How U.S. Conservatives Perceive and Respond to International Nutrition Issues, and How to Shape Messaging for Successful Advocacy

Since 1990, tremendous strides have been made in global health and development toward achieving the Millennium Development Goals. With a united front of forces, including governments, coalitions, private sector, foundations, philanthropic organizations, and the faith community, millions of lives have been saved from extreme poverty and disease. Yet, some issues enjoy more robust funding and notoriety than others. For instance, AIDS, tuberculosis, and malaria enjoy the majority of the U.S. foreign assistance funding in global health. Nutrition, notably, has remained stagnant for decades. Through this research, we sought to test the appetite for increased funding for international nutrition and food security issues among Political, Religious, Social Conservatives (PRSCs), and the General Population (GP) to gauge perception and response to the issue and its correlates. Our objective with these national surveys was to understand the best choice of language to promote awareness, education, and prompt advocacy for global nutrition and food security issues. With this research, we found that conservatives were motivated by national security issues first and at a macro-level, not their faith, finances or moral foundation. We recommend that education be enhanced among conservatives regarding U.S. foreign assistance, nutrition funding and implementation, and nutrition-related terminology, including stunting, wasting, and anemia. Moreover, we recommend communicating strong narratives about mothers, children, and infants, particularly a child’s first 1,000 days, from conception to two years, which has proved to elicit the most positive response among all messaging.


Introduction
Since 1990, the U.S. has led the world in reducing by half the number of people living under $1.25 per day and also reducing by half the number of deaths from epidemic diseases such as malaria and tuberculosis. [1][2][3] Maternal mortality and child mortality numbers have also been cut in half. 4,5 Access to health care, clean water, nutrition, family planning, and medicines played a role in these historic advances worldwide. Yet this epic story is not being heard. In two national surveys conducted, when asked if people's quality of life around the world has gotten better, worse or remained the same over the last ten years, more than twice as many PRSC respondents (59%) believed life had gotten worse over those (25%) who believed it had gotten better. Even so, the GP respondents were slightly more optimistic, whereby almost half (49.5%) believed life had gotten worse, and almost one-third (29.3%) believed it had gotten better. Continuing the momentum of success in health and development depends upon continued funding by the U.S. for the global assistance programs that have made these achievements possible. In 2003, less than 50,000 people in Sub-Saharan Africa had access to anti-retroviral medications. Today, President Bush's President's Emergency Plan for AIDS Relief (PEPFAR) program supports over 14 million men, women, and children globally with these life-saving drugs. 6 Alongside PEPFAR, the Global Fund to fight AIDS, Tuberculosis, and Malaria (GFATM) also contributed greatly with U.S.-led investments for the increased decline of deaths from these three infectious diseases. Because this is a multi-lateral mechanism, the U.S. is just one of many contributors, yet perhaps the most critical. The legislation for GFATM stipulates that for every $1 we invest in it, other donors must match it at $2, leveraging funding from other nations, foundations, and donors. The GFATM has saved more than 22 million lives since its inception in 2002. 7 These programs have been the catalyst for the dramatic drop in deaths in HIV/AIDS, tuberculosis, and malaria since the beginning of the Bush administration.
In the wake of this historic effort, President Obama wanted to expand upon this work and announced his Global Health Initiative (GHI) which would increase and streamline funding as well as broaden efforts to include a focus on the issues of women and girls in poverty. Ultimately, GHI was a grand vision but it faced obstacles of controversy amongst leadership and an austere budget environment after the 2008 crash allowing the funding to simply plateau with little increase. Yet in recent years, the U.S. has led the world in global health investments not only to combat infectious diseases but also other areas, such as vaccines (GAVI) and international family planning. However, this funding depends upon the advocacy of informed citizens to their elected representatives. Therefore, if we want to continue to lead the world in investments and successes in global health and development, it is important to understand how such citizens understand the life-and-death issues underlying global health efforts.
Encouragingly, more than 70% of the respondents in both studieswith women significantly more than menreported that they believed it was important for the U.S. to have a positive image in countries around the world. Despite such a strong basic affirmation, only 42% of PRSCs believed that the U.S. should take a leading role in helping poor people in other countries. There is an obvious ignorance to be rectified that foreign assistance funding is a critical component to boost U.S. branding worldwide.
More specifically, we sought to clarify how best to construct and communicate explanations of international nutrition as a crucial global health issue. While some global health issues have enjoyed robust increase in funding, nutrition has consistently remained at less than 2% of the global health account. This survey explores the appetite or interest among PRSCs and the GP as well as the method by which to promote an increase for bilateral and multilateral funding through awareness and July 2018. Christian Journal for Global Health 5(1):32-43 advocacy. That being said, the findings below will predominantly focus on the PRSC group results.
This survey research is timely given the current crisis of famine in four sub-Saharan countries, President Trump's recommended budget cut of bilateral funding for nutrition by 38%, and the rising questions of how climate change will influence access to water and food sources in the near future. It is now more critical than ever to gain a better understanding of how PRSCs think and feel about global nutrition.
With this knowledge, individuals and organizations on the frontlines of awareness, education, and advocacy for global nutrition can better shape their language, rhetoric, and arguments to compel conservatives, faith leaders and the GP, and to engage members of Congress to maintain or increase funding for global nutrition.

Materials and Methods
This research was conducted by developing and administering a perception survey to a sample of 1,000 self-identified PRSCs as well as to a sample of 1,000 respondents of the GP. Our sampling protocol, which was administered by Qualtrics, provided three seven-point scales respondents were asked to use to rate the degree of their political, religious, and social views from "extremely liberal" (1) to "extremely conservative" (7). In order to be selected to take the survey, respondents had to score 5 or above on each of the three scales.
First, to contextualize our findings in a macromotivations framework, we measured the degree to which PRSCs/GPs reported that they were compelled by various rationales to address health and development efforts. We then explored how PRSCs/GPs prioritized global nutrition against other critical global health issues. To gain a better handle on PRSCs/GPs' knowledge and grasp of the subject of global nutrition, we tested related nutrition concepts and perceptions about those affected by hunger and starvation. We also tested nutritionrelated messaging to see what resonated most highly, cognitively, and emotively with them. And finally, we probed with questions of personal versus general responsibility at various levels to ascertain how compelling the issue had to be to motivate the groups to advocacy or engagement.

Macro-motives Framework: Rationales for Global Health and Development
PRSC respondents are most compelled by domestically-focused rationales for international health and development efforts as seen in Figure 1  • An overwhelming majority of respondents (90% PRSC, 84% GP) answered that safeguarding national security was of key interest. Notably, education played a key role differently for each study. In the GP study, 100% of those with a doctoral or professional degree ranked safeguarding national security as an important reason, and at the 90% confidence level those with doctoral or professional degrees were significantly more likely to find the "safeguarding national security" rationale important as those with less education. Conversely, among PRSCs, those with a doctoral degree were the least likely of any educational group (86.3%) to rank it as important. • Respondents also viewed protecting the public health of citizens (81% PRSC, 86% GP) as a compelling rationale for international health and development. Within the GP, those with a master's degree were significantly more likely to find the "public health" rationale more important than any other educational group, at the 95% confidence level.
• Honoring moral or ethical responsibilities (76% PRSC) was the third most compelling rationale among respondents, especially among those with a master's degree (82%) or doctorate/professional degree (88%). (The confidence interval test for comparison of means was statistically significant at the 95% level for this PRSC question (Q4).) Interestingly, those with master's degrees were most likely to view it as important across both studies. Yet, different age cohorts responded differently in the two studies: among the GP, the 66+ age group found it most important; and among PRSCs, the 25 and under age group viewed the moral rationale as most important. In the GP, women were more likely than men to find this "moral and ethical responsibilities" rationale important at the 95% confidence level. Those with a master's degree were more likely to see it as important, at the 90% level.
• Respondents were significantly less convinced by the phrase "advancing economic possibilities in the developing world" (49% PRSC), "advancing US economic interests abroad" (52% PRSC) or "advancing democracy and freedom in other places of the world" (53% PRSC). Yet, it was encouraging to see that PRSCs still assigned value to these rationales. Moreover, these lower rationales among PRSCs were significantly more important to men than women, by an approximate average of seven percentage points. In the GP study, however, there was no consistent significant difference between male and female responses.

Global Health Issues: Priorities
Similar to the rationales, global health priorities of both PRSC and GP respondents align with those that are most likely to affect people in their own country. While we report on the PRSC findings below, it should be noted that a higher percentage of the GP found every issue more urgent than did the PRSCs, at an average difference of 6.15 percentage points and by at least 55% of respondents. Both groups found the same top five issues most urgentin order: water pollution, infectious/communicable diseases, malnutrition, chronic diseases, and mental health as shown in Figure 2. Females were more likely than males to find each issue more urgent. • Water pollution (73%) ranked the highest among all as the most critically urgent global health priority. • Infectious/communicable diseases (66%) ranked second as either very or critically urgent to respondents.
• Malnutrition/nutrition (63%) and chronic diseases (63%) co-ranked as third highest for urgent global health priorities. were more likely than men (62%) to identify nutrition as a global health priority. (The confidence interval test for comparison of means was statistically significant at the 99% level for PRSC Q10 and the 95% level for PRSC Q20; both questions related to the perceived urgency of nutrition/malnutrition). • The only areas where fewer than 50% of PRSC respondents attributed urgency were climate change (39%) and refugee health (46%). In both areas, individuals with a doctorate or professional degree were much more likely to be concerned.

Global Nutrition: Preferred Definition(s), Knowledge of Related Terminology, and Perceptions of Vulnerability
When responding to this definition of nutrition by the World Health Organization (WHO), 66% of PRSC respondents said that nutrition was a very or extremely urgent global health priority: Nutrition is the intake of food, considered in relation to the body's dietary needs. Good nutritionan adequate, well balanced diet combined with regular physical activityis a cornerstone of good health. Poor nutrition can lead to reduced immunity, increased susceptibility to disease, impaired physical and mental development, and reduced productivity. 4 When asked how to define the need/problem of a nourishing diet for stronger population health, 36% of PRSCs chose to label it as "global nutrition," instead of selecting other words such as "malnutrition," "food security" or "hunger." At the very start of our survey, prior to introducing PRSC respondents to information related to particular aspects of nutrition and hunger, we asked them in an open-ended format to briefly describe the first thing(s) they thought of when they read the word "nutrition" in the context of developing nations. Their responses reflected little more than rudimentary understanding of the most basic dimensions of nutrition ( Figure 3). Very few respondents were able to construct a response that revealed either correlates to or deeper knowledge of nutrition-related characteristics. Moreover, almost none of the respondents demonstrated a familiarity with technical aspects of nutrition or nutritional interventions. Unfortunately, fewer than half of the PRSC respondents were familiar with the provided nutrition concepts and related health terminology, with the exceptions of vaccinations and breastfeeding as noted in Figure 4. • Vaccinations (55%), breastfeeding (51%), and family planning (46%) were the terms with which respondents were most familiar. No other term scored over 50%. • Fewer than a quarter of respondents were familiar with the terms demographic dividend (24%), child wasting (23%), and child stunting (22%). • 63% of respondents claimed that more education about nutrition and nutritionrelated issues was needed in the U.S. "very much so" or "absolutely." Among the GP, those with no college education were significantly less likely to be familiar with most of these concepts than those with higher levels of education. • When thinking about nutrition in international aid, the vast majority of PRSC respondents (83%) perceived that infants and children combined were the ones primarily affected vs. other potential populations as shown in Figure 5. Among the GP, infants and children were also seen as most affected; however, those with a doctoral or professional degree were significantly more likely than any other group to also see the elderly as affected (22.7%).

Nutrition Messaging: Focus on Mothers and Children
In testing key words across 30 nutrition messaging statements, PRSCs were most compelled by language that focused on mothers and children as vulnerable populations, as seen in Figure 6. Key words that triggered positive responses by larger majorities of respondents included: pregnant mothers, unborn children, children, babies, and kids. Across all questions, women found the language of mothers (+5%), children (+6%), and babies (+5%) significantly more compelling within nutrition statements than men when key words were examined, as demonstrated in Figure 7. Across the questions that contained concepts most familiar regarding mothers and children, the average difference between women's and men's responses increased to 7.5%.
• Among both PRSCs and the GP, women were more likely than men to respond to the language of mothers and children: 5.5% average difference among PRSCs and 4.1% among the GP.

Taking Responsibility for Acting on the Issues
With regard to how the PRSC and GP groups ranked those responsible for handling issues of international nutrition/malnutrition, the two groups were surprisingly similar in their first-rank positions. For both, the majority of respondents signaled that it was, "the government of those people struggling with nutrition" that should bear primary responsibility. However, PRSCs ranked "individuals struggling with lack of nutrition" in the second most responsible place, while GP respondents assigned that rank to "international organizations such as the UN." Both groups ranked "agricultural companies," "nonprofit organizations," and "the U.S. government," among the least responsible for taking action.
When we aggregated the top three rankings (out of 8) for each group, we were encouraged to find a nearly identical relationship between PRSCs and the GP assigning responsibility to "people from developed countries, such as myself," at surprisingly high rates: 45.92% (PRSC) and 45.15% (GP). Interestingly, both groups' scores gravitated significantly toward the bottom two positions of the rankings (58.35% for PRSCs and 50.57% for GP) for designating "the U.S. Government" as responsible. Given the overwhelming need for the U.S. to lead in bi-lateral and multilateral development assistance, this finding was particularly disturbing. At the same time, though not surprisingly, PRSCs were more than twice as likely as the general population to rank churches and faith-based organizations as responsible (10.44% versus 3.90%).
Below are the findings solely based upon the PRSC study: • 85% of PRSC respondents answered "yes" when asked if they were committed Christians and three-fourths (76%) indicated that honoring moral or ethical responsibilities was a compelling rationale for international health and development efforts. • Yet, only 49% said that feeding the hungry in other countries was an important commitment with respect to their personal faith. • While 88% of (PRSC) women identified themselves as committed Christians (seven percentage points higher than male respondents; the confidence interval test for comparison of means was statistically significant at the 95% level for PRSC Q33), they were just as likely as men (50%) to say that feeding the hungry in other countries was a "strong or very strong" commitment with respect to their personal faith. • Moreover, only 32% were (very or extremely) willing to donate their personal resources to fight malnutrition internationally. • While 70% believed that it was important for the U.S. to have a positive image in countries worldwide, only 42% said that it was important for the U.S. to take a leading role in helping poor people in other countries. • PRSCs agreed with the statements that we should provide those in other countries with resources (66%) and that it was important to prevent people from other countries from starving (68%).

Limitations
Limitations of our survey methodologies were similar to those for most survey research and included: (1) potential bias toward younger and more technologically-savvy respondents, as the survey was administered via internet through Qualtrics; (2) potential bias in excluding some conservatives who scored lower on our PRSC ideological filter scales but may still have constituted part of the reference group; (3) potential bias associated with the low representation of minorities (especially Latina/ Latino) in the samples; (4) potential error as a result of the use of technical language associated with nutrition and international development efforts; (5) potential error associated with overstating the degree of concern or familiarity respondents had with certain related constructs. Qualtrics estimated the sampling error to be +/-4%.

Discussion
This survey was conducted in the first and second quarters of the Trump Administration. The PRSC respondents, many of whom were likely to have voted for this administration, may have had in mind a more nationalist agenda compared to the global-minded philosophy of the previous Obama and Bush administrations, perhaps particularly represented by foreign assistance. This potential bias might explain the emphasis in their responses on national security and public health as strong rationales for foreign assistance, as well as their apparent uncoupling of personal faith with a responsibility to "feed the hungry" in other countries.
Given the findings, we offer the following observations and recommendations in which to shape messaging for successful advocacy to maintain or increase funding for global nutrition among PRSCs and the GP in the U.S.:

Better U.S. foreign assistance branding
The American public consistently overestimates the share of the federal budget spent on foreign aid: the average answer is 31% (Kaiser Family Foundation Health Tracking Poll (conducted December 1-7, 2015)). 8 Debunking the twin myths of quality (the U.S. government is inefficient with foreign assistance) and quantity (the myth that foreign assistance comprises 25%+ of the U.S. budget) remains a challenge, including among PRSCs. We must tell a better story to uplift the branding. As a correlate, the public, including PRSCs, need further education on the role of foreign assistance as "soft power," "smart power," or the "third leg of the stool" as development, alongside diplomacy and defense. Though we find that 90.2 percent of PRSCs overwhelmingly note that safeguarding our national security is important for international health and development efforts, when nutrition is paired with national security, we find only 53.6 percent find the correlation compelling. On a more micro-level, we believe the respondents July 2018. Christian Journal for Global Health 5(1):32-43 shifted into analytical, deliberative thinking which can override both emotion and action. In a macro view of global health and development overall, among the metaphors of impetus, national security is the clear motivation. Much collaboration with the media and spokespersons is needed to aid in telling of the good news of progress in fighting disease and poverty, including with nutrition, with less than 1% of the U.S. budget, including the efficiency and efficacy with which the U.S. implements this funding through governmental infrastructures and partnerships worldwide. Moreover, linking national security with global health and development issues is also imperative in order to elucidate the relationship between the two. The good news is that most PRSCs do believe we should provide international assistance to combat starvation (68%). This belief can be a powerful leverage in a time of historic famines in order to mobilize PRSCs and the GP for advocacy.

Better education on global nutrition
Due to the open-ended response(s) of the most basic language around "nutrition," juxtaposed to the findings that fewer than a quarter of respondents were familiar with the terms such as child wasting (23%), child stunting (22%), or micro-nutritional deficiencies (24.7%), we recommend using the most basic of nutrition language when speaking with PRSCs of the importance of global nutrition. Educating PRSCs on the International Affairs Account (150 account), the role of nutrition in U.S. international food aid programs and agriculture programs, the importance of nutrition for mothers in the crucial 1000-day window between a child's conception and the age of two, and related nutrition terminology (e.g., wasting, stunting, anemia) will be necessary for this constituency to better understand the critical importance of funding for nutrition worldwide. With such learning, committed Christians and others may experience an increase in empathy for those humans behind the issues and a stronger commitment to foreign assistance.

Better stories about mothers and children
We recommend narratives that feature stories of the daily struggles of mothers, children, and infants for the most effective method of education and awareness building. From the research, we know that the most compelling messaging for nutrition stays close to saving the lives of both mothers and children or their flourishing. Eighty-three percent believe that infants and children are primarily affected by malnutrition, and more than 70 percent of PRSC respondents find this language about the mother-child connection with nutrition most compelling.
Our hope is that this research will better inform the messaging and education of both the American public at large, and more specifically, PRSCs in an effort to galvanize the interest of the members of Congress to enhance and shape better policies on global nutrition.