National Diabetes Education Program 'Thunder and Lightening' Campaign for Hispanic/Latino Diabetes Control

Disclaimer

This example is derived from the National Diabetes Education Program Thunder and Lightning campaign. It was modified and fictionalized in part to conform to the planning process set forth in CDCynergy 3.0. This example originally appeared in CDCynergy Diabetes Edition.

Step 1.1 Write a problem statement.

Few people with diabetes understand how they can best control their blood sugar, the importance of glucose control, and that complications can be delayed or prevented. The best way to avoid diabetes-related complications is to ensure that blood glucose levels are within normal ranges. The Diabetes Control and Complications Trial (DCCT) showed that intensive blood glucose control in people with type 1 diabetes reduced the risk for developing eye disease, kidney disease, and nerve disease (76%, 50%, and 60% reduced risk, respectively) by lowering hemoglobin A1C from 9 to 7 percent. The United Kingdom Prospective Diabetes Study (UKPDS) showed that intensive blood glucose control in people with type 2 diabetes delayed the onset of eye and kidney disease, reducing the risk by 12 to 33 percent, by lowering hemoglobin A1C levels from about 8 to 7 percent. These studies further showed that any sustained lowering of blood glucose helps, even if the person has a history of poor control.

If blood glucose levels are not well managed, complications may arise. It has been documented that diabetes is the leading cause of end-stage renal disease, adult blindness, and non-traumatic lower-extremity amputations. People with diabetes are also two to four times more likely to have a stroke or cardiovascular disease than people without diabetes. Indirect and direct costs associated with diabetes are estimated to be $98.2 billion each year in the United States. Diabetes disproportionately affects minority populations and the elderly and is likely to increase as minority populations grow and the U.S. population becomes older. For more information about diabetes and its prevalence (DB-National_Diabetes_Fact_Sheet-English.pdf).

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

Following the release of the DCCT and UKPDS study findings, the Centers for Disease Control and Prevention (CDC) and its partners had responsibility to develop and implement strategies to translate the findings into public health practice. As a result, CDC and the National Institutes of Health (NIH), National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) became joint sponsors of the National Diabetes Education Program (NDEP). The purposes of NDEP are to improve the treatment and outcomes for people with diabetes, to promote early diagnosis, and ultimately, to prevent the onset of diabetes.

To meet the goal of reducing the morbidity and mortality associated with diabetes and its complications, the NDEP has the following objectives:

1. To increase public awareness of the seriousness of diabetes, its risk factors, and potential strategies for preventing diabetes and its complications.
2. To improve understanding about diabetes and its control and to promote better self-management behaviors among people with diabetes.
3. To improve health care providers' understanding of diabetes and its control and to promote an integrated approach to care.
4. To promote health care policies that improve the quality and access to diabetes care.
5. To target health messages and education for those with diabetes and their families (with special attention to Hispanic Americans, African Americans, Asian Americans, Pacific Islanders, and Native Americans).

The NDEP Hispanic Diabetes Control Campaign relates particularly to Objectives 2 and 5. For a more complete description of NDEP goals and objectives (DB_changing_the_way_diabetes_is_treated.pdf).

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

The NDEP steering committee consists of representatives from different public and private, national, state, and local entities including:

Physician Organizations
Nurse Organizations
Diabetes Educator Organizations
Diabetes Advocacy Groups
National Minority Organizations
State Diabetes Control Programs
Pharmacy Associations
Diabetes Research Entities
Federal and Local Health Agencies
Service Organizations

Separate NDEP workgroups were established to develop strategies and campaigns for specific audiences at increased risk. Members of the workgroup dedicated to serving the Hispanic and Latino population include the following:

Hispanic/Latino Health Organizations
Latino Health Projects
National Coalitions Representing Hispanic Health & Human Services Organizations
Latino Advocacy Organizations

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

Diabetes surveillance is essential for identifying persons with the disease and for formulating strategies to educate and treat them. The Centers for Disease Control and Prevention, Division of Diabetes Translation’s Surveillance Section uses data from the U.S. Renal Data System, Behavioral Risk Factor Surveillance System, Vital Statistics, the National Ambulatory Medical Care Survey, the National Hospital Ambulatory Medical Care Survey, National Health Interview Survey, and the National Hospital Discharge Survey for diabetes surveillance. To view surveillance data: DB_Surveillance_1999_Chapt1.pdf, DB_Surveillance_1999_Prevalence.pdf, and DB_Surveillance_1999_Mortality.pdf.

The National Diabetes Education Program also hired a contractor to conduct additional formative research regarding the issue of diabetes control in the Hispanic and Latino populations. To view some of the findings of the formative research on the Hispanic/Latino population (DB_English Hispanic_Latino_Fact_Sheet.pdf).

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

Public health surveillance of diabetes has shown that minority groups and the elderly are disproportionately represented. It has been reported that Hispanic and Latino Americans have the second highest rate of type 2 diabetes, compared with other populations. Currently, Hispanic and Latino Americans are the second largest minority group in the United States with an estimated population of 27 million people. It is estimated that 1.8 million Hispanic and Latino Americans have diabetes. Risk factors associated with the Hispanic and Latino population for developing diabetes include: family history of diabetes, obesity, smoking, limited access to health care, being over 40 years of age, and a sedentary lifestyle.

Within the Hispanic and Latino population, diabetes is the sixth leading cause of death. Among Hispanic and Latino women and the elderly, diabetes is the fourth leading cause of death. Onset of type 2 diabetes has been documented as occurring earlier in life for the Hispanic and Latino population (ages 50 to 59 years versus 60 to 69 years for non-Hispanic populations). Data also indicate that among Puerto Rican Americans and Mexican Americans, the onset of type 2 diabetes occurs even earlier (ages 30 to 50 years). For more information about diabetes and its impact on the Hispanic/Latino population (DB_English_Hispanic_Latino_Fact_Sheet.pdf).

National Diabetes Education Program data indicate that Hispanic and Latino Americans are at higher risk of developing and dying from diabetes and are two times as likely to have complications of diabetes, such as heart disease, blindness, amputations, and nerve damage and kidney disease, than non-Hispanics. For additional information about the incidence and prevalence of diabetes and diabetes related complications among the Hispanic/Latino population (DB_Diabetes_in_Hispanic_America.pdf).

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

Three primary subproblems were identified, in relation to diabetes and its complications in Hispanic/Latino adults.

1. Lower rates of self-monitoring of blood glucose (SMBG). Data in Healthy People 2010 indicate that 36 percent of Hispanic or Latino adults with diabetes self-monitor their blood glucose levels, when compared with 45 percent of non-Hispanic, white adults with diabetes. (A Healthy People 2010 objective proposes increasing the proportion of Hispanic and Latino adults with diabetes who perform self-monitoring of blood glucose (SMBG) at least once daily from 36 to 60 percent.)
2. Lower rates of formal diabetes education. In 1998, it was estimated that only 34 percent of the 1.8 million Hispanics and Latinos with diabetes received formal diabetes education versus 45 percent for the overall population of people with type 2 diabetes. (One of the objectives of Healthy People 2010 is to increase the proportion of people with diabetes with formal education about diabetes to 60 percent.) As the Hispanic and Latino population ages, the incidence of diabetes and its complications is expected to substantially increase unless prevention and control practices can be established within this population. To view Healthy People 2010 objectives (http://www.health.gov/healthypeople/document).
3. Awareness regarding diabetes/glucose control. Few Hispanic/Latino persons with diabetes understand how they can best control their blood sugar, the importance of glucose control, and that complications can be delayed or prevented.

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

Research was conducted for the National Diabetes Education Program to further understand the incidence, prevalence, and related risk factors for diabetes within the Hispanic and Latino population. Focus groups determined audience knowledge, attitudes and practices in relation to diabetes. To view some of the findings of the formative research on the Hispanic/Latino population (DB_English_Hispanic_Latino_Fact_Sheet.pdf).

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

Strengths:

Diabetes has been self-identified by many Hispanic and Latino communities as an important health problem.

The Centers for Disease Control and Prevention (CDC) and the National Institutes of Health (NIH), National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), as well as more than 30 other organizations, are all working together and combining knowledge and experience to promote awareness of diabetes and its risk factors.

Much research has been conducted and is available to understand the incidence and prevalence of diabetes and the implications of diabetes within the cultural setting of Hispanic and Latino American communities.

Weaknesses:

Research reports that Hispanic/Latino adults are often unable to see a doctor because of cost and that culturally or linguistically tailored health care is often not available to Hispanic/Latino individuals.

Opportunities:

Many health and public health organizations have become conscious of the growing need to have culturally and linguistically appropriate diabetes education made available to the increasing Hispanic and Latino populations.

There are many underutilized prevention opportunities to address the burden of diabetes.

Threats:

A strong cultural belief among many Hispanic and Latino Americans is that "What happens to me is God's will." This belief can often interfere with prevention practices and a person's active participation in their care.

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

The Audience Profile Report developed by a CDC contractor) for the National Diabetes Education Program, indicates the following factors that contribute to the prevalence of diabetes and its complications within the Hispanic and Latino population:
Note: There are interrelationships and overlap among the causes for all three subproblems.

Subproblem 1 (self-monitoring of blood glucose):

• Lack of access to health professionals and health insurance. Hispanic/Latino Americans are less likely to have health insurance than any other minority group in the U.S.
• Lack of culturally or linguistically sensitive health care settings available to the Hispanic and Latino population.
• Lower level of formal education among some Hispanic/Latino adult populations compared with the non-Hispanic white adult population. A study by the National Eye Health Education Program indicates that Hispanic and Latino elderly have the least number of years of formal education compared with other elderly populations. The lack of formal education and language barriers are possible explanations for lower levels of literacy among Hispanic and Latino elderly.Consequently, there may be a need for providers to alter their methods of communicating diabetes health and treatment-related information when addressing this audience.

Subproblem 2 (formal diabetes education):

• Lack of access to health professionals and health insurance
• Lack of culturally or linguistically sensitive health care settings and formal diabetes education available to the Hispanic and Latino population, especially those living in more rural settings.
• Lower level of formal education among some Hispanic/Latino adult populations compared with the non-Hispanic white adult population, possibly contributing to the lack of understanding of medical diagnosis and medical advice/treatment (including referral for formal diabetes education). Again, there may be a need for providers to alter their methods of communicating diabetes health and treatment-related information when addressing this audience.

Subproblem 3 (awareness of ability to control diabetes and importance of diabetes control in preventing complications):

• Many Hispanic/Latino Americans have a fatalistic view of diabetes, believing there is nothing that can be done about it. This view may contribute to less active participation in their own care. Additionally, many Hispanic/Latino Americans believe that "What happens to me is God's will."
• Little, if any, culturally sensitive community based information is available to these populations about diabetes and the opportunities for prevention and control.
• Many cultural norms make it more acceptable to have a heavier body type. (Obesity can contribute to poor glucose control, as for all populations.)
• Focus group data suggest that Hispanics/Latinos believe exercise is for those who can afford health club memberships. Additionally some Hispanic/Latinos who work in an industry that is labor intensive (i.e. service, construction, etc.) may have a lower level of interest in wanting to continue physical activity on their time off. Hispanic/Latinos tend to be more sedentary than non-Hispanic whites. 61.5 percent of Hispanic/Latino men and 61.9 percent of Hispanic/Latino women lead sedentary lifestyles.
• Many of the foods that are culturally accepted and part of the diet are high in fat.
• Many Hispanic/Latino Americans have a history of diabetes in their family and poor diabetes-related outcomes for other family members may reinforce some fatalistic views.

To view the report DB_Hispanic_Latino_and_Diabetes-Audience_Profile.pdf.

Step 2.2 Prioritize and select subproblems that need intervention(s).

Subproblems that were identified as possible targets for intervention for this population included:

• Daily blood glucose monitoring
• Formal diabetes education (which could impact knowledge of healthy blood glucose (blood sugar) numbers; incorporation of a healthy diet, and incorporation of exercise into daily lives)
• The fatalistic 'What happens to me is God's will' belief that there is nothing one can do to control blood glucose levels and prevent diabetes complications

Step 2.3 Write goals for each subproblem.

The following overall goals were developed to address the subproblems identified. However, (as described in Step 2.6) only the last goal was a communication goal that would be directly addressed through the "Thunder and Lightning" communication campaign.

• To increase the percentage of Hispanic/Latinos with diabetes who perform self-monitoring of blood glucose
• To increase knowledge of healthy blood glucose numbers, improve eating habits, food preparation, and food choices, and increase physical activity among Hispanic/Latino persons with diabetes
• To increase the knowledge and awareness among Hispanic/Latino persons with diabetes that they can take control of their diabetes. It is not 'out of their hands.'

Step 2.4 Examine relevant theories and best practices for potential intervention(s).

• Health Communication/Education
• Health Policy/Enforcement
• Media Advocacy
  Health Engineering
• Health-Related Community Service

The following intervention methods were considered for an overall public health program to address all the goals listed above.

Health Communication/Education

• Develop culturally specific and language-specific materials to improve knowledge, attitudes, intentions, and behaviors regarding improved diabetes self-management among the target audience.

Health Policy/Enforcement (cultural/linguistic issues)

• Develop culturally and linguistically tailored health care settings
• Develop culturally and linguistically tailored diabetes health education programs.

Health Policy/Enforcement (access)

• Ensure that the Hispanic/Latino community has access to health insurance that covers quality diabetes care, education, and self-management training.

Health-Related Community Services

• Fund and provide technical assistance to Hispanic/Latino coalitions or community groups to raise awareness regarding proper diabetes care in this community.

Step 2.5 Consider SWOT and ethics of intervention options.

Health Communication/Education

Strength

• The National Institutes of Health and the Centers for Disease Control and Prevention have had previous success in health campaigns that are culturally specific and linguistically specific for the Hispanic and Latino community.

Weakness

• Large, national health campaigns require a great deal of funding for target audience pre-testing, implementation, and evaluation.

Opportunity

• Organizations within the Hispanic/Latino community (including organizations at the grassroots level) could be active participants in the development and implementation of the health communication campaign.

Threat

• Even with culturally/linguistically sensitive messages, it is hard to overcome previously held beliefs about one's ability to control their diabetes.

Health Policy/Enforcement (cultural/linguistic issues)

Strength

• Culturally and linguistically tailored health care settings would offer many Hispanic and Latino Americans who do not speak English fluently an opportunity to obtain medical services and to understand medical advice.
• Culturally and linguistically tailored diabetes education materials would allow those with low levels of literacy in English (or no literacy in English) to learn the proper information regarding diabetes care.

Weakness

• It is difficult to provide culturally and linguistically tailored health care facilities in all the communities that need them.
• There are no guarantees that all members of the target audience will be exposed to the promotional/educational materials.
• To reach the target audience, additional funding needed to be acquired.

Opportunity

• Local organizations within the Hispanic and Latino community promoted the culturally and linguistically tailored health care clinics and actively participated in the development of the promotional/educational materials.

Threat

• Transportation to these clinics is not always available to patients.
• Having culturally and linguistically tailored educational materials does not guarantee adherence to the recommendations.

Health Policy/Enforcement (access)

Strength

• Another essential but separate component of the National Diabetes Education Program is to influence health care payers, purchasers, and policy makers of both the need for and access to medical insurance that covers diabetes care and self-management.

Weakness

• Increasing coverage for people with diabetes may be outside the scope of the National Diabetes Education Program and will require other interventions.

Opportunity

• Business leaders within some Hispanic/Latino communities have incorporated diabetes care and self-management into the coverage provided by their health care plans.

Threat

• Having access to health insurance that covers diabetes care and self-management does not guarantee that individuals with diabetes will use these services, especially if cultural barriers still exist.

Health-Related Community Services

Strength

• The Centers for Disease Control and Prevention and the National Institutes of Health have a history of providing support to Hispanic/Latino coalitions or community groups.

Weakness

• Funding is not always available for coalitions and community groups.

Opportunity

• Each year more and more community organizations are applying for and receiving federally funded grants to promote health in their communities.

Threat

• Reliance on federal funding can put grantees at risk when funding is no longer available.

Ethical Considerations

• Possible ethical dilemmas exist if campaign messages are perceived to conflict with religious ideology.
• Interventions selected need to acknowledge and respect different cultural ideas of fitness, body image, nutrition, and physical activity.

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

All of the above types of interventions were considered, however health communication interventions were selected as the initial focus to address the last subproblem listed above, related to increasing the knowledge and awareness among Hispanic/Latino adults that they can take control of their diabetes.

Health communication strategies work best in changing awareness, knowledge, attitudes, and simple behaviors, especially if they are science-based, theory-driven, grounded in audience research, and implemented sufficiently during the planning, implementation and evaluation processes.

Click here to see the table.

Step 2.7 Explore additional resources and new partners.

Additional partners were added including Hispanic/Latino community leaders, Spanish language media (since a communication campaign had been an identified intervention), and various contractors.

Additional resources were secured to fund a number of national minority organizations to assist with implementing interventions and carrying the NDEP messages directly to high risk communities. More CDC staff were also involved at this time.

Step 2.8 Acquire funding and solidify partnerships.

A national conference with all program participants occurred prior to the kickoff of the National Diabetes Education Program general awareness campaign. Here, partners learned how they could each contribute to the development, implementation, and evaluation of the NDEP campaign and about opportunities to participate in the development of campaigns for specific high risk groups such as Hispanic/Latino populations. Directors from the National Institutes of Health and the Centers for Disease Control and Prevention were available during and after the conference to answer any questions and offer support to the partners. Communication was maintained primarily through e-mail, monthly teleconferences, and print.

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

• If communication is used as a dominant intervention, list possible audiences.
• If communication is to be used to support Community Services, Engineering, and/or Policy/Enforcement interventions, list possible audiences to be reached in support of each selected intervention.

Health Communication/Health Education

• Communication was selected as the dominant intervention. Potential audiences included:
• Adult Hispanic/Latino men and women under the age of 40 and Hispanic/Latino men and women aged 40 and over with Type 2 diabetes.
• Lower to middle socioeconomic status
• Urban, peri-urban, rural

While other interventions were not to be implemented at this time, it was determined that communication could also be used to support other types of interventions in the future, as described below.

Health Policy/Enforcement (cultural/linguistic issues)

• Communication could support the development of culturally and linguistically tailored health care settings and diabetes health education programs.
• Audiences could include: federal, state and local government, public health officials and advocacy organizations.

Health Policy/Enforcement (access)

• Communication could support engineering efforts to ensure access to health insurance that covers quality diabetes care, education, and self-management training for Hispanic/Latinos persons.
• Audiences could include: advocacy groups, local, state and federal government, Hispanic/Latino community organizations, and managed care and insurance companies, and purchasers of care (such as employers, Medicaid, Medicare, etc.)

Health Related Community Services

• Communication could support community service efforts to make the target audience aware of the guidance and funding opportunities available from the national level.
• Audiences could include: Hispanic/Latino coalitions or community groups, advocacy groups, and local, state and federal health care agencies.

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

The following segmentation of the target population was considered:

• Hispanic/Latino persons who spoke English as their primary language versus those who spoke Spanish as their primary language.
• Hispanic/Latino persons with high levels of literacy versus those with low levels of literacy.
• Hispanic/Latino men and women aged 40 and older.

Step 3.3 Finalize intended audiences.

Because of an increase in cost for each additional audience segmentation, two distinct priority audiences were selected for the intervention.

• Primary Language: Hispanic/Latino persons who spoke Spanish as their primary language.*
• Literacy: Hispanic/Latinos with higher levels of literacy versus those with lower levels of literacy.*

* Materials developed for these audiences included those targeted to Hispanic/Latino men and women of varying ages.

Step 3.4 Write communication goals for each audience segment.

The overall communication goal of the campaign was to:

• Promote the concept that a Hispanic/Latino person with diabetes can control his or her diabetes. It is not 'out of their hands’.

The communication goal was the same for each audience segment. However, the medium in which the message was delivered was different. For example, the message was delivered in both print and audio/visual format (TV and radio). Additionally, all messages (print, radio, TV) were in both Spanish and English.

Other related goals were identified to expand on the above goal. These behavioral goals are more directly linked to improved glucose control:

• To alter eating habits of Hispanic/Latino persons with diabetes
• To increase physical activity of Hispanic/Latino persons with diabetes
• To increase the percentage of Hispanic/Latino persons with diabetes who perform daily self-monitoring of blood glucose

These last three goals were not expected to be accomplished through the Thunder and Lightning campaign alone. Secondary messages would begin to address these issues, and planners determined that these goals could be dealt with in more depth through future interventions, including additional campaigns. Note: The next wave of NDEP campaigns for this audience included messages about nutrition and dietary habits. It included a meal planner and PSAs as well as other elements. For additional information about this campaign http://ndep.nih.gov/materials/puborder/resource.htm.

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

Social Marketing and Social Cognitive theories were used in the development of this intervention. In relation to promoting the concept that a person with diabetes can control their diabetes and to empower them to take control, two constructs from Social Cognitive Theory were especially relevant: “self efficacy,” a judgment of one’s capability to accomplish a certain level of performance, and; “outcome expectation,” a judgment of the likely consequence such behavior will produce. For more information about how to choose a theory that applies to an intervention Theory_at_a_glance.pdf.

Step 3.6 Undertake formative research.

A CDC contractor obtained primary data by conducting multiple focus groups with the selected target audience to determine the appropriate message settings, communication channels, and materials, the best practices/strategies needed, and to identify those threats and barriers perceived by the target population. To view report DB_Hispanic_Latino_and_Diabetes-Audience_Profile.pdf.

Additionally, secondary data was collected from the Centers for Disease Control and Prevention, National Institutes of Health and other agencies with access to valuable information. This information was used to validate the data collected from the focus groups and to better understand the target audience and those intervention strategies that have previously worked.

Step 3.7 Write profiles for each audience segment.

[Both audience segments have the same profile; however, the delivery of the message used multiple media (Spanish/English print versus Spanish/English radio and TV) to accommodate the needs of each audience.]

Primary Message: You can control your diabetes.

Secondary Message(s): these were only communicated through longer print ad formats

• You need to understand your blood sugar numbers and perform self-monitoring of blood glucose.
• You need to eat a balanced diet.
• You need to get regular moderate-intensity exercise.

Demographics:

• The majority of U. S. Hispanic/Latino Americans live in 20 urban areas in 10 states: California, Texas, New York, Florida, Illinois, New Jersey, Arizona, New Mexico, Colorado, and Massachusetts.
• Hispanic/Latino Americans have a median age of 26 versus 34 for the general population.
• Hispanic/Latino American families have a median income of less than $25,000 annually and are more likely than non-Hispanic white families to live below the poverty level.
• Approximately 56 percent of Hispanic/Latino elderly are literate in English and 22 percent of Hispanic/Latino elderly do not speak English (National Eye Health Education Program, 1994).

Cultural Norms:

• Food is highly symbolic (ethnic, cultural, and historical) and is often the focal point of celebrations and social activities within the family unit.
• The family is the single most important social unit in the lives of Hispanic/Latino Americans. Family responsibilities often come before personal needs. The entire family makes health care decisions with the opinion of the mother/wife often bearing the most weight.
• Individual Hispanic/Latino Americans with diabetes do not wish to 'burden' their family with their diabetes; therefore, this may lead to a lack of adherence to proper diet and necessary lifestyle changes. A family's support and involvement are very important to compliance with the treatment plan.
• Many Hispanic/Latino Americans will only answer those questions a doctor asks and will not volunteer any more information. Additionally, if a doctor is too distant or does not seem to 'really care', the Hispanic/Latino patient may perceive this doctor as not caring and may refuse to go back, or will be less likely to comply with recommended treatments.

Media Habits and Preferences:

• Television is the primary media source for Hispanic/Latino Americans, followed by radio.
• Hispanic/Latino persons who speak Spanish as their primary language prefer Spanish-Language media outlets.
• Celebrities should not be used as spokespersons because Hispanic/Latino persons believe they are not credible and that they have no concern for the community. Celebrities are perceived to serve as spokespersons only because they are paid to do so.
• Spokespersons should be Spanish-speaking physicians or otherwise respected and recognized persons with diabetes or diabetes in the family. Suggestions include: Dr. Antonia Coello-Novello (former U.S. Surgeon General), Dr. Elmer Huerta (research fellow at the National Cancer Institute and host of a Spanish-language syndicated daily radio talk show on health issues), or Dr. Aliza Lifshitz (President of the California Hispanic Medical Association).
• Other focus groups indicated that the ideal spokesperson should be a women (because women are the caretakers of the family), married with children, perhaps working as a doctor or community educator, who should have exercise as a hobby (because she is an active person who is full of life, happy) and who has diabetes and monitors her blood glucose daily.
• Brochures, pamphlets and flyers should be produced in both English and Spanish.

Settings:

Messages should, if possible, be conveyed in community-based settings, such as

• Community gathering places
• Neighborhood watch groups
• Community recreation centers
• Malls
• Churches
• Billboards
• Waiting areas such as bus stops
• Doctor's office
• Health centers

Activities:

• TV
• Radio
• Printed brochures, pamphlets, flyers
• Cooking demonstrations that offer opportunities to taste the foods which incorporate ethnic food preferences and demonstrations on how to buy and prepare healthful foods. (This would help overcome the barriers that challenge perceptions of cost, tastefulness and the time needed to prepare healthy foods.)
• Posters

For more information on the Hispanic/Latino audience profile DB_Hispanic_Latino_and_Diabetes-Audience_Profile.pdf.

Step 3.8 Rewrite goals as measurable communication objectives.

• By December 2001, increase the percentage of Hispanic/Latino Americans with diabetes who believe a person can control their diabetes to 50 percent (Baseline 1998, 30 percent).

The goals below were drafted to expand on the goal above and to help frame future interventions:

• By January 2003, increase the percentage of Hispanic/Latinos with diabetes whose eating habits are within the recommended guidelines to 45 percent (Baseline 2000, 20 percent).
• By January 2004, increase the percentage of Hispanic/Latino Americans with diabetes who perform regular moderate-intensity physical activity to 45 percent (Baseline 2000, 20 percent).
• By January 2005, increase the percentage of Hispanic/Latinos with diabetes who perform daily self-monitoring of blood glucose to 50 percent (Baseline 2000, 36 percent).

Step 3.9 Write creative briefs.

Target Audience Hispanic/Latinos who speak Spanish as their primary language and those with higher levels of literacy versus those with lower levels of literacy.

Objectives

• Promote the concept that a person with diabetes can control his or her diabetes. It is not 'out of their hands'.

As stated above, it was determined that additional objectives should be addressed through subsequent interventions:

• Improve the eating habits of the target audience
• Increase physical activity of the target audience
• Increase the percentage of the target audience with diabetes who perform daily self-monitoring of blood glucose

Obstacles

• Many Hispanic/Latino persons believe that a heavier body type is healthier.
• Some believe exercise is for those who can afford health club memberships. Additionally, those who work in an industry that is labor intensive (i.e. service, construction, etc.) may have a lower level of interest in wanting to continue physical activity on their time off.
• Many Hispanic/Latino Americans have a fatalistic view of diabetes, believing there is nothing that can be done about it. This view may contribute to a lack of active participation in the care plan. Additionally, Hispanic/Latino Americans believe that “What happens to me is God’s will”.
• Many of the foods that are culturally accepted and part of the Hispanic/Latino person's regular diet are high in fat.

Key Promise

If I take control of my diabetes, I will feel happier and healthier.

Support Statements/Reasons Why

• The United Kingdom Prospective Diabetes Study (UKPDS) showed that intensive blood glucose control in people with type 2 diabetes delayed the onset of eye and kidney disease, reducing the risk by 12 to 33 percent, by lowering hemoglobin A1C levels from about 8 to 7 percent. These studies further showed that any sustained lowering of blood glucose helps, even if the person has a history of poor control.
• Regular moderate-intensity physical activity can help control blood glucose levels.
• Obesity can contribute to poor glucose control.
• Healthy foods that are low in fat help control blood glucose levels.

Tone

Culturally sensitive and serious

Media

Radio, television, posters and print PSAs.

Creative Considerations

Radio, television and print PSAs should be in both Spanish and English.

To view Creative Brief DB_NDEP_creative_brief.pdf.

Step 3.10 Confirm plans with stakeholders.

A meeting with the stakeholders was held to discuss the results of the formative research and all planned communication efforts. The creative brief was shared with all partners, and plans were discussed for the next phases of the campaign. Stakeholders were asked what information they hoped to attain by implementing this campaign and what their desired outcomes were. Their responses led to a discussion of the need for an evaluation of the campaign. After receiving approval for all planned communication efforts, a timeline was drafted for creation of the messages and communication products, implementation of the campaign, and developing and implementing the evaluation strategy.

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

All partners and stakeholders agreed upon and finalized the timeline and budget for testing the communication messages. Stakeholders were invited to observe the concept and message pre-testing.

Step 4.2 Develop and test creative concepts.

Four creative concepts, which focused on the idea that a Hispanic/Latino person with diabetes can control his or her diabetes through blood glucose control, were developed from the formative research by the contractor and CDC staff, with input from the workgroup. A total of 8 focus groups (one all-male focus group and one all-female focus group in each of 4 major Hispanic markets: Miami, Florida; San Juan, Puerto Rico; New York, New York; and Los Angeles, California) were conducted by a contractor to test these creative concepts.

The four concepts were:

1. Lightning Bolt
2. Antonio
3. Family
4. Female

Lightning bolt-'Cosas que no se pueden controlar? Muchas! Pero la diabetes no es una de ellas. Entienda su diabetes y comience a controlarla.' (Are there things you can't control? Many, but diabetes is not one of them. Understand your diabetes and begin to control it.)

• This concept was the most preferred out of the four. It was well received in all four markets.
• The visual was impactful and different.
• The concept conveyed a strong message and elicited a call to action
• The concept put diabetes in context for a lot of people.

Antonio-'Antonio tiene mil y un motives para tomar su diabetes muy en serio. Entienda su diabetes. Evite los riesgos.' (Antonio has a thousand and one reasons to take his diabetes seriously. Understand your diabetes. Avoid the risks.)

• This concept was well received, particularly among older focus group participants (male and female) and participants with grandchildren.
• The concept portrayed an image of a long, happy life in the company of one's family (an 'ideal' that everyone strives for).
• The message had a strong emotional pull.
• This concept was not as effective for Hispanic/Latino adults who were not yet grandparents.

Family-'No hay mal que por bien no venga. La diabetes me obligo a cuidar mi salud y la de mi familia. Conzcase...Conozca su diabetes.' (Every cloud has a silver lining. Diabetes has caused me to look at my health and the health of my family. Know yourself. Know your diabetes.)

• This concept had a positive appeal.
• The family element was one everyone could relate to.
• The phrase, "no hay mal que por bien no venga" received a mixed reaction. Some liked it and felt it invited them to reflect on their illness as a positive event. Others felt it was a cliché and that it was more negative than positive.
• Some were confused as to who in the photograph (parent or child) had diabetes.

Female-'Conozco y controlo mi diabetes ya no soy carga para nadie. Tome su diabetes en serio para que no se vuelva cosa seria.' (I recognize and control my diabetes. I am no longer a burden for anyone. Take your diabetes seriously so that it doesn't turn into something serious.)

• This concept was the least preferred out of the four.
• Some participants of the focus groups felt they could not relate to the woman in the concept.
• Other participants felt the woman in the concept looked healthy and happy and that she controlled her diabetes. Others felt she looked too healthy and they did not believe she had diabetes.
• The words, "ya no soy carga para nadie" (I am no longer a burden for anyone) elicited some negative commentary because many felt they were not a burden. Others felt the idea of not being a weight or burden was a powerful one because it mirrored a very vivid fear for them and gave them a way to avoid being a burden to their families.

It was concluded that overall, the message for the campaign should be simple and one that lends efficacy to control.

Step 4.3 Develop and pretest messages.

Of the four previous concepts, the "Lightning bolt" concept was further developed into pretest materials. Additional focus groups were conducted to obtain feedback on the visual treatment and on the proposed message in both English and Spanish. Results indicated the message was well received in both languages and that no changes were needed.

Step 4.4 Pretest and select settings.

Focus group data from the formative research and additional market research data indicated the following settings would be most appropriate for this campaign message:

• Community gathering places
• Neighborhood watch groups
• Community recreation centers
• Malls
• Churches
• Homes
• Billboards
• Waiting areas such as bus stops
• Doctor's office
• Health clinics

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

On the basis of focus group data from the formative research, the most appropriate channels for this campaign were television, radio, and print (pamphlets, brochures, newspaper articles, etc.). Additionally, a 'Community Guide for Partners' and 'Campaign Guide for Partners' were developed to walk local organizations through the steps of disseminating the message to their community members. To view the 'NDEP Community Guide for Partners' DB_diabetes_community_partnership_guide.pdf. To order a copy of the 'NDEP Control Your Diabetes For Life Campaign Guide for Partners' http://ndep.nih.gov/materials/puborder/resource.htm.

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

Final versions of all print, radio, and television PSAs were tested among focus groups. Data indicated that participants felt the materials were clear and easy to understand. Further, the message was perceived to be very motivating.

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

The communication plan was disseminated among internal staff at the Centers for Disease Control and Prevention and the National Institutes of Health. Roles and responsibilities for staff, contractors, and workgroup members were identified. Additionally, the communication plan was disseminated among external partners at the state, city, and community levels. To aid the implementation of the campaign, a media workshop guide and a National Diabetes Education Program website address were distributed to all partners.

Step 4.8 Produce materials for dissemination.

Final clearance for the campaign materials was obtained and the distribution began. All external partners were given a media kit. This media kit included:

• Camera-ready versions of all English and Spanish 'Thunder and Lightning' print PSAs
• Masters of the TV and radio PSAs
• Sample letters to the newspaper public service director
• Sample letters to the radio public service director
• Sample letters to the television public service director
• Recorded radio PSA script
• Live-read radio script templates
• Media advisory template
• Diabetes and Hispanic/Latinos B fact sheet
• Diabetes overview fact sheet
• Hispanic/Latino working group media contact list
• National Diabetes Education Program (NDEP) executive media contact list
• 'Changing the way diabetes is treated' (NDEP Fact Sheet)
• NDEP publications list

Step 4.9 Finalize and briefly summarize the communication plan.

Public health surveillance of diabetes has shown that minority groups and the elderly are disproportionately affected. A CDC contractor reported that Hispanic and Latino Americans have the second highest rate of type 2 diabetes compared with other populations. Furthermore, National Diabetes Education Program data indicate that Hispanic and Latino Americans are at higher risk of developing and dying from diabetes and are two times as likely to have complications such as heart disease, blindness, high blood pressure, amputations, nerve damage, and kidney disease than non-Hispanics. Healthy People 2010 indicate that the proportion of Hispanic or Latino adults with diabetes who perform self-monitoring of blood glucose at least once a day is 36 percent compared with 45 percent non-Hispanic white adults with diabetes. The risk of developing complications of diabetes rises when blood glucose is not kept under control. The incidence of diabetes and its complications within the Hispanic/Latino population can be expected to substantially increase unless prevention and control practices can be established within this population.

The audience selected for this campaign was Hispanic/Latino persons who speak Spanish as their primary language and those with higher levels of literacy versus those with lower levels of literacy.

The communication objective was to promote the concept that a person with diabetes can control his or her diabetes.

The final message, titled "Thunder and Lightning," selected for this campaign was designed to be both culturally sensitive and serious. "There are many things in life that can't be controlled. Fortunately Diabetes isn't one of them." The body copy in the print PSA goes on to say: "Millions of us are living with diabetes. For many, it runs in our families. But we don't let that run our lives. Because diabetes can be controlled with the proper diet, exercise, and knowing and managing our blood sugar numbers. The more we learn about how to live with diabetes and avoid the many serious complications, the longer and better we'll live. And there are so many things to live for. Take your diabetes seriously, so it never becomes too serious."

The settings for this campaign included community-based organizations such as community recreation centers, malls, churches, homes, billboards, and waiting areas such as bus stops or a doctor's office. The channels selected for this campaign were television, radio, and print (pamphlets, brochures, newspaper articles, etc.). Additional activities conducted by some community organizations included food demonstrations and health fairs with music and dancing.

The previously agreed upon communication plan, timeline and budget were disseminated among internal and external partners. Once the final clearance of the campaign materials was obtained, distribution of the materials and a community guide for partners began. All external partners were given a media kit and the guide to help with the implementation of the campaign.

Step 4.10 Share and confirm communication plan with appropriate stakeholders.

A meeting of all stakeholders and key partners was held to share the summary of the communication plan and campaign materials. Buy-in was confirmed with the stakeholders, and campaign kickoff responsibilities were finalized.

Step 5.1 Identify and engage stakeholders.

The NDEP identified 2 types of stakeholders:

Level 1: Direct stakeholders that have input into the funding, design, and conduct of the program such as Congress, federal agencies including the Centers for Disease Control and Prevention (CDC) and the National Institutes of Health (NIH), the NDEP steering and executive committees, and NDEP partner organizations.

Level 2: Indirect stakeholders that are affected by NDEP activities, such as people with diabetes and their families, health care providers, payers and purchasers, and policy makers (e.g., business leaders, health care system decision makers, trade and professional associations).

Each of these stakeholders needed to receive information from the NDEP evaluation as it developed and both process and impact findings were included. Level 2 stakeholders and some Level 1 stakeholders were involved in developing and sustaining the NDEP through their support and ongoing activities in local communities; therefore process evaluation findings were of the greatest importance to this group. The majority of Level 1 stakeholders were responsible for policy and funding decisions; therefore, the extent to which NDEP achieved its intended impact objectives was of importance to this group.

Step 5.2 Describe the program.

The primary goal of the campaign was to:

• Promote the concept that Hispanic/Latino persons with diabetes can control their diabetes. It is not 'out of their hands.'

Future interventions would be developed to:

• Increase percentage of Hispanic/Latinos with diabetes who perform daily self-monitoring of blood glucose
• Alter dietary habits of Hispanic/Latinos with diabetes
• Increase physical activity of Hispanic/Latinos with diabetes

To achieve the primary goal, the following intervention was developed:

The campaign materials were developed and pre-tested with the target audience. The data from focus group discussions indicated that the campaign materials were considered to be culturally sensitive and well received in both English and Spanish. Additional focus group data from four leading Hispanic/Latino markets indicated the campaign message, "Thunder and Lightning," was the most appropriate concept for the Hispanic/Latino community. Television, radio and print PSAs , as well as pamphlets and brochures, were developed from the "Thunder and Lightning" concept in English and Spanish and were distributed nationally to NDEP partners for implementation.

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

The process evaluation measured what NDEP was doing and monitored its progress in order to identify promising and problematic activities. This information helped to determine if the program was on course for achieving its objectives. The following process evaluation questions were of importance to the stakeholders:

• To what extent did the NDEP promote networking among partners? Specifically, to what extent did partners exchange information, alter activities, share resources, and develop common activities and objectives?
• Were the NDEP communication activities such as the development of culturally appropriate materials and media messages implemented as planned? Did the messages reach the targeted audiences?
• Were partners supportive of the NDEP activities and did they actively contribute to their success? Did they market NDEP materials and products and promote its activities to other players in the diabetes community?

Impact evaluation questions and measures were designed to determine the program's influence on its intended beneficiaries as a result of direct programmatic activities. The impact evaluation focused upon the result of the activities of the NDEP and its partner organizations on the target audiences. Impact evaluation wanted to answer the following questions:

• Did the campaign increase the awareness within the Hispanic/Latino community that diabetes is a serious, yet controllable condition?

Additional questions of interest would need to be explored in the future, after subsequent interventions were implemented:

• Were those receiving diabetes messages acting on their awareness by more aggressively controlling their diabetes through daily self-monitoring of blood glucose, and improved diet and exercise?
• Did health care providers change their treatment behavior by providing culturally and linguistically tailored health care to Hispanic/Latino persons with diabetes?
• Did policy-makers increase the access to diabetes quality care for the Hispanic/Latino population?

For more information about how to determine evaluation measures http://www.cdc.gov/epo/mmwr/preview/mmwrhtml/rr4811a1.htm.

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

• By December 2001, increase the percentage of Hispanic/Latino Americans with diabetes who believe a person can control their diabetes to 50 percent (Baseline 1998, 30 percent).

Additional intervention standards were tentatively planned to correspond to the previously listed future goals:

• By January 2003, increase the percentage of Hispanic/Latinos with diabetes whose eating habits are within the recommended guidelines to 45 percent (Baseline 2000, 20 percent).
• By January 2004, increase the percentage of Hispanic/Latino Americans with diabetes who perform regular moderate-intensity physical activity to 45 percent (Baseline 2000, 20 percent).
• By January 2005, increase the percentage of Hispanic/Latinos with diabetes who perform daily self-monitoring of blood glucose to 50 percent (Baseline 2000, 36 percent).

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

Both process evaluation (to study the functioning of components of the campaign) and impact evaluation (to determine the extent to which the campaign was accomplishing the stated objectives) were used in NDEP evaluation. The evaluation plan detailed two types of measures, evolving measures and core measures. Evolving measures changed over time to reflect the changing activities of the NDEP and its partners. Because all of the process measures in the evaluation were evolving measures specific to the program, they were gathered through primary data collection methods developed for this purpose. Core measures included impact measures that were assessed at intervals throughout the program.

To collect process data from work groups, partners, and other stakeholders, a progress reporting system was developed. Work groups and other NDEP stakeholders were asked to provide data to the NDEP evaluation committee and contractors. The progress reporting system included the following primary components:

• List of activities and milestones achieved related to objectives.
• Samples of work or products.
• What NDEP did for stakeholders.
• What unmet needs partners had.
• Partner satisfaction with NDEP.

Additional process measures included:

• Number of plays of NDEP radio and TV spots (frequency)
• Estimated number of listeners/viewers with and without diabetes exposed to spots (reach)
• Number of copies of print materials (English and Spanish) distributed (reach)
• Estimated number of readers with and without diabetes exposed to print in English or Spanish (reach)
• Number of partner diabetes activities implemented
• Number of community activities implemented
• Estimated number of Hispanics/Latinos who learned they should consult their physician about their diabetes
• Estimated number of Hispanics/Latinos who instituted a self-management diabetes regimen since the campaign began

Collection of process measurements included media tracking reports; monitoring clipping services; conducting a series of in-depth interviews with key stakeholders; analyzing any available quantitative data on the partner's activities; and reviewing relevant documentation, including memos, letters, reports, press releases, etc. These data were supplemented by direct observation of the program 'in operation', through site visits to partners or stakeholders. Observers collected data on factors such as management strategies, staff skills and activities, application of policies and procedures, and problems and solutions.

Successful completion of the activities measured in the process evaluation was expected to have an impact on diabetes control awareness, attitudes, and behaviors of the target audience (Hispanic/Latino persons with diabetes and their families). The impact evaluation measured these effects through a variety of measurements obtained in part through surveys such as Healthstyles and the Behavioral Risk Factor Surveillance System. Some impact measures included:

• Estimated percent of Hispanic/Latino persons who know that diabetes is a serious condition
• Estimated percent of Hispanic/Latino persons who know that diabetes is controllable through blood glucose monitoring, diet, and exercise
• Estimated percent of Hispanic/Latino persons with diabetes and their families who consider controlling diabetes for life important

Additional related impacts to focus on in future interventions were:

• Estimated percent of Hispanic/Latino persons who know and understand the results of their daily blood glucose levels
• Percent of Hispanic/Latinos with diabetes who exercised 30 minutes or more on most days
• Estimated percent of Hispanic/Latino persons with diabetes who know their hemoglobin A1c target numbers
• Percent of health care systems that have policies and procedures for preventative and specialty care that is tailored to the Hispanic/Latino population

For more information about how to determine evaluation measures http://www.cdc.gov/epo/mmwr/preview/mmwrhtml/rr4811a1.htm.

Step 5.6 Develop an evaluation design.

The NDEP primarily used existing secondary data from credible sources such as the Behavioral Risk Factor Surveillance System, the National Vital Statistics System, the National Health and Nutrition Examination Survey and the National Health Interview Survey for evaluation. The NDEP further used primary sources to fill in any 'gaps' the secondary data left out. A classical experimental design was used to collect primary data, with pre/post-test measurements taken from the treatment groups versus a similar-comparison group. In addition, a mixed methods approach that entailed the use of both qualitative and quantitative measures was used.

Step 5.7 Develop a data analysis and reporting plan.

To adequately examine the process and impact measures among the target audience, partners, and stakeholders, a variety of evaluation methods and analysis techniques were employed. Quantitative data from surveys and secondary databases were analyzed using descriptive and inferential techniques. Basic descriptive information about measurements such as totals, means, percentages, and changes in these numbers were reported. Cross-tabulations showing the relationship between two variables of interest were also presented. Inferential techniques, such as analysis of variance, were also used. Repeated measures ANOVAs were used for quantitative data collected at multiple time points.

Examination of the qualitative data from interviews and focus groups identified common themes within and across the audience. The relative frequency of these themes among those participating was reported. Further, the themes were compared and contrasted among different audience members.

Reports were shared with the workgroup members for discussion. NDEP developed written progress reports and provided annual updates at the partnership network meetings.

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

Formal agreements between both internal and external stakeholders were finalized and individual roles and procedures to be used during the evaluation process were clarified. Information will be disseminated to partners and staff through inter-office mail, email, faxes, and conference calls. Additionally, formal reports at the end of each evaluation period were disseminated to Level 1 stakeholders within 3 months of publication and within 6 months of publication for Level 2 stakeholders.

Step 5.9 Develop an evaluation timetable and budget.

The NDEP campaign is a continuous campaign. Each year, the objectives and delivered messages change based on previous years' evaluation data and on current audience research. For this campaign, the kickoff occurred at the beginning of the year 2000. The complete timeline and budget for the evaluation was approved by all stakeholders and disseminated. Contractors and grantees were required to submit evaluation plans and budgets for their proposed NDEP activities. Partners were encouraged to incorporate evaluation components into their activities. NDEP also established a separate evaluation workgroup to assist in overall evaluation efforts.

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

The evaluation implementation plan included process evaluation and impact evaluation for Level 1 and Level 2 stakeholders. The process evaluation findings indicated what strategies were the most successful, and the impact evaluation findings helped to determine what impacts have been made within the diabetes community. A formal report of all evaluation findings was written and published at the end of each evaluation period.

Step 6.1 Integrate communication and evaluation plans.

A meeting with stakeholders, key partners, and staff was held to reaffirm team members' roles and responsibilities in the integration of the communication and evaluation plans. Persons responsible for communication activities updated all team members on when the communication campaign would begin and how the campaign would be executed. Those responsible for implementation of the evaluation plan brought the team up to date on the collection of baseline measures. Additionally, a series of meetings was arranged throughout the communication and evaluation phases of the campaign to keep all team members informed of the campaign's progress and to acquire feedback.

Step 6.2 Execute communication and evaluation plans.

The communication and evaluation plans were launched simultaneously. The communication campaign was launched with numerous activities including press releases and media spotlights. Evaluation data collection occurred at all phases throughout the campaign.

Step 6.3 Manage the communication and evaluation activities.

During the many phases of the campaign, stakeholders, key partners and staff met and monitored political, social, and health environments surrounding the campaign that could affect its success. Any threats to or weaknesses in the campaign were identified, and proper adjustments were put into action.

Step 6.4 Document feedback and lessons learned.

Stakeholders, key partners and staff were asked to submit reports indicating what each individual felt were the strengths and weaknesses of the communication campaign. Specifically, each team member was asked to evaluate, as objectively as possible, the planning phase and the implementation phase of the communication campaign. Results from these reports were compiled and recommendations were made for future campaigns. It was determined that the next campaign should address nutrition issues for the Hispanic/Latino population with diabetes and the “Control Your Diabetes. It’s more than food. It’s life” campaign has been developed. To order materials for that campaign http://ndep.nih.gov/materials/puborder/resource.htm.

Step 6.5 Modify program components based on evaluation feedback.

Feedback from the evaluation of the communication campaign indicated that only minor adjustments needed to be made to the current campaign and that plans to expand the scope of the campaign to include specific messages about nutrition should proceed.

Step 6.6 Disseminate lessons learned and evaluation findings.

A final report of all campaign activities and evaluation results was written. Because not every team member needed a complete comprehensive report, executive summaries were issued. Additionally, the highlights of the campaign were presented at a meeting with all stakeholders, key partners, and staff.