Elements of Successful Nutrition & Health Promotion Programs

Today’s Purpose

• Purpose: To provide background information on key components of health promotion programs to be used for consideration in program adoption.

Outline

• Introduction to the steps used in designing community interventions

• Discuss individual steps and key considerations

• Examine how this looks out in the community – Case Study

Program Planning Steps

1. Initial Planning

2. Formative Research

3. Strategy Formation

4. Program Development

5. Program Implementation

6. Evaluation

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Grier, S & Bryant, C. Ann Rev Public Health, 2005.

Initial Planning

• Questions– What is the problem you are addressing?– What is the context in which the problem exists?

• What services/programs might already exist

– Who is your target audience(s)?

• Actions– Set Initial Goals & Objectives– Review Literature– Conduct Needs/Community Assessment– Identify Funding & Resources– Establish Community partnership/coalition

building

WHO’S YOUR TARGET AUDIENCE?

Formative Research

• Formative research helps your organization find its audience; understand the needs and interests of the audience; and design programs, services, and products that address those needs.

•What do we know?•What don’t we know?•What do we want to know?

Formative Research

• Questions– How does your target audience think and behave

as related to the problem?• What are their values, beliefs, attitudes, behaviors?

– What can you offer and will that appeal to the target audience?

– How can you best reach your target audience?– What messages, strategies, materials, programs

work best with target audience?

Understanding your Target AudienceCost vs. Benefit

Walking your DogBenefits

• Health• Refreshing• Social opportunities• Better behaved dog• Access to Parks/Trails

Costs• Tired / Lack of Energy• Time• Weather• Safety• Access to Parks/Trails

HOW DO WE INFLUENCE THE AUDIENCE’S COSTS & BENEFITS?

Gathering Data

Types of Formative Data

• Primary Data– Original data that you collect and analyze

• Secondary Data– Information that was collected by someone else, but which

you can analyze or re-analyze

• Qualitative Data– Data presented in narrative form that generally cannot be

expressed numerically

• Quantitative Data– Data presented in numerical terms

Methods for Collecting Data

• Focus Groups• Key Informant Interviews• Community Forum• Group Discussions/Interviews• Surveys

Focus Groups

• A qualitative method involving a small group of people whose discussion is carefully planned and led by a trained moderator– Advantages: Relative small sample, structured questions,

creative atmosphere, clarification capability– Disadvantages: Moderately expensive and/or time

consuming, need trained moderators, can be challenging to analyze

Key Informant Interviews

• A qualitative method of conducting in-depth interviews with a small number of individuals carefully selected for their personal experiences and knowledge– In-person or telephone– Advantages: Inexpensive (telephone), easy to

administer, can cover wide region, gain in-depth data

– Disadvantages: Expensive (in-person), interviewer bias, trained interviewer, maybe difficult to analyze

Community Forums

• Large group method of collecting qualitative information from community members that is larger and less formal than a focus group.– Advantages: Large N, low cost, low time, audience can

participate on own terms, identify people with increased interest

– Disadvantages: Large N, silent majority, strong leader (argumentative), scheduling

Group Discussions/Interviews

• A qualitative method of conducting in-depth interviews with a small group of people; less formal than focus group– Advantages: Small N, high response rate, efficient

and economical, stimulate others– Disadvantages: Intimidation, fosters conformity,

group pressure may influence responses

Surveys

• A quantitative method involving systematic data collection from a sample of individuals selected from a target population– Data used to generate group-level summary– In-person, web-based, email– Advantages: inexpensive, anonymity, large N, easy to

administer, quantitative and qualitative data– Disadvantages: low response rate, lengthy process, no

opportunity to clarify, restrictive answers

MIXED METHODOLOGY

AudiencePhase of Formative Research

Budget

WE’VE GATHERED AND ANALYZED THE DATA. NOW WHAT?

Strategy Formation

Strategy Development

• Translate Data into Priorities– Refine Goals and Objectives

• Are they measurable?

– Where & how are you going to reach your target audience?

– Identify resources, community assets

Social Ecological Model

Utilize Resources

– Research-based program:• incorporates strategies, activities and principles that

have been shown through scientific research and evaluation to be effective and reliable.

– Evidence-based program:• (a) evaluation research shows that the program

produces the expected positive results; • (b) the results can be attributed to the program itself,

rather than to other extraneous factors or events; • (c) the evaluation is peer-reviewed by experts in the

field;

PROGRAM DEVELOPMENT

Approach vs. Framework vs. Theory

• Framework – systematic strategy used to plan programs

• Theory – explains food choices, nutrition related behaviors, and how they change– Theory gives planners tools for moving beyond intuition to

design and evaluate health behavior and health promotion interventions based on understanding of behavior.

• Approach – describes the best way to teach information to your target audience

Frameworks

• Logic Model• Social Ecological Model• Social Marketing - Systematic planning process

used to promote personal and societal welfare– Know your target audience (formative research)– Four P’s of marketing

• Behavior change theories are often embedded within frameworks

Types of Theory

• Explanatory– Explanatory theory describes the reasons why a problem exists. – It guides the search for factors that contribute to a problem and

can be changed.

• Behavior Change– Change theory guides the development of health interventions. – It spells out concepts that can be translated into program

messages and strategies, and offers a basis for program evaluation.

– Change theory helps program planners to be explicit about their assumptions for why a program will work.

Behavior Change TheoriesSocial Learning Theory

• Most useful for understanding what drives behavior & how we can influence behavior change

• Attempts to bridge the intention-behavior gap• Reciprocal determinism – personal, behavioral, and

environmental factors work together to influence behavior

• Outcome expectancies and self efficacy are driving forces

Social Learning Theory Constructs

• Personal factors (thoughts and feelings)– Outcome expectations vs. expectancies– Self-efficacy

• Behavioral factors (knowledge and skills)– Factual and procedural knowledge– Cognitive and behavioral skills– Self regulation

• Environmental factors– Imposed vs. selected vs. created environments– Observational learning and guided mastery

Behavior Change TheoriesStages of Change

• Describes processes people go through in order for behavior change to occur

• Stages categorize people according to readiness to act

• Decisional balance and self efficacy important to move people through stages

• Activities must match the stage

Stages of Change

• Precontemplation – unaware, uninterested, uninformed– Provide information, increase awareness

• Contemplation – considering a change in near future (6 mo)– Motivational activities

• Preparation – ready to change in immediate future (1 mo)– Action-oriented activities

• Action – started new behavior– Action-oriented activities

• Maintenance – new behavior has become part of lifestyle– Support, encouragement, reward

• Relapse – most likely to occur during action and maintenance – use it as a learning experience

Explanatory TheoryHealth Belief Model

• Most useful for designing motivational component of education program

• Constructs– Perceived Threat of Condition

• Severity and susceptibility– Perceived Barriers and Benefits

• Barriers can be physical or psychological• Benefits>barriers = action

– Self Efficacy• Lack of self efficacy is a barrier

– Cues to Action • External or internal• Influence perceived threat

For more information on theories refer to the National Cancer Institute’s Theory at a Glance.

http://www.cancer.gov/PDF/481f5d53-63df-41bc-bfaf-5aa48ee1da4d/TAAG3.pdf

ApproachExperiential Learning

• Allows people to learn by doing• Learner centered• Role of educator is to:

– Observe – Ask questions– Provide feedback and support

• Role of learner is to:– Do– Reflect– Apply

Experiential Learning

1. Experience

5. Apply

4. Generalize

3. Process

2. Share

Adult Learning Approach

• Describes the best way to teach new information to adults

• Four A’s– Anchor: Introduce material and ground the topic to the

learner’s lives– Add: Provide the new information– Apply: Have the learners do something realistic with the

information (activity)– Away: Help learns see how they can use new

information in the future

Summary

• Frameworks, Theories and Approaches are often used in combination

• One is not better than the other. It is dependent on the goals and objectives.

Program Content

• Narrow the focus!• 2 outcome objectives per 45 minutes• No more than 3 outcome objectives per

presentation• Reputable resources• Age appropriate

Are the sources reputable?

• Current information– Rule of thumb: literature should have been published or

updated in the last 5 years• Published scientific journal articles• Published professional journal articles• Textbooks• Fact sheets from other state Extension programs or

government agencies• Websites: government (.gov), university (.edu) • News paper articles, consumer

journals/magazines, .com and .net websites are NOT reputable sources

Is the program appropriate for the audience?

What to consider:• Age• Reading level

– Know your audience– Aim for 5th – 8th grade reading level– Use layman’s terms and short sentences– Check with Flesh-Kincaid reading level in Microsoft Word®

• Language– If working with a diverse group, offer materials in the

appropriate languages• What the audience wants (formative research)

Is the program appropriate for preschool learners?

• Use food-based activities• Use developmentally appropriate learning

activities and play• Focus on behaviors• Encourage self-regulation• Involve parents and families

Is the program appropriate for middle childhood and teen learners?

• Focus on behaviors children can control• Address motivations that are meaningful and

important to the children• Incorporate self-assessment• Use activities (food based if possible)• Use content appropriate for cognitive

development • Address social norms and peer influence• Encourage self-regulation

Is the program appropriate for adult learners?

• Provide specific information pertinent to their lives• Create a safe learning environment• Develop respectful relationships: power-with• Empower your learners, let them choose topics• Engage learners with activities and facilitated

discussion• Teach skills• Build on past experiences• Sequence tasks from simple to complex while

building the strength of new skills• Always end with conclusions

Implementation

Promote your program

• Does the program come with promotional materials?

• Promotional materials should be designed and tested specifically for your target audience

• Media: newspaper adds, flyers, newsletters, magazines, television, radio, word-of-mouth

• Placement: place adds where your target audience will see them

Present programs as they were designed!

• Respect the rationale, research, time and effort that went into designing the program and evaluations

• Altering a program:– Will change the content– Will change the outcomes– Evaluations may no longer be valid

• Al a cart presentation are designed and evaluated piecemeal, series programs are designed and evaluated as a full series

EVALUATION

Evaluation Basics

• Evaluation should be considered early; prior to program development

• Purpose: to determine the extent to which a program or intervention is effective, i.e., to determine if it is successful or how well it meets its objectives

• It should be conducted throughout program development.

Types of Evaluation

• Formative – Strengthen or improve the program being evaluated

• Needs Assessment, Implementation & Process

• Summative– Examine the effects or outcomes of the program

• Outcome, Impact & Cost-Benefit Analysis

Characteristics of Good Evaluation

• It is objective.– Self-assessments and subjective judgments of those responsible for a

program have low credibility.

• It is replicable.– Someone else should be able to re-do your evaluation and get the

same results.

• It is methodologically strong.– Confidence in the evaluation's findings; evaluation is able to resist

criticism and attack.

• Its results are generalizable.– The results should apply to the broad range of individuals, and

situations to which the program is aimed.

What can be evaluated?

• Demographics• Knowledge• Attitudes• Behavior

– Change– Intentions– Predictors

Ecological Model of Predictors of Childhood Overweight

Davison KK, Birch LL. Obes Rev. Aug 2001;2(3):159-171.

Applying Evaluation Methods

• Program/Curriculum – multiple sessions– Behavior change, knowledge, attitudes

• Presentation – one-shot– Knowledge, attitudes, intent to change behavior

• Written Materials – newsletter, fact sheet, etc.– Knowledge, attitudes

Logic Model

CASE STUDY:WHAT DOES THIS LOOK LIKE IN THE

REAL WORLD

Agency X

• Agency X is a statewide initiative aimed at reducing overweight and obesity rates and related chronic diseases.

• A partnership among foundations, health care organizations, non-profit organizations and state and local public health agencies.

• Current Objective: Develop and Implement a statewide Social Marketing campaign

• Current Organizational Budget: ~ $16 million

INITIAL PLANNING

Examining State Health Data

Disparities: ObesityPrevalence of obesity* by race and ethnicity, Colorado Adults, 2007 BRFSS

* Body Mass Index > 30

Disparities: Fruit & VegPrevalence of consuming 5 or more servings of fruits and vegetables per race

and ethnicity, Colorado Adults, 2007 BRFSS

Disparities: Physical InactivityPrevalence of physical inactivity by race and ethnicity,

Colorado Adults, 2007 BRFSS

Income Disparities: ObesityPrevalence of obesity* by income, Colorado Adults, 2007 BRFSS

* Body Mass Index > 30

Income Disparities: Fruit & VegPrevalence of consuming 5 or more servings of fruits and vegetables by

income, Colorado Adults, 2007 BRFSS

Income Disparities: Physical InactivityPrevalence of Physical Inactivity by Income, Colorado Adults, 2007 BRFSS

WHO ARE YOUR TARGET AUDIENCES?

HispanicsAudiences with Limited Resources

HOW DO WE LEARN MORE ABOUT THESE AUDIENCES?

Focus Groups

Focus Group Results

• Expanded target audience to include women• Resulted in strategy formation & message

– Limit emphasis on individual behaviors– Promote social support and networks– Make it fun– Reach those who are ‘tweeners’– The Power of All of Us!– Developed storyboards for Ad campaign

Ad / Storyboard Example

Will this resonate with the target audience?

• Will this reach who they want it to reach?• Is the scenario representative of the target

audience?• Are the foods culturally appropriate?• What emotions are they appealing to?• Will stakeholders support it?

DON’T ASSUME ANYTHING!

The only way to answer these questions is to:

Ask the Target Audience!

WHAT ARE THE GOALS/OBJECTIVES OF THIS AD?

What can you evaluate?

• Reach– Individuals/Communities– Demographics

• Recall– Is message on target? How does it relate to goal?– Likes/Dislikes

• Awareness building• No change to knowledge or behavior• Maybe attitude depending on goal

REVIEW PROTOCOL

QUESTIONS