Research Study Background

A. Purpose

The "TrEAT Yourself Well" program was a social marketing campaign and research study designed to encourage the selection of healthier meals by consumers in Southern California restaurants. The project was carried out between January 1999 and December 2001 by Juárez & Associates, a Los Angeles-based research company, and Accents On Health, a San Diego-based nutrition company that had been promoting restaurant nutrition for twelve years through their "Healthy Dining" program. Additional team members included Dr. Paul Patterson, agricultural economist at the University of Arizona at Mesa and his colleagues, Social Marketing Consultant Regino Chávez, and the Tom Feltenstein Neighborhood Marketing Institute of Palm Beach, Florida. The social marketing interventions and promotions were implemented in San Diego during a fifteen-month period between March 2000 and May 2001.

Sponsored by the State of California, Department of Health Services’ Cancer Prevention and Nutrition Section, the program was intended to contribute to the effectiveness and impact of ongoing California DHS campaigns (including the California 5 a Day Campaign, California Project LEAN and the California Nutrition Network for Healthy, Active Families) to prevent cancer and other life-threatening diseases by reducing nutrition-related risk factors. The originating funding source was the National Cancer Institute.

Improving the nutritional content of restaurant meals is becoming increasingly important because, according to research, the frequency of dining out is on the upswing, especially in California -- now averaging four to five meals per week. Busy schedules, travel, two-career families, business entertaining, socializing, celebration, relaxation and convenience have made dining out a way of life for time-starved consumers. Unfortunately, most restaurant meals contain insufficient quantities of fruits and vegetables and are high in fat. In this campaign, a healthy entrée was defined as including two or more servings of fruits and/or vegetables and containing under 30 percent of calories from fat (or under 20 grams of fat).

Restaurateurs do not consider it their responsibility or role to generate demand for healthy menu items. Rather they offer what they believe consumers want and leave it up to their patrons to make their selections. Restaurateurs believe that better-educated and/or health-conscious patrons will find the items they desire on the menu and will order them if they wish. But consumers have little chance of making informed decisions because even nutrition-savvy diners face an almost impossible task of deciphering which choices are in fact healthy, due to hidden fats and poor availability of appealing fruit/vegetable dishes and options. Health educators see the need for providing more accurate and complete information, not merely the subtle clues that the industry favors (using such words as "fresh," "seasonal" and "delightful").

The goals of this program, then, were

• To provide target consumers with information to create awareness of healthy menu choices in restaurant settings
• To position healthy menu entrées as positive choices among consumers
• To increase customers’ positive attitudes regarding the purchase of healthful menu items
• To increase the percentage of sales of healthy menu selections in selected chains

The target consumer was defined as a frequent restaurant diner who eats out at least three times per week, between the ages of thirty and seventy, likely middle-to-high income and likely female. Specific sociodemographic variables were determined by the type of chain implementing the project since, at the outset, a variety of concepts (restaurant classifications or themes) was considered desirable.

B. Approach/Implementation

The research design called for several restaurant chains, in which sales of identical menu items could be compared between experimental (intervention) sites in San Diego and control sites located outside of the San Diego campaign area. Within each chain, both experimental and control locations offered the same healthy menu items which were promoted in the same way on the menus. A multifaceted social marketing campaign was implemented in San Diego, including media advertising, in-restaurant and neighborhood promotions, and networking with health professionals as well as various health organizations.

Juárez & Associates, the primary grantee, was responsible for grant administration, developing the social marketing plan, conducting and evaluating the focus groups, collecting diner surveys and restaurant sales data, and submitting all reports. Accents On Health, the major subgrantee, was responsible for coordinating the campaign with the restaurant marketing departments and managers, and implementing the campaign in the San Diego locations. Statistical analysis and evaluation of survey and sales data were carried out by Dr. Paul Patterson and colleagues. The Tom Feltenstein Neighborhood Marketing Institute acted as consultant on restaurant promotions.

Shortly after the grant’s award, appropriate forms were submitted to the Committee for the Protection of Human Subjects of the State of California to gain approval for the consumer research. The project was granted exemption status, due to the fact that research subjects could not be identified, either directly or through links, and any disclosure of their responses outside the research could not reasonably place them at risk of criminal or civil liability or damage their financial standing, employability or reputation.

Six California-based restaurant chains, which were current clients of Accents On Health, originally agreed in writing to work with the California state-sponsored campaign to offer and promote healthier menu choices during the fifteen-month period between March 1, 2000, and May 31, 2001. They were offered the benefits of advertising and promotions for their San Diego units in exchange for their cooperation with recipe development/modification, instituting in-restaurant promotions, granting permission to conduct research (customer surveys) in the stores, and access to sales data during the campaign. Confidentiality or non-disclosure agreements were required by several corporate entities to obtain the latter.

The participating chains included

Restaurant A, a family-style Mexican concept

(Two experimental locations in San Diego, two control locations elsewhere in California)

Restaurant B, a quick-service California-style chicken and fresh vegetable concept
(Two experimental locations in San Diego, two control locations elsewhere in California)
Restaurant C, a 1940s style diner
(Two experimental locations in San Diego, one control elsewhere in CA)
Restaurant D, an upscale casual concept
(Two experimental locations in San Diego, two control locations elsewhere in California)
Restaurant E, a pair of fine-dining restaurants with individual names under the same corporate ownership
(Two experimental locations in San Diego, two control locations elsewhere).
Restaurant F, a quick-service Mexican concept
(Two experimental locations in San Diego and two control locations elsewhere in California)

The experimental locations were identified by corporate management as being the most amenable to and appropriate for implementing the social marketing program. During the course of the campaign, Restaurant Chain F dropped out due to a change in corporate ownership and direction, as did one of the control locations for restaurant E, due to a lack of commitment by management.

Upon selection of the restaurants, Accents On Health staff consulted with each of the chefs to identify appropriate menu items for the study, a minimum of six dishes per chain. In some cases, the selected items were ones which already met the study criteria, but in most cases the healthy items chosen by the chefs still required modification, such as the addition of fruits or vegetables and/or reduction in the amount of fat used in preparation. Restaurant B, which had on its menu up to fourteen side dishes that qualified as containing one or more servings of fruits or vegetables and less than 30 percent fat, agreed to designate and promote several TYW combination meals, each of which featured lean meats and two specific healthy sides dishes.

Within each chain or concept, measurements (sales data and customer surveys) were collected in the two experimental San Diego County locations that were subject to the social marketing promotions, and in the one or two control locations situated some distance from the San Diego region. Control locations were selected far away from the San Diego area of dominant influence (ADI) to ensure that diners would not be exposed to area-wide media promotions, i.e., television and magazine advertising, or to the Healthy Dining books that were also produced for the Los Angeles and Orange County markets. (In retrospect, this strategy proved to be difficult to implement and to monitor, as well as unnecessary, and therefore it is not recommended for future campaigns.) All locations offered the healthy items, albeit with varying degrees of visibility, so all were monitored for compliance with the program.

Focus groups were conducted with restaurant management, chefs, waitstaff and frequent diners before the campaign was instituted to refine the methodology and to define the slogan (TrEAT Yourself Well), the logo and the target audience. After the completion of the campaign, additional focus groups were held with frequent diners from the targeted restaurants to explore consumer reaction to the various promotions and the TYW meals.

A social marketing plan was developed in the fall of 1999 by the team’s consultant, Regino Chávez, in preparation for a spring 2000 launch. Before the campaign got under way, a San Diego-based advertising agency (Third Eye Advertising) and a public relations firm (Nuffer, Smith, Tucker, Inc.) were selected through a bidding process to develop a mass media advertising campaign, including assistance in designing, preparing and disseminating the promotions such as television spots and magazine ads. Shortly after the inception of the campaign, color brochures with coupons (e.g., buy one entrée and get one free, or $1.00 off a TYW item) were developed and distribution began through partners in the health community, hospitals, community events, the Accents On Health website and mailings.

The social marketing program implemented in the greater San Diego area included

• In-restaurant and neighborhood promotions, such as special menus, table tents, posters, etc. Additional promotions included waitstaff incentives and contests, a custom newspaper insert and direct mail campaign, samples of the TrEAT Yourself Well dishes distributed at neighborhood apartments and businesses, and frequency/discount cards. Different chains implemented various combinations of the in-store promotion strategies, as discussed below. Menus identifying the healthy dishes were available in both control and experimental locations; all other promotions occurred at experimental locations only.

  Promotion	Restaurant	Dates
  Menus	All restaurants	March 00 – May 01
  Posters	Restaurant B	Aug 00, March - May 01
  	Restaurant C	May – Dec 00
  	Restaurant E	July – Nov 00, April 01
  	Restaurant E	Oct. 00
  Table tents/cards	Restaurant F	July – Oct 00
  	Restaurant E	June – July 00, April 01
  Bingo cards	Restaurant B	April 01
  Takeout flyers	Restaurant D	April 01
  Healthy employee Meals	Restaurant E	March 01
  Server buttons	Restaurant C	April - May 01
  Free food samples	Restaurant D	Aug – Sep 00
  Business blitzes	Restaurant E	March 01
  	Restaurant B	March 01
  Apartment blitzes	Restaurant D	Jan. 24 - April 14, 01
  Community events	Several	March – July 00
  Waitstaff incentives	Restaurant D	Aug 00 (loc.#1), Sep/Oct 00, Mar 01
  	Restaurant C	Oct – Nov 00, April 01
  	Restaurant E	March 01
  	Restaurant E	March 01

• Paid advertising with KFMB-TV (Channel 8) and San Diego Magazine. KFMB produced 15- and 30-second television spots that aired during appropriate time segments, as agreed by the project team. Over1,000 spots were aired as planned, along with additional ones when time became available. KFMB’s programming and news directors also offered opportunities for interviews and programming emphasizing the campaign message.
• Over a twelve-month period, San Diego Magazine featured twelve full-color advertisements in the publication, which has a monthly circulation of approximately 47,000. In addition, the magazine produced table tents for in-restaurant promotions in all participating San Diego restaurants as well as extra column space periodically to promote the TrEAT Yourself Well message.
• Community events (educational seminars and food tastings). Called "Extravaganzas," these events included a seminar entitled "The Fat and Skinny on Restaurant Dining," a discussion about the TYW Campaign, a chef demonstration and a food tasting, as well as instructional materials. Community events were held between January 2000 and July 2000 at San Diego hospitals and medical centers, churches, YMCAs, fitness centers and businesses. They were discontinued in order to focus efforts in the target restaurants.
• Liaisons with health professionals in the community (dietitians, physicians, nurses, health educators, fitness trainers, etc.). Brochures were made available to the public through professional offices, clinics and hospitals. In addition, special gift certificates for a complimentary TYW meal at Restaurants A and D were mailed to dietitians, physicians and other health professionals to introduce the TYW menu offerings, in the hopes that the dishes would be recommended in turn to clients and patients. The gift certificates included a questionnaire on the reverse side requesting feedback on the TYW dishes.
• More than 200,000 copies of the custom newspaper, a four-page full color newspaper-sized promotion piece, were distributed in zip codes surrounding the experimental restaurant locations through inserts in the major San Diego daily newspaper, advertising packets and direct mailings to health-conscious households. These inserts were developed, produced and distributed by Horizon’s Publishing of Jupiter, Florida, under the supervision and assistance of the project team.
• Also part of the campaign was a website (www.treat-yourself-well.com), which was established relatively late, in April 2001. During the entire period between 1999 and 2001, however, Accents On Health’s website (www.healthy-dining.com) devoted several pages to TrEAT Yourself Well and the California 5 a Day program. All advertising and promotional materials encouraged the public to visit the website for restaurant and nutrition information, menu advice, and instructions for obtaining coupons and additional information. The KFMB-TV and San Diego Union Tribune websites also had links to the healthy-dining.com website throughout most of the campaign. At most of these websites, links were made to partnering organizations, including www.ca5aday.com.

C. Progress Relative to Specific Aims

Table 1 on the following page lists the estimated number of people reached by various media and print promotions during each month of the campaign. This table shows that by far the largest numbers of people were reached via television spots. However, since these spots were primarily 30 seconds or less in length, the total impact on viewers would be less for each exposure than from a brochure or seminar through which more information may be communicated. Furthermore, many of the television viewers as well as the magazine readers (in particular, the subscribers) were most probably the same over time, i.e., the same viewers and/or readers were receiving additional exposure to the same ads.

Sales data from the first few months suggested minimal effectiveness of the media and community efforts. To boost sales, the in-restaurant server-incentive promotion was instituted in two chains beginning late in 2000, and this strategy greatly enhanced sales. Additional promotions implemented in early 2001 further increased sales during the final months of the campaign. These included the custom newspaper with coupons, gift certificates to health professionals, the database mailing to restaurant customers, and further waitstaff incentives. In the one chain in which the team was able to obtain post-implementation sales data it was shown that sales generally regressed to pre-implementation levels after the campaign had ended. In some measure, this may have been due to the fact that patrons do not always eat in the same locations month after month, and that new customers were not motivated to try the healthy items even though they were still on the menu.

The level of cooperation from restaurant management ranged from indifference to helpful support. In each case, the project team needed to deal with various staff, from the heads of the marketing departments to the local managers and assistant managers. As the restaurant business operates in a busy and chaotic environment, most of these people were very busy with their day-to-day activities. Yet, in the end, five of the original six concepts generally adhered to their agreements, even when their chain was acquired by another or when management structure was reorganized. For example, during the initial 12 months of the campaign, over half of the corporate contact people left the company or moved to other positions within the company.

TABLE 1. MEDIA AND MAIL PROMOTIONS

D. Evaluation Findings

Customer knowledge and attitudes were measured by means of in-store surveys before, during and after the implementation phase; monthly restaurant sales data provided information on the number and percentage of designated healthy dishes that were sold. Customer data were analyzed to determine 1) changes in customer purchases, knowledge and attitudes, and 2) which marketing or promotion strategies were most closely correlated with increased sales.

Sales data: Table 2, below, displays the number of TYW entrée sales as a percentage of all comparable entrée sales. The sales data from the first few months of the campaign showed that the healthy choices constituted only a small percentage of comparable sales, but varied considerably among chains. Most sales ranged from less than 1 percent to 6 percent during the baseline periods and from less than 2 percent to 8 percent during promotions. The more upscale restaurants and communities appeared to have higher sales, regardless of promotional activity, but this observation was not tested statistically.

Sales data from Restaurant B present a special case. As can be seen on the first page of Table 2, sales of B’s TYW combination items never reached over 0.3 percent, due to the fact that the designated healthy combo meals were not promoted adequately (nor were they even available in some locations at some times) and in fact were dropped from the menus in early 2001. Nevertheless the healthy side dishes were still available at all stores and constituted, in fact, a significant portion of sales. Analysis of these side dishes only (second page of Table 2) proved inconclusive. Because neither the combination meals nor the side dishes were effectively promoted during the campaign, and because these data sets are not equivalent or comparable to data collected from the other restaurants, this chain’s sales could not be used in the final statistical analysis.

In the four remaining chains, the campaign raised the share of TYW items sold in the experimental restaurants from an initial 1.89 percent to 2.61 percent of all items. Thus the campaign produced a 38 percent increase in the sales of TYI items.

Regression analysis of the data was used to determine the effectiveness of the various promotions in increasing percentage share of the TYW menu item sales. Clearly the effectiveness of the promotion strategies varied. General market interventions such as media advertising and community events appear to have been ineffective in increasing sales of the TYW items in the target restaurants. Brochures and the custom newspaper were somewhat more effective, as were gift certificates sent to health professionals and database mailings to the restaurants’ mailing lists. By far the most effective strategy was the waitstaff incentive program, in which servers were paid a monetary incentive for each TYW meal they sold.

TABLE 2. SALES DATA