International Journal of

Environmental Research
and Public Health

Article
Swap Up Your Meal: A Mass Media Nutrition Education
Campaign for Oklahoma Teens
Dana E. Wagner 1, * , Gabrielle Seneres 1 , Elisabeth Jones 1 , Kelli A. Brodersen 2 and Sjonna Whitsitt-Paulson 2

1 Rescue Agency, PBC, 2437 Morena Blvd, San Diego, CA 92110, USA
2 Oklahoma Tobacco Settlement Endowment Trust, 2800 N. Lincoln, Ste 202, Oklahoma City, OK 73105, USA
* Correspondence: [email protected]; Tel.: +619-231-7555 (ext. 331)

Abstract: To address a statewide need for obesity prevention, the Oklahoma Tobacco Settlement
Endowment Trust launched Swap Up in 2021, a mass media nutrition education effort for teens, ages
13–18. Swap Up utilizes the SAVI messaging approach, an audience-centric message development
framework that recognizes barriers to healthy living and offers realistic solutions. Five months
into the campaign, an online survey was conducted (n = 200) to assess short-term program goals
related to campaign delivery, engagement, and relevance. A secondary, long-term goal related to
documenting and understanding self-reported changes in past month nutrition-related behaviors
was also explored. A majority of participants (72%) reported aided awareness of the campaign
brand logo/advertisements, and awareness (83%) of at least one main message. Nearly half (44%)
of the participants reported at least one engagement with digital media. Main message recognition,
perceived relevance, and self-reported nutritional behaviors were consistently highest among those
reporting both campaign awareness and digital engagement. Ultimately, Swap Up reached and
delivered nutrition education messages to Oklahoma teens within the first year of launch, as intended,
and was associated with self-reported changes in recent behavior. This study provides evidence that
SAVI offers a promising approach for nutrition education, and underscores why digital and social
Citation: Wagner, D.E.; Seneres, G.;
Jones, E.; Brodersen, K.A.;
media engagement strategies are critical for mass media teen behavior change campaigns. Campaign
Whitsitt-Paulson, S. Swap Up Your implementation and evaluation are ongoing.
Meal: A Mass Media Nutrition
Education Campaign for Oklahoma Keywords: obesity prevention; nutrition; nutrition education; mass media public health; public
Teens. Int. J. Environ. Res. Public health campaigns; digital and social media public health campaigns
Health 2022, 19, 10110. https://
doi.org/10.3390/ijerph191610110

Academic Editor: Paul B. Tchounwou

1. Introduction
Received: 28 June 2022
Oklahoma is among the states affected by disproportionately high rates of adult
Accepted: 12 August 2022
obesity, ranking fourth highest in the nation in 2021 [1]. Obesity poses major risks to
Published: 16 August 2022
both long- and short-term health outcomes, such as heart disease, high blood pressure,
Publisher’s Note: MDPI stays neutral depression, eating disorders, and 13 different types of cancer [2–4]. Obesity among youth
with regard to jurisdictional claims in is a concern due to its likelihood to continue through adulthood [5]. States across the U.S.
published maps and institutional affil- continue to see high rates of obesity in children and adults, including Oklahoma [6,7].
iations. For Oklahomans, in particular, there are structural and systemic barriers that make
healthy living an uphill battle. Oklahoma is one of many southern, largely rural states that
have a high density of food deserts, meaning there is restricted access to healthy and fresh
foods [8]. Oklahoma’s poverty rate is consistently higher than the national average [9] and
Copyright: © 2022 by the authors.
studies show that children in homes of lower socioeconomic status (SES) are more likely
Licensee MDPI, Basel, Switzerland.
to be overweight or obese [10]. This is largely because high-calorie foods and drinks are
This article is an open access article
more affordable than healthier alternatives [11,12]. High caloric intake is also exacerbated
distributed under the terms and
conditions of the Creative Commons
by the availability of fast food in the state; Oklahoma is ranked the fourth highest state
Attribution (CC BY) license (https://
for number of fast food restaurants (5.3 restaurants per 10,000 people) [13,14]. Issues of
creativecommons.org/licenses/by/ food insecurity were also amplified by the economic impact of the COVID-19 pandemic.
4.0/).

Int. J. Environ. Res. Public Health 2022, 19, 10110. https://doi.org/10.3390/ijerph191610110 https://www.mdpi.com/journal/ijerph
Int. J. Environ. Res. Public Health 2022, 19, 10110 2 of 16

In August 2020, approximately one in eight Oklahomans reported sometimes or often not
having enough food [9,15].
While these challenges are contributing to high obesity rates in the state, it is important
to consider the extent to which public health can help adolescents overcome barriers and be
empowered to make healthier nutritional choices in their day-to-day lives. Research shows
that establishing healthy nutrition and physical activity habits earlier in life can reduce the
risk of adulthood obesity regardless of current weight status [16,17]. Therefore, providing
adolescents with education and an easily adoptable framework for making daily nutritious
choices could have benefits beyond their teen years.

1.1. Mass Media Obesity Prevention

Obesity prevention and nutrition education in Oklahoma requires a large-scale, awareness-
driving approach that will reach all teens, regardless of current weight or living environment.
Historically, most successful obesity prevention efforts originated in schools or community-
based settings, educating younger children or families about nutrition or implementing physical
activity programs in small groups [18–23]. Government organizations and commercial mar-
keters also teamed up to promote healthy nutritional intake through mass media, such as milk
(“Got Milk?”) and fruit/veggies (“Five A Day”) [24]. However, many of these campaigns were
designed to promote product sales and their outcomes for public health and obesity prevention
are not well documented [25]. One notable exception is the CDC VERB campaign, which was a
multi-media social marketing campaign aimed at increasing physical activity among tweens
(ages 9–13) [26,27]. The campaign showed year-over-year successes with audience activity
levels increasing alongside increases in campaign awareness [26]. To our knowledge, a similar
mass media approach was never applied to public health nutrition education, though there is
evidence of its promise [28,29].
Digital media, especially social media, provides an increasing number of unique oppor-
tunities to reach teens through everyday media consumption behaviors [30–32]. While the
measurement of digital media delivery and consumption is lagging behind [33–35], more
research is emerging that demonstrates the ability of technology to successfully deliver
persuasive health messages to large populations of young people [36,37]. Evans and col-
leagues describe an ecological approach to obesity prevention that includes multi-channel,
mass-marketing strategies to promote the modeling of healthy behaviors and audience
engagement. An ecological approach considers both the social and physical environments
and challenges surrounding individuals as primary determinants of health [28,38]. In a
state like Oklahoma where obesity prevention is a statewide, population-level need, it
stands to reason that an ecological mass-media approach to educational messaging could
help adolescents to better navigate their daily nutrition.

1.2. Fast Food and Sugary Drink Marketing

It is important to note that the successful messaging about food and beverages to
young people by commercial industries spans decades. Studies show that fast food com-
panies, especially McDonald’s, use child-targeted marketing strategies (“Happy Meals”)
worldwide with price promotions disproportionately targeting low-income communi-
ties, which further supports higher risk of obesity for lower SES children [39]. Television
advertisements of unhealthy foods are also associated with increased consumption of
calories, which are often lacking in nutrients and are insufficient food sources for young
people [40,41]. In fact, Nickelodeon was shown to promote largely unhealthy foods, such as
sugar-sweetened beverages and candy or fruit snacks, with 65% of their food ads featuring
items of poor nutritional quality and limited ads for fruits or vegetables [42]. In 2018,
beverage companies spent USD 20.7 million advertising children’s drinks with added
sugars, and sugary drinks made up 62% of the USD 2.2 billion in total U.S. children’s drink
sales [43]. Therefore, it is not surprising that a 2010 study found 27% of children’s daily
calories come from snacking, with sugar-sweetened beverages and desserts as the highest
sources of caloric intake [44].
Int. J. Environ. Res. Public Health 2022, 19, 10110 3 of 16

The mass media and audience-centric strategies employed by the commercial market-
ing industry further exacerbate challenges for obesity prevention. This lifelong exposure to
food and beverage marketing heavily influenced nutritional beliefs and habits in today’s
youth, whereby exposure to healthy food marketing is an exception. Still, commercial
practices could offer insights into effective marketing and counter-marketing strategies.

1.3. The SAVI Framework

Rescue Agency (Rescue) developed the SAVI messaging approach to break down
complex behaviors and help identify new, simple solutions towards the goal of healthier
outcomes. SAVI identifies four areas of strategic messaging, which include: specific,
acceptable, viable, and impactful (see Table 1). SAVI assumes that lifestyle change is too
daunting or unrealistic for an audience’s circumstances or current ability and helps identify
appropriate educational messages that address their daily reality.

Table 1. Applying SAVI to Swap Up.

SAVI
Description Swap Up Application
Component
Must include a specific example When you go to the gas station for
Specific of what the audience can do to breakfast, get a low-fat and low-sugar
change their behavior yogurt and a banana instead of a donut.
Swap fizzy water for fountain soda at a
Must be acceptable within the
fast food restaurant (instead of “Don’t
Acceptable cultural, familial, and social
eat at fast food restaurants or
contexts of the audience’s lives
convenience stores”).
Do not expect a teen to be able to
revamp their family meals or overhaul
Must be realistic within the their diet and instead focus on a
Viable constraints of our audience’s reasonable individual action they can
available time, budget and skills control, like what they buy outside of
the home and what is within their
budget.
If adopted, the message would Pick a side of carrots instead of fries
Impactful cause a meaningful impact on the (this is impactful because fast food is a
audience’s nutrition daily occurrence).

SAVI draws on existing theories of behavior change commonly used in prevention and
intervention efforts, such as Social Cognitive Theory and Social Norm Theory. Social Cog-
nitive Theory states that human behavior is the result of the dynamic interaction between
personal (thoughts and feelings), behavioral (health knowledge/skill) and environmental
factors (external) [45,46]. Self-efficacy, or one’s confidence in their ability to take action on
the specific behavior and, the perceived benefits of taking the action are critical to behavior
change. SAVI addresses these factors by ensuring health messages provide a clear and
logical plan of action for changing behavior, which are tailored to the perceived benefits,
personal motivations, and challenges of the audience [47]. Social Norm Theory posits that
incorrect perceptions of similar others’ behaviors normalize and justify an individual’s own
unhealthy behavior [48,49]. Research shows that perceptions about normative behavior
among peers is related to sugary drink and unhealthy snack consumption, as well as body
mass index (BMI) [49–51]. Similarly, SAVI assumes that people are emotional and socially
driven decision makers who need to see themselves and their circumstances reflected to
care about a message. Therefore, it is important to conduct audience research to uncover
the deeply held beliefs, norms, motivators, and perceived barriers surrounding current
nutrition, and potential pathways to behavior change.
Int. J. Environ. Res. Public Health 2022, 19, 10110 4 of 16

1.4. Oklahoma’s Swap Up Campaign for Teens

Acknowledging both the current health status of Oklahomans and the common nu-
tritional challenges they face, a state agency, the Tobacco Settlement Endowment Trust
(TSET), launched a statewide effort to prevent and reduce obesity among adolescents (ages
13–18) in Oklahoma. Swap Up leans on principles of SAVI to offer Oklahoma teens relevant
and realistic tips related to daily nutritional choices (see Table 1). The campaign seeks to
reduce and prevent obesity by encouraging incremental lifestyle changes, beginning in teen
years, a time when young people gain increased autonomy and choices regarding meals
outside of the home. Swap Up is unique in two major ways. The first is its practical and
audience-forward approach to nutrition for teens. The second is that it is the first known
public health-driven obesity prevention effort that attempts to reach an entire state with
mass media messaging, encompassing both urban and rural audiences.
The long-term goal of the campaign is to reverse obesity trends by increasing con-
sumption of fresh produce and water and decreasing sugary drink consumption. The
campaign set short-term goals related to campaign and message awareness, relevance of
the messages, and documenting audience engagement with the campaign. Throughout
the campaign, self-reported behaviors are tracked in order to see trends in health-related
behaviors over time.

1.5. Current Study

In the first year of the campaign, the program sought to investigate whether the Swap Up
campaign successfully reached its short-term goals related to successful media delivery (50%
campaign and message awareness), perceived relevance by the audience, and evidence that
the audience was engaging with campaign assets. As a secondary research question related
to long-term goals, we investigated whether Oklahoma teens considered or tried to increase
healthy nutritional behaviors and decrease unhealthy nutritional behaviors. We expected that
those aware and/or engaged with the campaign to be most likely to report considering or
trying to engage in healthy behaviors, compared to those unaware or unengaged.

2. Materials and Methods

2.1. Campaign Intervention
Swap Up (SwapUpOK.com, accessed on 31 May 2022) was developed for Oklahoma
TSET by Rescue and launched in February 2021. Swap Up was created to complement a
current, statewide, adult-focused effort called Shape Your Future, which educates parents
and adults on nutrition inside and outside of the home. Following principles of SAVI, Swap
Up development included formative research to better understand the motivations and
barriers underlying Oklahoma teens’ nutritional choices.
In August–September 2020, a cross-sectional online survey was conducted (n = 403)
with Oklahoma teens to assess the status of their nutrition-related beliefs and behaviors, as
well as future intentions to change their behavior [52]. Importantly, when teens reported
they did not eat vegetables or fruits in the past 7 days, it was most commonly because
they did not think about it (43% for vegetables and 53% for fruits) and their family did
not buy it (38% for vegetables and 38% for fruits). Additionally, 78% of overweight teens
reported that there are fruits and vegetables available where they buy their food, but only
60% reported that there are fruits and vegetables available in their home. Rural teens were
significantly less likely than urban teens to report that vegetables are available where they
buy food (71% vs. 82%), that their family can afford to buy fruits and vegetables (63% vs.
79%), and that there is a large selection of fruits and vegetables where they live (60% vs.
72%; all ps < 0.05). Teens overall and overweight teens, in particular, reported high levels
of intent to change their behaviors in the next 7 days, with 89% reporting they would drink
more water, 62% reporting they would eat more vegetables, and 63% reporting they would
eat more fruits. These data provided context for the everyday challenges teens face and
provided hope that Oklahoma teens do desire better nutritional outcomes.
Int. J. Environ. Res. Public Health 2022, 19, 10110 5 of 16

As a follow-up, a series of in-depth interviews were conducted with Oklahoma teens

(n = 21) in October–December 2020 to test draft campaign messages [53]. The sample
was drawn from both urban (n = 12) and rural counties (n = 9), and 70% of participants
reported being overweight. Teens were most receptive to messages about the short-term
benefits and immediate consequences of healthy nutritional choices. They confirmed that
they know and understand the long-term consequences of unhealthy nutrition, such as
obesity and risk of various diseases, but were most persuaded by messages that convinced
them of how their immediate nutritional choices can impact them today. Following this,
the campaign messages were designed to focus on how nutrition-rich foods/drinks help
them think, act, and feel good, while nutrition-poor foods make them think, act, and feel
bad. Teens connected to messages portraying everyday activities that teens care about and
relate to, such as sports and school performance. Additionally, teens enjoyed light-hearted
messages that demonstrated facts with humor, so they did not feel as though the message
was telling them what to do. As expected, teens also expressed little perceived control
over their nutritional choices at home. Even when they eat out with friends and expressed
that fast food and convenience stores were readily available, accessible, easy hang out
spots, and within their budget. Messages that acknowledged the conveniences provided by
these venues while providing tips on swapping side dishes or drinks with healthy options,
instead of skipping fast food altogether, were thought to be helpful, feasible, and relevant.
Given the high risk of adulthood obesity among teens in the state and similar percep-
tions of draft campaign messages across obese and non-obese teens in formative research,
the campaign was designed to reach Oklahoma teens of varying levels of obesity risk with a
single message. However, teens’ perceptions of message context, tone, and setting did differ
between urban and rural counties. Source characteristics, such as the narrator’s accent and
style were most important to legitimize the nutrition message for rural teens. That is, rural
teens were most receptive to messages delivered by teens who looked and sounded like
they were from rural areas. For urban teens, the setting was important for receptivity. They
wanted to see teens in places that were realistic, such as a fast-food restaurant or a school.
As a result, a body of campaign advertisements was developed to maximize relevance to
rural versus urban audiences, with targeted media delivery to appropriate counties.
Swap Up is primarily a digital and social media campaign directed towards teens
13–18 years old that includes active Instagram, YouTube, Facebook, and Snapchat accounts,
and an interactive website. The social posts are designed to either drive traffic to the
YouTube page or website and/or to promote engagement with short videos, memes, or
GIFs that deliver facts. Across assets for all three message platforms that were launched in
Year 1 of the campaign (Fuel for Football, Sluggish, and Blank-Minded; see Table 2), there
were a total of 43 million video impressions and 40,000 website visits. Rescue and TSET
worked with an Oklahoma media agency, VI Marketing and Branding, to deliver Swap Up
advertisements on broadcast television, Over The Top (OTT) streaming services, and radio
on stations and programs consumed by parents and influential adults. Given cultural and
systemic barriers to healthy nutrition, the goal is to ensure visibility and support for Swap
Up among the broader Oklahoma population.

2.2. Design and Procedures

In June–July 2021, approximately 5 months after the launch of Swap Up, a cross-
sectional survey was administered (n = 200) to assess evidence of campaign and message
awareness, relevance, and engagement. Additionally, early evidence of long-term goals
was assessed to track nutrition-related behaviors among the audience. The majority of
participants (74%, n = 148) were recruited via online advertisements on Facebook and
Instagram. Recruitment advertisements directing individuals to the screening survey were
served with age and geo-targeting features. Respondents answered screening questions to
ensure they were age 13 to 18 years and Oklahoma residents.
 Int. J. Environ. Res. Public Health 2022, 19, x FOR PEER REVIEW 6 of 17
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Table 2.
Table 2. Examples
Examples of
of Swap
Swap Up
Up Year
Year 11 campaign
campaign assets.
assets.
Table
Table 2.
2. Examples
Examples of
of Swap
Swap Up
Up Year
Year 11 campaign
campaign assets.
assets.
Table 2. Examples of Swap Up Year 1 campaign assets.
Asset
Asset Media Type
Media Type Audience
Audience Main Message
Main Message Media Flighting
Media Flighting
Asset
Asset Media
Media Type
Type Audience
Audience Main
Main Message
Message Media
Media Flighting
Flighting
Asset Media Type Audience Main Message Media Flighting

Swap aa slushie
Swap slushie for
for water;
water;
Swap
Swap a slushie
aa slushie for for
water;
sugar
Swap
sugar slows
slows you
slushie
you down
for and
water;
down and
:30 video ad Statewide water;
sugar sugar
slows youslows
down you
and February–March 2021
:30 video ad Statewide causes
sugar crashes/water
slows you down ener-
and February–March 2021
Fuel for
for Football
Football :30
:30video
:30 videoad
video adad Statewide
Statewide
Statewide causes
downcrashes/water
and causes February–March
ener- February–March 2021
2021
February–March 2021
Fuel causes crashes/water
you ener-
gizes you
causescrashes/water
crashes/water ener-
Fuel for Football
https://www.youtube.com/watc
Fuel for Football
Football gizes
https://www.youtube.com/watc
Fuel for gizes you
gizes you
https://www.youtube.com/watc
h?v=99Ks8sG4dng
https://www.youtube.com/watc energizes you
https://www.youtube.com/watch?
h?v=99Ks8sG4dng
h?v=99Ks8sG4dng
accessed on 31 May 2022
h?v=99Ks8sG4dng
v=99Ks8sG4dng
accessed on 31 May 2022
accessed
accessed on 31
on 31 May
May 2022
2022

Swap
Swap chips
Swap forfor
chips
chips for apples
apples
apples and
and
Swap
peanut
Swap chips
chips for
butter;
for apples
greasy
apples and
foods
and
:30 video
video ad
ad Urban and peanut butter;
peanut butter; greasy foods May–June 2021
2021
Sluggish :30
:30video
videoadad Urban
Urban peanut
slow youbutter;
greasy
peanut foodsgreasy
down/protein
butter; foods
slow you
greasy gives
foods May–June
May–June 2021
Sluggish :30 Urban slow you down/protein gives May–June 2021
Sluggish :30 video ad Urban slow you down/protein May–June 2021
https://www.youtube.com/watc
Sluggish
https://www.youtube.com/watc slowdown/protein
you
youyou energy givesgives
down/protein gives
https://www.youtube.com/watc energy
https://www.youtube.com/watch?
h?v=1u-pjQI9NyQhttps://youtu.
https://www.youtube.com/watc you
you energy
energy
h?v=1u-pjQI9NyQhttps://youtu.
h?v=1u-pjQI9NyQhttps://youtu.
v=1u-pjQI9NyQhttps:
be/ONDIIPbUxKI
h?v=1u-pjQI9NyQhttps://youtu.
be/ONDIIPbUxKI
//youtu.be/ONDIIPbUxKI
be/ONDIIPbUxKI
accessed on 31 May
May 2022
be/ONDIIPbUxKI
accessed
accessed on
on 31
31 May 2022
2022
accessed on 31 May 2022

Swap
Swap a milkshake
for for
Swap aa milkshake
milkshake for water;
water;
:30 video adad Rural Swap
sugar
Swap a
water;milkshake
slows
a sugar
you
milkshake for
slows water;
you
down/water
for water; May–June 2021
:30video
:30 videoad Rural
Rural sugar slows you refreshes
down/water May–June 2021
May–June 2021
:30 down/water
Blank-Minded
Blank-Minded :30 video
video ad
ad Rural
Rural sugar
sugar slows you
you down/water
refreshes
slows
refreshes you
down/water
you
May–June
May–June 2021
2021
Blank-Minded you
refreshes
https://www.youtube.com/watc
Blank-Minded
https://www.youtube.com/watc
https://www.youtube.com/watch? refreshes you
you
https://www.youtube.com/watc
h?v=IlgYwdg0DCg
https://www.youtube.com/watc
h?v=IlgYwdg0DCg
v=IlgYwdg0DCg
h?v=IlgYwdg0DCg
accessed on 31
31 May
May 2022
h?v=IlgYwdg0DCg 2022
accessed on
accessed on 31 May 2022
accessed on 31 May 2022

Interactive
Interactive
Interactive Greasy foods slow you
Interactive Greasy foods
Greasy foods slow
slow you
you
website/
website/
Interactive
website/ Statewide
Statewide
Statewide down;foods
Greasy sugarslow
causes
you February
February 2021–current
2021–current
February 2021–current
website/ Statewide down;
down; sugar
Greasy
sugar causes
foods
causes crashes
slowcrashes
you February 2021–current
game
game
website/ Statewide down; crashes February 2021–current
game
game down; sugar
sugar causes
causes crashes
crashes
game
How Food
How Food Affects
Affects You
Food Affects You
How
How
How Food Affects You
Food Affects You

Fruits and vegetables

Fruits and vegetables give October–December
:15 digital video Statewide give and
Fruits you vegetables
energy; swap give October–December
:15 digital
digital video
video Statewide Fruits
you and
energy;
Fruits and vegetables
swap fried
vegetables give
foods
give 2021
October–December
:15 Statewide youfried foods
energy; swapfor fried
a salad
foods October–December
2021
October–December
:15
:15 digital
digital video Statewide you energy; swap
for swap fried foods 2021
video Statewide you energy;
for aa salad
saladfried foods 2021
2021
Dynamic Duo
Duo for
for aa salad
salad
Dynamic
Dynamic Duo
https://www.instagram.com/p/
Dynamic Duo
https://www.instagram.com/p/CU8
https://www.instagram.com/p/
https://www.instagram.com/p/
CU8raPQNnxf/?utm_medium=
raPQNnxf/?utm_medium=copy_link
https://www.instagram.com/p/
CU8raPQNnxf/?utm_medium=
CU8raPQNnxf/?utm_medium=
accessed on 31 May 2022
copy_link
CU8raPQNnxf/?utm_medium=
copy_link
copy_link
accessed on 31
31 May
May 2022
copy_link 2022
accessed on
accessed on 31 May 2022
accessed on 31 May 2022
Int. J. Environ. Res. Public Health 2022, 19, 10110 7 of 16

Nutrient-packed snacks will October–December

GIF Statewide
Int. J. Environ. Res. Public Health 2022, 19, x FOR PEER REVIEW fill you up 2021 7 of 17
Table 2. Cont.

SnackingAsset
Tips Media Type Audience Main Message Media Flighting
https://www.instagram.com/sw
apupok/
accessed on 31 May 2022

2.2. Design and Procedures

In June–July 2021, approximately Nutrient-packed 5Nutrient-packed
months after thewill
snacks
snacks launch of Swap Up, a
October–December
October–December
GIF
GIF Statewide
cross-sectional survey was Statewide
administered (n = 200) will fill
to you up
assess
fill you up evidence of 2021
campaign
2021 and
message awareness, relevance, and engagement. Additionally, early evidence of
long-term goals was assessed to track nutrition-related behaviors among the audience.
Snacking
Snacking Tips
Tips The majority of participants (74%, n = 148) were recruited via online advertisements on
https://www.instagram.com/sw
https:
apupok/ Facebook and Instagram. Recruitment advertisements directing individuals to the screen-
//www.instagram.com/swapupok/
accessed on 31 May 2022ing survey were served with age and geo-targeting features. Respondents answered
screening questions to ensure they were age 13 to 18 years and Oklahoma residents.
An
An additional
additional 26%
26%(n(n= =52)52)ofof
the
thesample
sample was retained
was retained from
from thethe
pre-launch
pre-launch survey in
survey
2.2.
2020. Design
Following andsurvey
Procedures
completion, participants who were interested were directed to a
in 2020. Following survey completion, participants who were interested were directed to
separate Insurvey
June–July
where 2021,
they approximately
could sign up 5 future
for monthsstudies.after the Age launch of Swap
qualification Up, a
criteria
a separate survey where they could sign up for future studies. Age qualification criteria
werecross-sectional survey waswhoadministered (n = 200) to the
assess evidence ofand
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informed assent or on
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depending
depending on their age. Instagram.
on their Recruitment
age. advertisements directing individuals to the screen-
ing survey were served with age and geo-targeting features. Respondents answered
2.3.screening
2.3. Measuresquestions to ensure they were age 13 to 18 years and Oklahoma residents.
Measures
An additional
Demographics.
Demographics. 26% (n = 52)
Participants
Participants of the demographics
reported
reported sample was retained
demographics including
including from thesex,
age,
age, pre-launch
sex, survey in
race/ethnicity,
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and 2020.
andzip Following
zipcode survey
codeofofresidence.
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Participants
Participants participants
were labeled
were labeled who were
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as “Urban” interested
or “Rural” were directed
basedbased
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[54].Figure
[54]. See studies.
See Figure Age qualification
1 for county
1 for county criteria
designations.
designations.
were adjusted to allow those who were 18 years old in the initial survey, and were 19
years old at the first follow-up survey, to participate. All participants received a USD 15
online gift card. The study protocol was approved by the Advarra Institutional Review
Board. Participants received a study information sheet and provided informed assent or
consent, depending on their age.

2.3. Measures
Demographics. Participants reported demographics including age, sex, race/ethnicity,
and zip code of residence. Participants were labeled as “Urban” or “Rural” based on pop-
ulation density of the corresponding county [54]. See Figure 1 for county designations.

Figure
Figure 1. Map of
1. Map of county
county designation.
designation. Note:
Note:Star
Starindicates
indicatesatatleast
least11participant
participantself-reported
self-reportedaazip
zip
code
codefrom
from that
that county
county within
within the
the study.
study.

Obesity Risk. Adapted from the Oklahoma Youth Risk Behavioral Survey (YRBS; [7]),
participants were asked to describe their weight on a five-point scale (5—very overweight,
4—slightly overweight, 3—about the right weight, 2—slightly underweight, and 1—very
underweight). Responses were dichotomized as Overweight (4–5) or Not Overweight (1–3).
Swap Up Main Message Awareness. Prior to brand or advertisement questions, par-
ticipants were asked, “Have you seen any ads with the following messages or taglines?”
without revealing the source. Ten phrases featured in Swap Up advertisements were pre-
Figure 1. Map of county designation. Note: Star indicates at least 1 participant self-reported a zip
code from that county within the study.
Int. J. Environ. Res. Public Health 2022, 19, 10110 8 of 16

sented with a prompt to select all that apply (See Table S1 for items). Two types of variables
were calculated: (1) dichotomized Swap Up Main Message Aware; and (2) summed score
(0–10) indicating number of Swap Up main messages recognized.
Increasing Water. Participants who reported considering or trying to increase the
“amount of water” they drank in the past 30 days (from YRBS [7]), were provided with a
multi-select list of 11 items assessing which of the following actions they took (see Table S2
for items). A summed score was created, ranging from 0 to 11.
Decreasing Sugary Drinks. Participants who reported considering or trying to decrease
the “amount of soda/pop or other sugary drinks (e.g., Coke, milkshake, Frappuccino,
slushies)” they consumed over the past 30 days (from YRBS [7]), were provided with a
multi-select list of 14 items assessing which of the following actions they took (see Table S3
for items). A summed score was created, ranging from 0 to 14.
Increasing Fruits and Veggies. Participants who reported considering or trying to
increase the “amount of fruits/vegetables” they ate over the past 30 days (from YRBS [7]),
were provided a multi-select list of 12 items assessing which of the following actions they
took (see Table S4 for items). A summed score was created, ranging from 0 to 12.
Decreasing Greasy, Fried, and Sugary Foods. Although tangentially related to campaign
goals, we sought to document reports of decreasing unhealthy food consumption. Partici-
pants who reported considering or trying to decrease the “amount of greasy, fried or sugary
foods” they ate over the past 30 days (from YRBS [7]), were provided with a multi-select
list of 14 items assessing which of the following actions they took (see Table S5 for items).
A summed score was created, ranging from 0 to 14.
Swap Up Aided Campaign Awareness. To assess brand awareness, participants were
presented with a series of 8 health and nutrition-related brand logos and asked if they
heard of each brand, with “Yes,” “No,” and “I don’t know” as response options. To assess
ad awareness, participants were shown two of three campaign advertisements, which
included “Fuel for Football” to all participants, and either “Sluggish” for Urban teens or
“Blank Minded” for Rural teens. After each ad, participants were asked “Have you seen this
video before?” with “Yes,” “No,” and “I’m not sure” as response options. Participants who
selected “Yes” to the aided brand or aided video ad awareness questions were designated
as Swap Up Campaign Aware.
Swap Up Digital Engagement. Next, participants were asked, “Have you ever seen,
interacted, or shared any Swap Up social media posts, videos, or advertisements?” Partici-
pants were provided a list of 5 methods of digital interaction or engagement with a prompt
to select all that apply (See Table S6 for items). A dichotomous variable was created where
any selected response was considered Swap Up Engaged.
Swap Up Awareness/Engagement. To help address moderate multi-collinearity and in-
crease sample sizes for subgroups, a 3-level analytic variable was created that combined cam-
paign awareness (Y/N) and digital engagement (Y/N). Based on responses for the two items,
participants were categorized as Aware/Engaged (n = 75), Aware/Not Engaged (n = 67), or
Not aware (combination of not aware/engaged and not aware/not engaged; n = 57).
Swap Up Perceived Relevance to Nutritional Mindset. After viewing two Swap Up video ads,
participants were asked to rate agreement on a five-point scale (“Strongly Agree” to “Strongly
Disagree”) for 3 items assessing Swap Up’s relevance to them personally. Statements included
“Swap Up feels like it’s for people like me”, “Swap Up offers a new way to look at nutrition”,
and “Swap Up has information that could be helpful in improving my nutrition”. A composite
variable was created by averaging the 3 items (Chronbach’s α = 0.75).

2.4. Data Analysis

Frequencies were generated in SPSS for demographics and Year 1 campaign outcomes
related to media delivery, relevance, and engagement. Statistical comparisons were con-
ducted between campaign aware/not aware, engaged/not engaged, urban/rural county,
and overweight/not overweight on message awareness, perceived relevance, and nutri-
tional behaviors to understand patterns (chi-squared tests of independence for dichotomous
Int. J. Environ. Res. Public Health 2022, 19, 10110 9 of 16

outcomes and t-tests for continuous outcomes). To test whether awareness of main mes-
sages, perceptions of campaign relevance, and considering/trying to increase nutritional
behaviors differed based on campaign awareness/engagement, we conducted a series of
MANCOVAs, controlling for obesity risk and county.

3. Results
3.1. Demographics
Two hundred participants ages 13–19, living in Oklahoma, were recruited. The
mean age of the sample was 16.8 (SD = 1.4), with a majority being female (70%) and
White/Caucasian (59%). The final sample included 73% urban (n = 145) and 27% rural
(n = 55) participants, with 44% reporting to be overweight (see Table 3). Demographic
distributions of the sample were similar across urban and rural counties. However, non-
Hispanic Black teens were more likely to live in an urban county than a rural county (9%
vs. 2%, p < 0.05). The race and ethnicity composition of the sample was reflective of the
state of Oklahoma in 2021 more broadly (e.g., 63.8% White/Caucasian, 7.8% Black/African
American, 11.7% Hispanic, etc.) [55].
Table 3. Sample Characteristics.

Total Sample
Variable
% (n)
Total 200
Female 70% (140)
Age 16.8 (SD = 1.4)
13 years old 2% (4)
14 years old 6% (11)
15 years old 9% (18)
16 years old 22% (44)
17 years old 24% (48)
18 years old 33% (66)
19 years old 4% * (9)
Race/ethnicity
Hispanic 11% (21)
Non-Hispanic White 59% (118)
Non-Hispanic Black 7% (14)
Non-Hispanic Asian/Pacific Islander 2% (7)
Non-Hispanic American Indian/Native
9% (17)
American
Non-Hispanic other or 2 or more races 12% (23)
County (Urban) 71% (142)
Obesity Risk (Overweight) 44% (87)
* Participants who were 18 years old at the pre-launch survey were invited to participate in the follow-up.

3.2. Campaign Delivery, Engagement, and Relevance

A majority of participants (72%, n = 143) reported aided awareness of the Swap Up
brand and/or video advertisements, and 83% reported awareness of at least one campaign
main message. The average number of messages recognized was 3.9 (SD = 2.8) and the
most recognized was “Water refreshes you” (46%) followed by “Fruits and veggies give
you energy” (45%). See Table S1 for main message awareness frequencies by item and
subgroup. Of note, 5 out of 10 items significantly differed based on campaign awareness
and 8 out of 10 items significantly differed based on digital engagement.
On average, teens rated Swap Up’s perceived relevance to their nutritional mindset at
3.8, (SD = 0.8). Nearly half of the participants (44%) reported at least one Swap Up digital
engagement (M = 0.7, SD = 0.9). The most commonly endorsed items were “Seen a GIF/short
video from Swap Up online” (22%) and “Opened or seen a story on social media from Swap
Up” (22%). See Table S6 for digital engagement frequencies by item and subgroup. Of note,
Int. J. Environ. Res. Public Health 2022, 19, 10110 10 of 16

two out of five items significantly differed based on campaign awareness and all five items
significantly differed based on overall digital engagement status.

3.3. Nutrition-Related Behaviors

Increasing Water. Eighty-three percent of participants reported trying or considering at
least one water consumption-increasing behavior in the past 30 days (M = 2.4, SD = 2.2).
The most commonly endorsed items were “Set a goal to drink more water” (62%), followed
by “Purchased, or asked others to purchase for me sparkling unsweetened water or bottled
water” (35%). One out of eleven items significantly differed based on campaign awareness
and five out of eleven items significantly differed based on digital engagement. See Table
S2 for frequencies by item and subgroup.
Decreasing Sugary Drinks. Sixty percent of participants reported trying or considering
at least one sugary drink-decreasing behavior in the past 30 days (M = 2.2, SD = 2.6). The
most commonly endorsed items were “Set a limit on how many sodas/sugary drinks I
should drink each day, or limited the times/days I drink them” (45%), followed by “While
I still had these drinks, I tried to drink a bit less of them by taking a smaller serving or not
finishing all of the drink” (36%). Two out of fourteen items significantly differed based on
digital engagement. See Table S3 for frequencies by item and subgroup.
Increasing Fruits and Veggies. Sixty-seven percent of participants reported trying or consid-
ering at least one fruit/vegetable consumption-increasing behavior in the past 30 days (M = 2.7,
SD = 2.7). The most commonly endorsed items were “Set a goal to eat more fruits/vegetables”
(44%), followed by “Told my family about my plans to eat more fruits/vegetables” (35%) and
“Looked up recipes or information about how to prepare fruits/vegetables” (35%). Three out
of twelve items significantly differed based on digital engagement. See Table S4 for frequencies
by item and subgroup.
Decreasing Greasy, Fried, and Sugary Foods. Sixty-five percent of participants reported
trying or considering at least one unhealthy food-decreasing behavior in the past 30 days
(M = 2.7, SD = 2.9). The most commonly endorsed items were “While I still had these
foods, I tried to eat a bit less of them by taking a smaller serving or not finishing all of the
food” (53%), followed by “Set a goal to eat less of these foods” (48%). Four out of 14 items
significantly differed based on digital engagement. See Table S5 for frequencies by item
and subgroup.

3.4. Do Message Awareness and Perceived Relevance Differ by Campaign Awareness and Engagement?
To better understand the role of campaign exposure and digital engagement on awareness
and relevance outcomes, the combined Swap Up awareness/engagement variable was entered
into a MANCOVA with main message awareness and perceived relevance to nutritional
mindset as dependent variables, controlling for obesity risk and county; Pillai’s Trace = 0.17,
F(390) = 9/15, p < 0.001. Significant univariate main effects of awareness/engagement were
detected for both dependent variables (ps < 0.05). Pairwise comparisons revealed that (a) both
aware/engaged and aware/not engaged teens recognized significantly more unaided main
messages compared to not aware, and (b) aware/engaged teens rated campaign relevance
significantly higher than not aware (see Figure 2 for all comparisons).
 vance to nutritional mindset as dependent variables, controlling for obesity risk and
county; Pillai’s Trace = 0.17, F(390) = 9/15, p < 0.001. Significant univariate main effects of
awareness/engagement were detected for both dependent variables (ps < 0.05). Pairwise
comparisons revealed that (a) both aware/engaged and aware/not engaged teens recog-
nized significantly more unaided main messages compared to not aware, and (b)
Int. J. Environ. Res. Public Health 2022, 19, 10110 11 of 16
aware/engaged teens rated campaign relevance significantly higher than not aware (see
Figure 2 for all comparisons).

Figure 2. Swap Up main message awareness and perceived relevance by campaign aware-
Figure 2. Swap Up main message awareness and perceived relevance by campaign aware-
ness/engagement, controlling for obesity risk and county. Note: columns with different letters are
ness/engagement, controlling for obesity risk and county. Note: columns with different letters are
significantly different (p < 0.05); columns with the same letter do not differ significantly from each other.
significantly different (p < 0.05); columns with the same letter do not differ significantly from each
other.
3.5. Do Self-Reported Nutrition-Related Behaviors Differ by Campaign Awareness and Engagement?
Finally, to better understand the role of campaign exposure and digital engagement on
nutrition-related behaviors, the combined Swap Up awareness/engagement variable was
entered into a MANCOVA with four dependent variables (increasing water, decreasing
sugary drinks, increasing fruits and veggies, and decreasing greasy, fried, and sugary foods)
and two covariates (obesity risk and county); Pillai’s Trace = 0.114, F(386) = 2.92, p < 0.01.
Significant univariate main effects of awareness/engagement were detected for all four
dependent variables (ps < 0.05). Pairwise comparisons revealed that aware/engaged teens
were more likely to report trying or considering increasing water and decreasing sugary bev-
erages in the past 30 days compared to teens who were aware/not engaged and not aware.
Aware/engaged teens were also more likely to report trying or considering increasing fruits
and veggies in the past 30 days compared to teens not aware. Finally, aware/engaged teens
were significantly more likely than aware/not engaged and marginally (p = 0.08) more
likely than not aware teens to report trying or considering decreasing greasy, fried, and
sugary foods in the past 30 days (see Figure 3 for all comparisons).
 aware/not engaged and not aware. Aware/engaged teens were also more likely to report
trying or considering increasing fruits and veggies in the past 30 days compared to teens
not aware. Finally, aware/engaged teens were significantly more likely than aware/not
engaged and marginally (p = 0.08) more likely than not aware teens to report trying or
considering
Int. J. Environ. Res. Public Health 2022, 19, 10110
decreasing greasy, fried, and sugary foods in the past 30 days (see12Figure
of 16
3
for all comparisons).

Figure 3. Swap
Figure Up awareness/engagement
3. Swap Up awareness/engagement on nutrition-related behaviors
on nutrition-related controlling
behaviors for obesity
controlling risk
for obesity
andrisk
county.
and Note:
county.forNote:
each for
behavior, columns with
each behavior, different
columns with letters areletters
different significantly different (pdifferent
are significantly < 0.05); (p
columns with
< 0.05); the same
columns letter
with the do notletter
same differdo
significantly from each other.
not differ significantly from each other.

4. Discussion
4. Discussion
4.1. Summary of Findings
4.1. Summary of Findings
The current study found evidence that Swap Up successfully reached and delivered
The current study found evidence that Swap Up successfully reached and delivered
nutrition education messages to Oklahoma teens within its first five months of implementation.
nutrition education
As a comparison messages
point, the to Oklahoma
CDC’s VERB campaignteens within
reached its first
the same levelfive months
of aided of imple-
awareness
mentation. As a comparison point, the CDC’s VERB campaign reached the
(72%) after two years [26]. Overall, teens felt the campaign was relevant and made for people same level of
likeaided
them.awareness
This finding(72%) after two
is especially years [26]
hopeful . Overall,
for an audienceteens
that felt
has the campaign
a series was
of major relevant
barriers
and made for people like them. This finding is especially hopeful
in the way of behavior change and is resistant to being “told” what to do. for an audience that has
Importantly, we found that various campaign outcomes and recent changes in self-
reported behaviors/intentions were most pronounced among participants both aware and
engaged with the campaign compared to those not aware. From a campaign planning
perspective, this suggests that engagement-driving media approaches could increase recep-
tivity and eventual behavior change. Similar to principles of the Elaboration Likelihood
Model, campaign planners should consider the extent to which engaging social media
assets and interactive games that utilize key messages may provide valuable opportunities
for education and persuasion [56]. As Swap Up implementation continues, it will be critical
to continue measuring self-reported digital and social media engagements across campaign
assets in order to better understand the relationship between engagement and behavior
change over time.
The ultimate goal of Swap Up is to see incremental trends of sustained, self-reported
behavior change, leading to prevention of adulthood obesity. In order to support this goal,
Swap Up is regularly refreshing content across brand platforms. Since the launch of the first
advertisements (Fuel for Football, Sluggish, and Blank-Minded), a new series of video ads
were introduced every six months. Additionally, new social and digital content is regularly
posted in order to mimic other brands and influencers that teens care about, aligning with
how they expect to consume media. This strategy is intended to increase the likelihood
of grabbing teens’ attention and creating opportunities for multiple engagements because
Int. J. Environ. Res. Public Health 2022, 19, 10110 13 of 16

there is consistently new content to interact with. With each new impression or engage-
ment, Swap Up is reinforcing relevant information, increasing the likelihood of multiple
exposures/engagements, and most importantly, normalizing nutritional messaging and
healthy swaps in teens’ everyday lives [57,58]. The hope is that campaign media and mes-
saging will reinforce teens’ current intentions to make healthy choices, ultimately leading
to behavior change [57–59].
It is possible that the observed effects of campaign engagement on teens’ behaviors are
actually in the inverse direction; teens who engaged with Swap Up may do so because they
are already receptive to nutritional messages and to increasing nutritional behaviors prior
to exposure. In this case, one would expect that teens who are not overweight may be more
aware/receptive to the campaign or be more likely to report increasing or considering nutri-
tional behaviors than overweight teens. However, we did not observe systematic differences
by self-reported obesity risk in the current sample, and instead utilized this variable as a
covariate to increase the accuracy of the statistical models. It will be important to continue
tracking campaign outcomes year over year, as well as individual characteristics of teens, to
better understand and observe the potential impact of Swap Up on Oklahoma teens.

4.2. SAVI Messaging

This is the first campaign to design, implement, and measure outcomes based on
SAVI messaging, an approach developed by Rescue Agency [47]. The empathetic approach
provided by SAVI led to insights and messaging that directly addressed teens’ everyday
nutritional challenges. This study provides promising evidence that SAVI can success-
fully be applied to nutrition education, that SAVI messages are memorable, and that an
intended audience is receptive to this approach. More research on SAVI is needed to better
understand its impact on campaign outcomes.

4.3. Limitations and Future Research

As with all studies, there are limitations to note. The cross-sectional design and conve-
nience sampling of the current research limit generalizability and attribution of outcomes to
the campaign or underlying messaging framework. Future studies utilizing a longitudinal
design would allow for a more concrete understanding of behavior change mechanisms at play.
Additionally, the reliance on self-reported behavioral data may introduce error through recall
bias or social desirability. Future research should consider the extent to which real-time reporting
of actual daily nutritional intake would more accurately measure teen behavior change as a
result of campaign exposure. Lastly, the campaign was implemented and the study was con-
ducted during the COVID-19 pandemic, which may have temporal effects on nutrition-related
behaviors and/or media consumption [60,61]. Thus, findings would potentially be different
if this campaign and/or study was implemented a year earlier or later. The campaign will
continue to collect data annually in order to assess mid-term and long-term outcomes.

4.4. Conclusions
Swap Up is the first known mass media nutrition education and obesity prevention
campaign to attempt to reach adolescents across an entire state, including rural and urban
audiences. The current study found evidence that, within five months of implementation,
Swap Up successfully reached and educated Oklahoma teens about nutrition, and exceeded
its Year 1 goals related to media delivery and receptivity. More importantly for the future of
Oklahomans’ health, Swap Up awareness and online campaign engagement was associated
with an elevated number of self-reported healthy behaviors compared to those not aware.
These findings provide a promising foundation for the campaign’s long-term goals of
documenting incremental changes in teens’ behavior and obesity prevention. Ultimately,
this research underscores the importance of the purposeful design and measurement of
digital and social media engagement strategies within teen behavior change campaigns.
Int. J. Environ. Res. Public Health 2022, 19, 10110 14 of 16

Supplementary Materials: The following supporting information can be downloaded at: https:
//www.mdpi.com/article/10.3390/ijerph191610110/s1. Table S1: Swap Up main message awareness
items and frequencies; Table S2: Increasing water items and frequencies; Table S3: Decreasing sugary
drink items and frequencies; Table S4: Increasing fruit and veggie items and frequencies; Table
S5: Decreasing greasy, fried, and sugary foods items and frequencies; Table S6: Swap Up digital
engagement items and frequencies.
Author Contributions: Conceptualization, D.E.W.; formal analysis, E.J.; funding acquisition, K.A.B.
and S.W.-P.; methodology, D.E.W. and G.S.; project administration, D.E.W., K.A.B. and S.W.-P.;
supervision, D.E.W.; writing–original draft, D.E.W. and G.S.; writing–review and editing, D.E.W.,
K.A.B. and S.W.-P. All authors have read and agreed to the published version of the manuscript.
Funding: Funding for this study and manuscript was provided by the Oklahoma Tobacco Settlement
Endowment Trust (hc23-03), a voter-approved constitutional trust created in 2000 to invest 75% of
Oklahoma’s annual Master Settlement Agreement payment into improving health for generations
to come. Each evidence-based initiative utilizing the trust is designed to fight Oklahoma’s two
leading causes of preventable death—cancer and cardiovascular disease—by promoting healthy
eating, physical activity and tobacco-free lifestyles.
Institutional Review Board Statement: The study was conducted in accordance with the Declaration
of Helsinki, and approved by the Advarra Institutional Review Board (PRO10824; 9 June 2021).
Informed Consent Statement: Informed consent was obtained from all subjects involved in the study.
Data Availability Statement: The data presented in this study are available on request from the
corresponding author.
Acknowledgments: The authors would like to sincerely thank those who provided thoughtful
guidance and feedback throughout the writing process, including Carolyn Stalgaitis, Mayo Djakaria,
Pamela Buchwald, Michelle Bellon, Jeff Jordan, Laura Beebe, and Dylan Jasna. We would also like to
thank the team responsible for the ongoing development, implementation, and research for Swap Up,
including Julie Bisbee, Kathleen Thomas, Allison Rubinoff, Erika Redke, Rebeca Mahr, and Lisa Ott.
In addition, we would like to thank the TSET Board of Directors for their programmatic direction and
support in improving the health of all Oklahomans, including youth.
Conflicts of Interest: D.E.W., G.S. and E.J. are employees of Rescue Agency, which receives funding
from Oklahoma Tobacco Settlement Endowment Trust to implement the campaign and research
described in this manuscript. There are no other conflicts to disclose.

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