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Workshop: Preventing Stroke and Heart Disease: Connecting Traditional and Emerging Approaches to Change Behavior

November 12-13, 2009
Executive Summary | Meeting Summary

Meeting Summary


The National Institutes of Health (NIH) is interested in new ideas that transform, improve, and strengthen programs that seek to reduce the risk of heart disease and stroke in the U.S.  NIH’s goal is to make the connection between research results and improvements in public health by helping health professionals design new and better strategies to improve the health of the American public.

To that end, NIH’s National Institute of Neurological Disorders and Stroke (NINDS), National Heart, Lung, and Blood Institute (NHLBI), and National Institute on Aging (NIA) sponsored a two-day workshop titled Preventing Stroke and Heart Disease: Connecting Traditional and Emerging Approaches to Change Behavior on November 12 and 13, 2009.  The purpose of the workshop was to identify strategies for strengthening community education and outreach aimed at reducing the risk for stroke and heart disease.  A key goal was to arrive at a set of recommendations for how current and future efforts can be more successful in prompting and supporting relevant health seeking and risk-reducing behaviors.  Specific objectives were to:

  • Examine lessons learned in supporting health behavior change through community education and outreach interventions and mass communication campaigns;
  • Foster consideration of non-traditional, new, and emerging innovations that hold promise of strengthening and extending reach and impact of community education;
  • Identify gaps and unmet needs in relevant research and evaluation with a focus on what remains to be done and how it can be done better; and
  • Recommend strategies and approaches for enhancing the effectiveness of current and future programs and interventions.

The workshop was chaired by Walter J. Koroshetz, M.D., Deputy Director, NINDS and Lawton Cooper, M.D., M.P.H., Health Scientist Administrator, NHLBI.  Participants included representatives drawn from public health, community programs, the academic and research community, communications and marketing, information technology, and patient and professional organizations.

The first day of the workshop was devoted to presentations that highlighted lessons learned from traditional approaches to community education, outreach interventions, and communications campaigns; examined gaps and unmet needs in public health approaches; and considered new and emerging communication tools and innovations for use in future public health campaigns.  The second day brought together small workgroups to distill content from the first day’s presentations and to advance recommendations for improving and expanding public health programs.


Summary of Day 1

Opening Sessions

The opening sessions focused on overarching successes, lessons learned, and challenges in realizing awareness and behavior change through public health and marketing initiatives, in addition to well-known, large-scale cardiovascular disease prevention programs. 

Panel 1: Key Elements That Have Driven Success and Behavior addressed cross-cutting best practices and program elements in programs and communications campaigns that have proven effective.  Speakers highlighted community involvement and mobilization, policy and environmental changes, and widespread exposure to messages.

Panel 2: Unmet Needs in Community Education and Prevention highlighted key program areas that require more application or research, including an increased focus on policy and environmental changes, a clearer understanding of how individuals use digital technologies, and a need for more effective evaluation.

Panel 3: Insights from Priority and Underserved Communities identified common elements for success in audience-centric programs, as well as audience-specific tactics that have proven successful.  The panel also addressed areas that need further focus and examination, such as effectively addressing barriers to preventive care and building community support.

Panel 4: New and Emerging Opportunities and Innovations focused on identifying new or promising ways of prompting and supporting behavior change.  Speaker presentations addressed how current and emerging technologies, new digital communications, behavioral economics, and commercial marketing and advertising strategies can help facilitate individuals’ health decisions.


Summary of Day 2

Workgroups focused on: policy and environmental level efforts for community change; impact of communications technology on change; designing evaluation for realistic and valid outcomes; and building community support and capacity for prevention programs.  Each workgroup considered the following questions:

  • What are the most promising practices that will improve reach and effectiveness of community education and behavior change interventions targeted to preventing stroke and heart disease?
  • What are the priorities for best practices and new interventions?
  • What are key challenges to success in adopting best practices?
  • What are recommendations for overcoming these challenges?
  • What considerations should be made for targeted outreach to priority and underserved communities?
  • What are strategies for dissemination and adoption of best practices and interventions?
  • What other issues should be considered for more attention and research?
  • What are the three most important things to do?

Recommendations that emerged from the work groups can be found at Work Group Recommendations. 

Elements for Success and Lessons Learned

Panelists looked at key findings from interventions and programs from recent decades and pointed to a number of common insights and key contributors to success as outlined below.

Change is Complex and Ongoing

Changing individual behaviors to improve the societal impact of heart disease, stroke and other chronic diseases has been challenging and elusive for public health professionals.  In a historical review of cardiovascular prevention trials conducted in the 1980s and 1990s—such as the Stanford Five-City Project, Pawtucket and Minnesota Heart Health Programs, COMMIT, and Child and Adolescent Trial for Cardiovascular Health—specific elements that contributed to the success of those interventions were highlighted.  Although small-scale behavior change is feasible, community-wide shifts were much harder to achieve and measure.

Several barriers prevented the anticipated larger-scale changes and posed challenges for evaluating the effectiveness of these trials and others.  These barriers included the influence of secular trends and exposure to other messages and interventions, as well as the need to more carefully target the health problem, address individual audience needs more carefully, employ marketing strategies, and use incremental approaches to program design and development.  

Panelists also noted that changes in public health are rarely permanent.  Individuals focus on challenges at specific points in time and ultimately new generations, leaders, and issues emerge and change the focus.  For example, despite targeted and persistent efforts that resulted in reducing the incidence of actors smoking in movies and reducing initiation of smoking among youth, smoking in movies recently has re-emerged, bringing back the same challenges.  Thus, program planners must consider the importance of continuity, adaptability, and sustainability to achieve long-term change, and devise ways to extend implementation, evaluation, and funding efforts as necessary.  


Change Occurs at Individual and Environmental Levels

A number of panelists focused on the interwoven relationship between an individual and the environment in which they live, and the influence this relationship and context has on health decisions.  This approach has begun to take shape and has become widely embraced in many programs, particularly in those focused on physical activity, nutrition, and smoking cessation.  The Socioecological Model of Health[1] is one theory that frames this approach, which has also been described as a “People and Places”[2] approach.

“People factors” are those that consider people as individuals, social networks, communities, or populations. “Place-based factors” are those products and services that can either promote or undermine health:  1) physical structures (e.g., sidewalks, accessible stairwells, airbags, and traffic lights); 2) laws and policies, such as those mandating seat belts and helmets or tobacco sales; and 3) media and messages that model and recommend behavioral practices beneficial or detrimental to health. 

Panelists strongly urged that programs consider both “people” and “place” factors, in order to achieve broad, population-wide behavior change.  “Place” factors, which are receiving renewed emphasis, also include any structural or systemic elements that can support or undermine health such as physical spaces (e.g., sidewalks, bike paths, and parks to promote physical activity), policies (e.g., seat belt and helmet laws and farmer-to-school relationships), and media and cultural messages (e.g., smoking and drinking in movies targeting teens).

Multifaceted Programs, Including Partnerships, Ensure Broader Exposure and Reach

Panelists addressed the strong need for multiple interventions and communications to repeatedly expose and reach individuals with health messages through media, community outreach and education, environmental and policy change, and partner organizations.  Using multiple tactics and “throwing the kitchen sink” at public health issues affords greater opportunities for reaching audiences.  A multifaceted approach also enables program planners to enhance activities, modify those that are not working, and tailor others to meet the needs and preferences of priority audiences.  The challenge for public health professionals is to design, coordinate, and evaluate multifaceted programs that move different audiences toward behavior change over time.

In particular, a number of panelists cited partnerships as an important part of multifaceted programs that can extend resonance, reach, and resources.  Strategic partnerships can provide access to insights about audiences, as well as access to recognized and trusted community leaders that can serve as messengers.  Partnerships with corporations, foundations, and advocacy groups also have proven effective in facilitating environmental changes that government organizations and others may not be able to achieve alone because of lobbying or funding restrictions. 

Panelists described several campaigns, including the NINDS Know Stroke. Know the Signs. Act in Time. campaign, NHLBI’s The Heart Truth ® campaign, and EX ® the adult smoking cessation campaign created by the Legacy Foundation, as examples demonstrating the power of partners.  The NINDS Know Stroke program has created significant community-based partnerships to increase awareness of the signs of stroke and the importance of calling 9-1-1 to receive immediate medical attention using on-site, lay health educators.  The campaign features a grassroots train-the-trainer program that recruits community leaders—stroke survivors, volunteers, and EMS workers—from across the country to serve as Stroke Champions and educate their local communities about stroke and using NINDS messages and materials.  A culturally adapted, bilingual toolkit developed for promotores (lay health educators) is distributed for community leaders to use with Spanish-speaking audiences.

The Heart Truth ® campaign has established relationships with 53 corporate partners, including the fashion industry, food and consumer products manufacturers, and nonprofit organizations to raise awareness of heart disease as the leading killer of women.  In addition, EX ® is an example of a public-private partnership that was created to fund and sustain a national public education campaign through state and local activities.  Partners include the Mayo Clinic, state health departments, state and local nonprofit groups, national public health organizations, and corporate partners. 

Key lessons learned from these partnerships were:

  • Establishing clear selection criteria and guidelines for working together so that all joint activities stay on-strategy and true to a program’s objectives;
  • Planning to invest the required funding and time to develop and maintain partnerships;
  • Engaging corporate partners by understanding their business goals and how the public health campaign can help to achieve them;
  • Creating visible national events with recognized spokespersons to attract partners; and
  • Recruiting a mix of diverse partners—from government, nonprofit, community, academic, and corporate sectors—to address different campaign needs.


Audience Segmentation Allows for Targeted Interventions

In a dedicated session, panelists described audience segmentation as critical for designing tailored messages and interventions that consider specific audience health beliefs, attitudes, and behaviors.  Effective segmentation recognizes that audiences are not monolithic and that distinct geographic, psychographic, behavioral, and technological variables all play a role in how people seek, process, and act on health messages.  Program planners should evaluate, understand, and pay attention to audience diversity, identify priority or high-risk clusters or sub-groups based on program goals, and develop programs rooted in audience needs and preferences. 

For example, individuals with limited income and education or who are living in rural or inner city neighborhoods often comprise higher-risk communities.  Effective strategies for reaching these communities have included the use of community-based participatory research, enlisting local health services and programs, and introducing environmental changes to facilitate healthy behaviors.  

Additionally, panelists noted that an intervention where uniformed firefighters went door-to-door communicating health messages in a neighborhood may have been successful for a general audience, but may not have worked for a Latino audience, for whom distrust can be a barrier to receiving messengers and health messages.[3]

Panelists cited research demonstrating other variables that impact messages and interventions for Latino audiences, including differences in countries of origin, language dialects and idioms, socioeconomic status, immigration status, and level of acculturation.  In addition to addressing these factors, behavior change campaigns tailored for Latinos should feature health workers and volunteers (promotores) from the community who can share information through message and activities that resonate with this group.   

Panelists also discussed effective strategies for reaching African American communities.  Similar to Latino communities, research has shown that African Americans are often more comfortable and receptive to health messages—including patient testimonials—communicated by trusted members of their community.  Additionally, programs targeting African Americans have shown to be more successful when delivered in familiar, cornerstone environments, such as churches, family gatherings, and community centers.

Understanding how to effectively reach older adults is also vital for helping to prevent and overcome cardiovascular disease and stroke.  Although research has shown that older adults are highly receptive to health messages and interventions, aging-related changes in cognition, vision, and hearing create challenges in how well people understand and act upon health information.  Interventions should address these changes, which include working memory (the ability to simultaneously grasp, retain, and manage new information); perceptual speed (the speed at which an individual processes information); text comprehension (the ability to understand written text); and attentional capacity (the ability to maintain focus and concentration and avoid distractions). 

Youth, too, were described as a priority audience that can be reached early with prevention information.  Messages and activities targeted to youth should consider the various developmental stages of children, tweens, and teens.  For example, young children, in most cases, are influenced to adopt healthy behaviors by their parents, who are their primary source information.  Mothers especially influence their children’s health by ensuring that doctors’ appointments and immunizations are up to date, purchasing and preparing food, and acting as gatekeepers for most health-related decisions.

One challenge for reaching parents is their comparatively low level of concern about prevention of health problems in their children over other issues, such as behavior problems and other immediate needs.  As children age, their parents’ influence decreases.  Tweens and teens are trying out new roles and freedoms, and evolve from the desire to fit in to establishing individuality.  The challenge for program planners is to design interventions that capture the attention of parents and empower them to engage their children as appropriate.  For example, they could offer tweens some mastery over their health choices and connect them with their peers, as well as provide teens with credible, authentic information so they can be responsible for their own health decisions. 

Unmet Needs and Challenges

Although there have been significant changes resulting from cardiovascular disease and stroke prevention programs, a number of challenges remain to achieving broader population level change. 

Progress Has Stalled

Panelists acknowledged that there have been tremendous strides in the prevention and control of heart disease and stroke.  Overall, there has been a dramatic decline in the age-adjusted mortality rate for stroke and heart attacks since 1968, when these rates were the highest[4].  These declines, driven by community-level behavior change programs and interventions, have played a crucial role in expanding the life expectancy and quality of life in the U.S.  Still, the challenge remains of motivating individuals to make healthy choices – especially in the areas of tobacco use, nutrition, and physical activity—because progress has stalled in recent years.

Centers for Disease Control data shows that from 1997 to 2003, smoking prevalence in high school students dropped dramatically from 36 percent to approximately 20 percent; however, there has been no change since then.  In adults, there have been no improvements since 2004, when 21 percent of U.S. adults smoked cigarettes[5].  There also has been no substantial progress toward achieving recommended levels of physical activity.  In fact, between 1995-1996 and 2005-2006, the percentage of adults who engaged in regular leisure-time physical activity or strength training remained unchanged.[6]  Additionally, obesity rates have more than tripled in adults since 1960.  A few decades ago, it was difficult to find a state where the prevalence of obesity was 15 percent; today, it is difficult to find a state where the prevalence is not more than 20 to 25 percent[7].

These lifestyle behaviors—rooted in daily personal choices—are increasing morbidity and mortality from stroke and heart disease in the U.S.  Had these adverse trends not occurred, the age-adjusted mortality from coronary heart disease would have declined an additional 18 percent in the last 20 years[8].  Panelists agreed that gleaning lessons from landmark research studies and community-level behavior change programs, as well as focusing on current unmet needs will lead to new paradigms for renewing and sustaining progress in communities.


Enhanced Understanding of “People”

Following the “people and places” model, the panelists addressed the need for greater understanding of the cognitive and cultural factors that influence individuals’ recognition of heart attack and stroke symptoms, health seeking behaviors, and preventative health behaviors.  They also pointed out that increased understanding of the individuals overall decision-making process, the premise of which is rooted in behavioral economics, is necessary to discover factors that motivate people to act in certain ways.  Key learnings about motivators should drive strategies, messages, interventions, and systems changes aimed at specific audiences—whether bystanders, early adopters, or members of a specific multicultural community.

For example, before patients or bystanders recognize an event such as a heart attack and call 9-1-1, they first experience a “pre-hospital delay,” whereby they identify that a medical event is happening and it is severe enough to require medical attention.  This is followed by the decision to seek care and arrange transportation to the hospital or doctor’s office, whether it is by calling 9-1-1 or choosing to self-transport.  According to the American Heart Association and the American Stroke Association, the longest phase of the pre-hospital delay is at the beginning of an event, when patients or bystanders recognize symptoms and decide to seek care[9].  Panelists pointed out that messages and interventions are needed to enable individuals to move more quickly from awareness of symptoms to seeking immediate, appropriate medical treatment.

Socio-demographic variables play a role in this timing.  For example, individuals at a lower socioeconomic status and persons who are older are more likely to delay calling 9-1-1.  Research also shows that Latinos and African Americans often delay calling 9-1-1, possibly because of mistrust or fear.  Additionally, some people may be receiving insufficient or incorrect information to help them recognize stroke or heart attack symptoms and may not know how to respond because translations are incorrect or incomplete, or because they are not receptive to hearing these messages from people outside of their communities.  Panelists agreed that, in order to be successful, planners of community-wide prevention and awareness campaigns need to better understand and address these distinct target groups—including their cultural beliefs, health literacy, and language nuances.

 Successful Change in “Places”

“Places” also play a critical role in reversing heart attack and stroke-related behavior trends.  Although individual behaviors are key, panelists agreed that the environment in which individuals live, eat, work, and play should provide systems, support, and resources to facilitate healthy behaviors.  For example, families may want to be more physically active and eat more healthfully; however, they may not have easy access to safe parks or low-cost, fresh vegetables.  This may be because of limited investments in recreational facilities or constraints placed on local farmers, who find it more cost-effective to limit their distribution to a few select retailers or farmers’ markets.  In addition, families may have to travel farther to access stores with a variety of healthy foods because they live in a “food desert”—areas overrun by fast food restaurants but lacking quality grocery stores because of zoning laws.

Panelists agreed that these complex systems are all social determinants of health and should be addressed through environmental and policy changes and partnerships to have a positive impact on population health.  The need lies in educating community health leaders about how to work together to navigate the policy environment, work with policy makers at all levels, and devise innovative, creative solutions to systemic challenges.


Online Collaboration and Digital Communities

More than ever, individuals are using digital technologies to find health information, track behaviors, and make decisions related to their care.  Tools and applications ranging from downloadable factsheets to widgets and electronic cards (“e-cards”) have enabled the health community to quickly and cost-effectively tailor information for specific audiences and virally disseminate messages and materials.  Still, while significant advances have been made in keeping up with social media, panelists agreed there should be increased focus on understanding how and why different audiences use different technologies to leverage the communal nature of many online mediums and build applications into health promotion strategies that are part of individuals’ daily lives. 

For example, CDC’s Division of e-Health Marketing, a leader in digital communications, created the Know It mobile texting campaign to reach the growing population of individuals receiving health messages on their mobile phones.  This includes African Americans, Hispanics, and persons with chronic health conditions who may not have broadband at home, but who instead access online sites using their phones.  Through this campaign, individuals who want to know their HIV status can text their zip code to a specified code and receive information about the nearest testing center. 

This mobile application is part of a larger integrated campaign that uses a mix of social media to do more than deliver information.  E-cards, banner ads, and digital badges— widgets that individuals place on their MySpace or Facebook pages to show that they know their HIV status—are intended to stimulate communication about HIV and inspire others to get tested.  Panelists agreed that this type of online collaboration and peer influence is powerful and needs to be applied more through blogs, social networking pages, virtual worlds, and other high-use resources.  

More Effective Evaluation

A common theme among the panelists was the need for more effective evaluation of community studies to accurately assess the value of different strategies and inform the development of larger-scale or longer-term programs.  Given the sophistication of many integrated interventions—which can include elements as varied as peer outreach, mass media, and web-based tools—a key challenge lies in teasing out and comparing the effects of specific components.  Panelists agreed that it is important to understand the synergistic impact of these components.  However, program evaluation should be designed so that they can be “unpacked,” examined, and re-stacked to determine impact.

Another challenge is the environment in which studies are conducted.  Individuals in open community studies, for example, may be influenced by spillover messages from external sources such as the media, family and friends, other campaigns or interventions, and other community sites.  At the same time, randomized controlled trials, including clinic-based trials where small groups of patients are brought together, force exposure to specific types of health information and attitudes.  These “false environments” remove outside influences and consist of limited conditions that can skew health intentions and behaviors.  There is a need to recognize and address the limitations of both types of environments before they are replicated on a larger scale.

Timing of interventions in community studies also is important.  Information to help individuals make healthy choices is often provided to them “just in time,” or when they are most receptive to receiving the information because they are actively seeking it out.  Just-in-time interventions include healthy recipe cards that are placed next to specific products at grocery stores or websites that provide instant access to health information and tools.  Panelists noted that these types of interventions can be effectively implemented and evaluated, but they also encourage researchers and campaign planners to consider interventions at riskier moments.  The Stanford Heart Disease Prevention Program, for example, was cited for its success in helping individuals maintain healthy eating behaviors simply by using refrigerator magnets to remind them of their goals. 

Panelists also noted that the sequence of interventions in community studies needs to be considered.  Knowing that effects dissipate over time, researchers should decide from the outset what type of intervention to start and how to ensure that messages are refreshed or remain top-of-mind throughout the study.  This includes following up with a phone call, releasing a new, complementary message, or placing a related story in the media.

Timing of evaluation efforts presents another challenge.  Panelists discussed that measurements should be taken at multiple points throughout a study rather in two—pre- and post- phases in order to more accurately capture trends and data that can be used in comparative analyses.  The need lies in determining the best times to conduct assessments, allowing sufficient time for interventions and messages to take effect, and also corresponding with deadlines of short-term studies.

Finally, panelists discussed studying the effects of viral messages.  They agreed that this is a new area for researchers and that new methodological limits are being identified as these types of interventions are conducted and assessed.  Preliminarily, program planners review metrics, such as usage statistics, to ensure that new media tools are raising sufficient traffic to validate their investment.  However, in the long term, planners will be interested in knowing how people are reacting to viral messages.  They will need to address the unique technological barriers, sampling limits, and self-reporting limits that make it challenging to measure the effects of digital activities.


New and Emerging Approaches

A number of new disciplines and novel research interventions have emerged in recent years that are forcing public health professionals to take a new look at developing programs designed to effect change.  Public health campaigns are evolving at a rapid pace.  New marketing techniques and media technologies are changing the way that health information is communicated and received.  Panelists agreed that these emerging approaches should be factored into interventions and behavior change programs to increase their reach and impact. 

A New Wave of Policy Influencers

As discussed, “places” play a key role in facilitating healthy behaviors and reversing prevalence and mortality trends.  Panelists agreed that health issues should be viewed systemically and that creative, structural solutions should be proposed in areas where health promotion policies do not exist.  One model to draw from is childhood obesity, which now is recognized as the outcome of many complex, adaptive systems.  Researchers, policymakers, health professionals, and industry professionals understand that the problem cannot be addressed in a linear fashion. 

Factors such as exercise environments, access to healthy foods, transportation systems, land-use planning systems, and school meals must all be evaluated and financed.  In some lower-income cities with large academic communities such as Philadelphia, for example, universities and high schools are beginning to open their athletic facilities so that local youth, who do not have access to safe, quality parks, can play and exercise.  Across the country, program planners also are working with local and state policymakers to provide incentives to farmers, allow debit cards and food stamps to be used at farmers markets, and build developments with more sidewalks, bike lanes, and access to public transportation.

A first step in this type of systemic change is bringing together leaders from different segments – community, academia, public health, government, and industry – to: 1) increase their recognition of their role in community health; 2) share perspectives about what works in current national, community, and state-level programs and policies; and 3) determine how to apply best practices locally.  Leaders from grassroots and on-the-ground organizations, such as parks and recreation departments in particular, should be heavily involved in this process because they have a significant understanding of the messages and activities that motivate or deter their communities.

Community action guides, including those produced by the Partnership for Prevention, offer guidance to help these types of working groups build partnerships and leverage their unique skill sets and networks for systems change.  Community guides also provide practical information to help local leaders modify their environments for health by creating new opportunities (e.g., new places for physical activity) and building on existing resources (e.g., raising awareness of and increasing access to current parks). 

New Ways to Prompt Healthy Individual Choices

Panelists also discussed individual decision-making and strategies for prompting health choices.  Behavioral economics, which merges psychology and economics, offers a new lens for examining why individuals adopt certain behaviors and how concepts of moral compassing, convenience, default, self-control, and limited attention can be factored into planning successful interventions and programs.  This theoretical approach shapes many of the ideas put forth in the book Nudge by Richard H. Thaler and Cass R. Sunstein [10].

Panelists cited examples of subtle contextual factors—“nudges”—that can have a significant impact on prompting individuals to adopt certain behaviors.  For instance, behavioral economists found higher rates of organ donation in countries where individuals had to sign cards not to donate, and higher rates of savings among employees who had to opt-out of participating in their retirement savings plans.  They also found that text messages reminding diabetics to take their insulin were critical for gaining a patient’s attention, especially among a cluttered “attentional sphere,” and increasing adherence to this behavior.  Additionally, loss aversion was used to encourage patients to take daily medications in an intervention that used a lottery system.  Patients who took their medicine entered into a lottery and received a potentially winning ticket; patients who did not take their medicine received tickets telling them what they could have won. 

At the same time, behavioral economics can be used to manage the tension between health and cost in larger-scale programs.  As an example, co-payments in health insurance systems are used to dissuade over-utilization of unnecessary services, but they may lead to procrastination and underutilization by patients who cannot pay for critical services.  Another challenge that can be navigated by behavioral economics lies in increasing the involvement of business and industry sectors in community health.  Panelists noted that incentives should be realigned and provided to these sectors so that they are motivated to research and participate in health promotion programs. 

New Marketing Techniques and Technologies

Marketing techniques have also advanced with the emergence of new perspectives and communications tools.  Panelists noted that traditional strategies such as targeted messaging and materials, community outreach, mass media, and partnerships remain at the core of health education campaigns.  Despite this, they have nimbly developed alongside cultural (e.g., savvier consumers) and technological advancements (e.g., social networking) and now include tactics as varied as text messaging and virtual world outreach.

Panelists agreed that the central component of any behavior change campaign or program should be a strong brand.  More than a logo or tagline, a brand is an expression of the “face” that a campaign seeks to present publicly and of the promise and value that it will provide to audiences.  The Red Dress®, which represents the NHLBI’s The Heart Truth ® campaign, is an example of an effective brand that brings to life the mission of raising awareness that heart disease is the leading killer of women in the U.S. and motivating women to adopt heart healthy behaviors.  The Red Dress® symbol has gained strength through consistent application across the campaign’s many elements – partnership with the fashion industry, placement on food and beverage products, in all messages and materials – and has become the symbol for women and heart disease awareness.

New media tools can be used to spread brand messages rapidly and to a wide spectrum of audiences.  Panelists pointed out that digital activities should be a regular part of behavior change programs and should focus on the tools that target audiences use in their daily lives.  CDC, for example, conducted a seasonal flu campaign for tweens in “Whyville,” a virtual world for tweens.  To highlight the importance of getting a flu shot, CDC infected the Whyville community with the flu.  Avatars, or individuals’ virtual selves, were sick, sneezed frequently, and had dots on their virtual bodies.  Word spread immediately throughout the community that this could be prevented by getting a flu shot, and individuals lined up to become vaccinated in Whyville. 

Other untapped resources include YouTube videos, which can be tailored for specific populations and disseminated widely and rapidly; and photo sharing sites such as Flickr, where some audiences are already documenting health stories such as chemotherapy and heart attack recovery with raw footage from their lives.  These images and messages, shared virally, facilitate communication and interactivity and build a sense of community around a common cause.  They also empower individuals to make decisions about their health, serve as advocates, and disseminate information to others.

Although panelists agreed that it is important to “push the envelope” with new strategies, they also emphasized the importance of staying on strategy.  Before deciding to implement an intervention or communication tactic, program planners should confirm that it follows a campaign brand and strategy.  Otherwise, they run the risk of expending valuable time and resources on activities that may yield misaligned results.


New Ways of Partnering With Industry

Partnerships, including those with industry, have long been part of health education and behavior change programs.  Panelists agreed that today’s public-private partnerships should leverage the industry mindset of being financially successful while also being socially responsible.  They discussed new ways of partnering with industry, including research exchange, product reformulation, and policy advocacy.  One model to draw from is the Foundation for NIH’s Biomarkers Consortium, which brings together the expertise and resources of government, nonprofit, and industry groups to study new biological markers to accelerate the diagnosis and treatment of a range of diseases. 

Food and beverage companies, in particular, play a critical role in risk factors for stroke and cardiovascular disease, including obesity and diabetes.  They have unique insights into how and why consumers make purchasing decisions that have an effect on their health.  For example, they understand why consumers will buy a can of soup with a high amount of sodium despite their knowledge about heart health.  Panelists agreed that this consumer insight should be channeled and integrated into interventions and communications, while also driving the sales of heart healthy products.

Industry also has the resources to investigate how products can be reformulated for health, whether it is by decreasing or increasing specific ingredients.  Coupled with the scientific knowledge and oversight of agencies such as NIH and CDC, this research can help advance the development and marketing of healthier products.  The World Health Organization, too, is working with industry conglomerates, including PepsiCo, Kraft Foods Inc., and Nestlé, to implement the Global Strategy on Diet, Physical Activity and Health.  Together, these organizations are applying their resources to develop and implement strategies such as improved food labeling so that consumers can be better informed about the benefits and content of foods.

Panelists agreed that industry can also be a leader in environmental and policy change.  A leader in this area is PepsiCo, which is working with food and credit card companies in Chicago to develop a protocol that will track and reward consumers’ healthy purchases.  They are also working with the Clinton Foundation and American Heart Association to minimize sugar-sweetened beverages in elementary schools, and with the Healthy Weight Commitment Foundation—a consortium of 40 of the nation’s largest food manufacturers, retailer, non-profit and other groups—to encourage behavior change in the marketplace, workplace, and schools.

Finally, panelists pointed out that working with industry requires management of the tension between health and cost.  For instance, reducing sodium in a product may decrease sales and thus not be financially viable.  Incentives for food and beverage companies that reformulate products and marketing strategies for health were discussed as a possible motivation.  Panelists also noted that a comprehensive, coordinated approach backed by multiple industries has the potential to lead to true and lasting environmental change.

Work Group Recommendations  

During the second day of the workshop, panelists and participants convened in workgroups to review and reflect on the first day’s presentations and offer recommendations based on lessons learned, unmet needs, and emerging ideas and technologies.  Workgroups addressed policy and environmental level efforts for community change, impact of communications technology on change, designing evaluation for realistic and valid outcomes, and building community support and capacity for prevention programs.  Specific recommendations that emerged from the workgroups and during the course of the two-day workshop are outlined below.  

Recommendation: Cultivate public-private partnerships and increase collaboration with government, community, policy, industry, and academia.

Participants agreed that partnerships extend program reach, resources, and resonance.  Whether with corporations, foundations, or advocacy organizations, partnerships enable behavior and environmental changes that government may be unable to achieve alone (e.g., funding, lobbying, access to industry consumer insights, advertising reach, and product reach).  Although public health professionals must carefully weigh the pros and cons of certain types of partnerships (e.g., corporations and trade associations) and set clear guidelines, a thoughtful and aggressive partnership strategy has the potential to break through the competing “noise” in the marketplace. 

Participants suggested that today there is a generation of industry leaders that seeks to be socially responsible while being financially successful.  While competitive issues must be addressed in any industry, panelists believe that many corporate leaders (e.g., food, pharmaceutical, fitness, and retail) are ready to join public health professionals to bring about behavior changes to prevent CVD and stroke. 

In addition, participants recommend building on existing coalitions and collaborations to recruit more members from agencies and organizations representing government, nonprofit, foundation, and corporate sectors.  These additional partners may offer credibility, support, expertise, and resources to champion policies and communicate those policies to different decision-makers across sectors.  Examples of existing successful collaborations include:  National Forum for Heart Disease and Stroke Prevention; Healthy People 2010 MOU partnership; Center for Tobacco Free Kids; Alliance to Build a Healthier Generation; Commission to Build a Healthier America; a number of programs funded by the CDC, such as the Strategic Alliance for Health, REACH, and ACHIEVE; multi-stakeholder coalitions that seek to increase access to healthy foods in communities;  Kellogg Foundation’s Food and Community program; and a number of Robert Wood Johnson Foundation programs. 

Additional recommendations for increasing and best utilizing collaborations among groups in all sectors were to:

  • Build a base of resources, expertise, and support, and attract additional organizations that can offer credibility, expertise, and channels for distribution of messages and materials;
  • Engage leaders at national and community levels who resonate with priority and underserved audiences and who can serve as trusted messengers of health information; and
  • Enhance the strength of clear, unified messages and calls to action among multiple partners and avoid conflicting or confusing information about cardiovascular disease and stroke prevention.


Recommendation: Focus on policy and environmental change for broader social change. 

In order to create a prevention culture, participants agreed that public health professionals need to focus both on environmental and individual change.  Public policy changes provide the “push” that creates an environment receptive to healthy behaviors while individual interventions provide the “pull” that leads to individual behavior change.  Panelists used the “people and places framework” to explain how communication and marketing can be used to advance public health objectives.  Communication, the provision of information, can be used in complementary ways to foster beneficial change among both people (e.g., activating social support for smoking cessation among peers) and places (e.g., convincing city officials to ban smoking in public venues). Similarly, marketing—the promotion of products and services—can be used to foster beneficial change among both people (e.g., by making nicotine replacement therapy moreaccessible and affordable) and places (e.g., by providing city officials with model anti-tobacco legislation that can be adapted for use in their jurisdiction).

Panelists concluded that while people and places are inextricably linked, public health professionals are just beginning to recognize the significant influence of place on behavior change.  Public health coalitions, collaboratives, and consortia are working at changing the way people live by changing community design and focusing on policy, environmental, and systems changes—for better food, fitness, access to care, and a change in the health paradigm from illness to wellness.  Behavior change programs need to work on national, community, and state-level program and policy initiatives that are integrated with individual change efforts.  In addition, public health professionals need to examine the health implications of policy decisions to promote a culture of prevention.  Most important is being able to convince legislators on the Hill, city or county councils, or mayors that health truly makes a difference and it is necessary to translate some of the research into a compelling narrative to make it salient and important to policymakers. 

Further, participants acknowledged that research, communications, and policy efforts to prevent CVD and stroke are discrete and sometimes disconnected, thus stakeholders do not speak with one voice and their impact is weakened.  Developing national priorities for research and a single national agenda for public policy and environmental change is seen as critical to significantly advancing prevention of CVD and stroke.  

Additional recommendations included:

  • Focusing on legislative efforts (e.g., taxes on tobacco and bans on soda machines and fast food in public schools); local zoning changes (e.g., include more parks, sidewalks, green spaces, and bike trails to promote exercise); and building incentives (e.g., to attract farmers markets, grocery stores into “nutritional deserts,” or health care  into rural areas or urban neighborhoods);
  • Developing a policy development toolkit to help partners navigate the policy environment, advocate for changes, and promote activities to prevent CVD and stroke.  The toolkit would offer guidance for translating research and data into a salient and compelling story for the media, policymakers, advocates, and other stakeholders (e.g., story and photos of parks with garbage and broken swings with children); and
  • Supporting employee health and wellness policies that advance a more comprehensive approach to behavior change.

Recommendation: Engage priority and underserved communities.

Key recommendations for better serving priority and underserved communities focused on engagement and health equity as two major areas.  Engagement is a commitment to obtaining community involvement in developing and conducting interventions from planning and implementation to evaluation.  Creating health equity involves establishing a level playing field by examining what causes health inequity (e.g., myths, biases, culture, language, and late adoption) and the importance of the role of place, community, and neighborhood to change.

Further, intervention approaches must be rooted in culture, social norms, social environments, socioeconomic status, social class, and the support systems surrounding communities.  Panelists emphasized the special challenges of driving behavior change to prevent stroke and CVD in communities that are ethnically, racially, socioeconomically, and age diverse.

Additional recommendations included:

  • Recruiting community organization partners to represent target communities and participate in planning, design, formative research, implementation, intervention delivery, and evaluation of behavior change programs;
  • Engaging in conversation with the community to identify beliefs, biases, and health literacy to ensure message comprehension and culturally sensitive content;
  • Identifying familiar and non-intimidating environments in the community to deliver messages (e.g., churches, community centers, family reunions, health fairs, and screenings) that require little or no expenditure of limited individual and community resources;
  • Training community change agents to conduct or assist in public health interventions as community health workers; and
  •  Promoting collaborative leadership models and sharing resources.


Recommendation: Obtain adequate funding from a variety of sources, including foundations and corporations.

Program funding was a key issue raised throughout the workshop.  Panelists and participants discussed the logistical and systemic challenges that occur when funding runs out.  They suggested that program planners seek funding from a variety of sources to extend the length of time and types of activities that can be covered.  They also recommended seeking funding from multiple organizations that align with particular elements or phases of a campaign – such as planning, mass media outreach, and social media implementation.  An additional recommendation was to establish larger partnerships with these organizations so that additional significant activities may be pursued together, such as lobbying for environmental changes and embarking on larger community-wide research studies. 

Additional recommendations include:

  • Cover gaps in funding that expires—participants recommended that grants should be extended beyond their usual five year limit because many behavior change programs take many years to show effects;
  • Distinguish formative research, partnership development, policy development implementation, and evaluation costs to provide a more accurate picture of the funds needed to develop and implement a behavior change program; and
  • Align with organizations that have similar missions and goals and pursue more involved partnerships that include lobbying for environmental changes and sharing resources.

Recommendation: Harness the power of new and emerging communication tools.

Participants recommended that public health professionals embrace “Web 2.0” technologies that focus on engagement, online communities, collaboration, user generated content, and new and innovative applications to efficiently and effectively communicate health messages about stroke and heart disease.

Despite this, they agreed that the use and messages communicated through these types of activities should be highly tailored to meet the needs, interests, and social media habits of key audiences.  They also agreed that new media technologies should not take the place of traditional forms of communications, but should augment them and provide additional channels for reaching audiences with the tools already in use. 

Recommendations included:

  • Reaching target audiences effectively through the technologies they use the most (e.g., Facebook, Twitter, mobile phone);
  • Using new and emerging technologies to communicate, add onto existing networks, and build new ones;
  • Recognizing that the quality of messages and dialogue are more important than their quantity when using technologies such as Facebook and Twitter;
  • Consider the power of mobile phone interventions, for which there is evidence of effectiveness.  These interventions enable campaigns to disseminate information to multiple segments of the population and provide reminders to enhance periodic behaviors and adherence (e.g., take a walk at two o’clock; take medicine at three o’clock);
  • Evaluate the reach and impact of new and emerging technologies; and
  • Monitor changing trends to identify new ways of communicating with target audiences.

Recommendation: Develop more effective evaluation measures.

Evaluation of behavior change programs was another central topic discussed by panelists and participants.  Focus should be on identifying and examining specific elements of an intervention, as well as understanding which elements are succeeding in motivating audiences to change their behaviors.  Evaluation activities should be conducted and measurements should be taken at more regular intervals rather than just at the start and end of a campaign.  These measurements should assess actual behavior change rather than just knowledge, which is not a strong proxy for behavior.

Finally, a new layer of evaluation should be included to study and better understand the effectiveness of policy and environmental changes in prompting better personal health choices, leading to greater health outcomes. 

Specifically, panelists agreed that evaluation of interventions and programs should:

  • Design evaluation with established theories of learning in mind;
  • Allow different elements (e.g., one-on-one interventions and mass media) to be unpacked and examined to identify those that can be discarded, modified, or retained;
  • Focus on incremental measurements throughout a program rather than at just beginning and end.  Desirable points for evaluation, in order of priority, include:
    • Reducing incidence of CVD or stroke (e.g., incidence, recurrence, death);
    • Disease treatment (e.g., tPA and cardiac catheterization);
    • Risk factor change (e.g., lower blood pressure and BMI);
    • Behavior change (e.g., exercise, health food choices, medical adherence, and arrival time to ER);
    • Behavior intention (e.g., plan of action, skill set, and self-efficacy); and
    • Knowledge (e.g., patient, family, and medical community).
  • Include assessments of policy and environmental changes to determine their efficacy, scalability, geographic applicability, and sustainability; and
  • Include a component for translating and disseminating findings for practical use:
    • Participants recommended that findings be housed in a central location, such as the Center for Excellence for Training and Research Translation, so that campaign planners can have access to successful intervention models.


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Last Modified October 18, 2015