Step 1.1 Write a problem statement.

In 1989, there was an outbreak of severe diarrhea among African American infants in Atlanta, Georgia. It was caused by the bacteria Yersinia enterocolitica (YE) contracted through exposure to chitterlings (pork intestines or “chitlins”), a traditional dish served at Thanksgiving and Christmas. More than 90 percent of ascertained cases were in the African American population.

Symptoms of YE are fever, abdominal cramps and diarrhea (which was sometimes bloody); they begin 3-7 days after exposure. There were cases of young children requiring hospitalization due to YE infections, and YE-related fatalities. The 1989 outbreak was just one of a cycle of YE outbreaks that occur during the winter holiday season each year.

In November and December 1989, the Epidemiological Prevention Office of the Georgia Department of Human Resources (GA-DHR) began an informational intervention including flyers and short lectures, in an attempt to prevent another YE outbreak. The intervention emphasized hand washing and protecting children from exposure by removing them from home or the place of chitterlings preparation. The information was disseminated in metropolitan Atlanta through the Women, Infants and Children (WIC) group nutrition education program. By 1996, after several years following the trend of YE infections, the data showed that annual holiday season outbreaks had continued despite the WIC-based intervention.

In August 1996, the GA-DHR, the Georgia Division of Public Health Epidemiology and Prevention Branch, and the Georgia Office of Minority Health decided to try a pilot social marketing approach to prevent the next holiday outbreak of chitterlings-associated YE diarrhea cases in African-American children.

Step 1.2 List and map the causes of the health problem.

YE outbreaks were usually associated with the consumption of chitterlings, served as a traditional holiday food in the southern United States. While the infants were not old enough to eat chitterlings, they nevertheless became ill.

Step 1.3 Identify potential audiences.

With the preparation of chitterlings recognized as the point of transmission of the YE bacteria, the target audience of older African-American mothers and grandmothers and the possible behavioral objectives (the preparation methods and removing children from the preparation area) were identified early on.

Step 1.4 Identify models of behavior change and best practices.

The Health Belief Model led planners to identify the relevant beliefs of the target audience about the health problem and related behaviors. These beliefs included:

• Perceived personal susceptibility to a health threat. The women did not perceive that the children to be susceptible to any health threat during the traditional preparation of chitterlings.
• Perceived severity of the condition. While the women in this case recognized the severity of the children’s illness, they did not see how they could prevent it.
• Perceived benefits of a particular behavior in dealing with the condition. From the preparer’s point of view, is there a more healthy way to prepare the chitterlings that would result in a tasty dish AND keep children healthy? What benefits of this behavior would the women identify?
• Perceived barriers to that behavior. The women were accustomed to following traditional and cultural preparation methods. What barriers or costs of a new behavior would they identify?

In addition, the Diffusion of Innovations theory was used by the program planners to ensure that any new product (e.g., pre-boiling as the best way to prepare chitterlings) would spread through the African American community and between generations. Thus, communicating the advantages of pre-boiling (easy, faster preparation, no impact on taste, healthier) in messages was important.

In addition, this model led planners to consider personal and social characteristics—including age, knowledge and culture—that play roles in whether or not people modify their behavior.

Self efficacy and modeling the behavior, both central to the Social Cognitive Theory, also applied to the intervention.

Step 1.5 Form your strategy team.

• The program manager in the Georgia Department of Human Resources (GA-DHR) coordinated the effort between the Georgia Division of Public Health, Emory University, and the Georgia Office of Minority Health. The Office of Minority Health assisted in developing materials and provided gatekeepers' contact information.

Step 1.6 Conduct a SWOT analysis.

Strengths

• Campaign grounded in science-based research results
• Lessons learned from the earlier campaign informed this campaign

Weaknesses

• Extremely small budget ($25,000)
• Truncated time period—just three months before the next holiday season—to develop and implement the campaign

Opportunities

• Partnering organizations had access and credibility with the target audience and gatekeepers

Threats

• Target audience had long-term cultural traditions they used for chitterling preparations
• Preparers did not see a link between children's illness and preparation of chitterlings
• Issue was not on the radar screen of the target audience or stakeholders, including health care professionals and the media
• Community sensitivities to government involvement in local issues and hesitancy of government officials to target the community.

Step 2.1 Define your research questions.

The major research questions for the target audience were:

• How do you think the bacteria is being transmitted to small babies?
• How can transmission be prevented?

Step 2.2 Develop a market research plan.

Due to the extremely small budget, the research was planned and conducted using in-house staff.

A cost-effective research plan was developed to understand the audiences(s) and the environment. The plan was to:

• Review literature on medical, epidemiological, microbiological, and agricultural (pig/port) studies
• Conduct phone and individual interviews with pork producers and with food safety experts at the US Department of Agriculture, the Food and Drug Administration, and the Centers for Disease Control and Prevention
• Conduct community focus groups in a retirement center, a clinic waiting room, a grocery store, and at churches

The research plan included the research questions, methods and design, timetable, staff, responsibilities and budget. The strategy team, audiences and community gatekeepers reviewed the research plan before the research was conducted.

Step 2.3 Conduct and analyze market research.

During the focus groups, participants were informed about the annual YE outbreaks and findings from the literature review. Participants were then asked to discuss their preparation and hygiene practices, how they thought the bacteria was being transmitted to the children and what could be done to prevent transmission.

The preparation methods suggested by the focus group participants were later evaluated for their acceptability to the target audience in in-home cleaning and cooking trials. Barriers to acceptance of the interventions were assessed via follow-up phone interviews.

The methods were also tested in laboratory studies for their effectiveness in removing the threat of bacterial infection. The Georgia State microbiology laboratory tested the presence of YE bacteria in commercially available chitterlings before and after using the suggested preparation methods.

Step 2.4 Summarize research results.

Due to the small budget and the informal nature of the market research, a formal report of the findings was not written. However, records of important findings were maintained.

Literature review and expert interview findings
YE bacteria is unique in that it grows well in cold temperatures and will grow on plastic and other surfaces – major contributors to bacterial transmission.

Focus group findings

• Confirmation that many of the preparers were older African-American women who, as grandmothers and older mothers, often were caregivers for infants. It also revealed the strong cultural traditions surrounding chitterlings preparation, with holiday preparation recipes passed down through the generations.
  
• Participants perceived no risk of YE transmission during their customary preparation of chitterlings.
  
  
  • Although they acknowledged chitterlings as “dirty” with the potential for causing disease, many considered their individual hygiene and preparation habits effective.
    
    
  • The perception of risk was further diminished because of the long incubation period from preparation time to the time that symptoms appeared. Also, the most adversely affected were infants and children who did not consume chitterlings so participants did not see a direct connection.
    
    
• Keeping children out of the preparation area would be burdensome because they did not always have someone to watch the children.
  
  
• Women identified hygiene breaks, either during refrigeration or during the long hours of cleaning the chitterlings, as the likely window for transmission to children. The hygiene breaks varied but were included in each preparation story.
  
  
• When asked about potential preparation methods with the potential for preventing YE transmission, participants reached consensus on two methods:
  1. Washing chitterlings in a low concentration bleach/water mixture during cleaning
     
     
  2. Briefly pre-boiling chitterlings before cleaning
     
     
• Participants expected that adopting new preparation procedures would affect the taste of the chitterlings. For example, pre-boiling would “boil in the dirt.” However, the women identified prevention of bacterial infection in the children as a benefit of changing their behavior.
  
  
• Influencing audiences were identified as community leaders/gatekeepers:
  • Pastors and church leaders
  • Retail grocery associations
  • Chain grocery stores
  • Pediatric hospitals
  • Health care providers

In-home cooking trial findings

• Perfect hygiene was nearly impossible to maintain during preparation
• Pre-boiled chitterlings were easier and faster to clean than raw chitterlings, and did not taste different than chitterlings cleaned without pre-boiling.

Microbiological study findings

• While commercially available chitterlings varied in the levels of bacteria they contained, all had some risk of YE exposure.
• Of the two preparation alternatives for chitterlings—bleaching and pre-boiling—the pre-boiled method eliminated all of the potential bacterial from the chitterlings and thus from the refrigerator and entire kitchen area during and after the cleaning process.

Step 3.1 Select your target audience segment(s).

Target segment audiences were as follows:

• The primary target audience was chitterlings preparers - older African-American women in metropolitan Atlanta who, as grandmothers and older mothers, were often caregivers for infants and small children.
• Community leaders/gatekeepers were the secondary audience:
  • Pastors and church leaders
  • Retail grocery associations
  • Chain grocery stores
  • Major pediatric hospitals
  • Health care providers
  • Media

Step 3.2 Define current and desired behaviors for each audience segment.

See Table of Audiences, Current Behaviors, and Desired Behaviors.

Step 3.3 Describe the benefits you will offer.

The program offered these benefits to the primary target audience:

• Keeping their children and grandchildren healthy
• Being "good" mothers and grandmothers or caregivers for the young children in their families
• Preparing the chitterlings faster with no impact on taste
• Having confidence in protecting their family while maintaining cultural traditions
• Being viewed in the community as knowledgeable in solving health problems (the grandmothers are positioned as the source of information for this new preparation method).

Step 3.4 Write your behavior change goal(s).

Atlanta’s African American grandmothers and older mothers who prepare chitterlings for the winter holiday season will pre-boil their raw chitterlings before cleaning them in exchange for keeping their grandchildren and other young children healthy.

Step 3.5 Select the intervention(s) you will develop for your program.

See Table of Target Population, Product, Price, Promotion, and Place.

Step 3.6 Write the goal for each intervention.

• Increase knowledge of YE risks in young children from chitterling preparation.
• Increase awareness of pre-boiling alternative and benefits.

• Lend third party credibility to the message that young children are at risk for YE from chitterling preparation and that the solution, pre-boiling, will not impact taste.

• Increase awareness of YE caused by chitterling preparation in order to stimulate simple prevention messages.

Step 4.1 Select members and assign roles for your planning team.

Planners may have assigned roles as such:

• Chitterlings preparers, community organizations to develop content and message
• Student from local high school or university to design cartoon and flyers
• Local business to provide printing
• Grocery stores to post flyers
• Churches to post flyers
• Organizations with bulletins, such as local phone books, local ad newsletters, churches to include bulletin insert.

Step 4.2 Write specific, measurable objectives for each intervention activity.

Step 4.3 Write program plan, including timeline and budget, for each intervention.

Step 4.3.a Plan new or improved services.

This substep was not part of the strategy.

Step 4.3.b Develop or adapt a product.

In three months, the planners conducted focus groups, in-home cooking trials, follow up phone interviews, and laboratory tests to ensure that pre-boiling chitterlings did not impact taste and would speed up preparation at the same time it would eliminate the YE bacteria.

Step 4.3.c Plan a strategy for policy change.

This substep was not part of the strategy.

Step 4.3.d Plan communication intervention/promotion activities.

The program would disseminate its campaign message to its target audience using a variety of media outlets and promotional devices. The program's promotional materials included: informational and animated flyers, stickers, brochures, a published case story, public service announcements, news releases, and television news features.

To maximize the interventions' exposure, planners would utilize a broad array of venues to disseminate promotional material and reach the various targeted audiences:

• grocery stores (near point of sale and meat sections)
• churches (in church announcements and bulletins
• health care providers locations (hospitals, county and WIC clinics, private doctors' offices)
• gospel talk shows

Because health care providers and other gatekeeper community leaders have a strong influence on the behavior of the primary target audience, planners decided to design a separate set of promotional materials for these additional audiences:

• personalized cover letters for each sub-group
• a medical fact sheet
• face-to-face/telephone presentations for decision makers

The total budget for this project was $25,000, including $5,000 for printing materials.

Step 4.4 Pretest, pilot test, and revise as needed.

Step 4.5 Summarize your program plan and review the factors that can affect it.

Step 4.6 Confirm plans with stakeholders.

At key junctures, planners briefed key decision-makers in the Georgia Office of Minority Health, Georgia Department of Human Resources, Emory University, and the Epidemiology and Prevention Branch of the department of health to gain approval and support for the intervention plans. Community leaders and representatives from the targeted community were also consulted periodically. Shared the research findings and rationale for their decisions helped obtain buy-in and support for the program.

Step 5.1 Identify what information needs to be collected.

Planners wanted to know:

• Information about which gatekeepers disseminated the program message and materials and to what extent
• How many cases of diarrhea were diagnosed and YE infections reported by health care providers during the winter holiday season
• Target audience members’ response and feedback about the intervention

Step 5.2 Select the key evaluation questions.

Step 5.3 Determine how the information will be gathered.

Planners decided to contact target audience members, gatekeepers and health care providers for anecdotal reports of their experiences with the program. They also documented requests for copies of communication materials as well as the number of YE infection cases reported in Atlanta during the 1996 holiday season.

Step 5.4 Develop a data analysis and reporting plan.

There is no record of a formal plan, but as a low-budget means of developing, planners could have assigned a public health student intern to design a simple campaign evaluation, implement it, and then report on the campaign effectiveness to stakeholders, gatekeepers, and the community, as appropriate. The plan could also have outlined how the campaign would be judged a “success” and worthy of expansion. In addition, the plan would include how the campaign budget ($25,000) was allocated.

Step 6.1 Prepare for launch.

Because of the short lead time, the intervention did not start until after some families already had begun their holiday preparation in mid-November 1996.

Step 6.2 Execute and manage intervention components.

By December 31, 1996, implementation was widespread and accomplished at a low cost, despite having only three months for assessment, design and market penetration.

Planners coordinated the writing, review and distribution of educational materials as well as all targeted outreach to gatekeepers such as church pastors and health care providers.

Materials included:

• Holidays in the Hospital – flier.
• Keep Your Holiday Happy – poster.
• Keep Your Holiday Happy – flier.
• 5 Steps to Safety – flier.
• Chitterlings Could Make Children Sick – radio spot
• Share the Traditions – poster.
• Share the Traditions – flier.

Planners provided the program information to the media so that they would cover this preventable health problem and use the program message in their local print and broadcast stories.

Press releases and articles included:

• Chittlins; a lip-smacking delicacy – February 2003. Savannah Morning News article.
• Fix Chitterlings Safely – Nov 2002. Press Release.
• 'Chitlins' pose risk of food-borne illness – University of Georgia, College of Agriculture and Environmental Sciences article.
• Careful "Chitlins" Cooking – Cobb County Extension article.
• Youngster falls ill - April 2000. Reuters Health.

Step 6.3 Execute and manage the monitoring and evaluation plans.

The intervention did not start until after some families already had begun their holiday preparation in mid-November 1996. It was expected that health care providers would increase their efforts to find and diagnose cases of diarrhea in response to the messages targeted for them and there would be an apparent increase of cases reported. Compared to the previous year, the number of cases prior to the intervention effect was slightly higher, especially around Thanksgiving. Post intervention, however, there was no Christmas peak as there had been the previous year. Overall, the number of cases in the year of the project (11) was lower than the same weeks the previous year (16). While the changes were not statistically significant, they were suggestive of some intervention effect. Thus, the campaign was deemed successful because there was no corresponding peak in foodborne illness during the winter holiday season as there had been in previous years.

There was major media attention to the issue, including interviews on gospel radio shows.

Anecdotal feedback from gatekeepers and health care professionals found that they, for the most part, approved and helped distribute the educational materials. In some cases, they requested extra copies of the materials.

By combining audience research with new microbiological and behavior information on transmission, the campaign messages appealed to the audience and ultimately influenced behavior.

Step 6.4 Modify intervention activities, as feedback indicates.

References

Peterson EA Koehler JE. Changing Traditions: Preventing illness associate with chitterlings. Pp 4-8. "Innovations in Social Marketing Conference Proceedings," 1997, CDC Office of Communications: Atlanta.