ToolKit: Part 1

Developing and Implementing Health Promotion and Disease Prevention Activities for Refugee Communities

Table of Contents

1.1 Introduction
1.2 Learning the Health Needs of Your Community
1.2.1 Asking the Right Questions
1.2.2 Collecting Information to Answer Your Questions
1.2.3 Making Sense of What You Learned
1.3 Strategies to Plan Your Community Health Program
1.3.1 Choosing Your Target Audience
1.3.2 Determining Your Target Audience's Understanding of the Health Concern
1.3.3 Selecting Your Program Efforts
1.4 Community Resources and Partnerships
1.4.1 Identifying Resources in Your Community
1.4.2 Developing Effective Partnerships
1.5 Activities for Health Promotion and Disease Prevention
1.5.1 Using the Social Marketing Model for Health Promotion and Disease Prevention
1.5.2 Developing and Disseminating Information in the Community
1.6 Evaluating Health Promotion and Disease Prevention Activities
1.6.1 Developing and Implementing an Evaluation Plan

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1.1 Introduction

A variety of health concerns can affect your community. You and your organization can play an important role in helping to improve these health concerns. But you may not know where to begin or what to do once you have identified the health concern that most affects people in your community. This part of the manual is designed to help you do exactly that.

In designing a health promotion and disease prevention program, you must consider many steps to be successful. Most important, you must understand the people in your community and must work with them to develop ways to best meet their needs. This process requires careful thinking and planning. Part One of this manual is designed as a simple "how to" that will walk you through the necessary steps to get started.

In Part One, you will learn how to work with people in your community to

• Identify the major health issues affecting them and understand the health concerns from their perspective (Section 1.2).
• Decide who needs your help the most and what you should do (Section 1.3).
• Find people and resources in your community to work with you (Section 1.4).
• Develop a program from beginning to end (Section 1.5).
• Evaluate your efforts (Section 1.6).

Together, these five sections present an organized method for making sure you work with your community to develop the best program possible using your available resources. They also will help you build stronger relationships within your community. After each section, you will find a list of resources where you can go to find more information.

Remember, you can do many things in your community to promote health and prevent diseases. Use Part One of this manual as your guide and starting point for your efforts.

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1.2 Learning the Health Needs of Your Community

At the end of this section, you will be able to learn techniques to Identify which health concerns are most important to refugees in your community. This section answers the following questions: What is a needs assessment and why should you do one? How do you conduct a needs assessment?

In thinking about ways to promote health in your community, you should start by finding out what people in your community most need.

You do this through a needs assessment.

What Is a Needs Assessment and Why Should You Do One?

When you do a needs assessment, you are collecting information on the concerns and problems of people in your community. You also find out what other resources or organizations are there to help.

The most important reason to do a needs assessment is to make sure you understand the community's concerns from their point of view. Their priorities should be your priorities.

You may think that you know what they need, but it is important to hear it from them. If you don't ask them, you may find that they will not accept your program because it is not what they need.

Doing a needs assessment can help you to

• Identify what the community needs the most. You may learn that other things in the community need to be taken care of first, before you can deal with larger concerns. For example, you may first need to think about transportation issues before you try to convince refugee women that they should get a mammogram (if they have no way of getting to the test).
  
  
• Show that you care about improving and promoting the health of your community. By listening to the needs of people in your community, you are doing one of the most important things to gain support for your efforts: showing that you are interested in them and that their input is valued.

How Do You Conduct a Needs Assessment?

There are three easy steps you can follow in conducting a needs assessment:

1. Ask the right questions. Section 1.2.1 helps you figure out the most important things you want to learn about your community and how to pick the questions you want to answer.
   
2. Collect information to answer your questions. In Section 1.2.2, we suggest how you can talk with members of your community to better understand their health concerns and needs.
   
3. Make sense of what you learned. Section 1.2.3 gives you ideas of how to prioritize what you learned so that you can decide what your organization can do to help.

The following sections will take you through each of these steps to do a needs assessment in your community.

Resource:

Schust, Christina S. (1996). Community health education and promotion manual (2nd ed.).
Gaithersburg, MD: Aspen Publishers, Inc.

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1.2.1 Asking the Right Questions

The first step in doing a needs assessment is to figure out what questions you want to answer about the health needs of people in your community.

Outline Your Questions

You can learn many things about the needs of people in your community. We have listed some ideas below. You may have others you want to add to this list.

1. Community health concerns. You may want to ask members of community groups what they see as some of the health issues or concerns they face. Questions to ask are

• What are the most common health problems in your community?
  
• What are the most important health problems according to people in your community?

2. Barriers to healthy behaviors. You may want to learn more about what things stop or get in the way of people doing healthy behaviors. Questions to ask are

• What stops people in your community from ______ (e.g., getting tested for TB)?
  
• What do you think is needed to get more people in your community to ______ (e.g., stop smoking)?

3. Community resources. You may want to know what resources a community has in place to help with a health issue or concern. You also want to find out whether people know about these different resources. Questions to ask are

• How familiar are people with the available health services and programs in the community?
  
• How do people learn about the different types of programs?
  
• Do people use the services or programs? Why or why not?
  
• What is needed to increase the number of people who use the services or programs?

4. Solutions. You may want to learn about things the community can do to better help with the health concerns of people—things that you can change or programs that are needed. Questions to ask are

• What types of programs would be most helpful to people in your community?
  
• What are the best ways to educate and alert people in your community about the available resources?
  
• What is the best way to encourage people to use these resources?

Next Steps

Once you have thought about the questions you want to answer, we suggest you write them down so that you know exactly what you want to learn.

Section 1.2.2 will walk you through different ways of talking with members of your community to help answer your organization's questions.

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1.2.2 Collecting Information to Answer Your Questions

Now that you know what questions you have about the health of people in your community, we suggest you do some research and talk with people to help answer your questions.

This section gives you some ways that you can collect information for your needs assessment.

Ways to Gather Information

The following are two main ways you can collect information to answer your questions:
First, you can look for information that somebody else has already collected. Second, you can collect your own information. This section discusses both ways and gives instructions on how to do each one, depending on what is right for you and your community.

Using Already Existing Information

Relying on information that already exists in your community will save you time and money. Some information is easy to find, whereas other types will take some imagination and patience on your part. One thing to consider when using already existing information is that it may not be easy to find exact answers to your questions. The people or organizations that already collected the information most likely had different questions from yours. So, their information may not always match what you are looking for.

The box on the next page lists different places where you can look to find existing information. You may know of other sources in your own community that you can explore. When looking for information, consider the following:

• Determine exactly what you want to know. The more precise you are in deciding what you want to know, the easier your information search will be. Think about the type of information you want. For example, do you want just statistics, or do you also want to review reports of other effective programs?
  
• What time period do you want the information for? It's often helpful to collect information from the period right before you started thinking about the health issues in your community, as well as current information. This approach will give you a beginning point that you can use to compare how things have changed after you have begun any health programs in the community. In addition, you may want to continue collecting information during your program to track your program's progress on a regular basis.

Collecting Your Own Information

If you cannot answer your questions using information that others have collected, you will want to think about collecting your own information. The following are two types of methods you can use to collect your own information:

• Qualitative methods. These types of methods provide information that is in-depth and explores people's attitudes, opinions, and beliefs about a health topic. Examples of qualitative methods are public forums, listening sessions and focus groups, and interviews.
  
• Quantitative methods. These types of methods provide numeric estimates of how people think, feel, or act about a topic. For example, you may be able to determine the percentage of people in your community who exercise regularly. The most common type of quantitative method is a survey.

Possible Sources of Health Information The State or county health department can help you determine health indicators on a variety of issues. The State human services department should be able to tell you the number of Medicaid recipients and the number of Food Stamp Program participants. Hospital admission and exit records can give you information on teen fertility, causes of death, and other data. Depending on where you live, you may find that some of the data may not be part of the public record. However, it may be possible to purchase some of these data or to arrange to use them in some form. Demographic information from census data is available for your community and for the entire United States. You can find this information on the Bureau of Census Web site: http://www.census.gov. Many States have similar information on their Web sites. You also can try www.firstgov.gov for background information. Police records can tell you crime rates and the incidence of such problems as domestic violence or motor vehicle accidents. Chamber of Commerce data discuss, for example, job growth and the unemployment rate. Nonprofit service agencies, such as the United Way or Planned Parenthood, generally have records on a variety of different issues. Often, these agencies have already conducted surveys and found the information you need. School districts can tell you graduation rates, test scores, and truancy rates for your school and others. For comparative figures across school districts, check with your State department of education. The Centers for Disease Control and Prevention reportable disease files can give you national information on the rates of many diseases, such as AIDS. Its Web site is located at http://www.cdc.gov. The reference librarian at your local public library can be a useful resource. Other professional contacts you have can lead you to sources of information particular to your interest. The Statistical Abstract of the United States is a good general print source for national information. Produced annually, it is available in most local libraries (http://www.census.gov/statab/www/). Specialized local, statewide, or national organizations may help. For example, if you were interested in Alzheimer's disease, tree planting, or lead poisoning, you would want to track down and consult with an organization specializing in that field. (Gale's Encyclopedia of Associations is a good national source; http://library.dialog.com/bluesheets/html/bl0114.html). Many such organizations have their own Web sites. World Wide Web. Many Web pages not listed above may now exist with the information you are seeking. For some of the best, see this section of the Community Tool Box, Connections and Links, found under Community Building Tools. The Community Tool Box offers information on a wide range of topics related to working with refugees (http://ctb.ku.edu/). Important U.S. Federal Government Sites for Information Specific to Refugees U.S. Department of State, Bureau of Population, Refugees and Migration (http://www.state.gov/g/prm) U.S. Department of Health and Human Services: Office of Refugee Resettlement (http://www.acf.dhhs.gov/programs/orr/geninfo/index.htm) Substance Abuse and Mental Health Services Administration (http://www.samhsa.gov/) Office of Global Health Affairs (http://www.globalhealth.gov/oirh.shtml) For links to more specific information about refugees, go to http://www.mentalhealth.samhsa.gov/cmhs/specialpopulations/refugeelinks.asp

Qualitative Methods

It might be best if you start with qualitative methods when doing a needs assessment. You can ask more general questions of people in your community without its costing you a lot of money or time.

The following section will discuss three possible types of qualitative methods you can use:

1. Public meetings
2. Focus groups
3. Interviews

Public Meetings. At these meetings, members of the community get together to discuss their opinions on a given topic or problem. They can provide a first step toward understanding the community's needs and resources. Public meetings are good to use with large groups.

The following are some suggestions for organizing a public meeting:

• If possible, hold meetings at more than one site and time to be sure different people from the community can be involved.
  
• Schedule the meeting at an easy-to-find, public location that is accessible and comfortable, for example, a library, school, religious center, or place of worship.
  
• If possible, hold the meeting in the evening to avoid time conflicts with work and school.
  
• Publicize the meeting as widely as possible. Flyers, advertisements, public service announcements, and press releases all can be used. Make sure the date, time, location, and purpose of the meeting are included.
  
• Personally recruit community leaders and diverse community members to attend the meetings. Ask them to recruit others as well.
  
• Provide transportation to the meeting, if necessary.
  
• Serve light refreshments, if possible. They encourage mingling and set a friendly tone.

To conduct a public meeting, consider the following:

• Assign a discussion leader that the community knows and respects. This person should be a good listener and should be able to keep things moving on track.
  
• Agree on an ending time, and stick to it.
  
• Provide information about your own organization, if appropriate.
  
• During the meeting, tape paper to the wall and record the discussion on each of the topics so that participants can keep track of what has been discussed.
  
• Conclude with a summary of what was achieved and a plan of action. Announce the next meeting, if possible.

Focus Groups. These groups are similar to public meetings but are smaller (about eight people). They usually are easier to plan and less expensive to conduct.

Focus groups are a good way for your organization to get a sense of what members of the community know and feel about an issue.

The following are steps to run a focus group:

1. Find a community leader who is comfortable talking in front of groups to lead the discussion. Some things to look for when choosing a discussion leader are

• Experience leading discussions
  
• Knowledge of the topic to be discussed
  
• Ability to relate to the group participants

2. Find a note-taker. A lot of important information will be discussed at a fast pace, so you'll need someone experienced at taking notes to make sure important information is not lost. Also, try to tape record the group discussion so that you can go back and listen to it.
   
3. Invite people who represent the community you're working with. Select people who are similar to the population or community you are working with (e.g., age range, education level, or smoking status). This step will help you make sure that you get opinions that are representative of the different subgroups within the community. Other things to consider:

• Divide participants into groups based on gender, race, education level, or other characteristics that may affect their ability to speak openly and honestly. This ability to speak freely can be an issue when discussing such sensitive topics as sex. For example, some women may be uncomfortable talking openly if men are present.

4. Decide whether to give incentives. Depending on your budget, you may choose to reward people for participating. Rewards can be money, a gift certificate, or something else of value to your audience.
   
5. Plan the group meeting.

• Day: What is the best day to hold the group session? Are certain days of the week not very convenient?
  
• Place: The meeting should be held in a central location that is easy for people to get to.
  
• Time: What time of day is best? Do members of the community generally work day or night hours?
  
• Length: Groups should be scheduled for 1 to 2 hours, depending on the amount of material you have to cover.
  
• Number of groups: It is a good idea to conduct a minimum of two groups with each set of people (if you are conducting separate groups with men and women, you will want to have at least four groups—two with men and two with women).

6. Prepare ahead of time the topics you want to discuss. You should always make sure you have a discussion guide that the leader refers to in the group.

• A discussion guide usually consists of a list of topics and some questions you want to be sure to ask.

7. Use the information you gain. After the session is over, it is helpful for the leader and note-taker to meet briefly to discuss how the group went and to compare observations. The next step is to review the notes and tapes to look for patterns in what participants say.

Tip: Understand How Groups Rank the Health Issues Beyond finding out the health needs of people in your community, you also can use the following simple activity to learn how groups rank the importance of different concerns or needs: Tape a piece of paper on the wall and write down each community concern or need, no matter how unimportant it seems. List each issue on its own index card or sheet of paper. Ask the group to arrange the cards or sheets of paper on the floor in terms of how serious or important they are. Give the group time to discuss the items and work out the order. Ask the group to explain the order of the cards and record their responses.

Interviews. Another method to determine how members of the community understand different health issues is to interview them. Interviews take place one on one and not in a group setting.

Interviews should be conducted in the following situations:

• When the topic is more complicated and you want specific information. For example, when researching people's understanding of a particular illness.
  
• When it is a sensitive topic. For example, people may not be comfortable talking about drug use or other illegal behavior in front of a group.
  
• When people are located in different geographical areas. For example, if the people you want to talk to are living and working in different areas, it may not be convenient to get them together in a group.

The following are some tips to assist you in conducting interviews:

• Try to interview a range of community members on any particular health topic. If you have a list of people in your community, randomly pick people from the list to interview.
  
• Make sure you select interviewers who are trusted in the community.
  
• Arrange a time and place to meet with the individual you are interviewing. Again, try to do it in a setting where the person will feel comfortable.
  
• Prepare your questions in advance. When you are interviewing, feel free to ask other questions and think up new questions as needed. A good interview should be like a conversation, not a question-and-answer session.
  
• Start with a few questions about the person, to get familiar with him and the experience he brings to the community. Then, move on to more specific questions on your topic.
  
• Record notes as best you can during the interview. Once you are done, review your notes as soon as you can and complete them as needed.

You also need to make sure the interviewees feel safe answering the questions. You should find ways to ensure confidentiality of their answers—that no one will be able to connect what they say with their names:

• Provide them with a letter of informed consent explaining the steps you will take to keep their information confidential. This letter also should let them know that they do not have to answer any question that makes them uncomfortable and that they can stop the interview at any time and for any reason.
  
• Conduct the interview in a private place so that no one can overhear what they are saying.

Another type of interview that is useful in understanding community beliefs is the key informant interview. Key informants are people in the community who have "special knowledge, status, or access to observations" unavailable to others and are "willing to share their knowledge and skills." For example, if a member of the refugee community has medical training, she may have insights into health issues and can provide important information on the beliefs and needs of refugees. The process of interviewing key informants is the same as interviewing other members of the community, just with some additional questions concerning their special knowledge.

Quantitative Methods

Surveys. A survey is another way to find out what people in the community see as their most important needs. With its ability to put numbers to people's answers, a survey is also a good way to determine how large a concern the problem is in the community.

The goal with a survey is to ask enough people the exact same set of questions. A survey can be given either as a written set of questions on a sheet of paper or through talking, with someone recording the results on paper.

If you choose to do a survey, you may want to talk with someone who specializes in these surveys. First, you might try a college or university near you. Often, they have faculty members or students who will help you for very little cost. They also can give you ideas of other people who could help you.

The following are some reasons to conduct surveys in a needs assessment:

• Surveys can be done with large numbers of people. You can learn more about the needs of the community from a larger, more representative group of people than you can through other methods.
  
• You can use the data to look at differences between groups. For example, you may be able to tell whether differences exist in how health concerns are viewed or how they affect men, women, recent arrivals, older arrivals, and others.
  
• You can get information you might not get in a more public setting. Individuals may feel more comfortable responding to a survey on their own rather than speaking in a public forum or listening session.
  
• You can gather and document concrete information about the needs of your target group. This information may be required for funding and also can be used to lobby for your cause.

Consider these important points when conducting surveys:

• Consider waiting to do any surveys until after you have done some public meetings or focus groups. From those, you may find some health issues or concerns you want to learn more about; you can ask about these issues on the survey to find out how common they are.
  
• Depending on the population you are working with, you may find that many of the members have difficulty, or aren't comfortable, reading and writing in English. If this is the case with your group, you can have the survey translated into their native language or can administer the survey orally. Use your knowledge of the community to make a decision.
  
• Make sure people are comfortable with the questions you are asking. Try not to ask for more information than you need. If you are asking people personal questions, take steps to protect their privacy, such as making the surveys anonymous by leaving off any reference to the person who completed it.
  
• In small communities, it may not be possible to keep information anonymous. In such cases, you will have to weigh the need for that information against the greater chance that people will not answer your questions or will answer in a less-than-truthful way.
  
• How many surveys are enough? This often is a tough question to answer. The number of people to survey will depend on the population in the community and how many people you can afford to survey. For a population (the total number of people in the community) of about 200 people, you would need to have surveys completed by 85% of the people, if you hoped to say that the results from the survey are truly representative of that community.

A good survey will

• Only include set questions that are to be answered by all respondents.
• Collect information on the person being interviewed, to better understand the reasons behind his response.
• Ask as many people as possible in the community and get a broad range of individuals. If you survey only one group of people from the community, such as men or people under 25 years old, then you will not learn about the concerns of other groups in the community, like women and older adults.
• Allow for the results to be summarized numerically, when possible.

The following chart provides SAMPLE questions and formats that might be used to collect information:

SAMPLE Questions and Formats Demographic Questions First, I need to ask you some basic information. Which category best describes your age? Under 35 35 to 43 44 to 52 53 to 60 61 or over What is your gender? Male Female How long have you been in the United States? Less than 1 year 2-5 years 5-10 years 10 or more years Open-Ended Questions The next set of questions is about the tuberculosis education program you attended tonight. What part of the session did you find the most helpful? Why? Did you dislike anything about the program? What changes can we make to improve the program? Closed-Ended Questions There is nothing you can do to prevent yourself from getting tuberculosis. Strongly agree Agree Disagree Strongly disagree How many people live in your home with you? Nobody 1 person 2 people 3 people 4 or more people Likert Scale: rating items on a response scale Example Please check the answer indicating your reaction to the statements listed below. Strongly Disagree Disagree Undecided or Not Sure Agree Strongly Agree Violent crime is a big problem in my neighborhood.           The police are doing enough to prevent crime in my neighborhood.           If a citizen-watch program were implemented in my neighborhood, I would participate in it.           I would support organized activities for youth in my neighborhood.           Adapted from the following: National Cancer Institute. (2002). Making health communication programs work: A planner's guide (NIH Publication No. 02-5145). Bethesda, MD: National Institutes of Health. University of Kansas, Work Group on Health Promotion and Community Development. (2004). Community tool box. Retrieved from http://ctb.ku.edu/

Resources: Family Health International and Program for Appropriate Technology and Health. (2002). Developing materials on HIV/AIDS/STIs for low-literate audiences. Washington, DC: Family Health International. Lancaster, T. (1992). Setting up community health programs: A practical manual for use in developing countries. London: The Macmillan Press LTD. University of Kansas, Work Group on Health Promotion and Community Development. Community tool box. Retrieved January 2004 from http://ctb.ku.edu/

Next Steps

Section 1.2.3 will help you make sense of all the information you have collected thus far. It will also help you decide what health promotion or disease prevention activities you might want to do in your community.

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1.2.3 Making Sense of What You Learned

Once you have collected information to answer your important questions, you need to prioritize what you learned. This step will help you decide what health concerns your organization should focus on in the community.

Decide Which Health Issues to Address in Your Community

By this point, you probably have a long list of health concerns in the community that your organization could help with. They all appear important. So which of these should you focus your time and money on?

The following steps can help you choose the community issue you would like to address through health promotion activities:

1. Rank the list of health concerns by how much of a problem you think each one is in your community. Remember to rely on the information you collected. Think about how common and well-known each health problem is in your community.
   
2. Take your list of ranked items and find the middle of the list, the place where half the items are above it and half are below it. Take those above your middle point and label them More Important and those below the middle point and label them Less Important.
   
3. Mark next to each of the items listed whether you think they are Easy to Change or Difficult to Change in your community. Easy to Change items would be those you think your organization has the skills and resources to address and where change seems possible. Difficult to Change items are ones that will take a lot of new knowledge and resources and that you are not sure can be changed easily.
   
4. Draw a diagram with four boxes and label each box as pictured below. Using your list, write the items in the boxes based on the two labels you have assigned to each item, such as More Important or Less Important and Easy to Change or Difficult to Change.

	More Important	Less Important
Easy to Change	High Priority for Planning	Low Priority
Difficult to Change	Low Priority	No Priority

Adapted from the following: Green, L. W., and Kreuter, M. W. (1999). Behavioral and environmental assessment in health promotion planning, an educational and ecological approach (3rd ed., p. 138). New York, NY: The McGraw-Hill Company.

5. On the basis of the information you now have, you may want to consider first those items that fall in the More Important and Easy to Change box. You might be able to provide the greatest impact in the community for these items.

Resources: Family Health International and Program for Appropriate Technology and Health. (2002). Developing materials on HIV/AIDS/STIs for low-literate audiences. Washington, DC: Family Health International. Green, L. W., and Kreuter, M. W. (1999). Behavioral and environmental assessment in health promotion planning, an educational and ecological approach (3rd ed., p. 138). New York, NY: The McGraw-Hill Company. National Cancer Institute. (2002). Making health communication programs work: A planner's guide (NIH Publication No. 02-5145). Bethesda, MD: National Institutes of Health. University of Kansas, Work Group on Health Promotion and Community Development. (2004). Community tool box: Assessing community needs and resources. Retrieved from http://ctb.ku.edu/ For more information: Wikin, B. R., and Altschuld, J. W. (1995). Planning and conducting needs assessments: A practical guide. Thousand Oaks, CA: Sage Publications.

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1.3 Strategies to Plan Your Community Health Program

At the end of this section, you will be able to use a process to Identify the best group of individuals to focus your resources on (your target audience). Explain the problem that you want to improve. Develop your program goals. Identify the most appropriate activities for your program. This section answers the following questions: What is a target audience? Why do you need to pick a target audience? How do you choose a target audience? How do you decide the best use of your resources?

In Section 1.2, we explained how you can use a needs assessment to better understand and prioritize the health concerns of people in your community.

At this point, you have identified the health issue you want to address in your community.

Now, you need to identify who in your community is most affected by this health issue and what you can do to best address their needs.

The following pages will walk you through three steps to help you focus your health promotion and prevention efforts on the people in your community who have the greatest need:

1. Select your target audience. Section 1.3.1 helps you identify the specific group of people you want your health promotion and disease prevention activities to reach.
   
2. Determine your target audience's understanding of the health concern. Section 1.3.2 shows you how to explore and gain a better understanding of what your target audience thinks about the health concern and the factors that may influence these thoughts.
   
3. Select your program efforts. Section 1.3.3 describes how to write a problem statement, determine your behavioral goals, and select the appropriate program activities your organization can do.

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1.3.1 Choosing Your Target Audience

When you plan a health program for people in your community, you should decide who needs it the most. It is important to remember that one size does not fit all. In any community, people are not all alike. Different groups of individuals will need different types of programs.

For example, a program for women may not work for men. Or, people who are already exercising will want to hear different things than people who have not yet started exercising. Their motivations are different, and they will need different types of programs.

What Is a Target Audience?

Instead of trying to reach everyone, you should follow this recommendation: prioritize the different types of groups and then pick the one that is right for your program. The group you pick is called your target audience—they are the people you are most interested in influencing (targeting).

Target audiences can be made up of primary audiences and secondary audiences:

• A primary audience is the group of people you are most interested in helping. This group usually includes people whose behavior is most important to change. For example, if you wanted to focus on HIV/AIDS, your primary audience might include those people who are HIV negative but whose partners are HIV positive. The HIV negative people are at greater risk of becoming infected.
  
• A secondary audience includes people who can influence the primary audience and the success of your program. This group might include family members, friends, or community leaders (such as teachers, health care professionals, and local politicians) who can help you address a health problem.

Why Do You Need to Pick a Target Audience?

The more you focus your program on a specific group of people, the greater chance it has to be successful. That is the case because all the parts of your program will be designed specifically for your target audience. Getting their opinion on your ideas will help you fit the program to their needs. Then, they will pay more attention to what you are asking them to do.

How Do You Choose a Target Audience?

When you choose a target audience, you want to be as specific as possible so that you can make sure you focus your resources only on that audience. You do this by starting with a large group and then breaking it up into smaller groups. Then, your job is to decide which group is the most important for you to focus on.

Suppose you want to develop a health promotion program for "adults." Unfortunately, this group is very large and broad. You will spend a lot of money and time trying to reach all adults—and many adults will ignore your program because it does not relate to them. You want to think about the many smaller and more specific groups of adults who are most important to your program objectives. The question to ask is, "Who among adults is the best group to pick for my program?"

To narrow down your larger group, you can choose many ways. You want to look for the small groups of people who need your program the most. The most common ways are using the following categories:

1. Demographics. Demographic categories have to do with people's vital statistics—the sort of information you might get from Census statistics. If you find that different demographic groups react differently to your program goals, you would want to consider which group is best. Examples of demographics are

• Gender
  
• Age
  
• Marital status
  
• Race/ethnicity
  
• Language
  
• Income
  
• Education

2. Geography. Geography refers to where people live. Often, this is an important thing in reaching a target group because people who are similar tend to be concentrated in geographic areas. Some geographic areas are

• Area or neighborhood
  
• City or town
  
• County
  
• State

3. Physical and personal history. This category includes the physical, medical, and personal experiences that groups of individuals have in common and that may influence their responses to your program goals. Examples are

• Presence of certain health conditions or diseases (e.g., depression, vitamin D deficiency, overweight, diabetes, and cancer)
  
• Risk factors for health conditions or diseases (e.g., smoking, alcoholism, and overweight)
  
• Physical disability

4. Beliefs and attitudes about specific issues. These are things concerning people's lifestyles, beliefs, and values. Sometimes, the most important distinction between people is how they believe or feel about something and not what demographic group they are in. Things to consider are

• Political views
  
• Religious beliefs
  
• Attitudes about health care
  
• Beliefs on parenting
  
• Attitudes toward authority

5. Behavior you want to change. In health promotion and disease prevention, this means the behavior you are interested in changing. One helpful way to think about with behavior is to consider those people who are not doing the behavior versus those people who are already doing the behavior. Behavior can mean many things. You should consider

• How much people know about the health problem
  
• If they believe the health problem is important
  
• How much they want to change their behavior
  
• If they believe they can change their behavior
  
• How much they believe they can sustain the change

Example: Selecting a Target Audience The following diagram is a simple example of how you can break down a large group of "adults" into a specific target audience. For each category, answer "yes" or "no" and then mark your diagram pending those answers. Target Audience: Pregnant Women smokers who are from Vietnam In this example, you are interested in adult refugees. You discover from the information you collected that smoking is a big health problem among this group, especially for refugees from Asia and more so among those from Vietnam. You cannot afford to focus on all adult refugees from Vietnam. However, your information says that Vietnamese women, especially younger women who are pregnant, know the least about the bad effects of smoking but are the most likely to stop if they receive help. In this example, your target audience becomes Pregnant women smokers who are from Vietnam Anything you design for your program will be focused around their needs and preferences. You will want to get their reactions to your ideas as you create your program.

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1.3.2 Determining Your Target Audience's Understanding of the Health Concern

In Section 1.3.1, you picked your target audience, that is, who should be the focus of your health promotion or disease prevention program. Before you decide exactly what your program will do, it is necessary to understand it from your target audience's point of view. In the needs assessment, you were learning about all health issues from your community's point of view. Now, you are learning about your target audience's point of view on one specific health concern (that you picked in Section 1.2.3). You want to find out what your target audience knows, thinks, and feels about the health concern.

The process you will use to find this information is similar to a needs assessment (described in Section 1.2) but on a smaller level. First, you will decide what you want to ask and what you hope to learn from your target audience. Then, you will talk with members of your target audience to answer these questions.

To determine what to ask your target audience about the health issue, consider the following topics:

1. What your target audience knows and thinks about the health concern. For example, if you find that tuberculosis (TB) is the most important health issue facing your target audience, you might ask such questions as

• What do you know about TB? What have you heard about it?
  
• What causes TB? How do people get TB?
  
• What are the symptoms of TB?
  
• What can you do to prevent TB?
  
• What types of treatment can you get for TB? Can it be cured?

2. How your target audience makes health decisions. For example, you might ask such questions as

• Who is the most important person you listen to about health issues?
  
• Where do you learn about health issues?
  
• Where do you seek health care?
  
• Do you seek care from a doctor, nurse, or other health care professional?
  
• What do you think about when you make a decision about your health?

3. What issues keep your target audience from addressing or changing their health behaviors. For example, if you are discussing TB screening you might ask such questions as

• What do you think would help someone in your community get tested for TB?
  
• What do you think would keep someone in your community from getting tested for TB?
  
• What do you think people in your community need to know or have to help them get tested for TB if they have not been tested?

In Section 1.2.2, we discussed several ways you can collect information when working with people in your community. These same methods can be used with members of your target audience.

The following are some important tips to remember when you collect information on your target audience:

1. Make sure the people you talk with are members of your target audience. For example, if your target audience is pregnant women between the ages of 18 and 25 who are carrying their first child, then you want to make sure you are talking with women who fit this description. It may also be important to talk with women in this age group who already have another child, but this should be done separately and not at the same time as with your target audience.
   
2. Be sure to consider secondary audiences, in addition to your primary audience. In the example above, you might also think about talking with the children's fathers, the women's mothers, or other people who influence the pregnant women.
   
3. Remember to first find the information that already exists about your target audience, and then collect your own information. You can learn a lot from information that already exists, but it also will help you if you take the time to talk directly with members of your target audience.

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1.3.3 Selecting Your Program Efforts

How Do You Decide the Best Use of Your Resources?

The most important thing you can do to know exactly how to spend your resources wisely is to listen. All sections of this manual up until now are designed to help you identify exactly what people in your community need and who in the community needs it the most. We have suggested you go to people in your community, ask questions, and listen to their answers.

These answers should point you to what your organization can do to best meet the community's health needs. Now, you need to pick your program goals—these are what you hope to accomplish over a certain period of time with the resources you have available.

You should take three steps to help you pick your program goals and decide exactly what you should do:

1. Write a problem statement.
2. Determine your behavioral goals.
3. Select the best program activities for your target audience.

Step 1: Write a Problem Statement

What is the problem? What exactly should you do? To answer these questions, you must constantly turn to the information you have collected thus far. Relying on this information, you should first write a problem statement. A problem statement summarizes what you see is the gap between what you should want to happen in your community and what is really happening now.

To write the problem statement, you should briefly answer the following questions:

• What should be happening?
  
• What is happening now (the problem)?
  
• Who is the most affected by the problem, and to what degree?
  
• What will happen if the problem is not improved?

Sample Problem Statement Across the Nation, 20% of people under age 18 smoke at least three cigarettes per day (according to the 2002 Youth Risk Behavior Survey). A local survey found that 56% of teens in Community X smoked at least three cigarettes per day. The number of young Latinas and African American women who smoke in this community has doubled in the past 5 years. This factor is likely to cause a higher-than-average rate of smoking among adult women in this community, in addition to more chronic health problems, and even more disparities between minority women and the general population.

Step 2: Determine Your Behavioral Goals

Once you have written your problem statement, you should now try to write your behavioral goals for your program. These are the "blueprint" for what your program will do. Always keep in mind the target audience you chose. You should think about the one or two things you most need to change to help improve the target audience's health. You will also want to think about what you can offer the audience members in exchange for asking them to change their behavior. Try to answer the questions below. Be as specific as possible. You may have more than one goal. Fill out this information for each goal.

Behavioral goal: ______________________________________________________________ Who? (specific audience segment) ______________________________________________________________ Will do what? (specific behavior) ______________________________________________________________ Under what conditions? (when and where) ______________________________________________________________ In exchange for? (benefits)

The following is an example of a behavioral goal:

Parents of eligible uninsured children Who? (specific audience segment) Will call the toll-free telephone number to apply for coverage for their children under the State Children's Health Insurance Program (SCHIP) Will do what? (specific behavior) At a time and location that are convenient for them Under what conditions? (when and where) In exchange for the peace of mind that comes from being a good parent, from providing for their children's needs, and from ensuring their family's financial security In exchange for? (benefits)

Step 3: Select the Best Program Activities for Your Target Audience

For each behavioral goal you have written, select program activities that

• Can be completed with the amount of resources you have available.
  
• Meet the target audience's needs.
  
• Reach most of the members of your target audience.
  
• Have the potential to change behavior.

Activities can focus on

• Communication. For example, improving communication between the public and health care professionals.
  
• Providing or improving a service. For example, offering transportation to and from a clinic.
  
• Developing or adapting a product. For example, creating a resource guide for people in their native language.
  
• Changing policy through advocacy and community mobilization to reduce barriers to service. For example, requiring that translators be made accessible to people in the health care system.
  
• Some combination of the above.

Example of a Program Idea Health concern: Many non-English-speaking refugees in your area do not know that placing infants on their stomachs increases the risk of Sudden Infant Death Syndrome (SIDS). Program: You decide on a "Back-to-Bed" print campaign that relies heavily on pictures and drawings. Posters will be placed where milk and baby food are sold, in churches, and at bus stops.

Resources: The African Network on Participatory Approaches. (2000). Village participation in rural development. Royal Tropical Institute, World Bank. Bryant, C. (1999, Fall). Introduction to social marketing for public health (course materials). Department of Community and Family Health, College of Public Health, University of South Florida. Family Health International and Program for Appropriate Technology and Health. (2002). Developing materials on HIV/AIDS/STIs for low-literate audiences. Washington, DC: Family Health International. Lancaster, T. (1992). Setting up community health programs: A practical manual for use in developing countries. London: The Macmillan Press LTD. National Cancer Institute. (2002). Making health communication programs work: A planner's guide (NIH Publication No. 02-5145). Bethesda, MD: National Institutes of Health. Scrimshaw, S. C. M., and Hurtado, E. (1987). Rapid assessment procedures for nutrition and primary health care. Los Angeles: UCLA Latin American Center. University of Kansas, Work Group on Health Promotion and Community Development. (2004). Community tool box: Segmenting the market to reach the target population. Retrieved from http://ctb.ku.edu/ For more information: Community Tool Box Web site: http://ctb.ku.edu/ Turning Point Social Marketing Collaborative, Centers for Disease Control and Prevention, and Academy for Educational Development. (2003). CDCynergy: Social marketing edition (beta version) [computer software]. Atlanta, GA: CDC Office of Communication.

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1.4 Community Resources and Partnerships

At the end of this section, you will be able to follow a process to Identify available community resources to use for your program. Develop partnerships with other organizations to help you with your program. This section answers the following questions: What is a community resource? How do you find community resources? What are partnerships? What steps can you take to create partnerships?

Now that you know what types of health promotion activities you want to do in your community, the next step is to learn about the resources that already exist for you to use. Using existing resources can save you time and money. This step includes finding other groups in your community that can be your partner and can help you with your program. All you need to do is take some time to find out about the people, places, and programs already existing in your community.

This section will give you information about how to find resources, create partnerships with others, and use both to help you in your efforts.

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1.4.1 Identifying Resources in Your Community

What Is a Community Resource?

A community resource is anything that already exists in your area and that you can use to help promote healthy behaviors among people in your community. Resources can be

1. A person. For example, the mechanic down the street who can fix any car ever made. The stay-at-home mom or dad who organizes a playgroup. The church member who starts a discussion group on spirituality.
   
2. A building or a place. For example, a school, hospital, church, library, recreation center, or social club. It might also be an unused building where you could put a community hospice. Or, it might be a public place like a park or other open space.
   
3. A local business. For example, one that provides jobs and offers volunteers the chance to develop some skills.
   
4. You. You are a resource, too, and so are your friends and the people you know, even if you don't know them well. When you walk down the street, resources are all around you. This realization is a very encouraging and promising way of seeing the world.
   
5. Everything in the community. In a true sense of the word, everything in the community can be a resource. The key is to know what they are, how they can help you, and how to put them to use.

How Do You Find Community Resources?

A good place to start is by making a list of all the groups, organizations, and people in your community that you think would be helpful in some way.

1. Take out a pad and start writing. Begin with what you know. Write down anything that comes to mind.
   
2. Use other sources of information to add to your list. These can include

• Yellow Pages
  
• Internet
  
• Town directories, published for your community alone
  
• Lists of businesses, probably available from the chamber of commerce
  
• Lists of organizations, available at the library or town hall
  
• Local newspaper and other print sources
  
• Bulletin boards and also community-calendar listings that might be found on local cable television
  
• Friends and colleagues, who may know of groups, organizations, and community assets that are not on anyone else's lists.

3. When you finish, you may have quite a long list. That is a good sign—it means that there are a lot of assets in your community!

Helpful Hint: When learning about each community resource, ask about Available staffing Space Equipment Expertise Willingness to help and get involved in a variety of ways

Mapping Your Community Resources

Once you have made your list of resources, it often helps to put your findings on a map. That way, you can see all the possible places—right in front of you—that you can use to help you in your program.

One way to map your community resources is to find a large street map of your community. Then, just mark the locations of each group, organization, place, and person you have on your list with a dot, tag, or pushpin. You may start to see certain patterns. For example, you may find that certain areas in your community have different numbers or types of resources.

The picture below shows an example of how to map your resources.

Resource: University of Kansas, Work Group on Health Promotion and Community Development. (2004). Community tool box. Retrieved from http://ctb.ku.edu/

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1.4.2 Developing Effective Partnerships

What Are Partnerships?

Partnerships are formed when groups of people work together to make a difference. They are based on teamwork—people come together, combine their resources, and help each other improve their community.

Partnerships involve Two or more groups of people working together Cooperation Pooling resources Making a difference in your community

When you form partnerships, your organization can take advantage of what other groups have to offer, including

• Additional resources, such as funding, staffing, volunteers, and space to help you plan, carry out, and evaluate activities in your community
  
• Groups or people who have a lot of experience in addressing health issues, developing health programs, and working with people in your community
  
• Groups or people you can use to support and help you work with the community now and in the future
  
• The ability to reach larger numbers of people in your community

What Type of Partnerships Should You Consider?

You should consider several "levels" of partnerships (the 4 C's). The lower levels (1 and 2) are simpler and do not require as much involvement for you or the partnering organizations. You can decide which level of involvement is right for you and your organization.

• Level 1: Communicating. This level simply involves the exchange of information for mutual benefit. For example, a health clinic in your area may have statistics available about the types of health problems refugees seek treatment for. You may need access to these statistics, and in return, can provide the clinic with information about the refugee communities' health customs from their home countries.
  
• Level 2: Coordinating. This level involves the exchange of information and altering activities for a common purpose. For example, you and the health clinic (described in Level 1) continue to exchange information, but you also sponsor a weekly health seminar for refugees in your community. Your organization and the clinic alternate each week with the responsibility of picking the topic, announcing the seminar, and running the seminar.
  
• Level 3: Cooperating. This level involves the exchange of information, altering activities, and sharing resources. For example, added to sharing statistics and planning the weekly seminars, you also provide the clinic access to translators from your organization, while the clinic lets your organization use its waiting room to interview refugees about their health needs.
  
• Level 4: Collaborating. This level involves exchanging information, altering activities, and sharing resources (Levels 1-3). It also involves enhancing the capacity of the other partner for mutual benefit and common purpose. For example, in addition to all the sharing of information, activities, and resources described previously, you help the clinic write a grant application for additional funds to hire a nurse practitioner who is experienced at working with refugees in your community.

Adapted from the following: Himmel, A. (2001). On coalitions and the transformation of power relations: Collaborative betterment and collaborative empowerment. American Journal of Community Psychology, 29(2), 32-37.

Examples of organizations you may want to partner with in your community to promote health and prevent disease include the following:

State and local public health departments	Schools and local universities
Community hospitals, health clinics, community health centers, and doctors' offices	Other community-based organizations, such as United Way or YMCA
Mental health agencies	Youth groups Local government agencies
Ethnic and/or cultural groups and organizations	Area businesses
Churches, synagogues, mosques, and other religious houses of worship	Banks
Faith-based organizations	Media, for example, newspapers, television, and radio

For example, if you want to help make sure all refugee children are vaccinated, your group might involve the local health department, schools, religious organizations, and the YMCA. Because partnerships bring people together from all parts of the community, their efforts often have the chance to be successful.

What Steps Can You Take to Create Partnerships?

1. Think about what you can offer potential partners. Make a list of all the things that your organization brings to the table and that can help your potential partners. Be able to answer the question, "What do we [the potential partner] get in return for helping you?"
   
2. Make a list of groups or people who may be potential partners for your program. You may want to review your list of community resources, as described in Section 1.4.1.
   
3. Think about the roles that potential partners may play. Ask yourself how you can use the resources that these partners can bring. How can these organizations help you improve the health of people in your community? Some roles may include

• Helping develop and plan a health program for your community
  
• Using staff or volunteers to help carry out activities in your community
  
• Translating materials to give out to people in your community or providing language-appropriate materials
  
• Providing space for your program activities
  
• Publicizing or promoting your program within the community

4. Contact the persons or groups on your list of potential partners, and arrange a time to meet with each of them.
   
   
5. Meet with potential partners. During your discussions, you want to outline and explain carefully the following:

• The reasons why a health issue is of concern in your community
  
• Your program ideas and objectives for improving the health in your community
  
• Your vision for the role that the potential partner can play
  
• What your organization can offer them through this partnership, that is, the benefits of getting involved

6. Formalize the partnership. If potential partners agree to get involved in your program, you will want to formalize the partnership. You can do this through written letters that explain the partnership and the roles and responsibilities of each partner.

Tips for Maintaining Effective Partnerships Make sure the responsibilities of each partner are clear. Be flexible. Make sure partners understand the goals and objectives of the program. Allow partners to have a feeling of ownership in your efforts as long as it does not stray from your original goals. Give partners an appropriate amount of work. Ask your partners how things are going and/or what you can do to make the partnership better to keep your efforts on track. Talk with your partners about the progress you are making. After the program is over, tell them what was accomplished and talk about what else you can do or what resources they might find useful. Make sure they feel they are part of the program's success. Remember to say, "Thank you."

Resources: National Cancer Institute. (2002). Making health communication programs work: A planner's guide (NIH Publication No. 02-5145). Bethesda, MD: National Institutes of Health. University of Kansas, Work Group on Health Promotion and Community Development. (2004). Community tool box: Our model of practice: Building capacity for community and systems change. Retrieved from http://ctb.ku.edu/ For more information: Community Tool Box Web site: http://ctb.ku.edu/ Health Research and Educational Trust. (2003). The collaboration primer: Proven strategies, considerations and tools to get you started. http://www.hospitalconnect.com/hret/programs/content/colpri.pdf Himmel, A. (2001). On coalitions and the transformation of power relations: Collaborative betterment and collaborative empowerment. American Journal of Community Psychology, 29(2), 32-37.

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1.5 Activities for Health Promotion and Disease Prevention

At the end of this section, you will be able to Follow a social marketing process to design programs and activities that promote health and prevent disease in refugee communities. This section answers the following questions: What is social marketing and how can it help you? How do you design a program using social marketing? What are the 5 P's of social marketing? How do you know whether your messages and materials are appropriate for your target audience? How do you know which communication channels to use in your community?

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1.5.1 Using the Social Marketing Model for Health Promotion and Disease Prevention

In earlier sections of this manual, we talked about how to

1. Explore the health concerns of your community.
2. Select a target audience and understand the problem from their point of view.
3. Find resources and partners to help you meet the health needs of people in your community.

In this section, we talk about how you can design programs and activities to make a difference in your community. To do this, we recommend a "social marketing" strategy. Social marketing uses all the information and thinking you did for the earlier sections of this manual and combines them to help you create your program.

What Is Social Marketing and How Can It Help You?

Social marketing is a process that uses "commercial" marketing methods to help improve social problems. It takes the same ideas used to sell products—such as shoes, television shows, or pizza—and uses them to encourage people to make healthy choices.

Social marketing is most interested in changing behavior. In public health, the goal of social marketing is to develop programs that help people adopt and live healthier lifestyles.

For example, a commercial marketer is interested in selling hamburgers. But a social marketer "sells" a life without heart attacks. In this case, a social marketer wants to convince people that adopting healthy behaviors to reduce their risks of heart attacks is more important than smoking or not exercising.

The social marketing process understands that big changes can be made without lots of resources. But it takes a lot of listening and planning.

Social marketers understand that changing behavior involves many approaches. It can focus on individuals, such as getting refugee women who are pregnant to go to a clinic regularly. But sometimes, the change might have to take place with a system. For example, pregnant women may want to go to a clinic, but it is not open at convenient times or the staff is unfriendly toward them.

Social marketing is a step-by-step process to help you design programs that will meet the health needs of people in your community. Social marketers do not assume they know what people want or what is best for them. By following this process, you will see the problem through the eyes of people in the community. And you will learn from them what programs they need most from you.

How Do You Design a Program Using Social Marketing?

Social marketing is a five-stage process. The diagram below shows that these stages are circular. Each stage leads into the next, and the last stage goes back to the first so that the program can be revised and improved.

5 Stages of Social Marketing Planning and research Message and materials development Pretesting Implementation Evaluation and feedback

Stage 1: Planning and Research

This step is the base on which the other four are built. To create a successful social marketing program, you must understand the problem you are addressing, the audiences you are targeting, and the setting in which the program will operate. Having this information will allow you to plan the best method to change behavior.

In this "planning and research" stage, you should complete each of the following tasks:

• Task 1: Choose the behavior you want to change. The first task of social marketing is to define clearly what behavior you want to change with your program. For example, this behavioral change may be to encourage pregnant refugee mothers to see a doctor regularly. Section 1.2 of this manual shows you how to examine the needs of people in your community and decide which behaviors are most important to change.
  
• Task 2: Pick your audience. You also must ask yourself, "Whose behavior do I want to change?" Social marketing does not try to change everybody's behavior at once. It assumes different people will need different messages. Therefore, one approach will not work well for everyone. You will need to decide which groups of people—or audiences—should be the main focus of your program. Section 1.3 provides helpful advice to consider when picking the right audience for your social marketing program.
  
• Task 3: Learn the benefits you will offer and the barriers to change. Once you know whom you want to change and how, you will need to learn
  
  
  • The reasons why your audience would want to do the behavior (the benefits to them)
    
  • What makes the behavior difficult for the audience to do (the barriers)

  Let's say you want women refugees who are pregnant to get regular checkups at a local clinic. You will need to learn why they want to go and what prevents them from going. You know pregnant women want to keep their baby healthy—it is comforting to hear the baby's heartbeat and to have the doctor or nurse tell them that everything is fine. But, how friendly is the area clinic? How easy is it for the women to leave work to go to the clinic? Section 1.3 shows you how to find out these benefits and barriers for your audience.

• Task 4: Write your market plan, or strategy. After you have picked the best audience and learned their benefits and barriers, you will need to write a plan of action, or strategy, which will guide you through your entire social marketing program. It is important that you write this plan down on paper so that you can refer to it all the time. This plan will help keep your program focused when you need to make decisions. It will remind you of what you want to do and how. This market plan should be very specific in describing each of the following:
  
  
  • Your behavioral goals—exactly what you want your program to do
    
  • Your target audience—exactly whom you want to change
    
  • Your measurable objectives—these spell out the kind and amount of change you expect to achieve within a given time frame for your program
    
  • The benefits you will offer to the target audience—what they will get if they do the behavior
    
  • Your program interventions—the things you plan to do to encourage or support behavior change (Make sure you consider the 5 P's when planning your intervention. An explanation of the 5 P's is provided in Stage 5.)

Stage 2: Message and Materials Development

The message and materials development stage builds off the market strategy described in Stage 1.

Messages are the actual words or images that communicate what you want people in you target audience to know, feel, or do. You want messages that will persuade audience members to adopt the behavior—and to meet your program's objectives.

Things to Consider When Designing Your Messages: Appeals. What tone do you want to use? For example, should the messages use humor, fear, or facts? Styles. What can make your messages easier to understand? For example, are photographs, personal stories, or graphs needed? Formats. What is the best way to present your messages? For example, should the messages be in a brochure, a poster, on a Web site, or in a group discussion? Source. Who does your audience trust the most? For example, should the messages come from a doctor, another refugee, or someone else?

Your target audience will either hear your messages from other people (like doctors or speakers at a meeting) or see them in materials you provide to them.

Examples of materials include

• Brochures and pamphlets
  
• Posters
  
• Paid advertisements (magazine, radio, newspaper, and television)
  
• Public service announcements (PSAs)
  
• Web sites
  
• Mailings
  
  Announcements
  
• Videos and DVDs

Developing your own materials can be time consuming and expensive. Therefore, your first step is to see whether materials already exist that communicate your messages. To do this, you will need to explore what others have done. At the very end of this manual, you will find a series of inserts that briefly describe a range of health topics. Each has a list of sources and references you can contact. Start with these. Also, you might want to try a Web search for the health behavior and audience you are interested in. You can also look to the following sources to see what already exist:

• Your State and local health departments
  
• Voluntary organizations
  
• University or public libraries
  
• Health professional organizations
  
• Community-based health promotion coalitions

Before using another group's materials, you should ask Are they accurate? Do they say what you want them to say? Are they right for your target audience? Can the target audience understand them? Could they be changed to fit your audience? Are they available and affordable to your organization?

If no materials already exist that express your message, you will need to first decide which types of materials you need. Then, you will want to develop some draft materials and to test them with the audience members. Stage 3 talks about how you can test your ideas with people from the target audience. After getting input from your audience, you should make changes and then finalize the materials.

Stage 3: Pretesting

Before you finalize any messages or materials, it is important to show them to people in your target audience to see which ones work best with them. This stage is called pretesting. Section 1.2.2 of this manual presents different ways you can ask questions of your target audience about your materials. You might need to go back and forth a few times between development and pretesting as you make changes in the messages and materials to see whether the new approach works.

Depending on your budget, pretesting can range from formal focus groups to informal one-on-one interviews with members of your target audience. You need to decide what is right for you. You should pretest materials only with members of your target audience since they are the people that you want the materials to influence the most. The people you pretest with should be fluent in the language of your materials. They also should not be involved with the development of the materials (since their opinions will be influenced by their involvement).

Important Questions to Explore When Testing Your Materials: Do they clearly communicate what you want people to do? You need to make sure people understand your messages the way that you want them to in order to do the behavior. Do they have the right tone and appeal? Your materials should have the impact that you want them to; if you want them to reassure people, for example, then make sure they are not really scaring them. Do people believe and trust them? Your materials should come from a source that the target audience will want to listen to. Do they get people's attention? Your materials should be interesting and relevant to the target audience. Are they easy to understand? Your materials should be simple and easy to understand.

Stage 4: Implementation

Implementation is when the target audience is introduced to your program for the first time. The best chance for you to be successful is to be prepared. It will be important to monitor how well every part of your program is received to make sure it proceeds as planned.

• Publicize your program. When starting your program, you will want to publicize it to others. Talk it up ahead of time. Make sure you tell your local newspapers, radio stations, and television stations about your program. Give them plenty of notice so that they can fit your story into their schedules. Send them copies of your materials ahead of time, and write a press release to summarize the program's goals and other details (such as a contact person and answers to frequently asked questions). You should also tell health professionals about your program. They can talk about it to others and also help pass out your materials.
  
• Make sure you are prepared. Do you have enough materials to start the program and are they in place (e.g., in doctors' offices, at schools, or both places)? Does your staff understand the details of your program? Are they ready to answer people's questions? Are your partners ready?
  
• Be ready to start tracking your progress. You want to be able to make sure your program is working and working well. At this stage, you should make sure all the ways in which you will be measuring your success are in place. Stage 5 talks about how to evaluate your program.

Stage 5: Evaluation and Feedback

Finally, the evaluation and feedback stage looks at how well your program has met its goals to achieve behavior change. Evaluation occurs throughout the entire program, not just at the end, and feedback is used at each stage to improve the program. Section 1.6 of this manual provides more details on conducting an evaluation of your program.

What Are the 5 P's of Social Marketing?

To understand social marketing, it is important to have a grasp on the principles of commercial marketing, because that is the basis for social marketing. The heart of all commercial marketing can be summed up in what has been termed the "4 P's"—product, price, place, and promotion. With social marketing, these 4 P's are important, as well as a fifth "P"—policy:

1. Product. The product is what you are marketing. For social marketing, the "product" is a certain behavior you are trying to change. For example, the product might be that refugee children in your community will get all the recommended immunizations, or that adult refugees will exercise, or any other behavior that members of your community want to change.
   
2. Price. Here, you are considering how much it will cost a person to stop (or start) a certain behavior. In social marketing, price isn't just a question of dollars and cents. It can also be a question of time (how long will it take out of my schedule?) or effort (how difficult will it be to do the behavior?). A lifelong smoker may be the first person to admit that smoking is an extremely expensive habit but may still say that the costs of quitting—in terms of effort, possible weight gain, or nicotine withdrawal—are too high.

   A good social marketing plan will try to reduce these costs. For example, a smoking cessation group might offer support groups nutrition counseling to counteract weight gain and nicotine patches to reduce the challenges of withdrawal.

3. Place. Place refers to how your health promotion and disease prevention messages reach people in the community. These are also called channels and may include doctors' offices, shopping malls, mass media channels, or in-home demonstrations.

   Section 1.5.2 gives you more information about how to get your messages to the community.

4. Promotion. Promotion is the strategy you use to present your message to people in your community. This strategy may include brochures that you mail, PSAs, health fairs, or other community events.
   
   Promoting your cause does not need to cost a lot of money. It can take place through inexpensive methods, such as word of mouth. Convincing people through a one-on-one conversation can be just as effective at changing someone's point of view as the best-made commercial, or even more so. More detailed information about how to promote messages will be provided in Section 1.5.2.
   
5. Policy. Policy refers to any changes that might be needed beyond the individual level. Social marketing programs can do well in motivating individual behavior change, but that is difficult to sustain if the person's environment does not support the change for the long run. You might need to consider building a bike path, or changing a local law, or building a day care center, for example, before you can expect people to change.

Social Marketing Case Study: Community WIC Breastfeeding Promotion Project This case study was adapted from: Turning Point Social Marketing Collaborative, Centers for Disease Control and Prevention, and Academy for Educational Development. (2003). CDCynergy: Social marketing edition (beta version) [computer software]. Atlanta, GA: CDC Office of Communication. A nonprofit community-based organization in Florida conducted a breastfeeding social marketing campaign for women of low income. The following case study takes you through the steps they used to develop this social marketing program. Stage 1: Planning and Research Identify the behavior you want to change. A nonprofit community-based organization in Florida identified a need in its community that it wanted to address. Women of low income, especially those in the Women, Infants and Children (WIC) program, had lower breastfeeding rates than women of higher socioeconomic levels. The behavior organization members wanted to change was to increase breastfeeding and the duration of breastfeeding among pregnant women in their community who were enrolled in WIC. Identify your audience. They decided to target women enrolled in WIC who had not made a firm commitment to breast or bottle feed and, therefore, were open to the idea of breastfeeding. This group was the primary audience. The secondary audiences were people who influenced these women to breastfeed or not, such as mothers of the pregnant women, fathers of the baby, prenatal health care staff, and WIC staff. Identify the barriers to change. The program identified and focused on the following barriers to change: Embarrassment (of breastfeeding, especially in public) Competing demands on the mothers' time (work, school, or active social life) Confidence in their ability to nurse and nourish correctly No social support and encouragement from family and friends Explore how to reduce the barriers to change. The program manager designed a marketing plan to make a distinction between breastfeeding and bottle feeding (formula). The strategy emphasized the close, loving bond and special joy that breastfeeding mothers share with their babies. Ideas of ways to reduce the barriers included Counseling services for mothers to help them with breastfeeding Print materials for pregnant women and new mothers to use as reminders of benefits, techniques, and places to go for help Radio ads to create a positive, supportive, public environment for breastfeeding and to reinforce women's decisions to breastfeed Training materials and sessions to help WIC personnel become familiar with the goals, design, and materials of the project and to help identify breastfeeding barriers and how to overcome them Policy advocacy to change local laws about public breastfeeding and workplace policies to increase support for breastfeeding mothers in public places and on the job Stage 2: Message and Materials Development Breastfeeding was positioned as a way families can realize their dreams of establishing a special relationship with their children. The campaign slogan—"Loving Support Makes Breastfeeding Work"—and program materials emphasized the role family members and friends play in helping the mother to breastfeed. "Loving Support" also would become the brand under which all campaign activities would be organized. Public information and consumer education materials were developed for each target segment to influence attitudes about breastfeeding and to correct common misperceptions about the "price" of breastfeeding. The materials were developed to reach women in their homes where they could discuss breastfeeding with relatives and friends. Stage 3: Pretesting The campaign messages were revised and pretested using individual interviews in areas where the target audience members could be found (e.g., clinics and grocery stores). Revisions and pretesting continued until it became clear which messages worked most effectively with all the target audiences. As a result of testing, "Loving Support Makes Breastfeeding Work" was selected as the campaign theme because it best captured the necessity of family and friends' support for a mother to initiate and maintain breastfeeding. Stage 4: Implementation The WIC Breastfeeding Promotion project was implemented in the local WIC sites. Each site was responsible for its own implementation of the program. Intervention plans focused on the many settings in which women and their social network members seek information about infant feeding. The "Loving Support Makes Breastfeeding Work" campaign theme used original radio ads and materials designed to reach WIC mothers, their support network, health practitioners, and WIC employees as well as the general public and worksites. These included Three 60-second radio commercials, two in English and one in Spanish Outdoor advertising boards, in English and Spanish Nine posters, targeting the primary ethnic groups in WIC (English and Spanish) Nine educational pamphlets, targeting the primary ethnic groups in WIC (English and Spanish) A motivational and informational booklet for WIC staff A breastfeeding resource guide A breastfeeding promotion guide WIC staff support kit pocket folder to hold breastfeeding resource guide and motivational booklet for WIC staff Local WIC staff managed the interventions at each site. The program managers worked closely with the sites during the campaign's first 18 months to help them implement the program. Stage 5: Evaluation and Feedback The individual sites were responsible for monitoring and evaluating their own programs. Overall, data showed that breastfeeding increased in the sites that implemented Loving Support. However, reports from the State WIC agency identified two important problems: An important secondary audience—prenatal health care providers working outside the WIC setting—needed materials targeted to their special needs. The program failed to reach other ethnic groups not originally targeted. Addressing these problems required the program manager to return to the beginning of the social marketing process. The following strategy was used to fill both gaps: They found another nonprofit community organization willing to pay for a promotional kit to help prenatal health care providers outside of WIC participate in the program. The kit included program information and materials that allowed health providers to participate in the program, patient education materials, and outreach assistance resources to promote breastfeeding and help women manage lactation more effectively. This organization also helped reach other ethnic populations in the community.

Resources: Social Marketing Institute. (n.d.). Success stories: National WIC breastfeeding promotion project. Retrieved from http://www.social-marketing.org/success/cs-nationalwic.html Turning Point Social Marketing Collaborative, Centers for Disease Control and Prevention, and Academy for Educational Development. (2003). CDCynergy: Social marketing edition (beta version) [computer software]. Atlanta, GA: CDC Office of Communication. University of Kansas, Work Group on Health Promotion and Community Development. (2004). Community tool box: Understanding social marketing: Encouraging adoption and use of valued products and practices. Retrieved from http://ctb.ku.edu/ Weinreich, N. K. (1996-2003). Research in the social marketing process. Weinreich Communications. Retrieved from http://www.social-marketing.com/process.html Weinreich, N. K. (1996-2003). What is social marketing? Weinreich Communications. Retrieved from http://www.social-marketing.com/Whatis.html.

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1.5.2 Developing and Disseminating Information in the Community

How Do You Know Whether Your Messages and Materials Are Appropriate for Your Target Audience?

It is very important that your health promotion and disease prevention messages be appropriate for the members of your target audience. Throughout this manual, we stress that you must first understand the point of view of the people in your community for your program to be successful.

Your program also must respect the social and cultural norms of the community. For example, are the images you are using in your messages appropriate? Symbols, metaphors, pictures (including clothing, jewelry, and hairstyles), types of actors, language, and music used in materials are all important things to consider in your message.

Conducting careful research on your audience can help you identify those messages and images that are most important to your target audience and its culture.

You can use several guidelines to make sure your messages and materials are culturally appropriate. The following is a series of questions you can ask yourself. These will help you make sure your program is sensitive to the cultural needs of your target audience.

Ask yourself the following:

• Do your materials reflect and respect the attitudes and values of the community you are assisting? Attitudes and values include
  
  
  • Whether the individual or the community is most important
    
  • Accepted roles of men, women, and children
    
  • Preferred family structure (nuclear or extended)