Disclaimer

Some of the facts in this example have been fictionalized for instructional purposes.

Step 1.1 Write a problem statement.

Only 15% of adult women engage in the recommended amount of physical activity, which is at least 30 minutes of moderate activity, 3-5 days a week. More than 25% of adult women do not participate in any physical activity.

Over 30% of all adult women reported that they do not have a safe place to walk in their community. Only 46% of municipal and county parks and recreation departments provide fitness trails, 29% provide hiking trails, and 21% provide bike trails. Only 3% of medium and large-sized businesses provide on-site exercise facilities for their employees.

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

The Centers for Disease Control and Prevention (CDC), National Center for Chronic Disease Prevention and Health Promotion (NCCDPHP) provided scientific and technical leadership and assistance to help state and national organizations and professional groups promote physical activity. The CDC’s National Physical Activity Initiative was the primary focus for these efforts and reflected the CDC’s continuing commitment to reduce the major risk factors for chronic disease in the United States.

The NCCDPHP reorganized and created a Division of Nutrition and Physical Activity (DNPA) and the CDC formally placed high priority on increasing physical activity among American adults by developing the National Physical Activity Initiative. The initiative had seven main components:

• Program research and development
• Public information and education
• Professional education
• Policy and environmental guidelines development
• Promotion of partnerships
• Coordination and leadership
• Surveillance and evaluation

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

A list of suggested team members included:

• American Cancer Society
• American Heart Association
• American Lung Association
• Community Agencies
• Diabetes Foundation
• Governor’s Council on Physical Activity
• Healthcare providers
• Members of priority populations
• Parks and recreation
• University Researchers
• Worksites

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

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

• African American and Hispanic women
• Lower socioeconomic status women
• People who live in high crime areas
• People who live in urban areas
• Working women/single heads of households

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

Subgroup: working women
Only 3% of medium and large-sized businesses provided on-site exercise facilities for their employees

Subgroup: women who live in high crime areas
Over 30% of all adult women reported that they did not have a safe place to walk in their community.

Subgroup: single heads of households
Over 40% of adult women who are single heads of households report that they have childcare needs that supercede regular recommended physical activity.

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

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

Strengths

• The CDC and the American College of Sports Medicine recommend that every American adult engage in 30 minutes of moderate-level physical activity, 3-5 days a week. The CDC is committed to the National Physical Activity Initiative and contributed more than $3 million in annual funding.

Weaknesses

• Convincing someone to begin physical activity can be difficult.

Opportunities

• The surge of interest in physical activity pushed American women into a healthier way of life.
• Health clubs and fitness equipment manufacturers developed new, exciting, and glamorous marketing strategies to help women become more physically active.
• Special equipment was engineered for women with disabilities and/or other physical limitations. These devices appealed to a larger proportion of the female population.
• Two national nonprofit organizations, the American Lung Association and the Diabetes Foundation, also had campaigns that promoted physical activity.
• Walking with family or friends can be effective way to socialize and exercise at the same time.

Threats

• There were many other (and in some ways more appealing) distractions, like television, video games and movies, computers, and food.

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

The primary factors contributing to physical inactivity among adult women included:

External Contributors

• Lack of action by public health officials to create safe, accessible places for physical activity.
• Lack of employer-provided worksite fitness programs.
• Cultural values associated with physical activity (e.g. in some cultures, physical activity is associated with lower classes; in others, overweight is considered acceptable).
• Lack of childcare for mothers.

Internal Contributors

• Lack of motivation for physical activity.
• Belief that it costs money to be physically active.
• Lack of worksite fitness programs provided by employers.
• Lack of awareness of the benefits of physical activity.
• Lack of awareness of what activities are considered moderate physical activity.
• Belief that physical activity needs to be strenuous to achieve health benefits.
• Belief that one must belong to a gym to be active.
• Feeling of boredom with the routine of physical activity.
• Perception that there is not enough time for daily moderate physical activity.
• Belief by older women that physical activity puts them at risk for injury.

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

The factors on which the agency decided to intervene included:

• Belief that physical activity needed to be strenuous to achieve health benefits.
• Lack of awareness of what activities were considered moderate physical activity.
• Lack of awareness of the benefits of moderate physical activity.
• Belief that physical activity increased one’s risk for injury.

Step 2.3 Write goals for each subproblem.

The goals of the campaign were:

• Increase the number of older women who were physically active by motivating them to engage in at least 30 minutes of moderate activity, 3-5 days a week.
• Increase the number of older, African American women of low socioeconomic status (SES), who were aware of:
• activities that were considered moderate
• benefits of physical activity
• Decrease the number of older, African American women of low SES who:
• believed physical activity had to be strenuous in order to achieve health benefits
• refrained from moderate physical activity because they believed it increased their risk of injury

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

The following intervention methods were chosen because they were thought to produce desired results.

Health Communication/Education

• Proven to change awareness, knowledge, attitudes, intentions, and behaviors among target audience.
• Motivated people to make behavior changes.

Health Policy/Enforcement

• Developed safe and convenient places for people to exercise.
• Encouraged exercise by supporting worksite exercise programs.

Health Engineering

• An engineering strategy included developing safer, age-appropriate equipment to reduce the risk of injury.

Health-Related Community Services

• Health professionals encouraged physical activity.
• Health care organizations and community organizations offered/sponsored physical activity.

Step 2.5 Consider SWOT and ethics of intervention options.

Health Communication/Education

Strengths

• Communication was effective at reaching the goals set for the intervention.
• Physical activity was complex and targeting messages allowed for messages to be tailored to each audience segment.

Weaknesses

• The complexity of the behaviors involved in physical activity necessitated a good deal of audience segmenting and research.

Opportunities

• Other organizations implemented physical activity interventions, so people were hearing "pro-physical activity" messages from various sources.

Threats

• Many other messages (movie previews on television, billboards advertising television programs…) that did not promote physical activity had larger budgets and more airtime than health communication interventions.

Ethics

• The intervention acknowledged and respected different cultural ideas of fitness, body image and physical activity.
• The intervention did not promote physical activity that was impossible for the target audience to participate in because of cultural, economic and/or safety reasons.

Health Policy/Enforcement

Strengths

• This intervention impacted some structural barriers to physical activity.

Weaknesses

• Health policy did not do a great deal to motivate people to exercise.

Opportunities

• Some local governments and companies attempted to work on physical activity interventions as well.

Threats

• This intervention faced limitations such as participant commitment and financial restrictions.

Ethics

• There was criticism towards local governments because they were spending limited funding on this type of intervention.

Health Engineering

Strengths

• New exercise/physical activity equipment made it easier to motivate older women.

Weaknesses

• New equipment could only be used if it was located where women could use it.
• This type of engineering and development could have been expensive.
• There was little monetary incentive for manufacturers to develop this type of equipment.

Opportunities

• New equipment was being developed all the time.

Threats

• Placing new exercise equipment in the social environment (social engineering) is not a cure-all for adoption and maintaining moderate physical activity for women.

Ethics

• The intervention could not support equipment that could be harmful.
• The support of the manufacturers could have been viewed as supporting an industry that sold people expensive equipment with the promise that it would make them thin, fit and attractive.

Health-Related Community Services

Strengths

• Other health services were linked to physical activity.

Weaknesses

• Women did not regularly see a medical professional or have connections to any health related organizations; therefore, some did not receive the message.

Opportunities

• Medical and social service agencies that share a common mission can combine efforts to initiate and sustain physical activity for women.

Threats

• These community-based efforts need sustained formal and informal leadership.

Ethics

• Health-related community service agencies might not consider physical activity a high priority.

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

Since all four subproblems were based on changing beliefs or increasing awareness, communication was chosen as an appropriate strategy to explore for the following reasons:

• Communication can be very effective in increasing awareness and changing attitudes and beliefs. These were central issues for increasing moderate physical activity.
• Older women could be reached through communication channels.
• CDC had experience with a wide variety of communication programs for older women.

Logic Model

Step 2.7 Explore additional resources and new partners.

Some of the suggested partners were:

• American Association of Health Plans
• American Cancer Society
• American Heart Association
• American Medical Association
• Association for Worksite Health Promotion
• Association of State and Territorial Chronic Disease Program Directors
• Governors’ Council on Physical Fitness
• National Coalition for Promoting Physical Activity
• National Institutes of Health
• National Recreation and Park Association
• President’s Council on Physical Fitness and Sports
• State and local health departments
• Wellness Councils of America

Step 2.8 Acquire funding and solidify partnerships.

A proposal for funding was prepared. Existing partnerships were confirmed and new partnerships were explored. Interaction among staff, partners and stakeholders continued to keep communication lines open and to generate and elicit feedback on the program's progress.

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

Communication was selected as the dominant intervention.

Once the potential target populations were identified, older women were ranked as the highest priority target population group. They were followed by women with children, employers and public officials. Older women were ranked highest because they were at greatest risk for health problems associated with a lack of physical activity.

The other population groups were eliminated from focus because they were not considered a top priority, and resources were available to concentrate on only one group.

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

Possible segments of older women included:

• Non-Hispanic whites, African Americans, Hispanics, Asian Americans, Pacific Islanders, and Native Americans
• Low socioeconomic status (SES) vs. high SES
• Women who were thinking about becoming physically active (contemplators) vs. those who were not (precontemplators)

Step 3.3 Finalize intended audiences.

Older, low SES African American women were chosen as the primary target audience because the CDC could reach them through various mediums, and because they were disproportionately affected by the problem. These women were less likely to engage in physical activity than were non-Hispanic white men and women and African American men. African American women also had a significantly lower life expectancy than did non-Hispanic white women.

The Division of Nutrition and Physical Activity (DNPA) identified family members as a possible secondary audience because of their potential to interact with the target audience.

Step 3.4 Write communication goals for each audience segment.

The communication goals for the campaign were:

1. Increase the number of older, African American women of low SES, who are aware of:
• different activities that are considered moderate exercise
• the benefits of physical activity
2. Decrease the number of older, African American women of low SES who:
• believe that physical activity must be strenuous in order to achieve health benefits
• refrain from moderate physical activity because they believe it increases their risk of injury
3. Inform family members:
• of the benefits of moderate physical activity
• of support tactics that may be used to encourage the individual(s) who are beginning to exercise

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

Step 3.6 Undertake formative research.

Step 3.7 Write profiles for each audience segment.

The following were characteristics of older, low SES African American women:

• They often did not participate in many activities outside of the home.
• They perceived that they had little access to suitable facilities to be physically active.
• They tended to socialize with persons who lived nearby and, as a result, remained close to their homes.
• They believed physical activity involved vigorous exercise.
• They lacked motivation because they perceived that physical activity was boring.
• They lacked the self-efficacy that would help them begin increasing physical activity.
• They often thought about becoming more physically active.
• Credible sources of information for them included relatives, friends, celebrities and athletes.
• Their primary media channels included daytime television (soap operas, talk shows), and targeted print media (magazines tailored for African American audiences).
• They were less likely than the general population to state that they were in excellent health.
• They were likely to have many family responsibilities, which included caring for children, grandchildren and/or their own parents.
• They agreed that being physically attractive was important to them.
• They were likely to have been diagnosed with high cholesterol, high blood pressure and/or diabetes.
• They were likely to consider God and religion as an important part of their lives.
• Having a "little meat on your bones" was perceived as desirable and healthy within the African American community. This was unlike the non-Hispanic white community’s perception that "thinner is better."

DNPA identified family members as a possible secondary audience because of their potential to interact with the target audience. As a secondary audience, family members may have provided:

• Assistance with helping their family member(s) set specific, realistic goals and with daily and household responsibilities (so there is time for exercise)
• Encouragement and support
• Motivation
• Reinforcement by participating in physical activity with their family member(s)

Some barriers to working with family members included:

• Some did not want to be role models.
• Some were also physically inactive.
• Some younger family members had difficulty helping the woman/women who had always helped them.

Settings for reaching older, low SES African American women included:

• Beauty salons
• Churches
• Community recreation centers
• Doctors’ offices or clinics
• Homes (via television, newspapers, magazines, direct mail)
• Local businesses such as grocery or local corner stores (not chain stores)
• Senior centers
• Special events such as health fairs
• Waiting areas at bus stops

Settings for reaching family members included:

• Community recreation centers
• Homes (direct mail brochures, radio, television)
• Public transportation
• Workplaces

Step 3.8 Rewrite goals as measurable communication objectives.

Objectives for DNPA’s campaign included:

1. By December 2000, increase the number of older, African American women of low SES, who are aware of:
• activities that are considered moderate exercise by 50%
• benefits of physical activity by 40%
2. By December 2000, decrease the number of older, African American women of low SES who:
• believe physical activity must be strenuous in order to achieve health benefits by 50%
• refrain from moderate physical activity because they believe it increases their risk of injury by 25%

Step 3.9 Write creative briefs.

To achieve the objectives of the program, several creative briefs or talking points were developed. These points were used as a guide for the campaigns.

Target Audience - Older, low SES African American women

Objective(s)

1. Increase the number of older, African American women of low SES, who were aware of:
• activities that were considered moderate exercise
• benefits of physical activity
2. Decrease the number of older, African American women of low SES who:
• believed physical activity had to be strenuous in order to achieve health benefits
• refrained from moderate physical activity because they believed it increased their risk of injury

Obstacles

• Believed that physical activity must be strenuous
• Perceived little access to facilities to be physically active
• Found physical activity boring
• Lacked social support and self-efficacy

Key Promise

Exercise can be successfully achieved without engaging in strenuous activity.

Support Statements/Reasons Why

Physical activity could help these women:

• become more physically fit
• maintain or achieve health
• remain healthy to care for their family and uphold their daily responsibilities

Tone

Positive, encouraging

Media

• Billboards
• Brochures
• Calendars
• Family resource guides
• Pamphlets
• Posters
• Television PSAs
• T-shirts
• Water bottles

Creative Considerations

"Slice-of-life" depiction of women similar to the target audience members

Target Audience - Family members of older, low SES African American women

Objective(s)

Informed family members:

• of the benefits of moderate physical activity
• of support tactics that may be used to encourage the individual(s) who were beginning to exercise

Obstacles

• Some did not want to be role models
• Some were inactive
• Some younger family members had difficulty helping the woman/women who had always helped them

Key Promise

If you support your family member(s) as they begin exercising, they will become healthier and be around for you later in life.

Support Statements/Reasons Why

Your family member(s) will have a better chance successfully making exercise a part of their weekly routine if you support and encourage them throughout this behavior change process. Family and social support has proven helpful and necessary for a lifestyle change of this magnitude.

Tone

Encouraging

Media

DNPA chose small group, interpersonal, and mass media channels for the physical activity campaign because they were appropriate for raising awareness and changing beliefs among the target audiences. The following materials were identified as necessary to reach the target audiences through various settings:

• Billboards
• Brochures
• Calendars
• Family resource guides
• Pamphlets
• Posters
• Television PSAs
• T-shirts
• Water bottles

Creative Considerations

"Slice-of-life" depiction of women similar to the target audience members.

Step 3.10 Confirm plans with stakeholders.

A meeting with partners and stakeholders was held to gather feedback on the creative brief and to confirm their interests in the campaign. The necessity of evaluation was further discussed. Paths of communication were developed with stakeholders to acquire support, obtain ideas and input and monitor the campaign's progress and success.

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

Program staff, partners and stakeholders helped prepare a timetable and budget for this campaign. It was very important to the program staff that this was done collaboratively to ensure that the stakeholders' and partners' interests were met.

Step 4.2 Develop and test creative concepts.

For the Division of Nutrition and Physical Activity (DNPA) campaign, three communication concepts were developed based on the information gathered from members of the target audience.

• The perception that one must exercise strenuously to achieve health benefits was dismissed. For example, the phrase "physical activity is no sweat" encapsulated this concept for testing purposes.
• The belief that one must go to a gymnasium or pay for a membership in a heath club was dispelled. This was achieved by demonstrating a variety of ways to engage in moderate amounts of physical activity outside of a gym or health club. The phrase "no membership needed" summed up this concept.
• The benefits of physical activity were emphasized and different types of activities were suggested. How one could incorporate moderate amounts of physical activity into a daily routine and how one could choose from a wide variety of fun activities was explained. The statement "get more out of life with physical activity –it’s everywhere you go" incorporated aspects of this concept.

Ten focus groups were conducted with older, low socioeconomic (SES) African American women to obtain feedback on the communication concepts. The moderator asked the participants why specific concepts did or did not appeal to them. The concepts "physical activity is no sweat" and "get more out of life with physical activity – it’s everywhere you go" were selected by participants as the most appealing.

The focus groups supported the belief that a positive tone was important. Suggestions for types of physical activity that could be realistically worked into participants’ lives were also given. These included walking to the store when only small purchases were needed instead of taking the bus, walking the family dog and engaging in moderate exercise.

Step 4.3 Develop and pretest messages.

Step 4.4 Pretest and select settings.

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

Various types of materials were developed for the physical activity campaign. Examples of posters, t-shirts, brochures, billboards and a PSA included:

• A billboard with cartoon depictions of examples of moderate physical activity, such as walking, gardening, and housework, was displayed.
• A direct mail brochure which listed various moderate physical activities that could be easily incorporated into their daily lives was distributed.
• A poster that listed the benefits of moderate physical activity was displayed in local stores and clinics.
• T-shirts encouraging them to join a walking club were disseminated.
• A television PSA showing a mother and daughter walking together television was shown.

Thirty one-on-one interviews were conducted to pretest the brochures, pamphlets and PSA scripts and storyboards.

The interviewers obtained feedback from the target audience on what they liked and disliked about the materials. Overall, the materials were well liked for their clear, easily understood message and for their appeal. Most women agreed that the materials promoted moderate physical activity.

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

Various materials, such as brochures, calendars, posters and PSAs, were developed, pretested and selected. Based on focus group feedback, some materials were modified to better reach the intended audiences.

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

A Gantt chart was used to track the tasks, individual responsibilities and dates for completion. The following were example tasks:

• Create, duplicate, and send out family resource guidelines.
• Distribute PSA videos to broadcast media representatives.
• Duplicate posters, brochures, t-shirts, calendars, water bottles and PSAs.
• Hold a press conference.
• Prepare campaign materials for distribution.
• Send out direct mail brochures.
• Send out posters, and take t-shirts and water bottles to walking clubs.

After these materials were created and duplicated, the campaign kickoff was scheduled. To keep the campaign on schedule, a checklist was developed. The following are examples from the preparation checklist:

• Advise staff on how to answer questions about the physical activity campaign.
• Contact broadcast media representatives to schedule a press conference.
• Contact radio, television, magazine and other print media publishers to inform them of the press release and the press conference.
• Invite the Surgeon General, the Secretary of Health and Human Services, and representatives from the CDC and the President’s Council on Physical Fitness and Sports to speak at the campaign kickoff.
• Meet with campaign staff to brief them on how to present the messages.
• Notify program partners and gatekeepers of the kickoff activity and campaign schedule.

Step 4.8 Produce materials for dissemination.

Once organizational clearance was obtained, the following tasks were completed:

• Creation and duplication of the family resource guide.
• Duplication of materials such as posters, brochures, pamphlets, calendars, t-shirts, water bottles and print PSAs (billboards).
• Duplication of television PSAs.

Step 4.9 Finalize and briefly summarize the communication plan.

Please refer to the "Smoking" example for this step.

Step 4.10 Share and confirm communication plan with appropriate stakeholders.

Program staff wanted to confirm stakeholders' buy-in and support, so a preparation check was completed. It included producing adequate copies of the materials that were to be distributed, confirming the program kick-off date, verifying partner responsibilities, training staff, and developing tracking measures in order to monitor the program progress and success. Overall, this was to ensure that staff members and partners were prepared and that all materials were ready for the program launch.

Step 5.1 Identify and engage stakeholders.

Step 5.2 Describe the program.

Please refer to the "Folic Acid, H. pylori, and/or Smoking" example(s) for this step.

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

We found that most stakeholders wanted information on, and answers to, the following questions:

• Did the implementation run smoothly, as planned?
• Did the intervention change attitudes, knowledge or behavior?
• Did the target audience see the messages?
• Was the intervention cost-effective?
• Were any of the activities, channels or settings more cost-effective than others?

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

1. By December 2000, increase the number of older, African American women of low socioeconomic status (SES), who are aware of:
• activities that are considered moderate exercise by 50%
• benefits of physical activity by 40%
2. By December 2000, decrease the number of older, African American women of low SES who:
• believe physical activity must be strenuous in order to achieve health benefits by 50%
• refrain from moderate physical activity because they believe it increases their risk of injury by 25%

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

This chart illustrates the various evaluations used during this campaign and the sources and methods used to accurately assess the data.

Step 5.6 Develop an evaluation design.

Please refer to the "Smoking, and/or Folic Acid" example(s), or to "Resources" for this step.

Step 5.7 Develop a data analysis and reporting plan.

Methods for gathering and reporting data to stakeholders and campaign team members are noted below:

Data analysis

• Cost analysis of producing print materials versus television PSAs.
• Frequencies from mail surveys of knowledge and beliefs.
• Frequencies from tracking sheets to record who has received information on the program.
• Frequency calculation of number of members in walking clubs.
• Percentages and cross-tabulations of television PSA logs to analyze variables such as number of times aired and at what times of day.

Reporting

• Report on focus group findings.
• Report of mail surveys.
• Report on PSA airing logs.

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

E-mail, phone, and face-to-face meetings were used for internal communication. In addition, a list serve was developed for internal communication. Weekly meetings were conducted to update program staff on project status, new tasks and deadlines. Minutes of the meetings were given to program staff.

Faxes and a quarterly newsletter were used for external communication. The newsletter was sent to all partners to inform them of any key developments occurring with the campaign.

Step 5.9 Develop an evaluation timetable and budget.

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

For the benefit of program staff and stakeholders, a summarized evaluation implementation plan, providing a succinct account of the communication intervention in its entirety, was distributed.

Step 6.1 Integrate communication and evaluation plans.

Please refer to the "Smoking" example for this step.

Step 6.2 Execute communication and evaluation plans.

This campaign was launched in May of 1998, and ran for two years. The evaluation was completed within 5 months of the campaign's end.

Step 6.3 Manage the communication and evaluation activities.

Program staff managed the communication and evaluation activities. They continuously monitored these activities to counter any threats that may have come about and to relay the latest progress to interested stakeholders. Internal and external communication channels were maintained and informed of any information that may have been considered helpful or useful to them. Even if unplanned, positive and negative events that occurred during the campaign were addressed and handled as necessary during this stage.

Step 6.4 Document feedback and lessons learned.

A few examples of lessons learned were:

• A wider choice of "moderate physical activities" needed to be provided. For example, gardening may be irrelevant to women who live in apartment buildings.
• Research findings about physical activity needed to be shared with the creative team before they began working.
• The communication with partners was not adequate. In fact, it was often non-existent. Therefore, some partners lost interest in the program. The Division of Nutrition and Physical Activity (DNPA) learned that it is best to have direct, regular contact with all of its partners.
• The mail surveys needed to be more cultural-specific.

Step 6.5 Modify program components based on evaluation feedback.

Based on evaluation feedback, the following changes to the program were made:

• More varied examples of "moderate physical activity" were included in informational displays, disseminated materials and educational talks, to be more inclusive of a diverse audience.
• Communication between partners was improved to avoid losing them before the program's end.
• Mail surveys were re-created and made more culture-specific to better reach the intended audience.

Step 6.6 Disseminate lessons learned and evaluation findings.