A Five-Stage Model for Sustaining a Community Campaign

RIM A E. RUDD
Department of Health and Social Behavior Harvard School of Public Health Cambridge, M assachusetts, USA

JEAN N E GOLDBERG
School of Nutrition Science and P olicy Tufts University Boston, M assachusetts, USA

WILLIAM DIETZ
Division of Clinical Nutrition The F loating Hospital New England M edical Center Boston, M assachusetts, USA
T he Sisters Together, M ove M ore Eat Better pilot communication program focuses on young Black women in three inner- city communities to encourage improved nutrition and increased physical activity. T he design for Sisters Together is based on an expansion of a public health campaign that combines social market ing with community building e orts. T he pilot program design comprises ve phases : design, promotion, demonstration, transfer, and sustained activity. T he proposed ve- stage model holds potential for increasing the life span of a campaign and contributing to community building. Partnerships and coalition development promise to maintain the campaign beyond the limited budget period. T his descriptive article illustrates the elements of a hybrid model for the design of a communication program with examples from Sisters Together, M ove M ore Eat Better, a pilot program currently in the last year of implementation.

Introduction
For more than two decades public health educators have successfully applied marketing strategies to support public health education eV orts and to shape a wide variety of campaigns (Ling, Franklin, Lindsteadt, & Gearon, 1993). However, in a society that is inundated with messages, audience response is in uenced by both length and intensity of exposure. Substantial time frames and hefty budgets are
The authors acknowledge the valuable contributions of K elley Chunn, media specialist ; N ellie Knight, M .Ed., community educator and coordinator ; Donna DeCaille, R. D., community nutritionist ; Jamell Walker, ScM ; Osula Rushing, ScM ; Alexander M azard, M .D., ScM ; Karla English ; research assistants ; and all of the members of the Sisters T ogether Coalition. Sisters T ogether : M ove More, Eat Better is a Weight - Control Information Network Pilot Program. This work is supported by the National Institute of Diabetes and Digestive and Kidney Diseases of the National Institutes of Health, contract No. N01 - DK - 4 - 2203. Address correspondence to Rima E. Rudd, Department of Health and Social Behavior, Harvard School of Public Health, 677 Huntington Avenue, Boston, M A 02115, USA. E- mail : rrudd@ hsph.harvard.edu.

J ournal of Health Communication, Volume 4, pp. 37 48, 1999 Copyright 1999 Taylor & Francis 1081 - 0730/99 $12.00 1 .00

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needed to support any focused eV orts to deliver and sustain messages. Unfortunately, a social marketing approach o V ers a challenge to the resources generally allotted to public health interventions (Walsh, Rudd, M oeykens, & M aloney, 1993). Consequently, public health messages are outnumbered by many commercial sector interests that promote products and activities with unhealthful consequences. In many instances, however, sophisticated public health messages provide the only viable alternative to the pervasive commercials selling untoward health. New stra tegies are needed for launching and sustaining a health promoting community cam paign. Sisters T ogether, a pilot campaign designed to focus on obesity prevention among young Black women residents of inner - city communities, o V ered an opportunity to test a new strategy for a sustainable campaign. An advisory panel of scholars and community activists, referred to as the Sisters T ogether team, devel oped a campaign strategy that would bring an important message into the com munity and garner the assistance of a wide variety of community agencies to sustain both the message and activities that are needed to support it. This discussion focuses on a ve- stage model for campaign development with illustrations from Sisters T ogether implementation eV orts. The Sisters T ogether pilot program is in its last year of implementation and outcomes are currently being evaluated.

Overview : Campaign Focus

Sisters T ogether is an obesity prevention pilot program created for young Black women residents of three inner - city neighborhoods in Boston with a focus on healthful eating practices and increased physical activity. Health promoting messages emphasize group action and bring attention to existing community resources. In order to insure intensity of exposure to health promoting messages and to con tinue the eV orts beyond the limited campaign nding cycle, the Sisters T ogether planning team focused on methods to sustain vital campaign messages and to increase opportunities for community women to carry through with needed action. The overall framework for the Sisters T ogether campaign has been drawn from the ecological model that views patterned behavior as an outcome of multiple levels of factors ranging from individual factors to public policy (M cLeroy & Bibeau, 1988). Campaign themes and activities for the pilot program were designed to support local resources through expanded availability of healthy foods, increased use of existing programs, and augmented skills. Campaign promotional eV orts were designed to support normative change through messages of healthful eating, positive images of healthy ethnic foods, and positive images of active women. Demonstra tions were designed to both build skills and efficacy and to highlight local experts and available programs. If the Sisters T ogether eV ort was to move beyond the promotion of ideas and demonstration activities, then various community - based agencies and organizations would need to support Move More/ Eat Better themes and activities. These com munity agencies could then sustain the campaign themes over time and institution alize changes that promote womens health and support improved nutrition and increased physical activity. The campaign challenge was to combine message delivery with demonstration activities and, at the same time, to develop viable part nerships with local organizations and agencies. Consequently, the action plans for the Sisters T ogether campaign were divided into ve stages : (1) development and design of campaign themes and strategies, (2) promotion of key themes, (3) demon -

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strations to establish visibility in the community and viability with potential part ners, (4) transfer of activities and skills to partners, (5) work with partners to sustain themes over time and help others replicate the campaign elsewhere.

Overview : Five-Stage Model

The ve-stage model focuses on the diV usion of a campaign strategy among key organizations within a community that has the ability to support activities and services for the target population. The bene ts of this model accrue to both the population served and to the organizations that serve it through consistent messages, coordinated delivery, and expanded opportunities for action. Both Labonte (1997) and Walter (1997) stress the value of a community development approach and note the critical importance of forging partnerships to build appropriate agendas and to determine respectful approaches to change. The ve- stage model combines a campaign eV ort with community developm ent by strengthening net works and maximizing use of scarce resources. The rst stage of the model speci es the dimensions of the campaign through the use of well - established social marketing strategic guidelines (M ano V , 1980 ; Novelli, 1990, Lefebvre & Rochlin, 1997) and community organizing techniques. Stage two, the campaign promotion phase, focuses on implementation of campaign activities. The expanded ve- stage model includes two promotional eV orts rather than one eV ort. The rst is the traditional message delivery component ; the second is the promotion of local community resources. Stage three is the demonstration phase. It is not always part of a communications campaign ; however, when it is used, it serves to demonstrate the value or the ease of acting on the message. In this model, the demonstration phase has a dual function. F irst, it provides opportunities to build efficacy among members of the target population. Next, it provides exam ples to other agencies that might incorporate similar activities and promote the same messages. Stage four is the transfer phase and, based on Rogers Di usion of Innovations (1983), focuses on the transfer of skills, campaign activities, and materials to community partners for adoption and adaptation. In the fth stage, partners are drawn together in a collaborative eV ort to sustain campaign eV orts. See Figure 1.

Stage 1 : Campaign Design and Development

Campaign design can be enriched by lessons from community development and from social marketing. While marketing strategy was used to develop the work plan for the pilot program Sisters T ogether, community developm ent considerations shaped the formation of the planning group and informed the overall strategy leading to the ve- stage model. If, as M inkler contends, the public health mandate is to help create the conditions for community groups to set their health agenda and determine needed action steps, then public health programs must promote com munity building. The active engagement of community members in the design and implementation of programs is one key aspect of such work (M inkler, 1997). In the development of the Sisters T ogether pilot program, the contract man dated a focus on obesity prevention ; however, the decision to work with young Black women was determined through interviews with community - based nutritionists and representatives from community health centers. Health professionals

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FIGURE 1 F ive- Stage M odel for Sustaining a Community Campaign. were asked to identify where they saw the strongest need among the various popu lation groups they served and to suggest where new resources would be most welcomed. Their suggestions that program eV orts need to be addressed to young Black women were supported by ndings from the 1990 M assachusetts Behavioral Risk Factor Survey indicated that the prevalence of obesity was 20% ; that young obese black women with reported annual incomes of less than $15,000 were at high risk for health problem s ; that risk increased by urban address ; and that 5% of women ages 18 to 24 participate in regular exercise. These issues were being addressed in the literature (Kumanyika, M orssink, & Agurs, 1992 ; Lewis, Raczynski, Heath, Levinson, Hilyer, & Cutter, 1993) and have been explored in more recent studies (Airhihenbuwa, Kumanyika, Agurs, Lowe, Saunders, & M orssink, 1996 ; JeV ery & French, 1996 ; Caldwell, Brownell, Wil ey, 1997 ; K umanyika, 1997). Overall, these studies document the high prevalence of obesity among African American women, the cultural factors associated with high fat diets, and issues related to physical activity. The choice of focus on young Black women for an obesity prevention cam paign was seen as appropriate. Consequently, once the campaign target population was identi ed as young Black women, the size and composition of the initial group of program planners immediately changed. Experts in media, education, and nutrition who also lived or worked in the community or both and were familiar with or part of the culture of the target population were asked to become members of the pilot program planning and implementation team. This crucial step of expanding the design/decision making team to actively engage members of the population of interest enabled the pilot program team to set a strong foundation for community linkages and for community building.

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The strategic planning techniques of marketing shaped the teams work plan and set the agenda for the rst steps in campaign theme and message development. Social marketing emphasizes the importance of research, design, evaluation, and redesign as critical to the development of an eV ective campaign (Lefebvre & F lora, 1988 ; Lefebvre & Rochlin, 1997). EV ective strategies are based on formative research that includes an understanding of culture, gender, social class issues, attitudes, and preferences. Initial research for the pilot program drew information from three sources of data and used three methods to gather information related to Black women and nutrition and, similarly, to Black women and physical activity. This technique, termed triangulation, is often used to con rm data. F indings are strengthened when data from one source, uncovered by one method, or gathered by one researcher are con rmed by data gathered by another mechanism (Becker, 1958). In addition to corroboration, however, triangulation also oV ers the possibility of a more in - depth understanding of issues as well as a grasp of various perspectives on an issue (M iles & Huberman, 1994). The various sources of data, gathered by diV erent methods, yielded insight into practices, preferences, and issues related to nutrition and to physical activity. Thus, initial research eV orts for the Sisters T ogether campaign included analysis of existing survey data on the topic of prevention and treatment of obesity, liter ature reviews on diet and weight - loss practices of minority populations, and explo rations of the target audiences understanding of the link between disease and obesity, knowledge of sources of fat in the daily diet, perceptions of barriers to low - fat eating, use of food labeling, and perceptions of body weight and image. In addition, health and communication experts were interviewed, Boston- based com munity nutritionists were surveyed, and a meeting was held with the M assachusetts League of Community Health Centers. The information collected and insights gath ered were used to guide the development of message concepts and to prepare a focus group moderators guide. Six focus groups with members of the target audience were conducted to explore perceptions of health, healthy eating, physical activity, and credible sources of health information. The information gleaned from the various sources led to the development of the overall themes for the campaign, the formation of messages about healthy eating and physical activities, and ideas for activities in support of these messages. The themes, messages, and ideas for action were designed and then underwent rigorous and detailed testing with the target population. The campaign logo, for exam ple, combines a multilayered theme statement, Sisters T ogether : M ove M ore Eat Better, with a visual depiction of three women walking together. The language derives from focus group discussions and was one of several combinations of theme statements piloted and discussed in group and intercept interviews. A number of visuals were similarly tested, modi ed, and retested for many components including number of women depicted, size and shape of the gures, hair style variations, and logo color combinations. The nal logo has generated consistently positive reac tions. See Figure 2. Thus, formative research yielded a product that re ects the language of the population and resonates with cultural themes of sisterhood and collective action. Throughout the program , the design of all new materials and activities were and continue to be based on formative evaluations. The major questions shaping for mative evaluation eV orts include the following :
n

Do the contents address key thematic issues, key information, and needed skills ?

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FIGURE 2
n

Do the design components re ect the culture and preferences of the target popu lation ? Are the language and style appropriate and readable ?

Stage 2 : Promotion

Promotion serves as the cornerstone of any campaign. Lessons from the commercial sector point to the importance of message promotion through consistent repetitions of themes for community saturation. The primary purpose of promotional activity in Sisters T ogether is to convey the messages of healthy eating and physical activity to the target audience of Black women between the ages of 18 35 who live in the Boston neighborhoods of Roxbury, Dorchester, and M attapan. M edia promotion has been used to communicate speci c healthy eating and activity tips, help generate attendance at events, and cross promote partners. P romotional activities include the use of print and broadcast media - the use of local radio, TV, and print coverage or previews through calendar/ announcements or P SAs. These eV orts, combined with active participation in neighborhood events designed to attract members of the target population, brought the logo, messages, and materials to community women. At these events, team members set up a table, display a banner, distribute materials, talk about the themes and key issues, and, nally, use the opportunity to encourage women to sign up to participate in walking groups. On several occasions, participation in such events enabled the team to discuss and pretest materials such as the walking brochure and calendar menus. Sisters T ogether actively engaged in the planning for and implementation of festivals, carnivals, professional association meetings, sponsored family picnics, and walk - a- thons in support of community agencies. At the outset of the campaign, these events provided Sisters T ogether with visibility in the community. In addition, Sisters T ogether sta V compiled a mailing list from women who attended any sponsored event in order to send out a monthly newsletter. A typical newsletter includes an article highlighting the months theme, a review of one or two recent events, a description of a partner organization, and a detailed calendar of events for women. For the duration of the funding cycle, Sisters T ogether presents and continues to cosponsor monthly activities. Additional thematic messages are delivered in the community through yers, radio spots, and occasional feature articles in the major city and neighborhood newspapers. The traditional marketing campaign design focuses on the four P s : product, promotion, placement, and price. Here, in the ve- stage model, the promotion stage

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includes delivery of the campaign message as well as the promotion of local com munity programs and resources. These resources include existing health care and social service organizations, private entrepreneurs, and small businesses. At this important second stage, successful promotion begins to capture the attention of both the target audience and potential partners. Intercept interviews serving as interim evaluations of Sisters T ogether indicated that community women at farmers markets and walking in the local parks recognize the logo and can repeat the cam paign theme. Early promotional eV orts did capture the attention of both the target audience and potential partners.
Stage 3 : Demonstrations

The third stage of the ve-stage model focuses on demonstrations of action steps and activities. Demonstrations bring role models, o V er illustrations of how to implement the general campaign messages, and provide activities to practice or engage in action. Strategically placed demonstrations enable a campaign to serve as a vehicle to increase use of existing programs or familiarize community members with facilities that they had not visited before. The purposeful selection of demonstration activities can be designed to garner partners and to in uence programming at the community level. The demonstration phase of the Sisters T ogether campaign estab lished visibility within the community, o V ered evidence of concrete mechanisms to promote the Move M ore Eat Better messages, and o V ered support to potential part ners. F or example, the Sisters Together planning team mobilized a group of women to walk in a fund raising eV ort by a local organization. Demonstrations focused on increased activity reinforced the concept that the move more component of the Sisters T ogether campaign symbolizes health pro moting action and simultaneously re ects the cultural traditions and preferences of the target population. Activities have included a comprehensive structure for walking groups and aerobic groups, including the development of a brochure for walking, a training curricula for aerobic groups, as well as the formation of desig nated walking routes and scheduled walk sessions, indoor activities for the winter, the promotion of existing and often underutilized community centers, and dis counted membership at the local YMCA as well as for private aerobic programs. The nutrition component has included support for the development of a local cable television show W hats Cooking in the Neighborhood hosted by a local nutritionist. The television program highlighted local chefs who demonstrated healthy recipes available at their restaurants and who, in turn, promoted the shows in their restaurants with table tents. A nutrition and tness calendar contained recipes based on nutrition recommendations from the dietary guidelines and behavioral ideas for food preparation and physical activity. The calendar was promoted over the local radio station and at various meetings in the community. It was also given to Sisters T ogether partners and distributed to all women on the mailing list. The second calendar included the names of all partner groups. Additional nutrition related activities included discussion groups and seminars such as a book signing for an ethnic cookbook, cooking demonstrations, market tours, and work with a local organization to establish a supermarket to increase the availability of healthful foods. These visible demonstrations emphasize efficacy building and are designed to include small achievable steps, incorporate role models, and support collective action (Baranowski, P erry, & P arcel, 1997 ; Bandura, 1986). All of the activities were

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supported by a popular radio station disc jockey, an athlete and entrepreneur, a dance instructor, and a health center nutritionist. P rocess evaluation measures included exit interviews at events and follow - up phone interviews to assess percep tions as well as proximal outcomes such as intent to act and reported behavior changes. P rocess evaluations have included the traditional paper and pencil mea sures used in exit interviews to assess participants reactions to programs and events. Two waves of telephone interviews with members of Sisters T ogether serve as baseline and midpoint evaluation measures for a nal analysis but have also served to assess health related perceptions and to report change among members of the target population. F urthermore, intercept interviews with shoppers at farmers markets and with walkers in a local park have focused on questions pertaining to program recognition as well as to reported change in eating or physical activity. In- depth interviews with partners and coalition members assess perceptions of needs and progress in terms of partnerships and coalition membership. F inally, weekly meetings have enabled the planning team to regularly review, assess, and redirect program eV orts. The regular weekly meeting of the team pro vides an excellent forum for tracking a very complex set of activities : developing materials, making decisions about participation in and coverage of community events, designing and implementing a strategy for partnerships and resource expan sion, and monitoring and assessing activities. The demonstrations enabled the Sisters T ogether planning group to develop partnerships with local groups and service organizations. In addition, the Sisters T ogether team began to coordinate events in the community by forging relation ships among Sisters T ogether partners who had not worked together before.
Stage 4 : Transfer

The fourth phase of the ve- stage planning model focuses on enabling community based groups and organizations to incorporate key themes into their own activities and program s. Transfer is the diV usion of innovation with community organizations and the adoption and adaptation of the materials and activities that support cam paign themes. While some organizations may choose to adopt materials, messages, and themes, others will choose to modify or adapt key campaign elements to more closely meet their own mission. The transfer phase of the Sisters T ogether campaign includes three separate activities : (1) the identi cation and establishment of partnerships based on mutual or overlap ping goals ; (2) active engagement with partner organizations in the community through cosponsorship ; (3) shared use of logos, materials, and evaluation ndings. The demonstrations in the third phase of the campaign set a strong foundation to facilitate di V usion of themes, materials, and programs developed by Sisters T ogether. P otential partners were identi ed through a community mapping activity at the program startup. This focus on existing resources, instead of on existing de cits, yielded potential partners (M cKnight & Kretzmann, 1997). A resource guide was developed early in the campaign and listed all the places women might gather as well as all the program s and organizations that serve womens health interests. The

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planning team augmented traditional program listings of health centers, health and exercise programs, and child care centers. Walking and driving tours of the com munity enabled team members to add beauty salons, churches, laundromats, markets, and restaurants to the resource guide. P artners for Sisters T ogether had to meet established criteria : to address womens issues and concerns, have themes compatible with those of the Sisters T ogether campaign, serve women in the communities of interest, and have a demon strated interest in promoting Black womens health. P artnerships were established with a rich assortment of individuals, businesses, community - based programs, and organizations. A variety of events have provided the opportunity for interaction with partners and the start of the transfer phase of Sisters T ogether activities. For example, a disc jockey began walking herself as she promoted the walking program and other activ ities related to the Sisters T ogether P SAs her station had agreed to air. Sisters T ogether walking programs used several partners sites as a starting or ending point for walks. Demonstration aerobic programs and cooking demonstrations were o V ered at sites that could continue such oV erings. Leadership training for walking groups and for aerobic programs was o V ered to the sta V of community organi zations. The long - term goal of the transfer process is to build a joint consumer professional coalition within the targeted communities to focus on womens diet and activity. M eetings with the sta V of existing organizations were structured to exchange information and to discuss partnership ideas. The focus of these dis cussions was to determine interest in the Sisters T ogether campaign, in the joint sponsorship of activities, in the use of current materials, and in the joint production of materials. These individual meetings set the stage for formal partnerships. Part ners enjoyed access to materials that had been piloted with community women and revised based on their preferences and recommendations, use of the Sisters T ogether logo to promote events, and cosponsorship for key events. The newsletter, sent in white paper stock to partner groups, enabled some to repackage timely and inter esting notices. Others appreciated the listing and promotion of their key events. Subsequently, interviews with those who had been partners over time helped the planning team gather information about organizational goals and objectives, planned activities, barriers to action, and current needs. A meeting of all Sisters T ogether partners to learn about interview ndings set the stage for coordinate eV orts among partner organizations. The rst meeting was focused on developing strategies for increasing the participation of community women and on enhancing community capacity (Pilisuk, M cAllister, & Rothman, 1997). P artners scheduled regular monthly meetings. This initial gathering led to the development of a Sisters T ogether coalition. This coalition has the potential to integrate the move more, eat better themes into individual organizations and support the themes through a coordinated eV ort. To realize this potential, however, all parties must focus attention on articulating common interests and support and sustain collective action (Fisher, 1997). The pilot program team served a critical function by identifying materials and resources needed by partners and helping the various member organizations plan quarterly calendars and cosponsor activities. Currently, the coalition comprises seventeen member groups and continues to meet and plan monthly. Over the course of the past program year, all campaign activities were coordinated by the coalition and most community - based programs addressing nutrition, physical activity, or both

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among Black women were cosponsored by the Sisters T ogether Coalition. Events include a yearly mother and daughter brunch, numerous health fairs, cooking demonstrations, a winter long fun and tness program, dance programs, and com munity walks. Collaboratively developed materials include a coalition poster listing all partners and a brochure providing hair care tips for the active woman.
Stage 5 : Sustained Activity /Replication

Sustainability must be at the heart of a successful campaign. If a campaign eV ort is to survive beyond initial funding, then themes and programs must be promoted and continued by established organizations. The sustained activity phase of the model must bring the campaign into the strategic planning eV orts of community - based organizations. The last phase of the Sisters T ogether campaign is addressing sustained eV ort as well as replication. Sustained eV orts focus on strengthening the existing coalition of partner organizations. In this last year of assured funding, an entry level position for a coalition sta V person has been created and will be supported. The sta V will focus on coalition mailings, meeting agendas and minutes, and calendar building. Coalition meeting sites rotate and the meetings themselves are facilitated by various members in turn. Scheduled skill building sessions that are focused on evaluation techniques and on proposal writing may enable the coalition to garner new funds. The Sisters T ogether planning team is also engaged in evaluation activities. Replication eV orts are supported by case analysis, discussions of delineated steps, and by evaluation ndings. Learning points, lessons learned, case illustrations, and evaluation ndings all enable other organizations to incorporate activities and pro grams developed as demonstration eV orts. Evaluations have been an essential com ponent of each of the campaign stages and include formative, process, and proximal outcome measures. Formative evaluations included measures of the intent and eV ec tiveness of materials designed for the campaign. P rocess evaluations considered whether the process of the campaign, such as an event, has achieved the goals for which it was designed. Outcome evaluations will incorporate measures that relate to the success of the campaign or its elements in the achievement of the primary goals of the campaign. These activities are currently underway and will include intercept interviews in the community, phone interviews with women who have participated in one or more events, and in - depth interviews with community - based agencies (including partners). Overall, evaluations and case study descriptions support replication eV orts. However, the guiding assumption underlying this phase of work is that an innova tion must be conceptualized as relatively malleable. Organizations will modify aspects of a product or process to t their established goals and objectives (Rogers & Adhikarya, 1984). As long as key components of the campaign are carefully iden ti ed, there is ample room for partners to adapt rather than completely adopt a campaign design. Evaluation activities for Sisters T ogether will examine ways in which community organizations adopted or adapted campaign themes.

CONCLUSIONS
Like many social marketing products, public health products are new ideas, prac tices, and community - based action steps. These products, like those in the com mercial sector, must be well packaged, actively promoted, strategically placed, and

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reasonably priced. The public sector has borrowed liberally from the private sector and has successfully designed strategic marketing campaigns. However, limited funding continues to handicap the public sector and limit the length and intensity of campaign eV orts. The proposed ve- stage model for sustaining a community cam paign moves beyond strategic design and promotion and o V ers a strategy for extending the life and increasing the depth of a campaign eV ort. The ve- stage model does not assume that a complete adoption of even the most rigorously designed campaign will take place ; rather it assumes that adapta tion is the rule. Dialogue and discussion with potential partners, contracts with partners, and an openness to creative participatory processes can support and enrich a community campaign. It is, however, incumbent upon the designers to share research ndings and evaluation evidence and to delineate key themes and highlight key ingredients. These themes and ingredients become the core com ponents of a exible design. The ve- stage model for sustaining a community cam paign o V ers a mechanism for expanding the life of a campaign.

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