Diabetes - "Flu and Pneumococcal Shot Campaign"

Disclaimer

The flu example is derived from the "Life Preserver" campaign. Portions were modified and fictionalized in part to conform to the planning process set forth in CDCynergy 3.0. This example originally appeared in CDCynergy Diabetes Edition.

Step 1.1 Write a problem statement.

The Advisory Committee on Immunization Practices (ACIP) and Centers for Disease Control and Prevention (CDC) recommend that persons with diabetes obtain a pneumococcal and annual flu shot. However, according to the state-based 1997 Behavioral Risk Factor Surveillance System (BRFSS), only slightly more than half (52.1 percent) of those diagnosed with diabetes reported getting a flu shot, and 33.2 percent had ever been immunized against pneumonia.

Diabetes affects approximately 16 million persons in the United States. It is currently the seventh leading cause of death and the leading cause of blindness and non-traumatic lower extremity amputations. Persons with diabetes are also more vulnerable to common, seasonal health risks. Epidemiological research by the (CDC) shows that persons with diabetes are at greater risk both of getting and of dying with the flu and/or pneumonia. Each year 10,000 to 30,000 persons with diabetes die from flu or pneumonia complications.

Step 1.2 Assess the problem's relevance to your program.

The Centers for Disease Control and Prevention (CDC)/Division of Diabetes Translation's (DDT) mission is to eliminate the preventable burden of diabetes through leadership, research, programs, and policies that translate science into public health practice. One way to accomplish this goal is through coordinated media strategies and through the funding of Diabetes Control Programs (DCPs) in health departments throughout the United States, the District of Columbia, Puerto Rico, the U.S. Virgin Islands, and six island-based programs in the Pacific Basin.

Addressing and highlighting the need for persons with diabetes to get a pneumococcal and an annual flu shot through a national campaign as well as local campaigns (carried out by the DCPs) fits well with the mission and strategy of the Division. Tackling this problem is consistent with the focus on preventive health care practices included in Healthy People 2000 and Healthy People 2010.

Step 1.3 Explore who should be on the planning team and how team members will interact.

In an effort to represent various perspectives and bring the campaign to the state level, the following organizations served on the planning team:

Centers for Disease Control and Prevention (CDC)
CDC's Division of Diabetes Translation (DDT)
CDC's National Immunization Program (NIP)
Diabetes control programs (DCPs) in State Health Departments
State Health Department Immunization Programs

Formative focus groups acknowledged that both persons with diabetes and health professionals were not aware of the risk for flu/pneumonia mortality with diabetes, therefore it was necessary to build partnerships with a variety of organizations related to diabetes care. The CDC provided funding for the campaign, and the DDT, NIP, and DCPs combined information gathered from previous campaigns and best practices used to encourage persons to obtain flu shots. The diversity of the planning team allowed for an effective campaign to build awareness about this problem to increase the number of persons with diabetes who receive flu/pneumococcal immunizations.

Step 1.4 Examine and/or conduct necessary research to describe the problem.

A situation analysis showed that a great deal had already been done to raise awareness regarding specific risks associated with diabetes, such as the need for foot and eye care, by the federal government and organizations like the American Diabetes Association (ADA). No group, however, had focused specifically on the fact that persons with diabetes are more vulnerable to common, seasonal health risks. CDC's national epidemiological research showed that persons with diabetes are at greater risk both of getting and of dying from the flu and pneumonia. Each year 10,000 to 30,000 persons with diabetes die with flu or pneumonia complications.

Data in the CDC's Morbidity and Mortality Weekly Report (October 1999) revealed that immunization behaviors varied according to ethnicity, age, gender, and geographic location for persons with diabetes. Non-Hispanic whites were more likely to report receiving pneumococcal vaccine and flu shots than non-Hispanic blacks and Hispanics. As age increased, reports of vaccination also significantly increased, likely due to successful flu campaigns to get persons over the age of 65 vaccinated. Overall, Health Styles research revealed that only 40 percent of persons with diabetes get an annual flu shot, leaving a large at-risk population for whom pneumococcal and annual flu shots would be a simple, safe, and inexpensive preventive measure.

Step 1.5 Determine and describe distinct subgroups affected by the problem.

The data clearly indicated a need for a national program that would target persons with diabetes and the health professionals treating them, and a need to work through DCPs to implement the campaign at state levels.

The following were identified as being subgroups affected by this problem:

• Persons with diabetes:
  • 25 to 54 years of age
  • Over age 54
  • African American
  • Latino/Hispanic American
• Persons impacted by the disease, i.e. family members
• Health care providers caring for patients with diabetes

Step 1.6 Write a problem statement for each subgroup you plan to consider further.

• Persons aged 25 - 54 with diabetes - This group is not currently part of the target audience for flu shot campaigns (which typically have focused efforts on those 65 years of age and older) and is four times more likely to die with influenza and pneumonia than persons the same age who do not have diabetes (NCCDPHP Communications, 1999).
• African Americans - Diabetes disproportionately affects African Americans at a rate 60 percent higher than that of non-Hispanic white Americans. African Americans are less likely to obtain pneumococcal and annual flu shots.
• Latino/Hispanic Americans - Diabetes affects this group at a rate 110-120 percent higher than that for non-Hispanic white Americans. This group is also less likely to obtain pneumococcal and annual flu shots.
• Persons impacted by the disease - Diabetes care requires many lifestyle changes and health care challenges, therefore, support and encouragement of persons with diabetes by their friends and/or family may affect whether one gets a pneumococcal and an annual flu shot.
• Health care providers caring for patients with diabetes - Flu and pneumococcal shots are often overlooked due to a lack of health care provider awareness about the increased risks of flu and pneumonia for diabetes patients, competing priorities, or an overestimation of the percentage of people with diabetes in their care who have been vaccinated.

Step 1.7 Gather information necessary to describe each subproblem defined in new problem statement.

• Persons with diabetes aged 25 - 54 - This group had not previously been selected as a primary audience for flu shot awareness campaigns targeted to older Americans. This age segment represents those at significantly increased risk of dying with the flu and/or pneumonia compared to people the same age without diabetes. The planning team therefore chose to focus on this audience to relay the importance of obtaining pneumococcal and annual flu shots.
• African Americans - Because some African Americans may not have regular access to a health care provider, this population is considered an "at risk" group. Additionally, there is a perception among many in this group that a shot will give them the actual disease that it is intended to prevent, which also contributes to lower vaccination rates. Furthermore, the belief in the effectiveness of the pneumococcal and annual flu shot within this community is often times low; therefore, obtaining the shots is not often a priority for this group.
• Latino/Hispanic Americans - Cultural beliefs among some Latino/Hispanic Americans may prohibit them from seeking medical attention or obtaining immunizations of any kind. Some members of this group have a fatalistic view of life and do not believe that things happen by chance but rather for a reason. This may prevent them from engaging in preventive care behaviors. Additionally, lack of health insurance, the limited availability of culturally competent care, fear regarding citizenship status and low income are other factors that may affect their health care decisions.
• Persons impacted by the disease - Many people in this group are not aware that there is an increased risk for persons with diabetes if they do not get a flu or pneumococcal shot, therefore, there may be a lack of support provided for their family and friends with diabetes.
• Health care providers caring for patients with diabetes - The need to see many patients and the consequent lack of time may prevent physicians from recommending flu shots. For some providers there may be a lack of knowledge about guidelines for flu and pneumococcal shots. Finally, flu vaccination is only available and effective a few months during the year. Patients may not be seen during this time unless they have previously scheduled appointments.

Step 1.8 Assess factors and variables that can affect the project's direction.

Click here to see the table.

Step 2.1 List the direct and indirect causes of each subproblem that may require intervention(s).

Persons with diabetes do not obtain pneumococcal and annual flu shots for various reasons including:

• Fear of side effects or actually getting the flu. Past experiences and myths cause some people to worry that the vaccines will produce severe side effects or give them the illness, which the vaccines are intended to prevent. This is true especially in the case of the flu shot.
• Access and cost. Patients, in general, are often concerned about the cost of the vaccines and whether these costs will be covered by insurance. Elderly patients and those who are homebound often face transportation and mobility problems that make it particularly difficult to get their vaccinations.
• Cultural barriers. Some patients will not get vaccinations because they do not trust the medical establishment or simply because receiving inoculations is not part of their culture.
• Avoidance and denial. Patients with diabetes also resist shots because it is "simple human nature" to avoid unpleasant situations - particularly a flu shot that has to be repeated on an annual basis.
• Lack of clear patient information for persons with diabetes. Some of the information provided to patients is unclear and is therefore not successful in raising public awareness of the increased risk for persons with diabetes of getting and dying from pneumonia and/or the flu.
• Lack of provider recommendation. Research has shown that one of the strongest motivators for adult vaccination is a recommendation by a health care provider. However, providers may not routinely recommend flu or pneumococcal shots for their patients with diabetes.

Step 2.2 Prioritize and select subproblems that need intervention(s).

After careful consideration, the subproblems were prioritized as follows:

First, patients should be properly and adequately educated about the adverse effects of flu and pneumonia on persons with diabetes. Accurate information would raise awareness regarding the increased risk and dispel any myths about obtaining these shots.

Second, overcoming cultural barriers to vaccination and developing strategies to adapt cultural and ethnic beliefs into beneficial health practices should be encouraged.

Third, providers should be educated about the need for persons with diabetes to receive the appropriate flu and pneumococcal vaccines so that they routinely recommend these to their patients. Health systems that support and encourage appropriate vaccination should be created.

Fourth, access and cost concerns demand direct attention. It is necessary that persons with diabetes have access and can afford their vaccinations.

Step 2.3 Write goals for each subproblem.

On the basis of the subproblems this campaign chose to address, the planning team decided on the following goals:

Goal 1: Raise awareness of the risk of contracting and dying from pneumonia and the flu among persons with diabetes.

Goal 2: Explore cultural barriers among patients and address the barriers to
obtaining pneumococcal and annual flu shots.

Goal 3: Raise awareness among providers regarding the need for persons with diabetes to receive pneumococcal and annual flu vaccinations.

Goal 4: Motivate persons with diabetes to get pneumococcal and annual flu shots.

Goal 5: Gain participation and support from partners in the first year of the campaign.

Goal 6: Develop health system interventions that support and encourage appropriate vaccination of persons with diabetes.

Step 2.4 Examine relevant theories and best practices for potential intervention(s).

After examining various theories and "best" practices of diabetes interventions, the following models and strategies were considered.

Health Communication/Education

• Increase awareness about the risk of not getting a flu or pneumococcal shot for persons with diabetes, persons affected by diabetes (family and friends of persons with diabetes), and health care providers through media messages and educational materials.

Health Policy/Enforcement

• Develop convenient places for people to get flu and pneumococcal shots within their community.
• Require health clinics and other organizations that provide services to persons with diabetes to advertise and offer flu and pneumococcal shots.
• Ensure access to quality diabetes care and reimbursement for vaccination of persons with diabetes.

Health Engineering

• Produce an adequate supply of flu and pneumococcal vaccines so that there is no shortage.
• Create and implement chart reminders, recall systems, and /or tickler files to ensure patients with diabetes are identified as needing appointments for vaccines during flu season.
• Incorporate vaccination practices into other quality improvement initiatives within health systems.

Health-Related Community Services

• Fund groups within the community to raise awareness about the importance of flu and pneumococcal shots for persons with diabetes.
• Provide free or low cost flu and pneumococcal shots at different community organization sites, businesses and within the homes of those who have diabetes.

Step 2.5 Consider SWOT and ethics of intervention options.

Health Communication/Education:

Strengths

• Flu vaccination messages are appealing to the news media because of the timing of flu season and efforts to hold community flu shot clinics.
• Past health communication and education campaigns have been found to be successful with target populations that had been identified.
• The campaign included involvement and expertise of various specialists in health education and communication.
• There were existing relationships among many of the partners involved in the campaign.

Weaknesses

• Many health education/communication programs designed for the general population may not adequately address the sensitive, personal issues that can arise for persons with diabetes.
• Difficulty in promoting behavior change because the target audience may need additional interventions to change vaccination seeking behavior.
• Difficulty in measuring the success of such an effort.

Opportunities

• Opportunity for collaboration and team building.
• Diabetes spotlighted as a public health issue in the media.
• Opportunity to serve as a model for other educational programs for persons with diabetes outside of the CDC.
• Some DCPs have developed a strong communication presence. For those who haven't, the opportunity may exist to build capacity in this area.

Threats

• Even with culturally sensitive messages and educational strategies, it may be hard to influence people to obtain a flu and pneumococcal shot or to encourage health care providers to encourage flu and pneumococcal shots with a sole focus on raising awareness and improving knowledge.

What ethical considerations were considered for this strategy?

• Some people do not want it known that they have diabetes and would not want to be encouraged to get a flu or pneumococcal shot by health care providers or family/friends and be identified as a "diseased" person.
• Campaign materials must be designed in ways that are sensitive to the different cultural backgrounds of the target audiences.
• Additional ethical issues related to program planning (Marketing_Ethics.pdf).

What aspects were strengthened within the program staff to carry out this activity?

• Increase in open communication between the CDC and DCPs allowed for any obstacles related to the campaign material dissemination to be addressed.

Summarize the needs of the intervention:

• A national campaign to create educational and communication materials to increase the awareness about the need for persons with diabetes to obtain a flu and pneumococcal shot.

Health Policy/Enforcement:

Strengths

• Increase in the number and variety of places that give flu and pneumococcal shots would allow target audience to obtain them on their own.
• Once partners are involved and engaged in the campaign, they can help to leverage policy changes.

Weaknesses

• There is no guarantee that the increased access created by the policies will translate into an increase in persons with diabetes getting a pneumococcal and annual flu shot.

Opportunities

• National interest has been raised about diabetes and the importance of flu and pneumococcal shots, setting the stage for policy changes.
  Threats
• Additional funding and legislation may be needed to facilitate policy changes or to increase the number of flu and pneumococcal shots that are produced.

Ethical considerations

• Potential that the creation of policy to increase the number of persons with diabetes who obtain a flu and pneumococcal shot could limit the number of shots available for other high-risk groups.

Health Engineering:

Strengths

• Health system changes are already being conducted by DCP partners, and incorporating vaccination practices fits this model.
• Adequate amounts of flu and pneumococcal vaccine may motivate action by health care providers and persons with diabetes.

Weaknesses

• Adequately estimating the demand for flu vaccine each year is challenging.
• Production of annual flu vaccine is complicated and subject to difficulties.
• Increased amounts of services alone may not be enough to change the behavior of people.
• Quality improvement initiatives require sustained effort over time.

Opportunities

• Interest in the benefit of obtaining a flu and pneumococcal shot has been raised on a national level.
• Appropriate and effective health system changes can be incorporated into existing or developing quality improvement initiatives.

Threats

• Many people who are not high-risk and can afford vaccinations want to get flu and pneumococcal shots, therefore limiting the availability of the vaccines for some high-risk groups.

Ethical Considerations

• This intervention strategy ignores the cultural and personal factors that influence a person's desire to get a flu and pneumococcal shot.

Health-Related Community Services:

Strengths

• There are many strong community organizations that provide health care services.
• The target audiences have strong ties to many organizations in their communities.
• Using community groups to disseminate the message and services of the program will allow the messages to be tailored in ways germane to the target audiences.

Weaknesses

• Many community organizations often have limited staff and resources and may not want to become involved in a national public health program.

Opportunities

• Community organizations may increase the awareness of issues from a specific intervention through the dissemination of information across community groups, friends, and families outside of their primary influence.

Threats

• National health care issues that occur may overshadow the need for communities to encourage flu and pneumococcal shots for persons with diabetes.

Ethical Considerations

• Persons with diabetes may not want their community to know that they have diabetes.

After reviewing the SWOT of the four intervention frameworks, Health Communication/Education strategies were chosen as the first set of interventions for the Flu Campaign. Health Engineering Strategies are also very important and serve as another component of the overall effort to increase the percentage of persons with diabetes who receive a pneumococcal and annual flu shot. Further development of these latter interventions, however, will not be covered here.

Step 2.6 For each subproblem, select the intervention(s) you plan to use.

A logic model was developed by the planning team members to show the subproblems, their causal factors, the intervention chosen for each subproblem, and the result that was desired. Various types of logic models exist. For this campaign, a logic model in the form of a table was chosen because it is easily readable and understandable. To read more about Logic Models, refer to the tutorial text for this step.

Click here to see the logic model.

Step 2.7 Explore additional resources and new partners.

Additional resources were available because campaign partners included the CDC (DDT, NIP), State health departments, and other large organizations that had access to resources, expertise, patients and media outlets.

New partners included:

• Diabetes organizations
• Community organizations
• Managed care organizations (MCOs)
• Health care providers
  • Primary care physicians (PCPs)
  • Nurse practitioners
  • Endocrinologists
  • Internists
  • Pharmacists
  • Diabetes educators
  • Physician assistants
• Local hospitals
• Local health departments
• State Peer Review Organizations (PROs)
• State Adult Immunization Coalitions
• State Public Health Information Officers

Additionally, the DCPs were responsible for working with local managed care organizations, retailers and other intermediaries, state immunization program directors, and public health information officers to disseminate the campaign message. Other partners relayed the campaign's messages to patients, provided education as necessary, and stressed the importance of obtaining pneumococcal and annual flu shots.

DCPs were encouraged to cultivate local partnerships to broaden the campaign. Some of these local partners included:

Faith Community. Faith-based community leaders have significant influence over portions of the target group. The DCPs were encouraged to partner with the members of this community to stress the importance of flu and pneumococcal vaccines for persons with diabetes in their congregation. This approach could be particularly effective with minority populations.

Grocery stores and pharmacies. Since shopping for essentials is a regular occurrence, reminders and flyers were distributed to many grocery stores. Partnerships were developed so that flyers and brochures regarding the need for pneumococcal and annual flu shots would be placed in prescription bags, because persons with diabetes frequently visit their local pharmacy for diabetes medication and supplies. In addition, pharmacists were encouraged to speak to their customers with diabetes about the importance of obtaining a flu and pneumococcal shot. Businesses displayed educational posters as yet an additional reminder. Partnerships with these establishments were explored on both local and national levels.

Physicians' offices and health departments. Because patients with diabetes seek medical attention and advice from physicians and other health care providers, planning team members chose to involve physicians' offices and health departments. Consumer information brochures and posters for waiting rooms were distributed.

Area malls and movie theatres. Area malls and theatres displayed posters on their entrance and exit doors and in the restrooms.

Community centers and YMCAs. Informational meetings for persons with diabetes were held at these locations. The importance of pneumococcal and annual flu shots were stressed, and the phone numbers and locations of clinics, health departments, and hospitals that offered the shots were distributed.

Step 2.8 Acquire funding and solidify partnerships.

The primary funding source for this campaign was CDC. DCPs were encouraged to devote state funding to the effort and solicit "in kind" or donated funds from organizations with similar missions.

Communication between staff and partners was an essential part of this campaign. External and internal communication, as well as the sharing of baseline data occurred among partners and participating agencies and organizations. Internal communication was used to discuss the progress of the campaign, elicit feedback, and generate ideas on events that were occurring. External communication was used to update stakeholders on the progress of the campaign and to ensure their needs were being met. New partners were invited to assist in strategy and implementation development, and existing partners and staff indicated what they could contribute and how their participation would benefit the stakeholders and the campaign.

Step 3.1 For each subproblem, determine if intervention is dominant or supportive.

• If communication is used as a dominant intervention, list possible audiences.
• If communication is to be used to support Community Services, Engineering and/or Policy/Enforcement interventions, list possible audiences to be reached in support of each selected intervention.

Initially, communication proved to be the dominant intervention for almost all of the subproblems addressed in Phase 2. Communication was required to raise awareness, educate persons about the adverse effects of pneumonia and the flu for persons with diabetes, adapt cultural and ethnic beliefs into beneficial health practices, motivate persons with diabetes to obtain pneumococcal and annual flu shots, and educate physicians and providers on the importance of recommending pneumococcal and flu shots to their patients with diabetes.

Step 3.2 Determine whether potential audiences contain any subgroups (audience segments).

The planning team did not feel that sufficient resources were available to segment the target audiences any further. Because the campaign was centered on creating awareness, it was decided that the messages could be properly delivered within the existing groups:

• Persons with diabetes:
  • 25 to 54 years of age
  • Over age 54
  • African American
  • Latino/Hispanic American
• Persons impacted by the disease, e.g., family members, or others who support those with diabetes
• Health care providers caring for patients with diabetes

Step 3.3 Finalize intended audiences.

Planning team members intended to reach all of the target audiences previously mentioned. CDC was responsible for launching the campaign at the national level, and it relied on DCP partners to localize the campaign.

Step 3.4 Write communication goals for each audience segment.

The communication goals for selected audiences were:

• To raise the awareness among persons with diabetes aged 25 - 54 years that pneumonia and flu present an increased risk for them and immunization can safely and significantly reduce that risk.
• To raise the awareness among African Americans with diabetes that pneumonia and flu present an increased risk for them and immunization can safely and significantly reduce that risk.
• To raise the awareness among Latino/Hispanic Americans with diabetes that pneumonia and flu present an increased risk for them and immunization can safely and significantly reduce that risk.
• To motivate the previously mentioned target audiences to get pneumococcal and annual flu shots.
• To educate physicians and health care providers on the need to recommend pneumococcal and annual flu shots to their patients with diabetes.

Step 3.5 Examine and decide on communication-relevant theories and models.

After careful consideration of the numerous communication-relevant theories and models, the Health Belief Model was chosen as the basis for this campaign. For many years, the Health Belief model has been used to describe health behavior change and maintenance and has been employed as a framework for health interventions. The concepts that compose this model are perceived susceptibility and severity of disease impact, perceived benefits and barriers, cues to action, and self-efficacy. This campaign chose to focus on the perceived susceptibility to and severity of problems that persons with diabetes could incur by not obtaining flu and pneumococcal shots; the perceived benefits of and barriers to obtaining these shots; and the self efficacy, or perceived ability, of persons with diabetes to get their pneumococcal and annual flu shots. To read more about the Health Belief Model, see the resource entitled "Change Theories" in the tutorial text of this step.

In addition to the Health Belief Model, social marketing was used during this campaign. Social marketing is the application of commercial marketing technologies to the analysis, planning, execution, and evaluation of programs designed to influence the voluntary behavior of target audiences to improve their personal welfare and that of their society.

Step 3.6 Undertake formative research.

The Behavioral Risk Factor Surveillance System (BRFSS) was used to gather necessary information on the target audiences. To view a report with this information, see CDC website (http://www.cdc.gov/mmwr/preview/mmwrhtml/mm4842a3.htm).

On behalf of the CDC, Prospect Associates conducted separate focus groups with persons with diabetes, physicians, and diabetes educators. These sessions produced information on the knowledge, attitudes, and behaviors among persons with diabetes and among health professionals about the necessity of flu and pneumococcal shots for persons with diabetes. Prospect also explored barriers to immunizations and looked to establish communication strategies and messages to overcome these existing barriers. To view the full report, see "Focus Group Report" (DB_Flu_Focus_Group_Report.pdf).

Additionally, an extensive literature search and review was conducted to gather information on target audiences, best practices, intervention methods, and communication strategies that would be most applicable to this campaign.

Step 3.7 Write profiles for each audience segment.

Persons with diabetes, aged 25 - 54:

• Characteristics - Generally healthy; moderately to highly active (approximately 62 percent); yearly income $13,500 or higher (23 percent make less than $15,000); tend to be married with children (63 percent); some computer literacy; interested in a broad range of music and leisure activities; varied regarding desire to consult with physicians; more focused on physical appearance and fashion; self described as more competitive and less reserved; 66 percent feel less in control than they would like to be.
• Key messages -With diabetes, prevention is control.
• Settings - The settings thought to be most appropriate for communication to reach this group included grocery stores and pharmacies, malls and movie theatres, and physicians' offices and health departments.

African Americans with diabetes:

• Characteristics - Disproportionately affected by diabetes; some religious, regularly attending church or faith-related sessions and seminars; some moderately to highly active; others minimally active or inactive; family-oriented; music preferences range from jazz to rhythm and blues to modern rock; interested in magazines and newspapers tailored to African American audiences, trusting of family members, celebrities, musicians, athletes and ministers/preachers.
• Key Messages - With diabetes, prevention is control.
• Settings - The settings selected for this group included grocery stores and pharmacies; malls and movie theatres; youth centers and churches/religious organizations; physicians' offices and health departments.

Latino/Hispanic Americans:

• Characteristics - Two to three times more likely to have diabetes; often fatalistic view of life or believing that things happen for a reason; persuaded and directed by cultural beliefs against obtaining immunizations in any form and seeking medical attention; more sedentary; more likely to live at poverty level; a median yearly income of less than $25,000; more likely to have inadequate insurance or be uninsured; more likely to see a physician or health care provider if the clinic setting offers services that are culturally or linguistically competent; television and radio primary sources of media; most trusting of Spanish-speaking physicians and other well-known figures with diabetes or a history of diabetes in the family.
• Key Messages - With diabetes, prevention is control.
• Settings - The settings chosen for this target audience included local grocery stores and pharmacies; local malls and area theatres and community centers; churches and other religious organizations and physicians' offices and health departments

In addition to primary target audiences, planning team members identified secondary audiences. These included:

Family members and/or friends of persons with diabetes:

Family members and/or friends of persons with diabetes would most likely encourage loved ones to obtain flu and pneumococcal shots, prompting action on the primary target audiences' part. The distribution and display of informational posters, flyers and brochures at grocery stores, local pharmacies, area malls and movie theatres was intended to assist in raising awareness among this group.

Physicians/Health Care Providers:

These persons were chosen as a secondary target audience because they offer and prescribe health care and oftentimes carry credibility. To garner this group's support, campaign planners reminded physicians and health care providers of the importance of flu and pneumococcal shots for their patients with diabetes. Planning team members also communicated to this group that one of the strongest motivators for adult vaccination was a recommendation by the health care provider. Informational flyers and kits were distributed to various offices and places that provide health care.

Step 3.8 Rewrite goals as measurable communication objectives.

The communication goals helped to establish the objectives of the campaign:

• By May 2000, 60 percent of persons with diabetes aged 25 - 54 will be aware that
  • Pneumonia and the flu provide an increased risk
  • Immunization can safely and significantly reduce that risk (1997 baseline, 40 percent).
• By May 2000, 60 percent of African Americans with diabetes will be aware that
  • Pneumonia and the flu provide an increased risk
  • Immunization can safely and significantly reduce that risk (1997 baseline, 40 percent).
• By May 2000, 55 percent of Latino/Hispanic Americans with diabetes will be aware that
  • Pneumonia and the flu provide an increased risk
  • Immunization can safely and significantly reduce that risk (1997 baseline, 35 percent).
• By May 2000, 40 percent of the previously mentioned target audiences with diabetes will obtain a pneumococcal shot (1997 BRFSS baseline, 30 percent) and 55 percent will obtain an annual flu shot (1997 baseline 45 percent).
• By May 2000, 70 percent of physicians and health care providers will be aware that
  • People with diabetes have an increased risk of pneumonia and the flu
  • Immunization can safely and significantly reduce that risk (1997 baseline, 55 percent).
• By May 2000, 60 percent of physicians and health care providers will have recommended pneumococcal and annual flu shots to their patients with diabetes (1997 baseline, 30 percent).

Note: It was the intent of the campaign to contribute to this goal, though it was not expected that this communication component of the campaign alone could accomplish this objective. See Steps 2.5 and 2.6 for the non-communication interventions that would contribute to this goal.

Step 3.9 Write creative briefs.

Primary Target Audiences:

1. Characteristics of persons with diabetes aged 25 - 54
   • generally healthy;
   • moderately to highly active (approximately 62 percent);
   • yearly income $13,500 or higher (23 percent make less than $15,000);
   • tend to be married with children (63 percent);
   • some computer literate;
   • interested in a broad range of music and leisure activities;
   • varied regarding desire to consult with physicians;
   • more focused on physical appearance and fashion;
   • self described as more competitive and less reserved;
   • 66 percent feel less in control than they would like to be.
2. Characteristics of African Americans with diabetes
   • Disproportionately affected by diabetes;
   • some religious, regularly attending church, faith-related sessions or seminars;
   • some moderately to highly active;
   • others minimally active or inactive;
   • family-oriented;
   • music preferences range from jazz to rhythm and blues to modern rock;
   • interested in magazines and newspapers tailored to African American audiences;
   • trusting of family members, celebrities, musicians, athletes and ministers/preachers.
3. Characteristics of Latino/Hispanic Americans
   • two to three times more likely to have diabetes;
   • often fatalistic view of life or belief that things happen for a reason;
   • persuaded and directed by cultural beliefs against obtaining immunizations in any form and seeking medical attention;
   • more sedentary;
   • more likely to live at poverty level;
   • a median yearly income of less than $25,000;
   • more likely to be underinsured or uninsured;
   • more likely to see a physician or health care provider if the clinic setting offers services that are culturally or linguistically competent;
   • television and radio primary sources of media;
   • most trusting of Spanish-speaking physicians and other well known figures with diabetes or a history of diabetes in the family.
     
     
   Secondary Target Audiences:
   
   
4. Family members and/or friends of persons with diabetes
   Family members and/or friends of persons with diabetes would most likely ask loved ones if flu and pneumococcal shots had been obtained, prompting action on the primary target audiences' part.
5. Physicians/Health Care Providers
   These persons were chosen as a secondary target audience because they offer and prescribe health care and the primary audience oftentimes believes them to be more credible.

Objectives

• By May 2000, 60 percent of persons with diabetes aged 25 - 54 will be aware that
  • Pneumonia and the flu provide an increased risk
  • Immunization can safely and significantly reduce that risk (1997 baseline, 40 percent).
• By May 2000, 60 percent of African Americans with diabetes will be aware that
  • Pneumonia and the flu provide an increased risk
  • Immunization can safely and significantly reduce that risk (1997 baseline, 40 percent).
• By May 2000, 55 percent of Latino/Hispanic Americans with diabetes will be aware that
  • Pneumonia and the flu provide an increased risk
  • Immunization can safely and significantly reduce that risk (1997 baseline, 35 percent).
• By May 2000, 40 percent of the previously mentioned target audiences with diabetes will obtain a pneumococcal shot (1997 baseline, 30 percent) and 55 percent will obtain an annual flu shot (1997 baseline, 45 percent).
• By May 2000, 70 percent of physicians and health care providers will be aware that
  • People with diabetes have an increased risk of pneumonia and the flu
  • Immunization can safely and significantly reduce that risk (1997 baseline, 55 percent).
• By May 2000, 60 percent of physicians and health care providers will have recommended pneumococcal and annual flu shots to their patients with diabetes (1997 baseline, 30 percent).

Obstacles

1. Motivating persons aged 25 - 54 with diabetes to obtain pneumococcal and annual flu shots may prove somewhat challenging because they had not previously been identified as high risk in earlier flu communication efforts because of their age.
2. Convincing African Americans that obtaining pneumococcal and annual flu shots would not give them the illness the shots were intended to prevent may prove challenging. Additionally, it may be difficult to convince some members of this group that these shots will actually be beneficial to their health.
3. Cultural obstacles exist among Latino/Hispanic Americans with diabetes. The challenge for the planning team members was to encourage and motivate members of this group to obtain pneumococcal and annual flu shots, while remaining aware and sensitive to their culture and beliefs.
4. Ensuring that family members and/or friends of persons with diabetes relayed informational messages to persons with diabetes will be difficult to measure. Additionally, convincing this audience that their family members and/or friends needed to obtain pneumococcal and annual flu shots to protect their health may prove difficult at times.
5. Some physicians or health care providers were not aware of the increased risk of developing pneumonia and flu in patients with diabetes; therefore, they were not recommending the shots. Others believed that their patients had received appropriate recommended vaccines when in actuality, they had not. The challenge is to create a health system that encourages and supports physicians and health care providers to add this recommendation to their health care prescriptions and to offer the services on site or at various convenient sites for their patients.

Key Promises

1. For primary target audiences: If I take preventative measures like getting a flu shot, then I'll be more confident I'm doing all I can to not be a victim of my disease. If I obtain pneumococcal and annual flu shots, I will decrease my risk of getting pneumonia and the flu and of visiting or staying in the hospital because of pneumonia or the flu. Furthermore, if I do get the flu even after obtaining a shot, my symptoms are likely to be much less severe and last a shorter period of time than if I had not obtained a shot.
2. For family members and/or friends of persons with diabetes: If I recommend that my family member and/or friend with diabetes obtain a pneumococcal and annual flu shot and support them in that effort, I will have taken a positive part in protecting and bettering their health.
3. For physicians and health care providers: If I recommend that my patients with diabetes obtain pneumococcal and annual flu shots, my patients will be in better health and suffer less from the adverse effects of pneumonia and the flu.

Support Statements/Reasons Why

1. For primary target audiences:
   • Pneumococcal and annual flu shots are necessary to protect my health because they will decrease my risk of getting the flu and pneumonia and the ill effects associated with it.
   • Pneumococcal and annual flu shots will decrease the chances of my visiting and staying overnight in the hospital because of the flu or pneumonia.
   • Pneumococcal and annual flu shots will decrease the symptoms and duration of the flu if I get it.
2. For secondary target audiences:
   • Recommending pneumococcal and annual flu shots to my family members and/or friends with diabetes will allow me to take an active and beneficial role in their health.
   • Recommending and prescribing pneumococcal and annual flu shots to my patients with diabetes will decrease the risk of them getting the flu and will ultimately better their health.

Media

Various print materials were developed, such as "frequently asked questions" flyers, informational brochures (to be distributed a points were people get flu shots, diabetes care and other community information venues), and posters. Informational flyers and kits were distributed to various offices and places that provide health care. A print public service announcement (PSA), media kit, and community kit were produced. Radio and television PSAs were also created. These materials were developed in both English and Spanish.

Activities

• Distributing and displaying question sheets on pharmacy counters.
• Holding informational meetings at churches and other religious organizations, and at community centers and local YMCAs.
• Distributing and displaying flyers and posters in grocery stores, pharmacies, physicians' offices, and health departments.
• Distributing flyers and posters to community centers for display, creating brochures for display, and distributing materials at health fairs.
• Creating radio and television PSAs in English and Spanish.
• Creating billboards.

Tone

Key messages had to motivate target audiences and initiate action. Planning team members believed that using tones of concern, hope, and empowerment were the way to do this. Additionally, an optimistic, warm, and positive tone was seen as the best way to present culturally sensitive, diverse, motivating and attention-getting (without being fear based) messages.

Creative Considerations

To reach both the primary and secondary target audiences, materials had to take different approaches at relaying key messages. Additionally, the radio and television spots were designed to address diverse populations; thus, cultural sensitivity had to be considered and incorporated into the key messages. Materials were developed in Spanish and English and the PSAs were tagged with local contact information for their audiences. These were distributed nationally by CDC and locally by DCP personnel prior to flu season.

View the creative brief developed by Prospect Associates (DB_Flu_Shot_Creative_Brief.pdf).

Step 3.10 Confirm plans with stakeholders.

The planning team held a meeting with stakeholders, partners, and involved staff to discuss the status of the campaign thus far. The creative brief was distributed to everyone present, and ideas and feedback were solicited. The planning team members wanted to confirm the stakeholders' support and commitment to the campaign. Preliminary timelines were set and necessary resources, including time and personnel, were reviewed. During this planning stage, training sessions necessary for the implementation of the campaign were planned and program materials were distributed to the media.

It was decided that the CDC would be the primary funding source for this campaign. Another meeting was scheduled and responsibilities were assigned to the various attendees. The necessity of evaluation was stressed, and information regarding the stakeholders' desired outcomes was revealed.

Step 4.1 Draft timetable, budget, and plan for developing and testing communication mix.

The campaign initially received funding in November 1996, which totaled $700,000 and was used to conduct formative research, concept testing, creative development, and pre-testing of communication materials. This money was also used to build local DCP's capacity to implement an awareness-raising campaign targeted at persons with diabetes through trainings for DCP staff, media materials and other strategies.

Before the national campaign rollout, the campaign was piloted and extensively evaluated in Florida, Texas, Montana, and California. These DCPs teamed with their counterparts from the NIP to conduct the program in each pilot state. The training began in mid-June of 1997, and the first year campaign launch was set for September of 1997. While the local DCPs were gaining the necessary skills to implement and distribute a consistent message across all states/territories, message concepts were being created and tested. In subsequent years, because of the success of the pilot, the campaign was launched nationally in September/October 1998, 1999, and 2000.

Various campaign enhancements were developed and implemented during these years. To reach members of both the primary and secondary target audiences, materials were distributed and displayed in many different settings including grocery stores, pharmacies, local malls, movie theatres, physicians' offices, health departments, churches and other religious organizations. The planning team decided that it would be best to implement activities at different levels, creating a call for action targeted to the wider community.

These activities were later implemented at interpersonal, small group, organizational, community and mass media levels. All print materials, such as brochures and flyers, are described in more detail in Step 4.8 and can be viewed by visiting the CDC website (http://www.cdc.gov/diabetes/pubs/index.htm). Video and audio PSAs can also be viewed at http://www.cdc.gov/diabetes/projects/psas.htm. For campaign timeline: DB_Flu_Timeline.pdf.

Step 4.2 Develop and test creative concepts.

Using a creative platform that could cover multiple risks and prevention steps in future campaigns, the overarching theme of "Diabetes. One Disease. Many Risks." was developed, with the tagline "With Diabetes, Prevention is Control." It underscored that diabetes is a disease that can be controlled with some simple, preventive measures. Several creative concepts were tested with persons with diabetes of various ethnicities and locales to ensure effectiveness across a wide audience. The final concept used the visual metaphor of a life preserver to communicate the significance of a flu shot for persons with diabetes.

Step 4.3 Develop and pretest messages.

Based on feedback collected from the target audiences, materials that incorporated their thoughts and ideas were created. The key messages selected were "Flu shots can be a life preserver for people with diabetes" and "With diabetes, prevention is control." This represents a social marketing approach because it is target audience-driven and because it produced messages that selected audiences will listen to, and may lead them to take appropriate action. The target audience felt that the life-preserver metaphor best expressed their own empowerment to do something simple to help control their diabetes.

Step 4.4 Pretest and select settings.

The planning team selected various settings in which to expose the primary and secondary target audiences to key messages. Careful consideration, extensive formative research and focus group testing selected grocery stores and pharmacies, local malls and theatres, churches and other religious organizations, community centers and local YMCAs, and physicians' offices and health departments. Displaying materials and distributing information in all of the aforementioned settings allowed the key messages to reach the primary and secondary audiences both directly and indirectly.

Step 4.5 Select, integrate, and test channel-specific communication activities.

After selecting the settings for material dissemination, the planning committee choose communication activities. Activities would be conducted at different levels (i.e. interpersonal, small group, organizational, community and mass media) in an attempt to involve the community in addition to persons with diabetes. It was important to the planning team members not to place sole responsibility for obtaining pneumococcal and annual flu shots on persons with diabetes, but to take a more ecological approach and involve and place responsibility on the wider community as well.

Activities were performed at different levels:

1. Interpersonal - question sheets were placed on pharmacy counters as reminders to patients. These sheets contained questions persons with diabetes should ask their pharmacist regarding flu and pneumococcal shots.
2. Small Group - informational meetings and discussions were held for African American and Hispanic/Latino target audiences at different churches, religious organizations, and community centers to reveal the adverse effects of flu and pneumonia on persons with diabetes.
3. Organizational - flyers and posters were distributed in grocery stores, and displayed at pharmacy counters.
4. Community - flyers and posters were distributed and displayed at area malls and throughout community centers, posters were also displayed in local movie theatres and informational booths were set up at local health fairs.
5. Mass media - radio and television PSAs were aired, print PSAs were included in print media, pre-printed news stories were included in weekly community newspapers, the DDT website was publicized, and billboards and transit ads reminding people to get their pneumococcal and annual flu shots were created.
   
   Note: For the Hispanic/Latino target audience, materials were created in Spanish and English.

In addition to the media activities, campaign planners created materials to remind physicians and health care providers of the importance of flu and pneumococcal shots for their patients with diabetes and that one of the strongest motivators for adult vaccination was a recommendation by the health care provider.

Step 4.6 Identify and/or develop, pretest, and select materials.

Several creative concepts were tested with persons with diabetes to ensure effectiveness. The final concept used the visual metaphor of a life preserver to communicate the significance of a flu shot to persons with diabetes.

Materials included press kits outlining the connection between diabetes and the flu, pre-printed newspaper stories in English and Spanish; a news release sent over the newswire, television, radio and print PSAs; consumer and health care provider materials (i.e. brochures, provider reminder postcards, patient reminder letters, and posters); and DCP implementation kits containing tips on developing story angles and sample press releases. All campaign materials were placed on CD-ROM for states to use and adapt to their needs.

Step 4.7 Decide on roles and responsibilities of staff and partners.

CDC took on the role of implementing this campaign at the national level by creating audience-tested materials, providing training and technical assistance to DCPs, and conducting the national media campaign overlay. DCPs agreed to localize the campaign by distributing and pitching materials locally to key markets, engaging their partners in the effort, coordinating health systems interventions, and evaluating results of their efforts. Some DCPs modified materials for the specific audiences in their state.

Step 4.8 Produce materials for dissemination.

Materials were created in English and Spanish for four campaign components used at national and local levels:

• News media relations: Press kits outlining the connection between diabetes and the flu were developed and distributed to the top 1,200 English and Hispanic news media outlets. DCPs also received press kits to use in smaller markets. The Spanish release was sent to Hispanic media with diabetes and flu information specific to the population. A pre-printed newspaper story written in English and Spanish and tailored to African Americans was mailed to smaller weekly newspapers. The news release was sent over the news wire, and top media outlets were contacted.
• Public service advertising: Television, radio, and print PSAs were created in both English and Spanish and sent to public service directors. The television PSAs used verbatim quotes from the target audience focus groups. In the words of one participant, "A flu shot? Guess you could say it's like a life preserver when you have diabetes." A strong call to action said to "See your doctor about getting a flu shot today." Teaser packaging showed the life preserver with the line "Open this package to save thousands of lives" to entice busy public service directors to use the PSAs. Special radio and print PSAs created to reach African Americans with diabetes were developed and tested for media serving that audience.
• Consumer and health care provider materials: Nearly 1 million consumer information brochures and posters for health care providers' waiting rooms were printed and sent to DCPs for dissemination. In 1999, reproducible materials including a low literacy brochure, an informational insert on pneumococcal vaccination, a transit ad/billboard design, physician reminder postcards, patient reminder letters, campaign letterhead, bill/prescription bag stuffers, diabetes flu event posters, and all other print materials were developed and sent on CD-ROM to DCPs. Health provider kits, which included sample standing orders for vaccination of adults with diabetes were also developed and disseminated.
• DCP implementation kits: Kits were created to guide the DCPs and their local partners (county health departments, managed care organizations, other health service delivery organizations, etc.) in implementing the campaign on a local level. Included were specific tips on developing story angles, interviewing, and pitching, as well as sample press releases and pitch letters. Such materials kept the message consistent across all DCPs.

These materials can be viewed on CDC website http://www.cdc.gov/diabetes/pubs/index.htm and http://www.cdc.gov/diabetes/projects/psas.htm.

DCPs received a requested quantity of consumer posters and brochures for distribution. They received a sample quantity of all other materials and a CD-ROM with Quark or PageMaker files of the other materials that they could take to a printer to produce quantities for distribution.

English public service advertising materials were distributed and tracked (through Nielsen) by Goodwill Communications, with monthly reports sent to the contractor, Prospect Associates. Spanish materials were distributed and tracked by a Prospect partner agency, Bienestar LCG.

To generate news stories in print media about the need for persons with diabetes to receive annual flu shots and pneumococcal vaccines, a special media outreach was conducted:

• Development of a media list of feature magazines for men and women, sports and health publications, some national news magazines, and medical trade publications.
• Development of a pitch letter for the publications
• Development of a Diabetes and Flu Fact Sheet

A national news release about the need for at-risk populations to obtain flu shots was developed and sent out by the Department of Health and Human Services.

Health systems interventions were developed and encouraged including the incorporation of annual flu shots for persons with diabetes into health systems delivery. This was done by encouraging the inclusion of vaccination of persons with diabetes in guidelines/standards of care. Some DCPs and their partners created other materials using the campaign information, while adapting it to their needs.

Step 4.9 Finalize and briefly summarize the communication plan.

The audiences selected for intervention included the persons with diabetes aged 25 - 54, African Americans and Latino/Hispanic Americans with diabetes, family members and friends of persons with diabetes, and physicians and health care providers. Persons ages 25 - 54 were selected because they were at increased risk of dying with flu and pneumonia and had not been targeted in previous flu shot communication campaigns. African Americans and Latino/Hispanic Americans were chosen because they are disproportionately affected by diabetes and are less likely to receive pneumococcal and annual flu shots. Family members and friends of persons with diabetes were selected as a secondary target audience because they are impacted by the disease and may have the ability to influence persons with diabetes. Physicians and other health care providers were chosen because they provide and prescribe health care and often carry credibility with their patients.

Key messages to be relayed during the campaign were:

• Flu shots can be a life preserver for people with diabetes.
• With diabetes, prevention is control.

Campaign settings included grocery stores and pharmacies, local malls and theatres, churches and other religious organizations, community centers and local YMCAs, and physicians' offices and health departments. Displaying materials, such as question sheets and brochures, and distributing information to all of the campaign settings allowed the key messages to reach the primary and secondary audiences both directly and indirectly.

Partners and resources were numerous and varied. Partners were key for DCPs to be able to disseminate the messages and affect pneumococcal and flu vaccination among target audiences. Such partners included:

• Pharmacies
• Managed care organizations
• Grocery stores
• Churches and other religious organization
• Community centers and YMCAs
• Physicians' offices and health departments
• Local malls and movie theatres
• Television and radio stations, newspapers
• Various Centers/Institutes/Offices (CIOs) within the CDC

The CDC was responsible for launching the campaign at the national level, while DCPs agreed to localize the effort. The campaign began with a pilot in September of 1997 and was offered nationally in the fall of 1998, 1999 and 2000.

Internal communication was used to discuss the progress of the campaign, elicit feedback, and generate ideas on events that were occurring or those that could be planned to further campaign efforts. External communication was used to update stakeholders on the progress of the campaign and to ensure their needs were being met. New partners were invited to assist in strategy and implementation development, and existing partners and staff indicated what they could contribute and how their participation would benefit the stakeholders and the campaign.

The national budget for this campaign totaled $700,000 for the first two years, and was supported primarily by the CDC. DCPs were encouraged to dedicate State funds to the effort as well as solicit "in kind" or donated funds from organizations with similar missions.

Step 4.10 Share and confirm communication plan with appropriate stakeholders.

A preparation check was completed by the planning team to ensure that all materials were ready for dissemination, that everyone involved was aware of their responsibilities, and that the communication plan was reviewed and agreed upon by appropriate stakeholders. This task assured the planning team that the persons involved were committed to the effort and that the stakeholders' needs were being met.

Step 5.1 Identify and engage stakeholders.

Meetings and conference calls were held to engage the stakeholders involved in this project, including the DDT and NIP, diabetes organizations, community organizations (i.e. local grocery stores, pharmacies, community centers and YMCAs, churches and other religious organizations, physicians' offices and health departments), managed care organizations, other health service providers, DCPs, diabetes educators, and members of the primary and secondary target audiences.

It was important that the planning team review the communication plan once more and ensure commitment and support from the individuals mentioned above. Team members solicited feedback on the progress of the campaign planning and asked if it was moving in a direction desirable to the stakeholders. Evaluation was discussed, and additional roles and responsibilities of those involved were confirmed. States were in the process of lining up partners for the campaign, so other organizations had an additional interest in the evaluation efforts.

Step 5.2 Describe the program.

Activities completed throughout this campaign were targeted at both the individual and at the community as a whole. It was important to the planning team members that those who might influence persons with diabetes also be targets of the message.

Many settings were selected for the dissemination of campaign materials. Some local grocery stores agreed to display informational posters on their doors. Pharmacies agreed to leave question sheets and brochures on their counters to act as reminders to individuals picking up prescriptions. A small number of malls and area theatres also agreed to display informational posters on their entrance, exit, and restroom doors. Churches, other religious organizations, community centers, and YMCAs held informational lectures to discuss the benefit of obtaining pneumococcal and annual flu shots for persons with diabetes in addition to displaying posters for their attendees to see. Physicians' offices and health departments displayed posters and brochures in their waiting rooms as well.

Numerous resources were used for this campaign. Planning team members and other partners contributed their time, expertise and vast knowledge to make the campaign work. The latest technology was used to communicate internally and externally and to disseminate information through the CDC website. Information from varied sources was collected to compile the latest and most accurate data on persons with diabetes, pneumococcal and annual flu shots, the target audiences, and best practices used when trying to reach them.

Expected outcomes of the campaign were:

Individually

• Increased awareness among persons with diabetes about the need for pneumococcal and annual flu shots
• Increase in motivation for persons with diabetes to inquire about and obtain pneumococcal and annual flu shots
• Increased awareness among physicians and other health care providers about the importance of recommending pneumococcal and annual flu shots to their patients with diabetes
• Increase in physicians and other health care providers recommending pneumococcal and annual flu shots to their patients with diabetes

Collectively

• Decreased rates of hospitalization, illness, and death from the flu and pneumonia in persons with diabetes
• Increased general health of persons with diabetes

Below are the opportunities and challenges used to guide campaign development:

Opportunities:

• There has been a renewed federal focus on diabetes prevention and control, with an allocation of funds for research and education.
• Proven success in outreach and the translation of scientific findings about diabetes placed CDC in a good position to increase its visibility and recognition as a federal leader in the field.
• CDC's established network of DCPs provided a natural framework for the dissemination of campaign materials, which fostered repetition of messages on national and local levels.
• DCPs could expand their capacity to implement a communication campaign.

Challenges:

• Media professionals saw increasing competition for unpaid/public service air time because of an expansion in the number of health and social issues that required media attention.
• Several major television networks have implemented their own public service campaigns, often incorporating a range of issues under one umbrella theme.
• Specific populations have increased risk for diabetes and its complications. African Americans and Hispanics have vastly different needs, beliefs, and attitudes, and may respond to different types of communication and outreach. This campaign faced the challenge of either selecting an overall message that was relevant and motivating to these groups or designing different approaches and messages to reach various segments of the target audience.

Step 5.3 Determine what information stakeholders need and when they need it.

The various stakeholders involved in this campaign sometimes needed different types of information. Some simply wanted brief reports on the status of campaign planning, the persons involved, and the success of its progress. Others wanted more detail, and these stakeholders requested reports on the status of the campaign planning, challenges and opportunities that had arisen, the effect of the message on persons with diabetes, task assignments for the campaign, and the success of the campaign's progress. The planning team delivered requested information to the different stakeholders on a monthly basis. Prospect Associates gathered results on the implementation process and on some outcomes of the campaign, while Westat, the evaluation contractor, is in the process of compiling final reports on the national and state/territory efforts in the campaign.

Step 5.4 Write intervention standards that correspond with the different types of evaluation.

The intervention standards used were the communication objectives decided upon earlier in the campaign. The planning team, stakeholders and other partners thought that using these objectives would reveal if the campaign had moved in the desired direction. The objectives were:

• By May 2000, 60 percent of persons with diabetes aged 25 - 54 will be aware that
  • They are at increased risk for flu and pneumonia
  • Immunization can safely and significantly reduce that risk (1997 baseline, 40 percent).
• By May 2000, 60 percent of African Americans with diabetes will be aware that
  • They are at increased risk for flu and pneumonia
  • Immunization can safely and significantly reduce that risk (1997 baseline, 40 percent).
• By May 2000, 55 percent of Latino/Hispanic Americans with diabetes will be aware that
  • They are at increased risk for flu and pneumonia
  • Immunization can safely and significantly reduce that risk (1997 baseline, 35 percent).
• By May 2000, 40 percent of the previously mentioned target audiences with diabetes will obtain a pneumococcal shot (1997 baseline, 30 percent) and 55 percent will obtain an annual flu shot (1997 baseline, 45 percent).
• By May 2000, 70 percent of physicians and health care providers will be aware that
  • People with diabetes are at increased risk of pneumonia and flu
  • Immunization can safely and significantly reduce that risk (1997 baseline, 55 percent).
• By May 2000, 60 percent of physicians and health care providers will have recommended pneumococcal and annual flu shots to their patients with diabetes (1997 baseline, 30 percent).

The information that the contractor, Prospect Associates, collected revealed how the campaign was going through process evaluation measures. At the end of each year of the campaign, evaluation team members determined whether the objectives were met to assess the outcome/effectiveness measurements. Additionally, a national and individual state reports were to be generated.

Step 5.5 Determine sources and methods that will be used to gather data.

Click here to see the table.

Step 5.6 Develop an evaluation design.

The planning team hired Prospect Associates to complete the process evaluation. This included tracking how many consumers were exposed to campaign materials, how many PSAs ran on television, radio and in print, and how many DCPs participated in the program. Technical assistance efforts by the CDC aided in gathering data for process evaluation.

The outcome/effectiveness evaluation was conducted at both local and national levels. Data were collected through surveys and focus group interviews. The process and outcome/effectiveness evaluation occurred at different times, with the process evaluation occurring while the campaign was ongoing and the outcome evaluation occurring once the campaign was over.

In the last year of the campaign reported on here, Westat was hired as the evaluation contractor and they took the lead in answering the most recent National and State Report Questions

Step 5.7 Develop a data analysis and reporting plan.

The data analysis and reporting plans were conducted as follows:

• Methods such as questionnaires, focus group interviews, and patient self reporting were used to obtain data on increased awareness, motivation and physician recommendations.
• Contractor staff conducted data analysis on the different media components of this campaign. Variables of interest included how many consumers were exposed to campaign materials, how many PSAs ran on television, radio and in print, and how many DCPs participated in the program. These results are outlined in full in the 2000 Strategic Plan (DB_2000_Strategic_Plan.pdf).
• National surveys such as BRFSS and Healthstyles were used to track self reported vaccination practices among persons with diabetes.

Reporting

• Results were disseminated to stakeholders and partners in the form of reports and presentations. At meetings, the data was presented orally and followed by a written national and individual state reports summarizing the findings. These methods of dissemination allowed stakeholders to ask questions while in the meeting and to receive a post-meeting record of what was discussed.
• Additional meetings were scheduled for partners and stakeholders to review any information that was not covered and to answer any questions that were left unanswered. This occurred for both the process and outcome/effectiveness evaluations.
• Results were also shared via email and regular conference calls with DCP partners.
• The evaluation contractor will produce the latest national and state/territorial reports regarding their communication campaign efforts and their health systems work.

Step 5.8 Formalize agreements and develop an internal and external communication plan.

As before, there was an internal and external communication plan, consisting of similar elements - monitored use and cost of time and resources, and documented challenges, opportunities and threats. As the campaign came close to the end each year, the planning team decided to share the results of the campaign at the annual Diabetes Translation Conference. This report, which would include outcomes, best practices, and the successes and failures of the campaign, would be beneficial to those choosing to implement this campaign or similar campaigns in the future. Before deciding to share results, the planning team formalized these plans with stakeholders and partners to ensure that their ideas were represented.

Step 5.9 Develop an evaluation timetable and budget.

The evaluation timetable and budget evolved as follows:

• The budget for the first two years of the campaign totaled $700,000 which included campaign formative research, creative materials development and testing and implementing the campaign. Additional resources were added in subsequent years and this generally included evaluation resources.
• Partners also participated financially and supported evaluation efforts.
• Baseline data were collected and DCPs were prepared for implementation of the campaign in late spring 1997.
• The pilot campaign was launched in September of 1997 and process evaluation began soon after, occurring throughout the duration of the campaign.
• Outcome/effectiveness evaluation has conducted throughout , primarily at the local level.
• Final results each campaign year were shared at the annual Diabetes Translation Conference, and plans were made for the upcoming year's campaign.
• The campaign was implemented in 1997, 1998, 1999 and 2000.

Step 5.10 Summarize the evaluation implementation plan and share it with staff and stakeholders.

The summarized evaluation plan included process and outcome/effectiveness evaluation questions, data analysis and reporting plans, a brief communication plan, the allocated budget, the participation of the DCPs and timeline for evaluation. This was presented orally and then distributed to the appropriate staff and stakeholders in a document format. Questions, concerns and suggestions were solicited from staff and stakeholders.

Step 6.1 Integrate communication and evaluation plans.

The communication and evaluation plans were integrated throughout the campaign to ensure that the evaluation measures were tracking the actual campaign activities. Involving the creative contractor's evaluation team (Prospect Associates) in the implementation of the communication plan through teleconferences, material distribution and meetings allowed gathering of data on the program activities, thus assisting evaluation efforts. The status and completed tasks of those involved were shared with the stakeholders and partners. The communication and evaluation team stayed in close contact to ensure that the campaign was on target.

Step 6.2 Execute communication and evaluation plans.

The original communication plan was launched in September 1997. Process evaluation immediately began by tracking the distribution of campaign materials in the media. It was very important to the planning team that the communication campaign produce measurable. Because the campaign simultaneously executed the communication and evaluation plans, the relationship between the two became apparent. Although outcome/effectiveness evaluation would not come until later, activities were planned throughout the duration of the campaign to produce answers and information in support of the objectives stated in Phase 3.

Additionally, Health Systems interventions were tracked by individual interviews and work with CDC's program development officers assigned to the DCPs. This was done to determine the 1) extent of participation in the program, 2) increase in partner and health intervention activity, 3) use of materials, 4) helpfulness of technical assistance, 5) success of their effort, and 6) suggestions for improvements.

Step 6.3 Manage the communication and evaluation activities.

At the CDC, the campaign had a technical monitor, with additional activity oversight by members of the DDT Health Communication Section. The creative contractor, Prospect Associates, assisted by managing the creative materials for the program and partner outreach, and assisted in capacity training and results collection. Monthly teleconferences with the DCPs covered different aspects of conducting the campaign and shared information between the states. Meetings held every two weeks by the CDC reviewed campaign activity and allowed discussion about program needs. Budgets and activities were tracked and reported to the CDC on a monthly basis.

Management strategies included dealing with unexpected challenges and opportunities that arose throughout the duration of the campaign. For example, planning team members had to respond quickly to the potential flu vaccine delay and/or shortage and determine how to best implement the campaign given this situation. In this case, this included writing press releases and other media materials that emphasized prioritization of high-risk populations in the vaccination efforts, and working with local partners to develop and implement contingency plans. Some communication efforts were delayed to accommodate the new schedule of vaccine availability.

Step 6.4 Document feedback and lessons learned.

The campaign evolved on both a state and national level, so it was important to stay focused on what was successful and ways to increase the impact of the program. Each year the DCP partners were formally and informally provided an opportunity to give campaign related feedback and suggestions for improvement. Certain aspects that proved to be of vital importance for the future included reaching and working with more health professionals, forging new partnerships and programs, identifying more people who need the campaign information and finding methods to sustain the program in the future.

It became clear that communication, although extremely important and the dominant intervention in the early phase of the campaign, was not the only intervention necessary for achieving desired behavioral outcomes and sustaining campaign success in the future. Health systems interventions and capacity building were necessary to reach the target audiences and make the campaign successful. This point was documented, and strategic recommendations for future years were proposed.

Step 6.5 Modify program components based on evaluation feedback.

Based on the feedback from stakeholders, partners and staff, strategic recommendations for future years were developed. For example, after the pilot year of the campaign, pneumococcal vaccination was more heavily emphasized and additional materials were developed around this message. Healthcare providers were also targeted more specifically with special materials developed for this audience.

The planning team decided that for the campaign to evolve, both nationally and locally, those involved should focus on what previously worked for the campaign and on increasing the impact of the program. In order to do that, the group developed "opportunities" to guide the strategic efforts and plan for additional successful campaigns:

• Stay focused on the singular message of getting pneumococcal and annual flu vaccinations, for current and new audiences.
• Emphasize additional strategies to deliver shots to persons with diabetes. For example, continue to use communication as an intervention method, but promote and use health systems interventions as well. These interventions might include increasing the target audiences' motivation to obtain pneumococcal and annual flu shots by creating more opportunities to deliver the shots and minimize the failure to remind patients with diabetes to obtain these shots. This objective involves moving past the primary care physician and working with the entire continuum of health professionals, including nurses, health educators and physicians' assistants.
• Integrate organizations/professions that already have links with diabetes patient care. This too involves moving past the primary care physician and working with the entire continuum of health professionals.
• Help DCPs move toward partnerships and interventions that impact shot delivery, and place less emphasis on mass media and materials dissemination. Evaluations results revealed that although most DCPs distributed materials as their primary health intervention, this was not enough to accomplish the desired behavior change. More access points such as health fairs, pharmacists-administered flu shots, and community diabetes flu clinics, are needed. Programs, training and technical assistance, with emphasis on immunization opportunities, should be created and implemented.
• Leverage key relationships with organizations that reach African American and Latino/Hispanic American communities and other audience groups that are added to the program. Campaign efforts can be expanded. Partnerships with existing networks that work with these audiences and with diabetes, should be established.
• Build sustainability for the program by including DCPs and other key partners in campaign evolution plans. This can be done by giving DCPs a range of interventions and partners, and by inviting them to take a more active part in the direction of the program.

Step 6.6 Disseminate lessons learned and evaluation findings.

Each year after the campaign was completed, lessons learned and evaluation findings were distributed to stakeholders, partners, participating DCPs, planning team members and other staff. Results were presented at a final meeting and in report format as well. Detailed reports and executive summaries were compiled because some persons wanted to see the campaign in its entirety, but others simply wanted a brief, concise document for review. Although the campaign effort was over for the year, the planning team members took this step very seriously to assist individuals who planned to implement this campaign or similar campaigns in the future. Results were placed on the CDC web page, and were shared at the annual Diabetes Translation Conference (DB-2000_Strategic_Plan).