Elizabeth St, Surry Hills, NSW 2010, Australia and 2 Prevention Research Collaboration, Level 2, Medical Foundation Building, 92 Parramatta Rd, University of Sydney, Camperdown, NSW 2006, Australia *Correspondence to: A. C. Grunseit. anne.grunseit@sydney.edu.au Received on October 22, 2012; accepted on July 10, 2013 Abstract In 2008, the Australian Government launched a mass-media campaign Measure-Up to reduce lifestyle-related chronic disease risk. Innovative campaign messages linked waist circumference and chronic disease risk. Communication channels for the campaign included television, press, radio and outdoor advertising and local community activities. This analysis examines the impact of the campaign in the state of New South Wales, Australia. Cross-sectional telephone surveys (n ¼ 1006 adults pre- and post-campaign) covered self-reported diet and physical activity, campaign awareness, knowledge about waist circumference, personal relevance of the message, perceived confidence to make lifestyle changes and waist-measuring behaviours. The campaign achieved high unprompted (38%) and prompted (89%) awareness. From pre- to post-campaign, knowledge and personal relevance of the link between waist circumference and chronic disease and waist measuring behaviour increased, although there were no significant changes in reported fruit and vegetable intake nor in physical activity. Knowledge of the correct waist measurement threshold for chronic disease risk increased over 5-fold, adjusted for demographic characteristics. Measure-Up was successful at communicating the new campaign messages. Continued long-term investment in campaigns such as Measure-Up, supplemented with community-based health promotion, may contribute to population risk factor understanding and behaviour change to reduce chronic disease. Introduction There is evidence that overweight status, unhealthy diet and low physical activity levels contribute to population risk for non-communicable disease [1]. In Australia, the direct costs of overweight and obesity have been estimated at AUD21 billion annually [2]. In , 68% of Australian men and 55% of women were classified as overweight or obese [3]. Furthermore, 70% of Australian adults are either sedentary or had low levels of exercise, 52% do not eat the recommended servings of fruit and almost 80% report a usual intake of less than four serves of vegetables per day [4]. These risk factors increase the risk of chronic (non-communicable) disease, particularly diabetes, cardiovascular disease andsomecancers[1,5,6]. As these are modifiable risk factors, State and Federal governments across Australia have invested in policies and programmes to promote healthier lifestyles. Mass-media communications, led by television advertising, is one tool that Governments have used to increase awareness of risk factors and encourage behaviour change [7 9]. Mass-reach communications and marketing principles have been used to promote socially beneficial behaviour ß The Author Published by Oxford University Press. All rights reserved. For permissions, please journals.permissions@oup.com doi: /her/cyt084

2 E. L. King et al. change [10] and have been used in Australia to address smoking [11], cancer screening [12], sun exposure [13], nutrition [14] and physical inactivity [15], but rarely to influence obesity. Mass-media campaigns can positively influence community knowledge, awareness, beliefs, attitudes and some behaviours across large populations [16 18] and influence behaviour in both direct and indirect ways. Direct influences are through the campaign messages, influencing knowledge to stimulate behavioural awareness and attempts to change behaviour; indirectly, campaigns influence social norms, public opinion and public policy. There are a few previous examples of mass media to influence adult overweight and obesity-related cognitions and behaviours, and these have improved population understanding of the risks associated with obesity, and to a lesser extent, the weight-related behaviours of participants [19 21]. In 2008, the Australian Government launched the first nation-wide mass-media campaign aimed at reducing the prevalence and impact of chronic disease by raising awareness of the relationship between waist measurement, physical activity, healthy eating and obesity risk among adults. This Measure-Up campaign ( represented a considerable investment (approximately $AUD30 million over a 4-year period) from both national and state Governments. The purpose of this study was to evaluate the population-level impact of the Measure-Up campaign on adults in the state of New South Wales (NSW), Australia. The specific research questions were developed to examine the impact of the immediate campaign priming steps relating to increased campaign awareness, knowledge, personal relevance, confidence and behaviour change relating to improved nutrition and physical activity levels. The research questions were: (i) did the campaign achieve sufficient reach (as measured by unprompted and prompted awareness and recognition) of the main messages of the campaign, (ii) did knowledge and personal relevance about the link between waist circumference and chronic disease increase following the campaign and (iii) was there an increase in respondent s perceived confidence to make changes to their lifestyle risk factors (diet and physical activity) and waist measuring behaviours post-campaign. Methods Measure-Up campaign The Measure-Up campaign focused on the innovative message of waist circumference as an indicator of an unhealthy lifestyle and objective indicator of chronic disease risk. Formative qualitative research prior to the campaign indicated the broad appeal of information about a healthy waist circumference as a compelling, credible and easy to understand goal [22]. Further qualitative research confirmed the salience of the consequences for the media advertisement portrayal of progressive weight gain over time [23]. The first wave of the Measure-Up campaign advertising ran from late October 2008 to April 2009 and utilized television, radio, magazines, online and out of home settings as the main media channels. Two television commercials led the campaign and are described in Box 1. The Measure-Up campaign targeted all adult Australians, with a particular focus on 25- to 50- year olds with children, with the message identifying that parental behaviour is likely to have an impact on their longevity and their children s lifestyle behaviours. The secondary target audience was 45- to 60-year olds, due to the likelihood of either having been diagnosed with a chronic disease or experiencing the consequences of an unhealthy lifestyle ( The first wave of activity (late 2008) included a launch of the 60- and 30-s television commercials airing across NSW at 150 Target Audience Rating Points (TARPS) as a measure of the volume of weekly television advertising scheduled to reach the target audience [24], and was followed by shorter television messages, magazine and online advertising. Based on the media purchased, media plan estimates indicated that 75 80% of the target audience would likely see the TV commercial at least once (1 + reach 75 80%); 65% were expected to see the 1030

3 Evaluating the Measure-Up obesity prevention campaign Box 1. Description of the Measure-Up campaign television commercials The first commercial (60 s) shows a young man walking along an oversized tape measure. As he walks towards the viewer he progressively ages and gains weight. His young daughter comes in to the picture. As he ages, the same daughter, now aged 10, enters again and he attempts to run after her but loses his breath and stops. The voiceover says unhealthy eating and drinking, and not enough physical activity can seriously affect your health. For most people, waistlines of over 94 cm for men and 80 cm for women increase the risk of some cancers, heart disease and type-2 diabetes. The final voiceover says The more you gain, the more you have to lose, with the tagline How do you measure up? The second commercial (30 s) shows the same man with a waist measurement of 100 cm who says that he is choosing to turn his life around. As he turns around to walk back down the tape measure, signifying a reduction in his waist circumference, the voiceover says it is never too late to start taking steps, and aim for 30 minutes or more of physical activity every day. Then the man is shown eating an apple (Voiceover: 2 serves of fruit and 5 serves of vegetables a day can improve your health ). The graphic What measures will you take? is followed by the web address Australia.gov/au/MeasureUp (Note female versions of very similar Measure Up messages were also shown). magazine advertisement and 70 75% of the target audience were estimated to hear the radio advertisements. The second wave of advertising (March 2009) had 150 TARPS in the first week and 100 TARPS in the subsequent 3 weeks. Estimated TV reach was 72 77% of the target population, estimated magazine reach was 77% and estimated target audience reach via radio was 70 75%. The media campaign used the risk of chronic disease as an emotional hook and to convey and persuade adults why lifestyle change is necessary. It promoted waist circumference as a new way of objective indicator for risk of chronic disease and as an impetus to personalize the call to action. Motivation to improve nutrition and physical activity levels was supported by the positive modelling of these behaviours. Within NSW, regional health services and key non-government organizations were funded to undertake local support activities around the campaign, including the distribution of campaign messages and materials, public relations and media activities and co-branding of local events and groups. Evaluation study design A key component of campaign evaluation is an assessment of campaign reach and impact [25]. The campaign was evaluated using cross-sectional pre post-campaign telephone surveys of randomly selected adults aged years. The campaign tracking survey collected data in four main areas: awareness and exposure (including campaign recall, campaign recognition and placement); understanding of the message (including message takeout and knowledge); salience of message (including perceived personal relevance) [25] and behavioural intentions and action. Baseline data collection was in October 2008 prior to the launch of the campaign, and follow up was completed in April A market research company specializing in the design and implementation of mass-media tracking surveys were contracted by the Australian Government to undertake the Measure-Up tracking survey. This study was approved by the University of Sydney Human Research Ethics Committee. Study population and sampling The analysis was based on a NSW sample, targeting adults living in NSW households with landline telephones. Households were contacted using random digit dialling, and sampling was based on population representative quotas for age, gender and location (capital city and non-capital city) with stratification so that smaller locations had a robust sample size. Up to five call attempts were made to each generated number before retirement from the sample, and 1031

4 E. L. King et al. where there was more than one eligible respondent in the household, the next birthday technique was used to select a participant [24]. Response rates, as a proportion of those contacted, were 28% and 35% for each wave of data collection. Data were weighted to the 2006 Australian Bureau of Statistics (ABS) population distributions by gender, age and location for analysis (capital city and non-capital city) [26]. Analysis Measures Self-reported risk factors. Fruit and vegetable consumption were measured by asking respondents the number of serves they usually eat each day, accompanied by a definition of a serve. Responses were coded as to whether the amount met current Australian Dietary Guidelines for adults of two serves of fruit and five serves of vegetables per day [27]. For physical activity, respondents were asked the number of sessions and total minutes spent walking (including for transport), in moderate activity (other than walking), and in vigorous activity in the last week [28]. Total minutes per week spent in physical activity were calculated [28], and respondents were classified as sufficiently physical active or not, based on meeting national recommendations [29]. Body mass index (BMI) was calculated from self-reported height and weight and categorized as underweight/acceptable: BMI < 25, overweight: 25 BMI < 30 or obese: BMI 30. Awareness of Measure-Up campaign. Unprompted recall of the Measure-Up campaign was assessed by asking respondents to describe: any advertising campaigns about lifestyle, being overweight and chronic disease they had read or heard in the last month. The open-ended responses were systematically coded separately by two researchers (E.L.K. and B.J.O H.) and cross-validated as to whether the description was identifiably related to the campaign. Responses considered as definitely referring to Measure-Up included references to the creative execution of the advertisement (e.g. man walking along measuring tape ) and/or messages about waist size and risk of chronic disease. Prompted awareness was measured by describing the specific advertisements used on television, radio, in the print media, on shopping trolleys and the internet and asking whether respondents recalled seeing these advertisements. Knowledge. Knowledge of the health information conveyed in the Measure-Up campaign were assessed by open ended questions asking for: chronic diseases caused by an unhealthy lifestyle; recommended amounts of vegetables, fruit and physical activity required to maintain good health; and the waist measurement(s) associated with increased risk of chronic disease. Answers were coded as correct only if they were exactly correct; that is answers nominating an amount of fruit/vegetables or physical activity higher (or lower) than national recommended guidelines were coded as incorrect. Although men s and women s risky waist size thresholds were asked of all respondents, for the current analysis only respondents answers for their own sex (80 cm for women, 94 cm for men, [30]) are reported. Perceptions about lifestyle and chronic disease prevention. Five questions gauged respondents perceptions of lifestyle factors and the prevention of chronic disease. Table II details the exact wording for these measures. The first asked whether respondents agreed that waist measurement is strongly related to a person s risk of developing a chronic disease with a five-point Likert response scale from strongly agree to strongly disagree with a further option of don t know (recoded to neither agree nor disagree for analysis). Four further questions asked respondents to rate the importance of preventing chronic disease on a scale of 0 (not at all important) to 10 (extremely important) of a number of weight-related practices (details in column 1, Table II). Variables were analysed individually and as a scale ( Importance of chronic disease prevention scale) created by summing the raw scores over the four items where there were no missing data (range 4 40, Cronbach s alpha ¼ 0.74). Perception of relevance. Four items examined respondents perceived personal relevance of the risk of chronic disease and perceived confidence to 1032

5 Evaluating the Measure-Up obesity prevention campaign change their lifestyle (exact wording in column 1, Table II) using a five-point Likert scale rated from strongly agree to strongly disagree with don t know recoded to neither agree nor disagree for analysis. Behaviour. Two behaviours directly relating to the main message of the Measure-Up campaign regarding waist circumference were used in the current analysis: (i) whether the respondent had measured their waist in the last 6 months (yes/no) and (ii) whether they were able to provide their waist measurement (yes/no). Statistical analysis Demographic characteristics, self-reported risk factors and behaviours, awareness of campaign, knowledge, perceptions, personal relevance, perceived confidence and behaviour were compared pre- to post-campaign. Categorical variables were analysed using chi-square and one-tailed t-tests (testing whether outcomes improved pre- to post-campaign) were used for continuous/ordinal variables. Where the data were skewed, median tests were carried out. Multivariable logistic regression analysed change pre- to post-campaign for unprompted recall of the Measure-Up campaign, knowledge of correct risk waist measurement (matched for gender) and whether the respondent reported measuring their waist in the last 6 months, adjusted for age (binary years approximating the secondary target group versus reference category years), gender, education (less than high school, completed high school, higher degree), employment (employed versus not employed) and household yearly income tertiles (<$50 000, $50 $ , more than $ ). Data were weighted for age, gender and location (Sydney versus elsewhere in NSW) to the NSW population [26], and analyses were conducted using Stata version 11.1 survey commands to incorporate the sampling weights [31]. Results The demographic and risk factor behavioural characteristics of the survey samples before and after the campaign were similar. Half were male, 60% in the age group and over two-thirds in paid employment (Table I). Just over a third reported completing tertiary education. There were no significant differences between the survey samples pre- and post-campaign on demographic characteristics. Overall, 55.3% and 54.4% reported height and weight data that classified them in the overweight or obese categories pre- and post-campaign, respectively, and there were no differences between the pre- and post-campaign samples in proportion meeting dietary guidelines for fruit and vegetable consumption (Table I) or the median number of serves of fruit (two) and vegetables (two) consumed (data not shown, P > 0.05). There was a small (but statistically marginal) decrease in the proportion meeting physical activity recommendations from pre- to post-campaign. Additional analyses, however, showed that the median minutes of total physical activity did not change from pre- to post-campaign (330 and 300 min, respectively, P > 0.05). The impact of the campaign on message awareness and knowledge is shown in Table II. Unprompted campaign awareness increased from 1.1% pre-campaign to 38.2% following the campaign (P < 0.001). Prompted awareness (post-campaign only) was reported by almost 90% of survey responders. Specific message recognition was also asked post-campaign, and the messages that respondents had perceived to be communicated by the campaign were about waistline and risk (reported by 82%), 30 min of physical activity (82%) and healthy nutrition (66%). Among the knowledge items (Table II), a significant increase was noted for recommended vegetable intake, recommended minutes of physical activity and correct risk waist measurement threshold (asked separately by gender). Five statements asked for perceptions about chronic disease risk (Table II) and only the two items about the link between waist size and chronic disease and the importance of maintaining an acceptable waist circumference along with the overall importance of prevention of chronic disease scale showed significant increases. No change was seen in the perceived confidence questions. In terms of behaviour, the proportion of respondents 1033

6 E. L. King et al. Table I. Demographic characteristics and self-reported risk profile for pre- and post-campaign samples Pre-campaign Post-campaign P-value a Demographic characteristics b Gender Male Female Age Highest level of education Less than HSC HSC/TAFE Degree or higher Employment status Not in paid employment In paid employment Household income <$50 k $50 k to <$100 k $100 k Do not know/refused Language spoken at home English Other Self-reported risk factors c % Current smoker % meeting PA recommendations % meeting fruit recommendations % meeting vegetable recommendations BMI d Underweight/acceptable Overweight Obese % self-rated health good/very good/excellent a Significance of chi-square test of independence. b Unweighted analyses. c Percentages weighted to population for age, sex location (capital/non-capital city). d Missing 7.9% (n ¼ 159) for self-reported height/weight. who reported measuring their waist recently and gave a waist measurement at survey both increased significantly following the campaign. Table III shows the adjusted odds ratios (AOR) for the waist-measurement-related variables, comparing post- with pre-campaign values. Unprompted recall was much more likely post-campaign (AOR ¼ 55.8, the pre-campaign rate is a ghost baseline ). In addition, older adults (45 65 years) had almost half the odds of recalling the campaign, and more educated and more affluent adults were more likely to recall the Measure-Up campaign. In the second model, women had higher odds of knowing the correct waist measurement associated with increased risk of chronic disease, and post-campaign responders had over 5-fold the odds of being correct compared with the pre-campaign sample. For the final model (right hand column, Table III), the post-campaign responders and adults with Grade 12 or higher education were 1034

7 Evaluating the Measure-Up obesity prevention campaign Table II. Awareness, knowledge, perceptions and behaviours relating to main messages of Measure-Up campaign at pre- and post-campaign Pre-campaign Post-campaign Variable n ¼ 1006 n ¼ 1006 P-value a Awareness Unprompted awareness of Measure-Up advertisement 1.1% b 38.2% <0.001 Prompted awareness of Measure-Up advertisement n/a 89.4% Did Measure-Up communicate the message... Waistlines over 94 cm for men and 80 cm for women increase risk n/a 82.2% 30 min or more physical activity helps maintain good health n/a 82.3% Two serves of fruit and five serves of vegetables can improve health n/a 65.8% Knowledge Chronic diseases caused by an unhealthy lifestyle (% mentioning at least one of type 2 diabetes, heart disease, cancer) 90.9% 90.1% Recommended serves of vegetables/day (5) 26.6% 29.6% <0.001 Recommended serves of fruit/day (2) 38.5% 37.8% Recommended minutes of physical activity/day (30) 50.3% 56.5% Waist measurement associated with increased risk of chronic disease for men (% correct men only, n ¼ 994) 0.2% 7.9% <0.001 Waist measurement associated with increased risk of chronic disease for women (% correct women only, n ¼ 1018) 6.4% 24.5% <0.001 Proportion of Australian adults who are overweight (% 1 in 2) 42.9% 46.3% Perceptions about lifestyle and chronic disease prevention Waist measurement is strongly related to risk of developing a chronic disease (% agreeing) 76.2% 82.7% <0.001 Importance of eating five serves vegetables day to prevent chronic disease (mean, SD) c 7.9 (2.0) 8.0 (1.9) Importance of doing 30 min physical activity to prevent chronic disease (mean, SD) c 8.7 (1.5) 8.7 (1.5) Importance of maintaining a waist circumference of <80 cm/94 cm to prevent chronic disease (mean, SD) c 7.6 (2.1) 7.9 (1.9) <0.001 Importance of maintaining a healthy weight to prevent chronic disease (mean, SD) c 8.7 (1.4) 8.7 (1.4) Importance of prevention of chronic disease (scale) (mean, SD) 33.0 (5.0) 33.4 (5.2) Personal relevance of ad message My lifestyle is increasing my risk of getting a chronic disease (mean, SD) d 3.4 (1.5) 3.3 (1.5) Perceived confidence I am confident I could increase my PA to improve my health (mean, SD) d 1.9 (1.1) 1.9 (1.1) I am confident I could increase my fruit and vegetable intake to improve my health (mean, SD) d 2.0 (1.1) 2.0 (1.1) I am going to change my lifestyle to become healthier (mean, SD) d 2.2 (1.2) 2.2 (1.2) Behaviour Have you measured your waist circumference in the last 6 months 31.4% 36.6% Gave a measure of own waist circumference 21.1% 26.6% a Significance value for comparison pre- to post-campaign using chi-square for categorical data and one-tailed t-test for means. b Unprompted recall pre-campaign reflects spurious recall of images/messages related to the Measure-Up campaign. c Range 0 10, higher scores indicate greater importance. d Range 1 5, higher scores indicate greater disagreement. 1035

8 E. L. King et al. Table III. Factors associated with unprompted recall of Measure-Up campaign, knowledge of waist measurement (matched for gender) and waist measurement in the last 6 months a Unprompted recall of Measure-Up ad Knowledge of correct waist measurement Measured waist in last 6 months Variable (reference category) AOR (95%CI) P b AOR (95%CI) P b AOR (95%CI) P b Gender (male) Female 1.27 ( ) ( ) < ( ) Age (18 44 years) years 0.55 ( ) < ( ) ( ) Education (<12 years) <0.001 c c <0.001 c Graduated high school 1.52 ( ) ( ) ( ) Degree or higher 2.40 ( ) < ( ) ( ) <0.001 Employment (not employed) Employed 0.70 ( ) ( ) ( ) Household income (<$50 k) c c c $50 k to <$100 k 1.63 ( ) ( ) ( ) $100 k ( ) ( ) ( ) Wave (pre-campaign) Post-campaign ( ) <0.001 d 5.57 ( ) <0.001 d 1.23 ( ) d a All models adjusted for age, gender, education, income and employment. b Category compared with reference category. c Overall significance test for multiple category variable. d One-tailed test to detect an increase in odds post-campaign compared with pre-campaign. more likely to have measured their waist in the previous 6 months, although employed adults had 24% lower odds of having done so, compared with those not-employed. Discussion Using a completely new way of framing obesityrelated lifestyle risks, the Measure-Up campaign reached most NSW adults with campaign-relevant messages. Waist measurement as an indicator of chronic disease risk rather than just weight was an innovative approach, never before explicitly used in purposive mass-reach campaigns. There are few campaigns reported that have focused on weight rather than weight-related behaviours (such as nutrition and physical activity) [19 21]; and the Measure-Up campaign is the first nationwide campaign implemented in Australia that has focused explicitly on this important public health issue. Consistent with other similar campaigns, the findings show that mass media of this type can achieve effective awareness and impact health knowledge, attitudes and motivations [19 21]. Campaign awareness in other studies that have evaluated obesity campaigns, has been estimated at around 60% (at first wave for continuing campaigns) therefore the recognition rate of almost 90% in the current campaign demonstrates high comparative reach [20, 32 34]. The sizeable media purchase was a likely contributor to substantial population reach and reached the target age group. Awareness of the campaign was higher among women than men, and among more educated and more affluent adults, unsurprising as women are often more receptive to health messages than men [35, 36], as are those from higher socioeconomic strata [37]. Women were also more likely than men to accurately recall the waist measurement associated with chronic disease for their gender which may reflect their greater likelihood to attempt weight loss when compared with men [38, 39]. Future campaign development could explore how women s receptiveness to weight-based campaign messages could be used to leverage male engagement. 1036

9 Evaluating the Measure-Up obesity prevention campaign The NSW adult population showed increases in understanding the waist message, the link between waistline and risk of chronic disease and recommended daily physical activity levels and in reported waist-measuring behaviour in the previous 6 months, again, showing an educational gradient. It was encouraging that these more distal effects of understanding and trialling of the new behaviours of waist assessment changed, and were likely to have been influenced by the campaign. However, there were no notable changes seen in self-reported physical activity or healthy nutrition behaviours, or in confidence that these could change. This is a limitation: the campaign created a waist-awareness climate, but did not, by itself, influence antecedent obesogenic behaviours, at least not in the short term. Similar underestimations of the personal relevance of key lifestyle factors and lack of behaviour change have been identified in other adult overweight and obesityrelated mass-media campaigns [32, 33, 40]. Such findings highlight the complexity of translating awareness into motivation to change behaviour despite formative research for the current [22] and other campaigns [41] guiding campaign development to maximize personal relevance. Few previous whole-population mass-media campaigns have focused on obesity prevention [14, 33, 42]. Several have focused on nutrition alone, such as the Five-a-Day or Two-and-Five campaigns [9], mostly targeting fruit and vegetables, or have been part of the media components of multi-strategy cardiovascular prevention programmes [43, 44]. Numerous campaigns have targeted physical activity [15, 25, 45], including total energy expenditure through active travel, workrelated activity and leisure time activity [25]. Most of these healthy lifestyle (nutrition and physical activity) campaigns used a positive message frame, rather than the fear arousal approach that emphasizes health risks and consequences; the latter approach has often been used in anti-tobacco campaigns, HIV prevention and some immunization campaigns [16]. The Measure-Up campaign framed the risk of chronic disease as being avoidable if lifestyle risk factor behaviours were changed. To this end, this campaign targeted adults with young families, with message appeals focussed on long-term lifestyle consequences and the potential impact on adults ability to engage with their children. In addition, the Measure-Up message was individually focused, with the emphasis on personal responsibility and behaviour change (see Box 1). Formative qualitative findings suggest that the characters in the messages were seen as credible and socially normative ( like me...or its happening to me ), which could stimulate thinking about behaviour change [23]. However, there is a risk that this approach to message development may appeal to the worried middle-class, who may be receptive to the message, as it does not acknowledge the social and physical environments in which obesity occurs [46]. Omitting these structural and ecological factors from the message, or only emphasizing solutions that are within the realm of individual-based choices could be viewed as supporting a victim blaming style of communication. This approach may make the action steps following this campaign less accessible for more disadvantaged population segments [47, 48]. This campaign evaluation had several limitations. First, the design was uncontrolled, as is commonplace in whole population campaigns [25]. However, as this message was quite new, and waist measurement was not well understood prior to the campaign, and campaign exposure was high it is plausible that the campaign was a contributor to the observed changes in waist-specific understanding and behaviour change. Second, there was no objective measurement of weight, physical activity, nutrition or waist assessment, and the primary campaign outcomes were self-reported phenomena. Third, the response rate was low, but baseline risk factor levels were very similar to NSW adults in the state-wide representative population health surveys [49]. Finally, there are no clear process evaluation data on the implementation of concurrent community-wide activities and programmes to support this mass-media led campaign, nor data from other sources such as primary care visits, enrolment in overweight/obesity services that could provide further information on impact. That is, these data report 1037

10 E. L. King et al. primarily on the impact of the mass-media component, and only in the short term. Longer term community, non-government organization and regional government engagement with the subsequent phases of the Measure Up campaign will be required to support and reinforce the media messages, to develop programmes that recognize the socio-ecological causes of obesity, and to provide a range of programmatic and service options that people can access. The Get Healthy Information and Coaching Service, established in February 2009 [50], provides an example of how effective programme delivery, focused on the adoption of healthy behaviours amongst NSW participants [51], can support the longer term impact on behaviour change initiated by mass-media campaigns such as Measure-Up. Conclusion The Measure-Up campaign was effective in raising awareness and improving knowledge about the relevance of waist circumference as a personal indicator of chronic disease risk. It is important to build on the initial successes of this first phase of the Measure-Up campaign. To continue to influence the priming steps of increased awareness, and turning that into population behaviour change and changes in long term social and cultural norms will require more than mass communications alone, and needs an integrated multi-faceted approach. Mass-media campaigns such as Measure- Up are only a first but important step. Conflict of interest statement None declared. References 1. Australian Institute of Health and Welfare. Chronic Diseases and Associated Risk Factors in Australia Canberra: AIHW, Colagiuri S, Lee CM, Colagiuri R et al. The cost of overweight and obesity in Australia. Med J Aust 2010; 192: Australian Bureau of Statistics. National Health Survey: Summary of Results Canberra: Australian Bureau of Statistics, Australian Bureau of Statistics. Australian Health Survey: First Results, Canberra: Australian Bureau of Statistics, NSW Centre for Public Health and Nutrition. Report on the Weight Status of New South Wales: 2003.Sydney:University of Sydney, World Health Organisation. Obesity and Overweight: WHO Global Strategy on Diet, Physical Activity and Health. Geneva: WHO, Bauman AE, Bellew B, Owen N et al. Impact of an Australian mass media campaign targeting physical activity in Am J Prev Med 2001; 21: Grier S, Bryant CA. Social marketing in public health. Annu Rev Public Health 2005; 26: Cancer Institute NSW. NSW Go for 2& Campaign Evaluation. Sydney: Cancer Institute NSW, Australian Government Department of Health and Ageing. Evaluation of the National Get Moving Campaign. Canberra: Australian Government Department of Health and Ageing, Wakefield MA, Durkin S, Spittal MJ et al. Impact of tobacco control policies and mass media campaigns on monthly adult smoking prevalence. Am J Public Health 2008; 98: Mullins R, Wakefield M, Broun K. Encouraging the right women to attend for cervical cancer screening: results from a targeted television campaign in Victoria, Australia. Health Educ Res 2008; 23: Smith BJ, Ferguson C, McKenzie J et al. Impacts from repeated mass media campaigns to promote sun protection in Australia. Health Promot Int 2002; 17: Beaudoin CE, Fernandez C, Wall JL et al. Promoting healthy eating and physical activity: short-term effects of a mass media campaign. Am J Prev Med 2007; 32: Leavy J, Rosenberg M, Bull F et al. Effects of Find Thirty every day: cross sectional findings from a Western Australian population wide mass media campaign, Health Educ Behav 2012; 40: Wakefield MA, Loken B, Hornik RC. Use of mass media campaigns to change health behaviour. Lancet 2010; 376: Abroms L, Maibach E. The effectiveness of mass communication to change public behavior. Annu Rev Public Health 2008; 29: Snyder LB, Hamilton MA, Mitchell EW et al. A meta-analysis of the effect of mediated health communication campaigns on behavior change in the United States. J Health Commun 2004; 9: Miles A, Rapoport L, Wardle J et al. Using the mass-media to target obesity: an analysis of the characteristics and reported behaviour change of participants in the BBC sfighting Fat, Fighting Fit campaign. Health Educ Res 2001; 16: Morley B, Wakefield M, Dunlop S et al. Impact of a mass media campaign linking abdominal obesity and cancer: a natural exposure evaluation. Health Educ Res 2009; 24: Wammes B, Breedveld B, Looman C et al. The impact of a national mass media campaign in The Netherlands on the 1038

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