Community-Wide Campaign and Curriculum

Overview

Community-Wide Campaign and Curricula - Image for Banner

Evidence-Based Community Wide Campaigns

Education

An evidence-based community wide campaign is the framework for the efforts in Brownsville, TX (Zaza, Briss, Harris, 2005). The campaign titled Tu Salud ¡Si Cuenta!, known in English as Your Health Matters was adapted from the evidence-based intervention, the Stanford Five City Project (Young, Haskall, Taylor, & Fortman, 1996). The Guide to Community Preventive Services recommends multi-component community-wide campaigns to increase physical activity and improve upon other risk factors for obesity and diabetes, such as healthful food choices (Anon, 2011).  The core components of the community-wide campaign as large-scale initiatives in communities include: 1) delivering health messages using mass media; 2) providing individually-focused efforts such as physical activity counseling or social support, health risk screenings and education and 3) implementing environmental change strategies. 

Robert Wood Johnson Culture of Health


Effective Strategies

Towards this end, the following menu of strategies was created to help guide the implementation of the community-wide campaign. 

Community-Wide Campaign Component Example 1 Example 2 Example 3 Example 4
Mass Media delivery of health-promoting messages via audio, print, and visual media Work with city/school district TV channel to air content

Create article for popular local newspaper featuring role models

*Example

Identify role models/health champions and put in social media, city websites, school websites

*Example

Work with local mass media reporters to regularly feature on TV, newspaper or radio

*Example

Social Support including self-help groups, exercise groups, community health worker home visits, text messages and social media Begin free exercise classes at community locations like schools, parks and churches and advertise them in the community

Have the community health workers deliver newsletters door-to-door featuring local role models and health tips

*Example

Community health workers create support groups

Weight-loss challenges like Biggest Loser city-wide or through schools, workplaces

*Example

Risk Factor Screening provision of health risk screenings at easily accessible community locations and referrals to medical homes Coordinate among partners to provide screenings at a community location Participate with local institutions on national awareness days associated with health (e.g. Diabetes Day) providing screenings, education on risk Support existing community events and provide screenings for chronic disease with referrals to care
Education about physical activity and nutrition in community locations

Use evidence-based nutrition modules for talks with adults at churches, school parent groups, workplaces & 1 on 1

*Example

Use evidence-based physical activity modules for talks with adults at churches, school parent groups, workplaces & 1 on 1

*Example

Promote Coordinated Approach to Child Health (CATCH) trainings and activities in coordination with local schools

Promote CATCH curriculum in park and after school programs
Policy Improvements to support physical activity and healthy food choices Implement wellness policy for city employees where increased physical activity or weight loss receive incentives (time off, recognition, prizes) Implement a healthy food policy for city sponsored meetings (state that fruits and vegetables/low calorie options available)

Implement safe passing zone policy

**Resource

Implement smoke free city policy

*Example

Environmental/Infrastructure Changes to support physical activity and healthy food choices

Implement protected hike/bike paths or create a safe routes to school

**Resource

Organize Cyclovias (temporary closing of streets for pedestrians and cyclists)

*Example

**Resource

Community gardens/school gardens

*Example

**Resource

Install hydration stations in city offices, schools, and other community locations

*Example

People Dancing at Community Event (Zumbathon)

Addressing Health Disparities

Roadmap to Health and Economic Vibrancy

While other cities and counties have pockets or neighborhoods of poor, unhealthy residents, almost half of Brownsville's residents live below poverty, many in substandard housing, some still in undeveloped colonias without basic infrastructure like sewage and electricity. Over half of our population has little or no access to healthcare, and suffers from costly chronic disease at rates higher than the nation. There is no public hospital within a 350 mile radius, and little access to preventive care, so routine health problems often spiral into serious and costly complications (dialysis, amputation, blindness) and feed back into economic problems, missed work, unemployment, and low quality of life.

Brownsville's rapid growth over the past few decades due to population influx (immigration and high birth rates) has created an unhealthy landscape of unplanned development that resulted in an environment discouraging to health: limited regulations, subdivisions spread-out and connected by highways and streets without sidewalks, and lack of access to affordable fresh produce.


What determines health?

Determinants of Health

Building New Collaborations

Over a decade ago, a diverse group of leaders from city government, business, education, healthcare, and social service organizations, came together to imagine a better future for Brownsville and its many struggling residents. A subsequent transformation has taken place, reflected in the landscape, attitudes, health and culture of this city. The genesis of this collaboration was through the local campus of the UT School of Public Health’s Community Advisory Board (CAB). The CAB initially focused on poor health indicators, using the RWJF County Health Rankings and other local data.

  • We divided into efficient workgroups focused on measurable outcomes and recruited key leaders.
  • We determined that a multipronged strategic approach was needed including programs and partnerships to create and sustain an environment that supports active living (Healthy Communities of Brownsville); healthy food choices (Brownsville Farmers Market); and to increase awareness, education and support for healthy lifestyles for those who have a chronic condition and need individualized assistance (Chronic Care Management) or who can be reached through population-based strategies (Tu Salud ¡Si Cuenta! Community Wide Campaign).
  • Much has been accomplished by sharing resources and harnessing our greatest asset, human capital.

Now instead of being known as the poor, border city with grim statistics, we are leading the way as an example for our region and state, setting bold policies, changing our environment, improving social, economic and health indicators, and winning awards, often tapped as a model for creative, low-cost, solutions that capitalize on existing assets to create a vibrant, healthy community.

Community Advisory Board

Summary of Behavior Change Techniques Found in Components of the TSSC Campaign

Behavior Change Techniques

Media


Individually Focused Efforts
TV Radio Newsletters Risk Factor Screening CHW Visits Free Exercise Classes
Goals and Planning
Goal setting (behavior)/SCT Self regulation X X X
Problem solving/TTM Behavioral process X
Review behavioral goals/SCT Self regulation X

Feedback and Monitoring

Feedback on behavior/SCT Self-efficacy and Self regulation X X
Feedback on outcomes of behavior X X

Social Support

Social support (unspecified)/SCT Reinforcement and TTM Helping Relationships

X X X
Social support (emotional)/SCT Reinforcement and TTM Helping Relationships X X
Shaping Knowledge
Instruction on how to perform a behavior/SCT Self-efficacy and Self regulation X X X X
Natural Consequences
Information about health consequences/TTM Consciousness raising X X X X X X
Salience of consequences/ TTM Consciousness raising and dramatic relief X X X X
Information about social and environmental consequences/TTM dramatic relief and environmental re-evaluation X X X X
Anticipated regret/SCT Observational learning X X
Comparison of Behavior
Demonstration of the behavior/SCT Self-efficacy and Self regulation X X
Social comparison/SCT Observational learning X X
Information about others' approval/SCT Observational learning X X
Associations
Prompts/Cues / TTM Counter conditioning, stimulus control and Reinforcement Management X X X
Repetition and Substitution
Behavioral practice/rehearsal / SCT Self-efficacy and Self regulation X

Comparison of Outcomes

Credible sources X X X X
Pros and cons/TTM Pros and Cons X X X
Comparative imagining of the future/ TTM Self re-evaluation X X X
Reward and Threat
Material incentive/SCT Reinforcement and TTM Reinforcement management X X X
Social reward/SCT Reinforcement and TTM Reinforcement management X
Antecedents
Restructuring of the physical environment X
Restructuring of the social environment X
Identity
Identification of self as role model X X X X
Self-Belief
Verbal persuasion about capability X X X
Focus on past success X X
Covert Learning
Imaginary reward/SCT Observational learning X X X X
Vicarious consequences/SCT Observational Learning X X X X

Based on Behavioral Change Techniques by:

Michie, S., Ashford, S., Sniehotta, F. F., Dombrowski, S. U., Bishop, A., & French, D. P. (2011). A refined taxonomy of behaviour change techniques to help people change their physical activity and healthy eating behaviours: the CALO-RE taxonomy. Psychology & Health, 26(11), 1479-1498.

SCT- Social Cognitive Theory (Bandura, 1986)

TTM- Transtheoretical Model (Prochaska, 1992)

Goals and Planning

Goal Setting

TV: Role models discuss how they set their goals (small, achievable and defined with time-frame) for increasing physical activity, reducing portions and increasing fruit and vegetable consumption  providing specificity about how it guided their progress

Newsletter: Role models discuss their goals for increasing physical activity, portion control, increase of fruit and vegetable consumption and discuss the steps to setting goals, addressing barriers, and contingency planning.

CHW Visits: Using motivational interviewing strategies like confidence and readiness ruler, ambivalence building, and change talk participants set goals guided by community health workers. They work with the participant to complete action plans that are achievable and have a time frame. They address discrepancies between current behavior and goal related to physical activity and healthy food choices.

Problem Solving

CHW Visits: Using motivational interviewing strategies CHWs help guide participants to problem solve around the behaviors related to physical activity and healthy food choices. Visits include identification of barriers, strategies to overcome barriers, increasing facilitators and engaging in coping and contingency planning,

Review Behavioral Goals 

CHW Visits: Using motivational interviewing strategies, participants review progress towards goals guided by community health workers to be achievable and realistic around the behaviors of physical activity and healthy eating. The return visits provide an opportunity to revisit the goals set in previous visits and for the participant to assess progress and set new goals.

Feedback and Monitoring 

Feedback on Behavior 

CHW Visits: Community health workers provide informative/evaluative feedback to participants pertaining to physical activity and healthy eating.  The CHW encourages participants to keep a food log and/or exercise log and if a chronic condition a log of glucose readings, blood pressure readings, etc. This allows participant to observe and record behavior as part of a behavior change strategy. The CHW discusses recorded patterns and relationship to the participant’s progress on selected goals for behavior change and encourages continued self-monitoring beyond intervention.

Free Exercise Classes: Class leaders allow time for class to reflect on changes related to participation in exercise group and other behavior change associated with healthy lifestyle. Leaders provide feedback to participants about their performance of moderate exercise to ensure intensity is appropriate and movement is safely performed, and provide objective screening measures and results (BMI, hip and waist circumference, blood pressure) to each participant at regular intervals (monthly). Participants are encouraged to keep food and exercise logs for self-monitoring.

Feedback on Outcomes of Behavior

CHW Visits: CHWs monitor blood pressure, BMI, hip and waist circumference and glucose/HbA1c (if applicable) at each visit to provide feedback on the outcome of performance of the behavior between visits.

Risk Factor Screening: Risk factor screening tools are used in community settings and home visits so participants can see first-hand their risk score (for diabetes and obesity using ADA Risk Factor screening and BMI chart) and learn about the relationship between their family history, BMI and blood pressure and the behaviors of physical activity and healthy food choices

Free Exercise Classes: Class leaders inform participants of weight and blood pressure readings monthly and provide regular opportunities to obtain and record weight and blood pressure. 

Social Support

Social Support (Unspecified)

Risk Factor Screening: Staff provide participants risk factor screenings with referrals and information about exercise groups, nutrition and diabetes self-management classes that offer support for increasing physical activity, improving healthy food choices and managing chronic disease.

CHW Visits: CHWs provide participants in home visits with referrals and information about exercise groups, nutrition classes that offer support for increasing physical activity and improving healthy food choices.

Free Exercise Classes: Class leaders provide participants in exercise classes with referrals and information about nutrition classes, community gardening opportunities and local farmers markets to support improved healthy food choices.

Social Support (Emotional)

CHW Visits: Participants receive emotional social support from CHW using motivational interviewing strategies, connections to neighborhood exercise and nutrition groups, and consistent follow-up in the home. CHW’s encourage participants to identify one person in their life who will be supportive of the healthy changes and for them to talk with that person about their goals.

Free Exercise Classes: Participants connect with other class members socially/emotionally in a positive atmosphere to receive support for working toward a healthy behavior change. Members call one another if a person is absent, share recipes and tips for improving healthy choices. The members are recognized for progress made towards goals.   

Shaping Knowledge

Instruction on how to perform a behavior

TV: Nutritionist/Chef instructs viewers on preparation of traditional Mexican meals in healthier ways and with more fruits and vegetables.

Newsletters: Newsletters provide specific instructions about how to prepare healthy meals and perform specific types of moderate physical activity like brisk walking. The newsletters provide recipes and how to tips.

CHW Visits: CHWs provide instruction to participants about how to make healthy food choices, prepare healthy foods, and determine appropriate portions. Additionally, CHWs provide instruction to participants about incorporating moderate physical activity into daily routines and the level of intensity that one should achieve for moderate physical activity.

Free Exercise Classes: Class leaders provide instruction on exercise moves to exercise class participants. 

Natural Consequences

Information about Health Consequences

TV/Radio: Health professionals provide information about health consequences of physical inactivity/bad diets. 

Newsletters: Newsletters provide specific examples of health consequences of physical inactivity/bad diets. 

Risk Factor Screening: Participants are provided with information on health consequences of risk factors such as: elevated blood pressure, high glucose levels, and high BMIs. 

CHW Visits: CHWs provide educational modules with information about health consequences of physical inactivity and unhealthy diets. 

Free Exercise Classes: Class leaders provide participants with information about the health consequences of physical inactivity and sedentary lifestyles. 

Salience of Consequences

TV: Pictures and models are displayed as part of the segment to emphasize the consequences of physical inactivity and unhealthy diets. 

Newsletters: The newsletters include pictures of health consequences such as clogged arteries, to highlight the dangers of unhealthy diets. 

Risk Factor Screening/CHW Visits: CHWs emphasize the consequences of physical inactivity and unhealthy diets by showing pictures and models of health consequences with the aim of making the information more memorable. 

Information about Social and Environmental Consequences

TV/Radio: Role models inform viewers and listeners about the economic costs associated with management of an obesity-related disease such as diabetes or cancer

Newsletters: Inform readers about the economic costs associated with management of an obesity-related disease

CHW Visits: CHWs discuss with participants the economic costs and social isolation that can result from not performing the behaviors and managing obesity related diseases. 

Anticipated Regret

TV/Newsletters:The segments and newsletters raise awareness of expectations of future regret about performance of the unwanted behavior through role model stories that emphasize the regret associated with engaging in unhealthy behaviors. 

Comparison of Behavior

Demonstration of the Behavior

TV/Newsletters: The TV segments/newsletters provide observable examples of how to cook healthy dishesor perform various exercises for the viewers to imitate.

Social Comparison

TV/Newsletters: The newsletters and TV segments present health behavior statistics and ask participants how their behaviors compare.

Information about Others' Approval

TV/Newsletters: Peer models provide information about what other people think about the behavior, such as family approving or expressing admiration for regularly engaging in physical activity.

Associations 

Prompts/Cues

Newsletters: Newsletters provide examples of helpful environmental stimuli such as placing shoes by the door with the purpose of cueing the participant to take a walk after dinner.

Risk Factor Screening:

CHW Visits: CHWs provide the participants with a copy of their goal sheet to place in a location that is seen regularly with the purpose of prompting or cueing the behavior change. 

Repetition and Substitution

Behavioral Practice/Rehearsal

Free Exercise Classes: Class leaders provide participants in exercise classes the opportunity for behavioral practice of moderate physical activity. 

Comparison of Outcomes

Credible Source

TV/Radio: Health professionals/Experts present information to emphasize the importance of physical activity and healthy eating

Newsletters: Newsletter includes 'Ask an Expert' section which includes information from professionals such as nutritionists, on a variety of health topics. 

CHW Visits: Educational modules provided by the CHWs include information from credible sources such as the Centers for Disease Control and the American Heart Association to encourage physical activity and healthy eating. 

Pros and Cons

TV/Radio/Newsletters: Role model stories presented in the media include identification of perceived pros and cons of behavior change.

Comparative Imagining of the Future

TV/Newsletters: Participants are prompted through role model stories to imagine and compare possible outcomes of their healthy behaviors.

CHW Visits:

Reward and Threat

Material Incentive

Risk Factor Screening: Participants who participate in the Challenge are given a financial incentive for losing 5% of their total body weight.

CHW Visits: At times the CHW visits are part of a research study and then an incentive for completing the visits is provided to the participants. Most often the reward provided is verbal recognition of the participant’s progress by the CHW and encouragement for continued achievement.

Free Exercise Classes: Participants who attend exercise classes regularly qualify to enter into a drawing for exercise equipment, water bottles, gift cards, etc.

Social Reward

Free Exercise Classes: Class leaders and peers verbally congratulate participants for regularly attending exercise classes and showing improvement in their health behaviors.

Antecedents

Restructuring of the Physical Environment

Free Exercise Classes: The physical environment is restructured to increase opportunities for physical activity by providing access to free exercise classes in locations frequented by the priority population (churches, parks, schools etc.).

Restructuring of the Social Environment 

Free Exercise Classes: Class leaders encourage a social environment at exercise classes and walking groups to encourage helping relationships. 

Identity

Identification of Self as Role Model

TV/Radio/Newsletters: Participants are informed that if they practice healthy behaviors they be a good example for their family and friends.

CHW Visits: CHWs emphasize to the participants that if they engage in healthy behaviors this may be a good example for their family and friends.

Self-Belief

Verbal Persuasion about Capability

Risk Factor Screening/CHW Visits: Community health workers encourage participants to identify previous times they have made healthy choices (successes) and how they felt. They encourage them to focus on their capability to perform the behavior. Use of the confidence ruler allows discussion about why a participant feels they are relatively confident  (past success) and what they need to move forward on the ruler to successfully increase their physical activity and healthy eating. The CHWs encourage participants to practice positive self-talk, first aloud and then silently on a regular basis and report back in negativity has decreased.

Free Exercise Classes: Class leaders encourage participants to list and make note of healthy choices they have made (like showing up to class today) and they prompt positive self-talk by going around the group and asking participants to name something healthy they did between last class and present.

Focus on Past Success

CHW Visits: Using motivational interviewing strategies, community health workers guide participants to increase self-efficacy to engage in physical activity and healthy eating through focusing on past successes. 

Free Exercise Classes: Class leaders advise participants to think about previous successes in engaging in physical activity. 

Covert-Learning

Imaginary Reward

TV/Radio/Newsletters: Peer models discuss rewards of physical activity and healthy eating through personal stories on television/radio segments and newsletters. 

CHW Visits: CHWs advise participants to imagine themselves eating healthy and engaging in regular physical activity and the positive consequences from their healthy choices.

Vicarious Consequences

TV/Radio/Newsletters: Media messages include peer models discussing consequences of their behaviors through personal stories.

CHW Visits: CHWs discuss positive consequences of their own healthy behaviors.