CDCynergy Example
Cardiovascular Health Edition

Social Marketing

Step 1.1 Write a problem statement.

Heart disease is the number one cause of death in the state. In the nation, the state ranked second for deaths due to heart disease in 1996. White residents of Appalachia, a region that has come to symbolize poor rural America, die from heart disease at younger ages and in larger numbers than do other Americans. Researchers from the state university found that white Appalachians have about a 20 percent greater chance of dying from heart disease between ages 35 and 64 than other white Americans. Appalachians have less access to healthy foods and recreational facilities than other Americans do. This contributes to poor diet and exercise habits, which are leading risk behaviors for developing heart disease.

Nationally, changes in personal health behaviors and improvements in medical technology have caused significant declines in cardiovascular disease (CVD) deaths. However, while experiencing an improvement, deaths due to CVD in the state have not declined at the same rate as the national average. CVD mortality declined 44% nationwide between 1960 and 1990, while the state had only a 32% decline.

Many Appalachian residents do not recognize or may ignore the symptoms of heart attack. This, coupled with long travel times to heart units in urban areas of the state, creates a significant problem of CVD deaths in Appalachia.

Step 1.2 Assess the problem's relevance to your program.

The Regional Heart Center is the second-largest heart center in the state. The Regional Heart Center opened in 1979 with the mission to treat all forms of cardiovascular disease and promote primary and secondary prevention of heart disease. Annually, the Heart Center performs an average of 550 open-heart procedures and more than 4300 cardiac diagnostic and therapeutic catheterizations.

Step 1.3 Explore who should be on the planning team and how team members will interact.

In 1999 the Heart Center was named a partner in the state Cardiovascular Steering Committee for the Cardiovascular Health Core Capacity Grant funded by the CDC and administered by the state Bureau of Public Health. Other partners considered and ultimately included in the planning team were:

• The state Prevention Research Center
• The local American Heart Association affiliate
• The Nutrition & Chronic Disease Coalitions
• The state Coalition for Physical Activity
• Coalition for a Tobacco-Free state
• The state Coalition for Minority Health
• The state Department of Education
• The state peer review organization

Representatives of the Heart Center, the state Bureau of Public Health, the state-level cardiovascular health program, and the Hospital System Marketing & Public Affairs Department comprised the planning team. A contracted advertising agency developed the creative concepts and the communications campaign. A marketing research center researched and wrote the plan, tested the concepts and messages, and assisted with evaluation. Representatives from the Heart Center and the Bureau of Public Health oversaw the administration of grant funding, ensured that plan steps were followed, and assisted with evaluation. The principal investigator of a cancer intervention project in the rural part of the state and founder of the county Primary Care Center acted as a consultant.

Step 1.4 Examine and/or conduct necessary research to describe the problem.

On behalf of the planning team, a marketing research center developed a baseline study to identify:

• the range and level of public knowledge related to the signs and symptoms of heart disease and attack,
• what steps to take when experiencing symptoms of a heart attack,
• attitudes toward heart disease and its prevention and early detection, and
• sources of heart disease information.

The planning team had the marketing research center develop an interview guide for key informant interviews. Women interviewees were asked questions specifically about whether they knew what symptoms women experience when having a heart attack. Respondents were also asked to describe their current health status, age, sex, educational level and household income category.

Secondary research: A health status profile of counties served by the Heart Center was conducted. The prevalence of heart disease and heart disease risk factors was evaluated on a town-by-town basis. Nationally, the state's risk factor status ranks first in obesity, third in self-reported hypertension, and fifth in cigarette smoking. Towns with the highest prevalence of risk factors and disease showed up in all counties, but with the highest indices of concentration in the Appalachian county.

The marketing research center conducted a literature review of studies and interventions related to heart disease. The marketing research center also conducted a review of data specific to heart disease in the state and a 1994 intervention project that had taken place in the county. The Rural Cancer Prevention Project, a study conducted previously in the same geographic region of the state, was reviewed for information and knowledge related to (a) attitudes toward health in the county, and (b) barriers to care in the county.

Step 1.5 Determine and describe distinct subgroups affected by the problem.

Heart disease is an equal opportunity killer. Both men and women of all racial and ethnic groups are at risk for cardiovascular disease. Although it was once thought to be a disease of older Americans, heart disease also occurs in younger generations. Heart disease is the leading cause of premature disability among working adults.

Adult Females (35+) at risk for heart disease
Adult Males 35+ at risk for heart disease
Racial and ethnic groups at high risk for heart disease
Rural families and medically under-served populations across the state

After a study of the population it was decided to focus on the poorest population group of males and females ages 35+. This group is at high risk for heart attack due to a prevalence of risk factor behavior.

Research was conducted primarily utilizing Inforum's Demographic Expert, Household Targeter and Claritas Prizm market segmentation analysis. A review of population data through Claritas indicates that the top three Prizm cluster groups for the Huntington Ashland-Ironton MSA can be identified by the marketing terms as Hard Scrabble, Mines & Mills and Rural Industrial. Members of the Hard Scrabble group are poor (<$15,000 annual income per household), and are not highly educated (grade school education). By targeting this population group the campaign can be tailored in such a fashion to reach individuals who have not been successfully informed of the dangers of ignoring heart attack signs and symptoms. However, this group was also the hardest to reach and presented the greatest challenge for persuasive attempts toward attitudinal change. For this reason, the planning team also ensured that Mines & Mills and Rural Industrial families would receive messages as well, when the project later ran statewide.

Step 1.6 Write a problem statement for each subgroup you plan to consider further.

• Women: In the state, women rank third in the United States for heart disease death rates for all women (1991-1995). Only Mississippi and New York have a higher death rate. African-Americans have a higher propensity for heart disease and mortality. As a segment of the female subgroup, black women in the state are dying from heart disease at a greater rate (566/100,000) than white women (470/100,000)

  The symptoms of heart attack vary slightly between men and women. For example, researchers have indicated that women with coronary heart disease may experience chest pain as a sensation of heaviness or pressure (or not at all) while men may report it in the left chest or in the center of the chest (Milner et al., 1999). Most public service messages have alerted the public to men's heart attack symptoms. However, women as a group also need to know about heart attack warning signs and symptoms.

• Rural families. Time is crucial to survival of heart attack. The health service support communication interventions set forth in this plan should stress the urgency of not waiting to phone 911. A pilot study in the county, a county that is a 20- to 30-minute drive from the nearest hospital, is the place the planning team wished to test the campaign.

Step 1.7 Gather information necessary to describe each subproblem defined in new problem statement.

The marketing research center conducted four key informant interviews with individuals representative of the women and rural family subgroups just mentioned in step 1.6. They learned that there are specific needs for women:

• Women. Women are less likely to care for their own health because they are busy caring for others in their family. Conventional wisdom also holds that heart disease is primarily a killer of men. It is only recently that women have started hearing messages that heart disease is the leading cause of death for women. The Framingham study proved that women are even more likely to die from a first heart attack (39%) than are men (31%). That study also stated that female survivors are more likely to have re-infarction, heart failure and death. Women are traditionally the "gatekeepers" of health in a household and are more likely to seek help if they or a family member are experiencing a health problem. With greater education of the warning signs/symptoms for women, women should be better armed to call for help when needed.
• Rural families and medically under-served populations. Besides a lack of knowledge of symptoms, residents in rural areas of the state also are medically under-served and live long distances from hospitals. There is also a shortage in the region of hospital heart units and cardiac rehabilitation facilities, which are mostly clustered in more affluent and urban areas.

It was important to intervene because many deaths from heart attacks and diminished quality of life for heart attack survivors can be avoided if emergency medical care is sought at the onset of early warning signs or symptoms.

Step 1.8 Access factors and variables that can affect the project's direction.

Click here to see the chart.

Step 2.1 List the direct and indirect causes of each subproblem that may require intervention(s).

• Younger Mortality/Geographical Distance - Appalachians have a 20% greater likelihood of dying younger from heart attacks than other white Americans. As stated in Phase One, one reason Appalachians are dying from heart attacks and heart disease is the geographical distance from their homes to sophisticated hospital heart and cardiac rehabilitation units.
• Attitudes - Another reason is a prevalent attitude of fatalism and denial in certain rural areas of the state, which was supported by the findings of previous research. Some Appalachians believe that if they are going to die of something anyway, then they might as well die from smoking or eating an unhealthy diet. Or, they believe that they have "a time" to die and that nothing they do will alter that. However, other projects have found that when given a strong enough motivating impetus (e.g., being around to help raise or take care of their grandchildren), older Appalachians are motivated to make healthy changes in their lives.
• Information to Action Gap - Many Appalachians have yet to receive prevention and wellness information. Others may not pay attention to it or do not recognize heart attack symptoms for various reasons. This gap must be addressed before real behavioral change has a chance with the overall population.

Step 2.2 Examine relevant theories and best practices for potential intervention(s).

• Lack of awareness or poor recognition of warning signs and symptoms of heart attacks
• Allowing a situation to worsen (i.e., not calling a physician or emergency medical services)
• Lack of information about heart disease, particularly among women
• Access-to-care issues

Step 2.3 Consider SWOT and ethics of intervention options.

• To increase knowledge of warning signs/symptoms of heart attack in men.
• To increase knowledge of warning signs/symptoms of heart attack in women.
• To increase knowledge of what to do when experiencing these symptoms (e.g., what steps to follow and a sense of urgency with time).
• To reduce prevalence of opinions/attitudes of fatalism and denial about cardiovascular disease.
• To increase prevalence of opinions/attitudes of action-orientation and probable success to prevent and treat cardiovascular disease.
• To increase knowledge of heart-healthy habits.
• To advocate for increased access to emergency medical services in Appalachia.

These goals can help to reduce mortality from heart attack/disease in the state.

Step 2.4 Prioritize and select subproblems that need intervention(s).

Health communication-related planning models that were also considered were the Social Marketing model and the steps of the CDCynergy program planning tool. Social Marketing is the development of programs with a consumer-driven approach aimed at changing the behavior of target audiences. Social marketing uses strategies from commercial marketing but for the purpose of achieving social objectives. For more information about theories and intervention models please refer to Glanz, Lewis, Rimer (2000). Health Behavior and Health Education: Theory, Research, and Practice (2nd ed.). San Francisco: Jossey-Bass and/or the Communication Inititiative’s descriptions of theories and planning models at: http://www.comminit.com/

Step 2.5 Write goals for each subproblem.

The planning team generated a SWOT analysis for the Anticipated State-Wide Project. Click here to see the chart.

Step 2.6 For each subproblem, select the intervention(s) you plan to use.

• Increase Awareness and Knowledge - The planning team chose to use a mix of non-traditional methods, earned media, and newspaper ads to educate the target group about the early warning signs and symptoms of heart attack while stressing the importance of seeking emergency medical help. Opinion leaders within the communities who have survived heart attacks and are living healthier lives would provide testimonials.
• Influence Attitudes - The communication strategy stressed that "it is better to be safe than sorry" when dealing with a heart attack. The planning team also addressed fatalism and denial by "tapping into" the love for family and desire to help raise grandchildren: message - "be there for them."
• Influence perceptions of target audience members about their ability to perform a behavior for seeking emergency medical services (EMS) - The planning team intend to use testimonials of individuals who survived a heart attack due to prompt treatment and the testimonials of loved ones who have lost family/friends due to inaction.

By accomplishing the above steps and influencing people to seek prompt emergency medical treatment, program planners hoped that there would be a decrease in deaths due to cardiovascular disease in the target areas in Appalachia.

The campaign was implemented in two phases. The campaign was piloted in one county in the state and then revised as necessary before launching statewide. The primary market area of the Heart Center was evaluated as the first target market.

This market area included three counties in the state and one county in an adjacent state. After a review of the data from those counties, one county was proposed for the pilot campaign.

According to the state Bureau of Public Health Statistics for 1996, the number one cause of death in this county was heart disease. This county also has the highest index of risk factors for heart disease (obesity, high cholesterol, and hypertension) and the highest propensity of current households with heart disease. The population of the county is classified as Rural. This county was chosen not only for its high propensity of households with current heart disease and/or convergence of heart disease risk factors, but also because it has a well-established Primary Care Center and network of healthcare providers.

For this campaign to succeed in addressing the problem, it must act as a catalyst for discussion between provider and patient and utilize the physician's office as a distribution center for educational materials and posters.

Once the campaign was completed in the county and evaluated, it would be revised as necessary and launched statewide.

Step 2.7 Explore additional resources and new partners.

Step 2.8 Acquire funding and solidify partnerships.

As part of the core capacity grant for cardiovascular health, the Heart Center was to "develop culturally competent strategies for priority populations." This Heart Center, in cooperation with the American Heart Association/Heart Attack Alert program and the Emergency Medical System, developed a strategy to design a social marketing campaign that publicizes symptom awareness and therapies for the primary prevention of heart attack. The planning team met regularly face-to-face and via teleconference calls.

The planning team also chose to use the American Heart Association's (AHA) numerous publications and campaigns to increase awareness of the early warning signs of heart attack. Literature from the AHA urges individuals who experience these signs to immediately call 911.

Step 3.1 For each subproblem, determine if intervention is dominant or supportive.

• Poor recognition of heart attack symptoms
• Not seeking help if experiencing symptoms and allowing the situation to worsen
• Lack of information and access-to-care issues
• Access to care issues required community service support intervention to promote health-seeking practices.

Step 3.2 Determine whether potential audiences contain any subgroups (audience segments).

The planning team decided that two separate interventions were not necessary - however, the planning team intended to produce one or two messages that would address only women because of their gatekeeper role.

Copyright © 2000 Claritas, Inc. All rights reserved.

Step 3.3 Finalize intended audiences.

• Which has the highest priority?
• Which can be most easily reached and influenced?
• Which is most adversely affected?
• Which is a large enough group?
• Which is most vulnerable to health problems?
• Which are most likely to change contributing factors?
• Work currently underway with this group?

Step 3.4 Write communication goals for each audience segment.

• To educate women of the warning signs and symptoms of heart attack in women
• To educate women of the steps to follow when experiencing these symptoms
• To persuade women to call 911 immediately when experiencing these symptoms and not delay seeking necessary medical treatment
• To persuade women to promote heart healthy habits and behaviors for their families

Step 3.5 Examine and decide on communication-relevant theories and models.

Social Judgment Theory purports that on any given persuasive issue, there are likely to be a number of different points of view and, therefore, varying responses to the persuasive communication which define the respondent's judgmental latitudes. Positions the respondent finds acceptable form the latitude of acceptance; the positions the respondent finds unacceptable form the latitude of rejection; and the latitude of non-commitment is formed by positions neither accepted nor rejected (O'Keefe, 1990). The basic principle offered by social judgment theory is: "A communication that is perceived to advocate a position that falls within the latitude of acceptance or the latitude of non-commitment produced attitude change in the direction sought by the message." (O'Keefe, 1990)

From the Social Judgment theoretical perspective, peoples' reactions to the persuasive messages communicated through this campaign depend directly upon people's judgments of the positions stated in the messages. The positions upheld in the message: "If you call 911 immediately you will foster a better outcome," are the American cultural myths of action orientation and probable success. Those people who believe "I can't control my time to die" are harder to convince that calling 911 is an action they should take. This revelation does not predict certain failure of campaign objectives among this group of people. However, it does indicate the need for co-requisite messages that fall within this group's latitude of acceptance. Another belief held by many older adults in this group was that they are better equipped to raise their grandchildren than their children are. Therefore, stressing the "need to be there for them" as the motivation should help garner more acceptance of the campaign's main messages.

The concept of observational learning from Social Cognitive Theory was used in the form of testimonials in the social marketing campaign. People who had suffered heart attacks and survived in part by calling "911" served as credible role models to motivate the target audience to perform the same behavior if they ever experienced symptoms of a heart attack. Other concepts of the Social Cognitive Theory ( expectancies and reinforcements ( also were integrated into the campaign. Performing the desired behavior of calling "911" was expected to result in survival of the heart attack, and the reinforcements were living and continuing to be there for family and grandchildren.

Step 3.6 Undertake formative research.

Step 3.7 Write profiles for each audience segment.

• Profile of rural families(males & females (35+). There is a prevalent attitude of fatalism and denial in certain rural areas of the state. The research supports the findings of other research. Some Appalachians believe they're going to die of something anyway, so they might as well die from smoking or eating an unhealthy diet. Or, they believe that they have "a time" to die and that nothing they do will alter that. However, other projects have found that when given a strong enough motivating impetus (such as being around to help raise or take care of their grandchildren), older Appalachians have been motivated to make healthy changes in their lives.

As set forth in Social Cognitive Theory, people sometimes learn not only from their own experiences, but also by observing the actions of others and the consequences of those actions. The campaign's use of testimonials was an example of how this concept was applied. According to Social Judgment Theory, people respond to communication within latitude of acceptance, rejection, or non-commitment. The planning team intended to steer clear of audiences who were in the latitude of rejection because messages would fall short. The planning team attempted to reach rural families through the high schools (even older families with no children living at home meet and congregate at the high schools for different events), churches, community organizations, and healthcare providers. They utilized testimonials in local newspapers.

• Profile of women(Women are less likely to care for their own health because they are busy caring for others in their family. Conventional wisdom also holds that heart disease is primarily a killer of men. It is only recently that women have started hearing messages that heart disease is the leading cause of death for women. The symptoms of heart attack vary slightly between men and women. Most public service messages have alerted the public to men's heart attack symptoms. Women need to know with certainty what to look for.

Women are more likely to seek help if they or a family member are experiencing a health problem. With greater education of the warning signs and symptoms for women, women should be better armed to call for help when needed. The planning team attempted to reach women through their healthcare providers, grocery stores, schools and community organizations. They also reached out to women through the pages of the local newspaper, utilizing testimonials.

Step 3.8 Rewrite goals as measurable communication objectives.

• To educate 80% of the households in the county regarding early warning signs and symptoms of heart attack for males and females during the three-month campaign.
• To increase the number of households in the county that have behavior patterns that help to prevent heart attack/disease by 20%.
• To raise awareness among 100% of households in the county regarding heart-healthy habits and lifestyles.
• To increase the number of individuals who seek prompt medical attention when experiencing the early warning signs of heart attacks by 30%.

Step 3.9 Write creative briefs.

Profile/Position/Current Situation: According to the state Bureau of Public Health Statistics for 1996, the number one cause of death in the intervention county was heart disease. Out of the 232 total deaths for that year, 95 were attributed to major cardiovascular disease. Forty-eight deaths were due to ischemic heart disease, one from hypertension, twelve from cerebrovascular diseases, one from atherosclerosis, and four from other disease of arteries, arterioles and capillaries.

Potential Settings for Reaching Target Audiences:

• Home (via direct mail)
• the county Primary Care Center
• Harts Health Clinic
• Community Centers
• High Schools
• Grocery Stores
• Church/Civic Groups
• Newspaper

The following channels and activities were considered to reach the target audience:

• Interpersonal channel (early intervention and primary prevention). Distributed information at providers' offices, "bag stuffers" at grocery and convenience stores, and posters to high schools.
• Small group channel (early intervention). Asked opinion leaders to give talks at churches, social clubs, and civic organizations. (Used healthcare professionals and the testimonials of individuals who survived a heart attack due to prompt treatment and the testimonials of loved ones that lost family members due to inaction.)
• Community channel (early intervention and primary prevention). As part of a community event, local Emergency Medical Services (EMS) personnel gave tours of ambulances and promoted early intervention. The hospital and Heart Center participated in health fairs, at which healthcare personnel performed free blood pressure checks and total cholesterol screenings. EMS personnel offered free blood pressure checks at the office between runs.
• Media channel (early intervention and primary prevention). Directed mail piece with enclosed refrigerator magnet with warning signs; directed mail piece with primary prevention messages; posters; earned media/testimonials of opinion leaders in local newspaper; and print ads/testimonials in local newspaper.

Guide for Needed Materials:

• Interpersonal: brochures and flyers
• Small group: slide presentations, brochures, refrigerator magnets
• Community: brochures, refrigerator magnets, signage for booths, cholesterol Reflotron machine, blood pressure cuffs
• Media: direct mail piece, refrigerator magnets, posters, print ads; press releases

Proposed Message Variables:

• Tone - light with serious undertones
• Type of appeal - thought-provoking, lessen the fear of embarrassment if symptoms are not related to heart attack
• Message source - of same demographic as target audience. Or, strong opinion leader from the community who has survived a heart attack.

The research showed that the messages in this creative brief for the campaign appealed to the target audience. The planning team expected the messages that appeal to love of family and use children, as well as the messages that are from opinion leaders, to have the most success.

Step 3.10 Confirm plans with stakeholders.

Utilizing the input received from the partners, the planning team decided to evaluate a social marketing program based on the signs and symptoms of a heart attack/heart disease and the need to seek medical help in a more expedient manner than what is presently occurring, especially in a rural setting. This topic follows along the objectives of the cardiovascular program grant.

Given the nature of the campaign, the following stakeholders were identified:

• The Emergency Medical Services Department (Director) of the county
• Several physicians and staff of the county Primary Care Center, which treat approximately 80% of the population in the county
• A faculty member of a medical school, who was instrumental in developing as well as initially funding the county Primary Care Center and a network of rural health clinics in the area. (This medical school was also involved with the primary care center and its rural health care program).

After the stakeholders were identified, information was distributed, and meetings and discussions were held in the county with the identified stakeholders. During these stakeholder meetings, the design and implementation of the proposed campaign was discussed and evaluated, feedback was received, and information about expectations was obtained regarding the specific implementation of the marketing program. Following these meetings other "stakeholders" were identified and contacted.

Examples of other stakeholders identified were: prominent figures in the county such as elected officials of the county government, prominent business leaders, and well-known individuals who have heart disease and have gone through the process of receiving appropriate treatment for their heart disease.

Stakeholders felt that because the culture in the intervention county (and generally in Appalachia) was one of fatalism, it would be critical to the success of the campaign that the prominent leaders in the county were well aware of the proposed plan and were willing to publicly support the program. All of the stakeholders were very enthusiastic and willing to aid in any way they could. It was also noted that this was the only county in the state in which 100% of the people were required to travel completely out of the county when medical care required a hospital stay.

Step 4.1 Draft timetable, budget, and plan for developing and testing communication mix.

Click here to see the proposed timeline and plan.

Step 4.2 Develop and test creative concepts.

During the early stages of the creative process, focus groups were led through discussions regarding the signs and symptoms of heart attack for men and women and what to do when experiencing them. The output that was generated provided insight into the level of awareness, involvement and importance of the topic.

During the verification and revision stage of the creative process, nominal groups were led through discussions of the creative concepts, ideas and themes. The output allowed for the development of clear messages that attempted to reduce embarrassment for seeking emergency assistance for suspected heart attacks.

Step 4.3 Develop and pretest messages.

1. Knowing they are being asked to critique ads, jurors may try to become more expert in their evaluations than they would be normally.
2. A halo effect is possible in the evaluation: the ad may be rated "good" on all characteristics simply because the juror liked one certain element of it.
3. Jurors who have preferences for logical over emotional appeals (or vice versa) may allow these preferences to overshadow objectivity in their evaluation.

Each juror received a set of ads with a list of questions. Each juror also received ample space to rank order the ads according to merit and to answer the following questions.

• What does this ad ask you to think, feel, and do?
• What's your first thought when seeing this ad?

The questions listed below were included at the back of the ad-set handed to each participant. They were expected to answer each question only one time based on their evaluation of all of the ads.

• Which of these ads would you be most likely to read if you saw it in a newspaper?On a poster in your doctor's office? Why?
• Which of these headlines would interest you the most and cause you to read the ad further? Why?
• Which ad did you like best? Why?
• Which ad did you find most interesting? Why?

The output from this nominal group was an overall reaction to each ad and a rank ordering of the ads based on the participants' perceptions.

After a break, jurors were then asked the following questions:

• What message(s) do you remember?
• Which ad comes to mind first?
• What did that ad ask you to think/feel/do?
• Did any of the ads offend you?
• What was offensive about that ad?

The planning team did not want to send a message that offended someone or evoked a negative reaction. They also wanted to make sure the target audience would be able to comprehend the meaning intended in the message. The planning team wanted to ensure members of the target audience "stopped, looked and listened" to the messages when they encountered them.

Step 4.4 Pretest and select settings.

• Home (via direct mail)
• the county Primary Care Center
• the county Health Clinic
• Community Centers
• High Schools
• Grocery Stores
• Church/Civic Groups
• Newspaper

The planning group discussed the various settings that would attract large numbers of the target audience. After researching settings, they found that eighty percent of the population in the county receives health care from the county Primary Care Center; the rest of the population goes to the county Health Clinic. Through interviews with partners and stakeholders the planning team also discovered that area high schools are magnets for the population. Events held at local high schools are heavily attended. Informant interviews revealed that most of the people in the county read the local newspaper. Community organizations and senior citizen centers also are settings where people congregate.

The planning team determined that all of these settings were conducive to getting the message across. The newspaper and the health centers seemed most appropriate for the mass messages to inform and create awareness. On the other hand, health centers also are good settings for interpersonal discussions between providers and the target audience. Interpersonal channels offer an influential context for health messages.

Step 4.5 Select, integrate, and test channel-specific communication activities.

Interpersonal Channel/Early Intervention and Primary Prevention

• Distributed information at providers' offices; distribute "bag stuffers" at grocery/convenience stores; distribute posters to high schools.

Small Group Channel/Early Intervention

• Asked opinion leaders to give talks at churches, social clubs, and civic organizations. (Used healthcare professionals and the testimonials of individuals who survived a heart attack due to prompt treatment and the testimonials of loved ones that have lost family members due to inaction.)

Community Channel/Early Intervention and Primary Prevention

• As part of a community event, had local EMS personnel give tours of ambulances and promote early intervention. Participated in Harts Health Fair next year. As part of this community event, had healthcare personnel perform free blood pressure checks and finger-stick total cholesterol screenings. Asked EMS personnel to offer free blood pressure checks at the office between runs.

Media Channel/Early Intervention and Primary Prevention

• Directed mail piece with enclosed refrigerator magnet with warning signs; directed mail piece with primary prevention messages; posters; earned media/testimonials of opinion leaders in local newspaper; print ads/testimonials in local newspaper.

Step 4.6 Identify and/or develop, pretest, and select materials.

Posters/Ads - "No One Ever Died of Embarrassment"

• Style - black and white photography, head shot of subject
• Tone - light with serious undertones
• Type of appeal - Informational/rational appeal, thought-provoking, lessen the fear of embarrassment if symptoms are not related to heart attack
• Message source - of same demographic as target audience. Or, strong opinion leader from the community who has survived a heart attack.

Posters/Ads - "Don't Bet Your Life On It"

• Style - black and white photography, head shot of subject
• Tone - serious, straightforward
• Type of Appeal - fear appeal, appeals to instinct to "trust your gut" and "it's better to be safe than sorry."
• Message Source - of same demographic as target audience/or strong opinion leader from the community who has survived a heart attack

Posters/Ads "Bless their Hearts"

• Style - color photography, head shot of subject
• Tone - light, humorous, warm
• Type of appeal - humor appeal, slice of life appeal, appeals to the mothering instinct, "because you love her/him/them take care of her/his/their heart(s) through primary prevention
• Message source - of same demographic as target audience - or opinion leader

Posters/Ads "Because You Need To Be Here for Them"

• Style - black and white and color photography - family shots of interaction between grandparents and grandchildren
• Tone - warm, serious
• Type of appeal - Emotional appeal, appeals to the love of family and strong family ties in Appalachia; also a subtle fear appeal
• Message source - of same demographic as target audience - or opinion leader who took care of him/herself and is "there for them" now because of it.

Flyers - Early Warning Signs of Heart Attack (Three)

• Style - easy to read for low-literate individuals, eye-catching
• Tone - factual
• Type of appeal - informational/rational appeal, clearly explains the early warning signs of heart attack in males and females
• Message source - (1) Opinion leader, (2) Female, (3) Male

Flyers - Primary Prevention (Two)

• Style - easy to read for low-literate individuals, eye-catching
• Tone - factual with warmth
• Type of Appeal - informational/rational appeal, everyone can improve their lifestyle behaviors to decrease the risk of heart disease
• Message Source - (1) Child's viewpoint; (2) Grandparent

Slide Show/Power Point

• Style - easy to understand, colorful, eye-catching
• Tone - factual
• Type of Appeal - informational/rational appeal, easy to follow presentation stressing the importance of early intervention
• Message Source - healthcare providers; opinion leaders

Direct Mail/Brochures - Early Warning Signs of Heart Attack

• Style - easy to read for low-literate individuals, larger print, eye-catching
• Tone - factual
• Type of Appeal - informational/rational appeal, clearly explains the early warning signs of heart attack in males and females
• Message Source - opinion leaders; similar demographics

Direct Mail/Brochures - Primary Prevention

• Style - easy to read for low-literate individuals, eye-catching
• Tone - factual with warmth
• Type of Appeal - informational/rational appeal, everyone can improve their lifestyle behaviors to decrease the risk of heart disease
• Message Source - (1) Child's viewpoint; (2) Grandparent; (3) Female of similar demographics

Research indicated that these materials appealed to the target audience. Based on the pre-test results, the planning team chose the messages that appeal to love of family and use children as well as the messages that are from opinion leaders because the planning team expected them to have the most success.

Step 4.7 Decide on roles and responsibilities of staff and partners.

Click here to see the chart.

Step 4.8 Produce materials for dissemination.

After testing the concepts, messages, channels, and activities for the intervention, the planning team submitted the communication materials to the hospital system and the Bureau of Health for appropriate clearance.

They hired a production contractor to produce the materials for the pilot test intervention and made sure they had adequate numbers of materials (especially flyers) to distribute within the county.

Step 4.9 Finalize and briefly summarize the communication plan.

Step 4.10 Share and confirm communication plan with appropriate stakeholders.

Preparation Checklist:

Step 5.1 Identify and engage stakeholders.

The planning team met to discuss potential stakeholders who needed to be involved in the evaluation planning for the intervention. During this meeting, they agreed to invite the following organizations into the evaluation planning as stakeholders:

• The state Bureau of Public Health
• Heart Center
• Centers for Disease Control and Prevention
• The state peer review organization (PRO)
• the county Primary Care Center
• the county Emergency Medical Services/911
• Other primary care providers
• Other hospital representatives
• Health department personnel
• Community representatives who strongly believed in the implementation of the plan
• Community representatives who opposed the campaign and/or evaluation of it

The planning team invited individuals from the stakeholder organizations to an initial meeting to discuss roles and responsibilities for the evaluation. After the initial meeting, periodic meetings, conference calls, and newsletters delivered campaign updates and maintained open lines of communication. The stakeholders and partners in this intervention shared a similar vision for lowering heart disease mortality rates and prevalence of heart disease in the state.

Step 5.2 Describe the program.

How The Program Was Planned and Developed

Utilizing the input the planning team received from the partners, the planning team decided to evaluate the intervention, which was a social marketing campaign. The goal for this campaign was to increase awareness about the signs and symptoms of a heart attack and heart disease and the need to seek medical help in a more expedient manner than what was presently occurring, especially in a rural setting. This followed along the objectives of the cardiovascular program grant, which helped fund the intervention.

Planning Stage: The goal was to refine plans in this stage. The planning team formulated tracking measures for this stage.

Click here to see the chart.

Implementation: Year 1 program activities were field-tested and modified. The goal of the effects evaluation was to compare the actual outcomes of the intervention, as opposed to ideal outcomes. The planning team wanted to conduct a pilot project in the county to evaluate the response from healthcare providers and the target audience(s) to the persuasive messages. Tracking measures during this phase included:

• Informant interviews with healthcare providers in the county assessing the success of the collateral information pieces as catalysts for discussion between provider and patient.
• Informant interviews with healthcare providers in the county

Outputs/Results

Target Audience: Whom Would It Reach?

• Adult Females and males (35+) at risk for heart disease in specific rural and medically under-served areas within the Appalachian region of the state

Expected Effects: Immediate

• Increased levels of awareness of the prevalence of cardiovascular disease and stroke in the state, and specifically, in the pilot project market.
• Increased knowledge of warning signs/symptoms of heart attack in men
• Increased knowledge of warning signs/symptoms of heart attack in women
• Increased knowledge of what to do when experiencing these symptoms (e.g., what procedure to follow/sense of urgency with time)
• Reduced prevalence of opinions/attitudes of fatalism and denial
• Increased prevalence of opinions/attitudes of action-orientation and probable success
• Increased knowledge of heart-healthy habits

Expected Effects: Intermediate

• Increased numbers of people in the county and surrounding areas who take more active roles in their own healthcare.

Expected Effects: Long-term

• Reduced mortality from cardiovascular disease in the state.
• Reduced disability from heart attack and stroke.
• Overall reduction in incidents of heart attack, stroke, and cardiovascular disease.

Step 5.3 Determine what information stakeholders need and when they need it.

Through discussions with information stakeholders, the planning team established a checklist of what information they wanted and when they wanted it. This checklist was then compared to the evaluation plan. Changes were made as necessary. The following reports were requested:

• The Heart Center requested quantitative research reports once the evaluation was completed, so that it could archive the results. The center was very interested in learning the change in levels of awareness of symptoms, success ratio of actually reaching the audience the planning team targeted, and message recall/effectiveness numbers.
• The Heart Center also wanted to know the participation levels of the providers in the counties, as well as other people involved in the campaign that actually helped "get the message out."
• The Heart Center wanted to know what barriers were encountered in getting the message out and how the planning team overcame them.
• The Bureau of Public Health requested a quarterly, written progress report.
• A written progress report was submitted to the Centers for Disease Control and Prevention every six months.
• The Bureau of Public Health and the Heart Center requested a complete project evaluation report at the end of the pilot test evaluation.
• The county 911 and the county Primary Care Center representatives requested the quarterly reports. (In turn, the planning team requested their feedback to the reports and incorporated the feedback when necessary.)
• A special presentation was requested for the statewide Cardiovascular Conference in June.
• All of the stakeholders requested an evaluation of the potential for success when taking this campaign statewide.

The required reports necessitated the completion of the following types of evaluation:

• Implementation evaluation - responses, strengths and weaknesses, material/fiscal and human resources
• Exposure/reach evaluation - target audience impressions, degree of understanding
• Effectiveness evaluation - effects at each stage

It was hypothesized that:

The "Call 911 when experiencing signs/symptoms of heart attack" campaign, in its entirety, would increase the number of calls to 911 for heart attack symptoms and chest pain.

The "Because You Need to Be There For Them" segment of the campaign, would decrease the barriers to seeking emergency health care that exist in some of the target audience.

Step 5.4 Write intervention standards that correspond with the different types of evaluation.

Intervention standards that examined discrepancies between what was expected and what was observed in the evaluation process were followed throughout the campaign. The standards reflected the values of the stakeholders.

Stakeholders and the hospital planning staff agreed upon the following standards for intervention and the evaluation:

• Adherence to timelines
• Input from all partners must be requested and used wherever appropriate
• Ethical standards must be upheld in all aspects of the campaign
• Responsible parties would carry out their roles/responsibilities

The following specific intervention standards were evaluated:

• To educate 80% of the households in the county regarding early warning signs/symptoms of heart attack for males and females during the three-month campaign, the following interventions were completed:
  1. Marketing representatives created, tested, revised and developed the "No One Ever Died of Embarrassment," "Don't Bet Your Life On It," and "Because You Need to Be There for Them," campaign materials.
  2. Health provider partners in clinics and centers distributed educational flyers, brochures and other materials.
  3. Health provider partners held interpersonal discussions with patients using the posters and materials as points of discussion.
• To increase the number of households in the county that have behavior patterns that help to prevent heart attack/disease by 20%, the following interventions took place:
  1. Marketing representatives created, tested, revised and developed the "Bless their Hearts" and "Because You Need to Be There For Them," campaign materials.
  2. Health provider partners in clinics and centers distributed educational flyers, brochures and other materials.
  3. Health provider partners also held interpersonal discussions with patients utilizing the posters and materials as points of discussion.
• To raise awareness among 100% of households in the county regarding heart-healthy habits and lifestyles, the following interventions took place:
  1. Marketing representatives created, tested, revised and developed the "Bless their Hearts," and "Because You Need to Be There for Them," campaign materials.
  2. Health provider partners distributed educational materials, display posters and continue to discuss heart-healthy habits and lifestyles with their patients.
  3. Opinion leaders and partners presented to members of the target audience.
• To increase the number of individuals who seek prompt medical attention when experiencing the early warning signs of heart attack by 30% the following interventions took place:
  1. Marketing representatives created, tested, revised and developed the "No One Ever Died of Embarrassment," "Don't Bet Your Life On It," and "Because You Need to Be There for Them," campaign materials.
  2. Health provider partners in clinics and centers distributed educational flyers, brochures and other materials.
  3. Health provider partners also held interpersonal discussions with patients utilizing the posters and materials as points of discussion.

Stakeholders and partners met to discuss the communication interventions planned for the campaign. All acknowledged that the effects of advertising often occur over an extended period. Experts agree that advertising may create interest, awareness and/or favorable attitudes that linger as long as nine months. The campaign sought to create just such a "lasting effect." This campaign sought to provide information and a procedure to follow "if and when" the symptoms of a heart attack should occur within the target audience. Unlike advertisements that include an immediate "call for action," the call to action was one that the planning team hoped, for the sake of the target audience, would never have to be enacted. However, in the event that a heart attack should occur, the planning team wanted the target audience to know exactly what to do.

Step 5.5 Determine sources and methods that will be used to gather data.

The planning team selected informant interviews, focus groups, nominal groups, and consumer juries for the planning/development stages of the campaign to create the marketing materials. Sources of information were volunteer participants, representative of the target audience. The market research representative moderated the groups, evaluated the results and reported to stakeholders and partners.

The planning team also chose the survey method to determine baseline levels of awareness, comprehension and attitudes/behavior patterns within the target audience and then to post-test the same levels after the intervention. An outside vendor was contracted with to design, conduct, analyze and report the results of the telephone survey and four focus groups. The source of information for the survey was a random, representative sample of the target audience for this campaign.

They anticipated that the mix of quantitative and qualitative methods would be helpful to compare intervention outcomes with intervention standards. Focus groups post-tested campaign recall and comprehension and tested attitudes and resolutions to follow heart-healthy habits. Sources of information were volunteer participants who were representative of the target audience. The market research representative moderated the groups, evaluated the results, and reported to stakeholders and partners.

Step 5.6 Develop an evaluation design.

The planning team developed an evaluation design to develop and test intervention materials prior to the actual intervention. They used informant interviews, focus groups, nominal groups, and consumer juries for this purpose.

To analyze effects of the social marketing campaign, or the intervention, the planning group selected surveys and focus groups to determine what effects, if any, were associated with the intervention. The survey method asked a variety of questions regarding intervention-related behaviors, intentions, attitudes, awareness, motivations, and demographic and lifestyle characteristics. The planning team decided to ask the survey questions via telephone with close-ended questions.

For the effects evaluation, the sampling frame used was the county telephone directory. The random digit directory design was used to overcome the bias of unpublished and recent numbers. A sample of numbers was drawn from the directory and modified by adding a constant to the last digit, to allow unpublished numbers a chance of being included in the sample.

The planning team decided to utilize descriptive survey data because they would be feasible, given the budget and time constraints for the project. The survey would be administered one month prior to the intervention and one month after the intervention.

In the survey, participants were asked questions that:

• Identified any changes in health status
• Surveyed self-reported behavior
• Surveyed self-reported attitudes
• Tested audience knowledge

Step 5.7 Develop a data analysis and reporting plan.

All data gathered during this campaign were coded by one of three parties:

a. The market research representative,
b. The outside research agency with which the team contracted, or
c. The healthcare provider.

All data entered and analyzed during this campaign were entered and analyzed by one of two parties:

a. The market research representative, or
b. The outside research agency with which the team contracted.

Oral and written reports of all research conducted and tracking measures implemented were presented to stakeholders, team members and partners.

Step 5.8 Formalize agreements and develop an internal and external communication plan.

The planning team agreed to the following communication strategies with the partners:

• A monthly broadcast e-mail service communicated campaign progress to staff and partners.
• A quarterly newsletter was also mailed to staff and partners.
• Monthly group meetings of Heart Center, Bureau and marketing representatives were held.
• Press releases were distributed to media channels periodically, upon agreement of all parties, to announce campaign progress and effects.
• Formal presentations and reports were submitted to partners.

Step 5.9 Develop an evaluation timetable and budget.

Click here to see the proposed timeline and plan.

Step 5.10 Summarize the evaluation implementation plan and share it with staff and stakeholders.

The planning team summarized and presented the evaluation plan to stakeholders and partners in individual discussions and meetings of the whole group.

Step 6.1 Integrate communication and evaluation plans.

Step 6.2 Execute communication and evaluation plans.

Prior to the launch date, several activities needed to be arranged and coordinated. First and foremost, the planning team met with and informed the appropriate media representatives of the plans. Next, press releases and informational packets were dispersed to all pertinent individuals detailing the plans, objectives, and goals. Finally, media representatives were established to answer media requests. After satisfying all of the above, the group was able to prepare and carry out a successful kick-off to the plan.

Step 6.3 Manage the communication and evaluation activities.

Step 6.4 Document feedback and lessons learned.

The most important message the planning team was able to convey in this project was that Heart Disease is the number one cause of death in the state. The reasons for this staggering statistic were also conveyed, which are that Appalachian people have less access to healthy foods and recreational facilities than do other Americans. This leads to poor diet and exercise habits, which contributes to heart disease. The shortage of regional hospital heart units and cardiac facilities are also a major contributing factor.

This pilot project uncovered that the range and level of public knowledge related to the signs and symptoms of heart disease are low. Procedures to follow when experiencing a heart attack were also widely communicated to the intervention county population. This study also discovered that many Appalachian people's attitudes towards heart disease and stroke are fatalistic, meaning that those studied in the pilot project feel that heart disease will eventually come to them and therefore there is nothing that can be done to stop it.

Changing attitudes towards cardiovascular disease (CVD) was one of the biggest challenges of the campaign. This is definitely an area where future effort is needed. This is the area where advertisements to inform the target population of the causes and effects of heart disease and stroke were most valuable. With advertisements, the campaign was able to instill a sense of urgency to the widespread problem of CVD. It was necessary to appeal to a broad range of emotions in these advertisements including compassion, love for family, and fear of mortality. The campaign informed the target population that if they cared for their heart, they would be able to combat the incidence and effects of heart disease. It was important to stress family in relaying this important fact to the target population.

Because it is challenging to change the lifestyle of individuals in a community-based campaign, partners provided many lectures and seminars on healthy living. Reading materials on
healthy foods and healthy cooking tips were also provided to physicians' offices, schools, civic organizations, and grocery stores.

The planning group determined that a major component was missing in the intervention. They recommended that future similar social marketing campaigns work with health care providers and emergency care services to address access to emergency medical care prior to implementing a large-scale social marketing campaign such as this one.

Step 6.5 Modify program components based on evaluation feedback.

The planning team examined all areas of the program to ascertain which strategies worked and which ones needed improvement. While most of the main goals were met, the program planners agreed that combating such a widespread and severe problem such as cardiovascular disease was challenging within the project's brief timeline.

A major modification to a program such as this one, if it were to be implemented again, would be to expand the timeline of the project.

Step 6.6 Disseminate lessons learned and evaluation findings.

The planning team determined that more work needs to be done. However, they realized that this campaign was the beginning step in reducing the mortality rate related to cardiovascular disease in the state. The information learned in this study was valuable to health care providers including family doctors, dieticians, and cardiologists, and for hospitals that wish to raise awareness about the signs and symptoms of heart attacks.

The best way to relay this information to healthcare providers was through brief written and oral summaries of the key issues involved in this study. Some of these key issues are the prevalence of the issues of apathy in Appalachia, the degree to which health information is not being properly explained by healthcare providers and not properly understood by patients, and the overall lack of providing enough facilities to adequately provide access for treatment of the problem.

References

• Milner, K.A. et al. (1999). Gender differences in symptom presentation associated with coronary heart disease. The American Journal of Cardiology, 84, 396-399.
• O'Keefe, D.J. (1990). Persuasion: Theory and research. Newbury Park: Sage Publications.