Supervisor: drs. Mirjam N. G. van Ginkel-Bieshaar



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Erasmus School of Economics




Master Thesis

Supervisor: drs. Mirjam N. G. van Ginkel-Bieshaar


Erasmus University Rotterdam, The Netherlands
Erasmus School of Economics
Master Marketing

Frouwke Anna Eva de Vries


290308
Telephone number: 0610058864
E-mail address: froudevries@gmail.com


EXECUTIVE SUMMARY
The aim of this research is to asses the question whether or not health ability has an influence on consumers’ perception of products with a health claim and products with a health recommendation. Under the term health ability in this thesis I refer to the factors: health knowledge, education, age and income. A questionnaire, testing general nutrition knowledge based on the general nutrition knowledge questionnaire developed by Parmenter and Wardle (1999) and testing the perception of five different products with and without nutrition labels, was handed out and filled in by 153 respondents. Significant differences in knowledge were found between socio-demographic groups, with man having poorer knowledge than women, and knowledge declining when a lower educational level is attended throughout someone’s life. This latter statement is significant when students are excluded from the analysis.
In the second part of the questionnaire it was measured if there are differences in perception of healthiness for different nutrition labeling formats. Finally, it is measured if and how different socio-demographic groups focus on nutrition values or if they rather focus on nutrition labels. It is proven that respondents with greater knowledge are more likely to focus on real nutrition values instead of focusing on nutrition labels, whereas respondents in the lowest quartile focus more on nutrition labels to get an impression of the healthiness of a certain product. There are no differences in perception between different label formats for the whole population, although there are significant differences in the quartile with the lowest level of nutrition knowledge. This group perceived products with a nutrition claim (e.g. light) significantly healthier than the products carrying a health recommendation.

Key words: Nutritional Labels; Health; Knowledge; Logo; Labeling formats; Perception of healthiness



CONTENTS

1 INTRODUCTION 5


2 THEORETICAL BACKGROUND 10

2.1 Introduction 10

2.2 Effects of health claims on consumer behavior 11

2.3 Health Recommendation Logos 13

2.4 Effects of health recommendations on dietary intake 14

2.5 Effect of knowledge on dietary behavior 14

2.6 Hypotheses 15

3 METHOD 19

3.1 Design 19

3.2 Questionnaire 19

3.3 Data collection and analysis 22
4 RESULTS 23

4.1 Participants 23

4.2 General Nutrition Knowledge Questionnaire 24

4.3 Linear regression 28

4.4 Perception of healthiness 32

4.4.1. Gender 34

4.4.2. General Nutrition Knowledge 35

4.4.3. Education level 37

4.5 Other findings of the questionnaire 39

5 DISCUSSION 40


6 CONCLUSION 43

6.1 Conclusion 43

6.2 Managerial implications 43

6.3 Suggestions for future research 44

6.4 Limitations of the research 44

REFERENCES 46


APPENDIX A 51

Legal Regulation 51

Background information about health recommendations 52

Choice Programme 53

APPENDIX B 56
Tables 56

APPENDIX C 66


Figures 66
APPENDIX D 68

Questionnaire 68


LIST OF FIGURES

Figure 1: Overweight and Obesity among adults in the EU 6

Figure 2: Theoretical Framework 18

Figure 3: Total score for all participants 24

Figure 4: Frequency histogram of the total score 25

Figure 5: Mean percentage score for the different sections 27


Figure 6: Healthiness Perception based on Gender 34

Figure 7: Healthiness Perception based on Knowledge 36


Figure 8: Healthiness Perception based on Education 38

Figure 9: Different types of logo’s: from left to right: “Ik Kies Bewust”, 53

“Energielogo”, and the old “Gezonde Keuze Klavertje”
LIST OF TABLES

Table 1: Demographic characteristics of the study population 24


Table 2: Mean score GNKQ for different education levels 26
Table 3: Mean score GNKQ for different age categories 26

Table 4: Results multiple linear regression including students 29

Table 5: Results multiple linear regression excluding students 31

Table 6: Consumer Evaluation Measures 32

Table 7: Mean score differences between products with a health 33
recommendation and the control group


1. INTRODUCTION

There is strong evidence that dietary factors and obesity are related to the development of different chronic diseases like heart disease, cardiovascular disease, hypertension, dental decay, stroke, bowel disorders, cancer, and diabetes. When consumed in high amounts, the intake of saturated fat, trans fat, sodium and sugar can lead to the undesirable health effects as described above (Parmenter & Wardle, 1999).



Although you would expect that obesity, an excess of body fat leading to ill health, is only a recent phenomenon, in the year 1660 Tobias Venner already reported the term ‘obesity’. He suggested that obesity needs treatment, an aspect that is still very actual at this moment. However, in contrast what you might expect, the value of a good diet had been recognized much earlier, more than 2500 years ago, by Pythagoras and Hippocrates (Thirlaway & Upton, 2009).
In the United States an estimated amount of more than 300.000 deaths per year are directly related to conditions and diseases associated with being overweight and obese (Kozup, Creyer & Burton, 2003). This is roughly fourteen percent of all death in the United States per year, an enormous amount. The United States does not stand alone in this number, with other countries showing relatively similar amounts.
Although people evaluate the impact of food on health as important, in a study in Belgium 97.3% of the respondents underlined this statement (Viaene & Gellynck, 1997), we can see a growing trend of obesity in particularly Western countries. Of the Dutch population 35% of all adults are moderated overweight, and 11% is obese (CBS Press release, March 18 2008). Being overweight or obese is measured by using the Body Mass Index (BMI), which is computed as the ratio of weight, measured in kilograms, to squared height, measured in meters.1 This calculation is internationally accepted and does not differentiate based on gender. Although it is a useful measure of adiposity and it correlates well with the risk of obesity-related diseases it is rather crude and imprecise. For example it does not distinguish between fat mass and lean (non-fat) mass, and the distribution of fat over the body is not recorded. However, the distribution of fat over the body is important as studies have indicated that abdominal fat distribution is associated with increased disease risk, independent of overall obesity. Finally, the relationship between BMI and body fatness differs according to age and ethnicity (Thirlaway & Upton, 2009).
Obesity is a consequence of complex factors that interact with each other. These factors include an increase in the consumption of calories and a decrease in physical activity. However, the prevalence of obesity is also influenced by other environmental factors, stress, genes, and lack of sleep (Ogden, Carroll, McDowell, & Flegal, 2007; Thirlaway & Upton, 2009).
Other Western countries, besides the Netherlands, are showing the same trend of obesity with the United States as one of the countries with the highest amount of people who are overweight, namely around 65% of U.S. adults (Wansink & Chandon, 2006). In England, 65.2% of men and 57% of women were reported as being at least overweight (Thirlaway & Upton, 2009). In Europe, Germany has the highest number of people who are overweight according to the International Association for the Study of Obesity, namely 75% of men in the country, and 59% of women. This can be due to the fact that Germany has a strong beer-drinking culture, although a research conducted in Belgium did not find a relation between beer drinking and a higher BMI (Janssens, Bruckers, Joossens, Molenberghs, Vinck, Renard, & Tafforeau, 2001). Figure 12 provides an overview of the percentage of adults who are overweight in six major European countries.

T
FIGURE 1: Overweight and Obesity among adults in the EU



TABLE 1
his number of obesity drastically needs to be reduced in order to keep health insurance and medical costs stable as obesity is one of the major cost drivers in Western health-care systems (Janssens et al., 2001; Kurscheid & Lauterbach, 1998; Thirlaway & Upton, 2009). Another important reason to reduce obesity of individuals is to increase the quality of life of those who are overweight, and even prevent them from premature death.

Not surprisingly, due to the trend of obesity the food industry and their marketing departments, saw the opportunity to help consumers better control their regular food intake. Not only has the food industry been threatened with taxes, fines, restriction, and legislation but they almost got the stigma of being the “tobacco industry of the new millennium”. Measures needed to be taken to prevent these negative consequences. Of course, no food company wants to discourage consumers from purchasing its products. Product innovation leading to healthier ingredients for existing products or introducing new, healthier, products may be factors that encourage consumers purchasing their products. Besides these options, it may also be in the interest of the food industry to use relative nutrition labels to help consumers better control their food intake. These nutrition labels could help promote more favorable attitudes toward the brand and company and create a win-win situation for both consumer and company. Therefore, various nutrition and health claims on consumer goods were introduced to help consumers make a healthier choice and by that regulate their food intake and perhaps even lower the number of obesity.


Health claims can be defined, according to Williams (2005), as statements linking food components to a desired state of health. Nutrient content claims highlight specific nutritional features of a food, typically about the presence or level of a nutrient (eg, “low in fat” or “high fibre”). Health recommendations as a nutrition labeling format on consumer goods can be seen as a general statement, using a simple front-of-pack label, of the fact that a particular product is “healthier” due to the fact is contains less saturated fat, salt, or trans fat compared to other products in the same product category. It provides an interpretation of the healthiness of the overall product, whereby the processing load is reduced (Feunekes et al., 2008). Health recommendations give an identification of the healthier options, which meet qualifying criteria. The main differences between health claims and health recommendations in this thesis is the fact that health claims always highlight a specific nutrient claim which is not the case for health recommendations. For example the health claim “light” highlights the fact that the product has at least thirty percent less calories or 1/3 lower level of fat/sugar. A health recommendation says something about the overall healthiness whereby several nutrition ingredients are lower compared to other products.
In households with at least one member being overweight, the penetration of the use of products with nutrition labels is higher compared to households with no one being overweight. As 70 percent of Dutch households have at least one member who is overweight, we can assume that the market for products with a health claim or health recommendation will be more important in the near future (GFK, 2009). This increases the importance of this research.
Although health is valued by almost everybody, attempts to change eating patterns by informing, and thus increase nutrition knowledge about the link between diet and health have been difficult (Grunert & Wills, 2007). One of the major instruments in trying to bring more healthy patterns in consumers’ life has been nutrition labeling. However, it is still unclear which role general nutrition knowledge plays for the perception of these health claims and health recommendations. Are people with less knowledge more sensitive for products with health recommendations than for products without because they can not interpret the nutrition values on the back-of-pack? Besides are there differences in perception between health claims and health recommendations?
In general, there are two categories of consumer characteristics to predict consumer health behavior, namely health motivation and health ability (Moorman & Matulich, 1993). These general categories consist out of different factors that influence consumer behavior. Health motivation is defined as consumers’ goal directed arousal to engage in preventive health behaviors. The second category, health ability, refers to consumers' resources, skills, or proficiencies for performing preventive health behaviors. Health ability consists out of the following seven consumer characteristics: health knowledge, health status, health locus of control, health behavioral control, education, age and income. According to the research of Moorman and Matulich, the effect of health ability on health behavior is moderated by the level of health motivation.

Seeing all kinds of consumer characteristics raises the question how these different consumer characteristics influence the perception of customers on certain consumer goods carrying nutrition claims.


In the upcoming problem definition, the term health ability is used referring to the research of Moorman and. Matulich (1993). However, not all aspects of health ability will be used. Health ability in this research includes four of the seven characteristics namely health knowledge, education, age and income. As a consequent the other three characteristics: health status, health locus of control and health behavioral control are left out due to the difficulty of measuring them in a questionnaire and the increase in time load.

Health locus of control and health behavioral control indicate greater perceived ability to engage in health behaviors. The latter, health behavioral control, reflects a sense of control over health outcomes and behaviors, whereas health locus of control reflects the belief that health outcomes are controllable (Moorman & Matulich, 1993). The differences of these two characteristics lay in the fact that health locus of control focus on the control over health outcomes, whereas health behavioral control focuses on control over health behavior. The other characteristic, health status, refers to consumers’ perceived physical and mental well-being. To give a proper indication of someone’s perceived health status, health locus of control and health behavioral control, a lot of questions need to be answered. When these characteristics were incorporated in the questionnaire, the time load to fill in the questionnaire would raise enormously. As there is no budget, and all the respondents filled in the questionnaire voluntary, adding these characteristics to the questionnaire would probably lead to less motivation to fill in the complete questionnaire and therefore the whole research would get in danger. The other four characteristics of health ability which are used in this research are more straightforward and easy to answer. However, for future research with less budget constraints it is advisory to incorporate all characteristics.


The link between nutrition knowledge and consumer perception of nutrition claims is scientifically investigated by Andrews, Netemeyer and Burton (1998). They predicted that consumers with higher levels of nutrition knowledge will have less favorable evaluations of non featured nutrient and disease risk for an unhealthy product than will those with lower levels of nutrition knowledge. However, this hypothesis was only partly supported by their results. Therefore, it remains highly relevant for both the academic world as well as for the businesses and organizations supporting the different logos and claims to investigate the link of nutrition knowledge and other variables on consumer’s perception. A quantitative research will be conducted based on the following problem definition.
How does the health ability of consumers influence consumers’ perception of products with a health recommendation and products with a health claim”.

2. THEORETICAL BACKGROUND
2.1 Introduction

Back-of-pack nutrition labels were designed to help consumers make healthier choices due to the information communication about the nutrients inside the product. However, in general there exists a distinction between the provision of information and its impact. This relationship is not one-to-one. In order to have the desired impact, the consumers’ information environment needs to be designed in such a way that the information has its desired impact. In a purchase decision, when the right motive and desire exists, consumers must first acquire and then comprehend the nutrition information provided.



Early research showed that consumers say they want nutrition information, that they use or would use it, and even say that they are willing to pay extra for the provided nutrition information (Jacoby, Chestnut, & Silberman, 1977). In an experimental setting, the researchers found that consumers only devote a small proportion of their prepurchase search to acquire nutrition information. An explanation regarding these low rates can be the lack of comprehending. Why acquire nutrition information when you only get confused and thereby making product choices even more difficult (Feunekes, Gortemaker, Willems, Lion, & van den Kommer, 2008).
More recent research (Feunekes et al., 2008) shows us that the majority of consumers find back-of-pack nutrition labels confusing. Especially the numerical information and the terminology used are perceived as difficult. Another explanation for the lack of understanding of the nutrition information provided is poor nutrition knowledge which may reduce the ability to interpret this information (Cowburn & Stockley, 2005). Especially vulnerable groups such as older consumers and consumers with lower levels of education and income are likely to have difficulties understanding them (Cowburn & Stockley, 2005; Feunekes et al., 2008; Vyth, Steenhuis, Seidell, Feunekes, Jansen, Verhagen, & Burg, J. 2008). Especially converting the information for 100 gram into the information per serving gave difficulty for these consumers. To simplify this task consumers only take a single nutrient (for example fat) as a measure to compare products on overall health. This may lead consumers make a wrong choice. For example a product low in fat can be high in sugar or salt (Feunekes et al., 2008). Although designed to help consumers make a healthier choice, due the lack of understanding, the effect of back-of-pack nutrition labeling on making a healthy choice was in some consumer groups minimal. A second step has since been introduced in order to help consumers make a more conscious and healthier choice; nutrition labeling with front-of-pack formats like health claims and health recommendations. A dilemma with these kinds of health claims is that too much information can confuse consumers, while too little can mislead them (Wansink, 2003). The ideal combination of claims according to Wansink is that the presence of a short claim on the front-of-pack generates more specific attribute-related thoughts, creates a more believable and positive image of the product, and generates more inferences than does a longer health claim on the front label. A combination of a short health claim on the front-of-pack together with full health claims on the back-of-back creates a higher believability of the claim and led consumers more fully process it (Wansink, 2003). When combining both sorts of information, one can reach both types of customers, the more involved consumers who read the back-of-pack information and the less involved consumers who only skim the front-of-pack label.
Consumers and especially the vulnerable consumers must rely on their government that they are not mislead by the industry. This raises the question: how sensitive are these vulnerable groups for these logos? There is some experimental evidence that consumers are capable of accurately evaluate the nutrition value of back-of-pack information, even when a contradictory health claim is on the front-of-pack. In this experiment participants were exposed to both the health claim as well as the nutrition value. When only the health claim was presented, the participants were more likely to make unwarranted nutritional inferences about the product (Ford, Hastak, Mitra & Ringold, 1996).

2.2 Effects of health claims on consumer behavior

Academic research has been done about the effects of products with a health claim on consumer behavior. Putting a health claim on a product gives various interesting outcomes which will be described below.


In general consumers see health claims as useful, and view food as healthier if it carries a health claim (Williams, 2005). Especially claims on the front-of-pack have been found to create favorable judgments about a product (Drichoutis, Lazaridis, & Nayga, 2006).
Labeling formats increases the perceived healthiness of healthier products but slightly decrease the healthiness of less healthy products (Feunekes et al., 2008).

Partly due to the increased healthiness, anticipated consumption guilt is reduced. Why feeling guilty if a product is healthy, one must think when eating for example “light” products. Especially people who are overweighted are sensitive for this consumption guilt. Therefore the effect of the reduction is much greater among obese consumers. Furthermore due to the reduced anticipated guilt, consumption and the perception of an appropriate serving size increases. In short, these are some results of the study of Wansink and Chandon, 2006.


Another study about making healthful food choices is the study conducted in 2003 by Kozup, Creyer and Burton. They found that consumers have more favorable attitudes toward the product, nutrition attitudes, and purchase intentions when favorable nutrition information or health claims are presented. Besides higher favorable attitudes, the consumers perceive risks of heart disease and stroke to be lower. Aldo Ford and his colleagues (1996) found a main effect for products with a cholesterol-heart disease claim and their perceived health marks. Products with these claims received better ratings on heart and fat ratings scales than nutritionally identical products that were not carrying this claim. This effect was even greater when the respondents did not see the nutrition value provided on the back-of-pack. One must warn for these results, especially in situations where consumers rely solely on the health claims provided while ignoring the rest of the nutrition information provided. In another experimental setting with little time pressure, many consumers limit their information search to only the front-of-pack label, and this increases when health claims are present (Roe, Levy, & Derby, 1999).
According to Wansink, Van Ittersum, & Painter (2004), health claims have a more positive impact on the evaluation of hedonic foods than on foods that are more seen as being utilitarian.
However, these results are not automatically applicable for products with a health recommendation. Future research must be conducted on the topic of effects of health recommendations on consumer behavior.
A main issue in food labeling is the issue of taste suggestiveness. A claim can be so powerful that some people convince themselves that they do not like the taste due to the presence of a certain nutrition claim. This can be due to the fact that consumers may think that healthy food is not likely to taste good (Wansink & Park, 2002). There will always be a taste-nutrition trade off. Consumers may choose for an instant gratification of a tasteful product instead of looking at the long run benefits of a nutritious product (Drichoutis et al., 2006). In low involvement situations, like doing the groceries, consumers tend to rely more on extrinsic cues rather than intrinsic attributes to make a product choice (Jacoby et al., 1977). Food and nutrition labeling can be such an extrinsic cue which may influences the taste as less flavorful and even less satiating (Wansink et al., 2004). An important implication for the food industry is how to position the nutrition claims in the market, to reduce negative taste suggestiveness cues.

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