Bringing Heart Health to Latinos: A Guide for Building Community Programs

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Originally published by the National Heart, Lung, and Blood Institute (NIH Publication No. 98-3796). U.S. government work, public domain. Reproduced as archived reference, not current guidance.

OfficeofPrevention,Education,andControl

SALUD PARA SU CORAZÓN

BRINGING HEART HE A LT H TO LAT I N O S:

AGUIDE FOR BUILDING COMMUNITY PROGRAMS

H

E

The Salud para su Corazón logo was designed by Carlos Pastrana, second place winner in the Salud para su Corazón poster contest. The logo depicts two hands forming the shape of a heart on a mosaic background. The formation of the heart by the two hands is not only the graphic representation of the focus of this campaign, namely the healthy heart, but it is also the figurative representation of the importance of the health of every member of the community. The hands symbolize that heart health is in our hands, especially if we work together as a community to help each other achieve good health through behavior change. The mosaic background represents the harmonious blending of all Latino nationalities in the United States. Thus, the logo symbolizes the goal of Salud para su Corazón: to foster heart health in the extended family and within the Latino community at large.

This publication was developed by the National Heart, Lung, and Blood Institute of the National Institutes of Health. It may be copied or reproduced without permission. Citation of the source is appreciated.

The NHLBI anniversary logo represents 50 years of success; people doing science to improve the health of people.

SALUD PARA SU CORAZÓN

“ Salud para su Corazón is touching the hearts of people,

BRINGING HEART HE A LT H

and it is opening the door to better health and better living.

TO LAT I N O S:

AGUIDE FOR Salud para su Corazón is educating the community. If we BUILDING COMMUNITY have healthy hearts, we will have healthy families.” PROGRAMS

• Reverend José Eugenio Hoyos

NO. 98-3796

NOVEMBER 1998

NAT I O N A LINSTITUTES

OF HEALTH

National Heart, Lung,

and Blood Institute

TABLE OF CONTENTS

Phase 5: Select Messages, Channels, and Strategies . . . . . . . . . . . . . .19

Phase 1: Get Ready To Introduce Your Program . . . . . . . . . . . . . . . . . .45

Phase 4: Sustain Program Interest and Involvement . . . . . . . . . . . . . . . .59

iii

Phase 3: Prepare an Evaluation Report and Use Key Findings To

Salud para su Corazón Health Education Materials . . . . . . . . . . . . . . . . . . .86

iv

PREFACE

Dear Colleague:

Cardiovascular disease (CVD) is the leading cause of death for all Americans, including minorities. CVD claims more lives than the next seven leading causes of death combined. Fortunately, there are a number of ways that people can reduce their risk of developing heart disease, stroke, and conditions that lead to these diseases. Unfortunately, many people are not aware of ways to protect themselves and their families from developing CVD.

The National Heart, Lung, and Blood Institute (NHLBI) recognizes that culturally relevant and language-appropriate materials and interventions are necessary to reach minority communities and help eliminate the Nation’s health disparities. In 1994, the NHLBI launched the Latino Community Cardiovascular Disease Prevention and Outreach Initiative, now known as Salud para su Corazón (Health for Your Heart), to raise awareness about heart disease and promote healthier lifestyles among Latinos. The Initiative developed a model community education and intervention program that was successfully pilot-tested in the Washington, DC, metropolitan area Latino community. The model can be replicated entirely or in part by other organizations throughout the country to improve heart health and reduce CVD risk among Latinos.

Salud para su Corazón—Bringing Heart Health to Latinos: A Guide for Building Community Programs presents the basic steps

Dr. Claude Lenfant

for planning, developing, implementing, and evaluating a community-based health promotion program for Latinos. The guide contains important examples from the Salud para su Corazón program to help communities get started. Organizations or groups of various sizes and with varying levels of resources can use this guide as a springboard for initiating and sustaining a successful heart-health program within their Latino communities.

On behalf of the NHLBI, I would like to thank the health educators, community and business leaders, media experts, researchers, and the many representatives from the Latino community whose skills, hard work, and dedication have been essential to the success of Salud para su Corazón. I would also like to extend a special thanks to everyone who contributed to the development of this guide. The success of Salud para su Corazón demonstrates what active partnerships can accomplish.

Claude Lenfant, M.D. Director National Heart, Lung, and Blood Institute

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NHLBI NATIONAL EDUCATION PROGRAMS OFFER LEADERSHIP AND INFORMATION

Since 1972, the NHLBI has taken steps to apply the latest research to the development of practical methods to promote successful health interventions. Through its national education programs and initiatives, the NHLBI plays a leadership role by translating research into practical tools and materials for health professionals, patients, and the public about the prevention and treatment of heart, lung, and blood diseases and sleep disorders. The national programs develop and distribute patient and professional materials, including clinical practice guidelines, and sponsor special events such as the National High Blood Pressure Education Month (May) and the National Cholesterol Education Month (September), which promote awareness of heart disease risk factors and encourage regular screening.

Visit the NHLBI Web site at http://www.nhlbi.nih.gov for more information about the programs and initiatives listed below or to access publications in electronic format.

˛ Cardiovascular Information

National High Blood Pressure Education Program National Cholesterol Education Program National Heart Attack Alert Program NHLBI Obesity Education Initiative Latino Cardiovascular Health Resources

˛ Sleep Disorders Information

Sleep Education Activities

˛ Lung Information

National Asthma Education and Prevention Program

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ACKNOWLEDGMENTS

The National Heart, Lung, and Blood Institute wishes to acknowledge the following individuals who assisted with the development of Salud para su Corazón. Their help is greatly appreciated.

NHLBI LATINO COMMUNITY CARDIOVASCULAR DISEASE PREVENTION AND OUTREACH INITIATIVE, SALUD PARA SU CORAZÓN NETWORK

Ernesto Africano, M.D. Cardiologist Silver Spring, MD

Leo Albornoz D.C. Recreation and Parks Department Washington, DC

Zaida Arguedas Montgomery County Department of Health and Human Services Rockville, MD

Felícita Bernier, R.D. Nutrition Consultant Burke, VA

Jackeline Cadena, R.N. Silver Spring, MD

Carlos Crespo, Ph.D. American University Washington, DC

Yanira Cruz Gonzalez National Council of la Raza Washington, DC

Melissa Dhundale Share Our Strength Washington, DC

Jane Durken, R.N. Adventist HealthCare MidAtlantic Rockville, MD

Cristina Encinas Latin American Youth Center Washington, DC

Silvia Fajardo Citibank Potomac, MD

Daniel Flores Washington Gas Company Washington, DC

Armando García La Clínica del Pueblo Washington, DC

Sandra García Comité Hispano de Virginia Falls Church, VA

Silvana Gutiérrez Community Educator Fairfax, VA

Elmer Huerta, M.D., M.P.H. The Washington Cancer Institute at the Washington Hospital Center Washington, DC

vii

Wahida Karmally, M.S., R.D. Irving Center for Clinical Research Columbia University New York, NY

Eduardo López Educational Video in Spanish Washington, DC

Elsy Martínez, M.S.W. Catholic Charities Center for Family and Community Services Silver Spring, MD

Francis Hall Medina, R.N. La Clínica del Pueblo Washington, DC

Florentino Merced-Galindez, R.N., M.S.N. Bethesda, MD

Carmen Moreno, M.P.H., R.D. University of California at San Diego San Diego, CA

Luz Neira, Ph.D. Adams Morgan Adult Clinic Washington, DC

Elizabeth Ortega El Montgomery Newspaper Rockville, MD

Henry Pacheco, M.D. National Council of la Raza Washington, DC

Yvonne Rivera Consultant Washington, DC

Juan Romagosa La Clínica del Pueblo Washington, DC

Anabel Salazar Latino Health Coalition Takoma Park, MD

viii

Arturo Salcedo Educational Video in Spanish Washington, DC

NHLBI AD HOC COMMITTEE ON MINORITY POPULATIONS

Rina Alcalay, Ph.D. University of California at Davis Davis, CA

Hector Balcazar, Ph.D. Arizona State University Tempe, AZ

Zoila Ortega Harrison, Ph.D., R.N. Research Specialist in Community Health Chicago, IL

Ariela Rodríguez, Ph.D. Little Havana Activities and Nutrition Center of Dade County Miami, FL

Carlos Ugarte, M.S.P.H. Program for Appropriate Technology in Health Washington, DC

LATINO PROJECT TEAM STAFF

Matilde Alvarado, R.N., M.S.N. Salud para su Corazón Team Leader Coordinator of Minority Health Education and Outreach Programs Office of Prevention, Education, and Control NHLBI

Eileen Newman, M.S., R.D. Nutrition Education Advisor Office of Prevention, Education, and Control NHLBI

Gloria Ortiz Minority Health Specialist R.O.W. Sciences, Inc.

Laina Pack Publications Production Manager Office of Prevention, Education, and Control NHLBI

WRITERS

Maxine Forrest R.O.W. Sciences, Inc.

Amy Nelson R.O.W. Sciences, Inc.

Paula Panissidi, M.H.S. Prospect Associates, Ltd.

EDITORS

Daria Donaldson R.O.W. Sciences, Inc.

Cathy McDermott R.O.W. Sciences, Inc.

Barbara Shine R.O.W. Sciences, Inc.

NHLBI REVIEWERS

Glen Bennett, M.P.H.

James I. Cleeman, M.D.

Karen A. Donato, M.S., R.D.

Robinson Fulwood, M.S.P.H.

Mary M. Hand, M.S.P.H., R.N.

Terry Long

John McGrath

Gregory J. Morosco, Ph.D., M.P.H.

Nancy J. Poole, M.S.

Edward J. Roccella, Ph.D., M.P.H.

Carl Roth, Ph.D., L.L.M.

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INTRODUCTION

CONCERN FOR HEART HEALTH IN THE LATINO COMMUNITY

Latinos (individuals of Central American, Cuban, Mexican, Puerto Rican, South American, Dominican, and Spanish ancestry) are the fastest growing population in the United States. It is projected that the Latino population, now estimated at approximately 23 million, will contribute about 37 percent of the Nation’s growth between 1995 and the year 2000. By 2010, it is believed, Latinos will be the largest U.S. minority population (U.S. Bureau of the Census, 1993a).

CVD is the leading cause of death in the Latino community, as well as in all other population groups. Among Latinos, nearly onequarter of deaths are attributed to CVD (National Center for Health Statistics, 1994). Factors that indicate increased risk of developing CVD are generally the same in Latinos as for the total community. However, some of the risk factors are more common; for example, diabetes is a serious health problem in the Latino community. The age-adjusted prevalence rate of diabetes is two to three times greater among Mexican Americans and Puerto Ricans than among non-Hispanic whites (Keenan et al., 1992). Overweight—an independent risk factor associated with high blood pressure, high blood cholesterol, and diabetes—also is prevalent, particularly among Latino women. Data collected from 1982 to 1984 for the Hispanic Health and Nutrition

Examination Survey showed that the ageadjusted prevalence of overweight among U.S. Latinos ages 20 to 74 years was approximately 41 percent for Mexican-American women, 40 percent for Puerto Rican women, and 32 percent for Cuban-American women (National Center for Health Statistics, 1989). More recently, the National Health and Nutrition Examination Survey, Phase III (1988-1991), showed nearly half (47.9 percent) of Mexican- American women to be overweight (Kuczmarski et al., 1994).

Research and clinical studies indicate that many factors associated with the prevalence and severity of CVD can be modified (high blood pressure, high blood cholesterol, diabetes mellitus, overweight, physical inactivity, and cigarette smoking). Unfortunately, data show also that Latinos generally do not know that lifestyle changes such as eating in a hearthealthy way, being more physically active, stopping smoking, and maintaining a healthy weight could improve their health and reduce their risk of CVD. The data also show that many Latinos face significant barriers that make it difficult to adopt recommended lifestyle changes. The barriers include the inability to afford regular medical care, an inability to discuss health concerns with a health care provider or understand available health information, and the lack of access to culturally and linguistically competent information and services (National Heart, Lung, and Blood Institute, 1996). According to the U.S.

Introduction

Bureau of the Census, in 1990, 2 out of every 10 Latino families were living below the poverty level, 34 percent or one-third of Latinos under the age of 65 did not have health insurance (U.S. Bureau of the Census, 1993b), and more than one-third of Latinos living in this country spoke no English or spoke it poorly (U.S. Bureau of the Census, 1993c).

Finally, a very important CVD risk factor— age—is not within the individual’s control. The likelihood of developing CVD and many of its associated risk factors increases with age. Because most Latinos living in this country (about 66 percent) are younger than 35, many still have an opportunity to make necessary lifestyle changes before they develop CVD, hypertension, diabetes, and related health problems (U.S. Bureau of the Census, 1993a). However, without culturally relevant and language-appropriate interventions to ward off disease, illness and death from CVD will increase as this population ages.

HOW THIS GUIDE CAN HELP YOU

We will be able to use this guide for more than heart health promotion programs. It can be used as a framework to help the health educator, community advocate, and health planner tackle other diseases causing health problems in our communities.

• Beatriz Roppé, Director of Health Promotion, Colaborativo Saber

If you are a health educator or are interested in starting a heart-health program in a Latino community, this guide is for you! It discusses the necessary steps to establish a program to promote heart health in the Latino community

and illustrates the steps with practical and creative examples from Salud para su Corazón’s successful pilot program conducted in the Washington, DC, metropolitan area.

Salud para su Corazón was established by the NHLBI in 1994 to serve as a model for hearthealth programs in Latino communities across the Nation. Results from the evaluation of the pilot indicate that it met the Initiative’s goals to:

˛ Increase awareness and understanding of cardiovascular disease and its related risk factors

˛ Establish and sustain partnerships with the Latino community in developing and implementing a heart-health program

˛ Develop culturally appropriate educational materials in collaboration with the Latino community

˛ Utilize the media and other community channels to deliver CVD prevention messages

˛ Assess the effects of heart-health interventions on the community in order to improve future programs.

Salud para su Corazón is a comprehensive model that can be used around the country. Your program can select components from the model according to your own needs and resources.

However, one component—community participation—is necessary for all programs from the planning phase through the evaluation phase. Forming a group of partners from the community, called the Community Alliance Working for Heart Health, was one of the first steps taken by Salud para su Corazón and formed the foundation for all other work. For more information on the conceptual framework for Salud para su Corazón, see Appendix A.

Now let’s get started! ¡Manos a la obra!

Community alliance members participate in outreach activities of Salud para su Corazón.

STAGE 1—PLANNING

STAGE 1—PLANNING

1. Develop a Program Outline
2. Assess Your Latino Community
3. Select Your Participating Audience
4. Form Your Community Alliance
5. Select Messages, Channels, and Strategies
6. Develop Your Program Plan

PHASE 1: DEVELOP APROGRAM OUTLINE

The first step in planning a community-based program to promote heart health is to create a basic program outline. This outline will guide you throughout all phases of development and evaluation.

A basic outline typically includes the following:

˛ The problems you plan to address

˛ The intended audience

˛ Broad-based goals and objectives

˛ Key strategies that the program plans to explore

˛ The anticipated duration of the program (from planning through evaluation)

˛ Resources (including staff, funding, equipment, etc.) that are available and anticipated needs.

PHASE 2: ASSESS YOUR LATINO COMMUNITY

The next step in the planning process is to become familiar with the specific community you plan to reach. This is particularly critical when planning an intervention for Latinos because the population is very diverse. Determine how CVD affects the community, what resources are available, and where to focus your energies. Consider these questions:

˛ What do people living in the community know about CVD and its risk factors?

˛ Which CVD risk factors—high blood pressure, high blood cholesterol, smoking, lack of physical activity, overweight, diabetes— are most common in the community?

˛ What types of health services and information are currently available in the community?

˛ What types of health services and information are needed?

˛ Where do community members get information about heart disease and other healthrelated issues?

˛ What are the overall social, economic, and political characteristics of this community?

˛ How do those characteristics affect people’s health status and their ability to adopt hearthealthy behaviors?

This guide assumes that interested organizations have staff members who understand the target community and speak the language fluently, or that they can recruit individuals with these skills.

Stage 1— Planning

˛ Are community members interested in learning how to make changes to improve their heart health?

˛ Who are the respected leaders in the community?

To develop an accurate profile of the Latino community in your area and answer specific questions like those above, you will need to gather information from various sources. Here’s how to get started.

S ALUD PARA SU C ORAZÓN —

One of the first activities in the planning phase of Salud para su Corazón was developing a background paper and a demographic profile of the Latino population in the Washington, DC, metropolitan area.

The background paper provides an overview of the demographics of the Latino population in the United States. It also describes the impact of CVD and its risk factors on this population.

Gather sociodemographic information. Sociodemographic data include information such as age, gender, education level, income, employment, and population density, composition, and distribution. Be sure to include information on country of origin, length of residence in the United States, level of acculturation, and language preference. Start your fact finding with the U.S. Department of Commerce, U.S. Bureau of the Census (http://www.census.gov).

S OCIODEMOGRAPHIC I NFORMATION

The community sociodemographic profile illustrates population statistics (that is, areas of concentration, country of origin, age, gender, education, occupation, income, and language preference) specific to the geographical area.

Gather psychographic information. Psychographic information includes attitudes, lifestyles, interests, values, and beliefs, which will help you understand the audience’s health priorities and behaviors. Also, you can determine the types of messages and activities your audience is likely to understand and accept. This information can come directly from members of the community and from people who serve the community. Surveys, interviews, and focus groups can be used to collect these data. More detail on all methods is given in Phase 3.

I got involved with Salud para su Corazón because it is a program that has considered the needs of the community.

• Sandra García, Comité Hispano de Virginia

Get to know the community leaders. Local leaders are excellent sources of information about the area and its residents and they can determine the program’s acceptance in the community. Early in the planning phase, identify individuals and organizations that serve the community, and that are trusted by the community, such as community volunteers, lay health educators (promotores de salud), health care providers, clinics, community agencies or centers, neighborhood organizations, religious leaders and organizations, local media, and local businesses. Check Phase 4, page 12, for more details.

Gather published data. Information on the overall Latino population and data on specific communities that have been studied can be obtained through a literature search. This information can be useful in determining questions that you need to ask in your community. The sidebar shows examples of published data on media habits of Latinos. You may want to begin your search for relevant data by using

PubMed and GratefulMed—two National Library of Medicine databases that can be accessed free on the Internet (http://www.nlm.nih.gov/databases/freemedl.html).

PHASE 3: SELECT YOUR PARTICIPATING AUDIENCE

Once you have a clear, overall picture of your Latino community, you are ready to select a specific segment of the community that your program intends to reach. Start by using input from key community leaders (such as Latino health care providers, religious leaders, and business owners) and the demographic, psychographic, and community information gathered during your assessment (Phase 2).

Characteristics often used to define a participating or intended audience include:

˛ Age

˛ Gender

˛ Country of origin

MEDIA HABITS OF LATINOS

˛ The majority of Latinos 18 years and older prefer to use Spanish at home in both verbal communications and media use (Strategy Research Corporation, 1994).

˛ Television is the medium of choice for Latinos, regardless of the language they first learned (Mogelonsky, 1995).

˛ Latino viewers, whether Spanishdominant or bilingual, tend to be more receptive to Spanish-language commercials embedded in Spanish television programs than to English commercials shown during English television programs (Roslow and Nicholls, 1996).

Stage 1 — Planning

ELECTING

A UDIENCE

pilot program used demographic information collected for the community profile and interviews with key community leaders to identify segments of the Washington, DC, metropolitan area Latino population that could benefit most from a CVD risk factor prevention intervention. The primary participating audience included Latino men and women with the following characteristics:

˛ Ages 18 to 54,

˛ Primarily Spanish-speaking,

˛ Low acculturation level,

˛ Twelve or fewer years of formal education, and

This segment of the population was selected because their current lifestyles and poor access to health information, services, and screening increase their risk of developing heart disease.

˛ Length of residence in the United States

˛ Acculturation level

˛ Language preference

˛ Income and occupation

˛ General level of education.

The more you know about your participating audience, the better equipped you will be to choose messages and outreach strategies that they will understand and accept. Once you have defined your target audience, try to determine the following:

˛ Heart disease knowledge, and relevant attitudes and behaviors

˛ Health information sources used

˛ Values and beliefs

˛ Family structures

˛ Patterns of media use (types used most, when, and by whom).

Salud para su Corazón Premier Event draws a full house of community participants.

Three methods—surveys, interviews, and focus groups—can help you learn those characteristics:

Surveys are a popular method for gathering detailed information about your participating audience. Two types of surveys that gather information for this purpose include:

˛ Institutional surveys of organizations, such as clinics, that serve the participating audience. (See page 10.)

˛ Individual surveys of the target audience. (See page 11.)

Access to health care is a concern in our community and it is crucial for the success of any program for Latinos. We must be certain that there is a mechanism for followup when a demand for services is created.

• Juan Romagoza, Executive Director, Clínica del Pueblo

˛ Interviews offer another way to gather information for effective community-based programs. Three types of interviews are typically used—intercept interviews, telephone interviews, and scheduled interviews with community leaders.

• Intercept interviews are conducted in a

location frequented by members of the participating audience.

• Telephone interviews are another rela-

tively inexpensive way to gather information. If you are interested in conducting telephone interviews, first consider whether an adequate number of individuals in your participating audience have access to telephones. Then select interviewers who can establish rapport with your audience without speaking face-to-face.

• Scheduled interviews with key commu-

nity leaders can provide you with a wealth of information about the community and its residents that can guide your decisions in each phase of the program. Scheduled interviews are conducted by appointment, either in person or by telephone. These interviews also identify potential members for your community alliance (Phase 4).

S ALUD PARA SU C ORAZÓN —

Trained volunteer interviews participant.

Focus groups are an excellent way to assess attitudes and practices and the readiness to adopt heart-healthy behaviors among your target audience. Focus group analyses provide insights that are instrumental for selecting messages and strategies and designing educational products for your intervention. However, they should not be used to represent the views or practices of the entire population.

I think it is a good idea to have bilingual materials because many of us are trying to learn English.

• Focus group participant

I NTERCEPT I NTERVIEWS

Trained and experienced Latino Spanish-speaking field interviewers conducted 344 intercept interviews before the program activities began to assess knowledge and practices about heart health. After some activities had been conducted, 328 intercept interviews were held to assess changes in knowledge and practices about heart health. These interviews were conducted at three local churches and three Latino grocery stores.

Stage 1 — Planning

S ALUD PARA SU C ORAZÓN — C LINIC S ERVICES S URVEY ( I NSTITUTIONAL )

The Salud para su Corazón pilot program conducted a clinic survey to assess the types and location of health services available to the Latino population in the target area. The Community Alliance Outreach and Dissemination Committee developed the survey (see Appendix B, Service Provider Questionnaire), which was distributed to 48 local hospitals and clinics serving the participating audience. Incentives for the clinics to complete and return the questionnaire included:

˛ Enhanced visibility (participating health care providers were listed on a clinic referral sheet given to the community) ˛ Potential referrals ˛ Opportunity to create goodwill in the community ˛ A supply of educational materials.

Reminder cards were mailed and followup telephone calls were made to ensure that responses represented different sectors of the targeted geographical area. Fifty percent of the clinics surveyed returned their forms.

Community Clinics, Inc., a local group of community health clinics, volunteered to analyze and report the survey findings. Data from the clinic questionnaire provided up-to-date information concerning:

˛ Availability of CVD screening, counseling, and treatment (such as blood pressure and blood cholesterol screenings, smoking cessation programs) ˛ Cost of services, sliding fee scale and eligibility requirements, and acceptance of Medicaid ˛ Availability of general health education services and materials ˛ Needs and interests of clinics (such as conducting outreach activities or distributing educational materials) ˛ Ability and willingness of clinics to receive referrals from Salud para su Corazón and provide followup ˛ Proximity of clinic to public transportation.

The findings showed that in the clinics that responded:

˛ Treatment services were similar in the three areas that make up the Washington, DC, metropolitan area (District of Columbia, Northern Virginia, and the Maryland suburbs). ˛ Clinics in Washington, DC, offered the most screening services. ˛ In Northern Virginia, most screening services were provided in English only. ˛ None of the clinics offered smoking cessation programs in Spanish.

S ALUD PARA SU C ORAZÓN — F OCUS G ROUPS AND I NDIVIDUAL S URVEYS

To gather sociodemographic information and determine heart disease-related knowledge, attitudes, and behavior, participants were asked to complete a 29-item questionnaire prior to the focus groups. Also included were questions based on the General Acculturation Index (GAI) to measure the participants’ level of acculturation (the extent to which they had adapted to or adopted the American culture). The GAI measures the acculturation index of Latinos based on the mean scores for questions related to language preference, time spent in the country of origin, ethnicity of friends, and ethnic pride (Moreno et al. 1997). Age range of focus group participants

Information gathered during the focus groups helped identify:

˛ Information answered correctly that should be reinforced and expanded ˛ Key misconceptions regarding heart disease prevention ˛ Gaps in knowledge and information ˛ Common sources of information (both interpersonal and mass media).

Key insights from focus group research also revealed that the participants were:

˛ Experiencing an element of nostalgia attributed to living in two worlds (the United States and their country of origin) ˛ Going through a transition period in their health behaviors ˛ Living hectic lives and working several low-paying jobs ˛ Concerned with day-to-day survival that affected their lifestyles.

Information provided by the focus group participants also helped identify strategies and tactics to convey key messages that would appeal to the intended audience. The strategies and tactics included:

˛ Focus on positive behavior changes. ˛ Demonstrate positive health behaviors. ˛ Develop materials that reflect the lifestyles of the target audience. ˛ Develop easy-to-read materials in Spanish and English. ˛ Develop concrete messages. ˛ Reinforce correct information and introduce new facts. ˛ Use consistent medical/health terminology. ˛ Use all types of mass media channels, especially television and radio. ˛ Use a group discussion format (charlas and the health promoters program) as an interpersonal education strategy. ˛ Involve community members in all aspects of the program.

Stage 1 — Planning

PHASE 4: FORM YOUR COMMUNITY ALLIANCE

Select community alliance members. Having a strong community alliance is key to any successful community-based program. The importance of this step cannot be overemphasized. Your program will take shape within the context of your community alliance since members can participate in:

˛ Identifying the participating audience

˛ Establishing objectives and strategies to meet the overall program goal

˛ Identifying and accessing resources needed to accomplish the program’s objectives

˛ Accessing audiences and resources needed to conduct program activities

˛ Choosing messages that are culturally and language-appropriate

˛ Selecting channels best suited to reach the intended audience

˛ Increasing advocacy and access to Latino media channels.

Joining the community alliance helped me enhance my programs and gave me the opportunity to network with other health professionals.

• Cristina Encinas, Latin American Youth Center

Involve community “stakeholders” and “gatekeepers.” Developing partnerships with community members and local organizations increases resources available to your program and enhances the chance that the community will respond favorably to your intervention. Partners can foster the evolution, growth, and expansion of the program within the community and, through their contacts and channels, may also extend the program beyond the

immediate target area. They also support sustainability after the program has ended.

Build upon existing coalitions. Determine whether an appropriate coalition or similar group may be interested in supporting your program. If none is available, you may need to organize your own community alliance.

Select for diversity. Whether building upon existing coalitions or developing your own, consider the needs of the project and geographic representation of the community when selecting members. Enlist representatives from diverse organizations or affiliations in the community who:

˛ Have credibility in the community.

˛ Have knowledge and understanding of the Latino community.

˛ Show an interest in the program’s goals and a commitment to supporting the program’s activities.

˛ Are already involved in activities related to the program’s goals and objectives.

˛ Belong to a catalyst organization (that is, “movers and shakers” with strong community ties who provide services to Latinos locally, regionally, or nationally).

BENEFITS OF COMMUNITY ALLIANCE MEMBERSHIP

When inviting members to join the alliance, be sure to mention the following benefits of membership:

˛ Opportunities to network ˛ Sharing of information ˛ Increased access to resources ˛ Enjoyable and fulfilling teamwork ˛ Knowledge of and benefit from community alliance outcomes ˛ Experience working toward a common goal ˛ Personal satisfaction.

Consider “health” and non-health groups. Invite members of local health clinics and centers, State and local health departments, and community-based organizations such as social service organizations, sports groups, and social groups to participate in your community alliance. Use personal contacts when possible and follow with an invitation letter. Also consider organizations that are not health-related but have a commitment to heart health as nontraditional partners. (See Salud para su Corazón soccer tournament box on page 14 for an example of a nontraditional partnership.)

ORGANIZE YOUR COMMUNITY ALLIANCE

Get an early start. Organize your community alliance early to ensure its involvement in all aspects of the program. This helps create a shared vision for the community and a mutual understanding of how the program’s goals and objectives can be achieved. Meet informally with key community leaders to learn about the needs of the community and resources that are available. Tell them what your program is planning to do and ask for their input. When appropriate, ask them to send you descriptions of their organizations and the services they provide.

Be open and discuss expectations. Ask these key community leaders to recommend other people in the community who may be interested in participating in your community alliance. When you contact these candidates, let them know that another community leader has recommended them. Point out the benefits of becoming an alliance member. This includes the opportunity to meet and work with other groups and individuals who are interested in the overall program planning and implementation process. It provides the experience of working in a situation where individual and institutional agendas are set aside to work under a common agenda. Also remember that

you are asking them to add to their current commitments, so assure the candidates that the organizer will consult with members about schedules and availability before meetings or activities are planned.

Allow for a flexible committee structure. Before you hold your first community alliance meeting, develop a list of the proposed roles and responsibilities of members and review them at the first meeting. Involve the participants in creating the structure of the community alliance. Divide the members into smaller committees or working groups so individuals can plan and develop activities in specific areas that interest them. This also will allow them to work closely with other members who share the same interests. Usually, committees tend to form by self-selection. Keep the committee structure flexible to accommodate new members and to meet changing needs in each stage of the program. The composition, members’ roles, and committee structure of the Salud para su Corazón Community Alliance Working for Heart Health are discussed on page 15.

COMMITTEE FUNCTIONS

Let committees tackle specific tasks. At their initial meetings, the committees should outline objectives, strategies, and tactics to accomplish their specific tasks (see examples from Salud para su Corazón on page 16). At subsequent committee meetings, members may carry out various assignments (such as drafting assessment instruments, reviewing draft educational materials, or planning a specific event) aimed at meeting the committee’s objectives.

Give ownership to the committee. The committees report on their progress, give and receive feedback, and coordinate activities at general community alliance meetings. Involve the members in deciding how often the

Stage 1 — Planning

S ALUD PARA SU C ORAZÓN — Y OUTH S OCCER T OURNAMENT

The Salud para su Corazón community alliance members included several non-health-related organizations that served the participating community. Two members, Washington Gas Company and the D.C. Recreation and Parks Department, were key sponsors of a youth soccer tournament organized to provide educational materials and blood pressure and diabetes screening services for the parents, friends, and family members of the young players. Those members solicited additional support from Washington’s professional soccer team, D.C. United.

The Washington Gas Company coordinated the outreach effort and donated trophies for the winning soccer teams. The D.C. Recreation and Parks Department organized the teams and competition, reserved the public playing field, and provided electrical hookups for the screening equipment. A D.C. United player awarded the trophies and presented autographed pictures of his team to the players.

Other community alliance members also participated by providing free services for the event. La Clínica del Pueblo and Adventist HealthCare offered blood pressure screening, and the Diabetes Prevention Program provided diabetes screening. Registered dietitians from the community alliance volunteered to provide nutrition counseling.

The tournament provided visibility for the pilot program and served as a mechanism to keep the community alliance members interested and motivated to become involved in future activities.

Tournament players enjoy the awards ceremony.

Many companies have community outreach programs. They look for opportunities such as this tournament to link to the community.

• Daniel Flores, Washington Gas Company

The winning team

community alliance and the committees should meet. Select convenient times and accessible locations for all of your meetings. Consider

community alliance members. The following suggestions can help you retain their interest and commitment. using telephone conferences and e-mail to increase communication among committee Show results as soon as possible. If you members between meetings. expect to involve your community alliance in a lengthy planning and development phase (6

KEEP YOUR COMMUNITY ALLIANCE ACTIVE months or longer), be sure to organize activi- AND INTERESTED ties at reasonable intervals to keep a high level

of interest and continued involvement. As your program progresses, it is important to take steps to maintain the participation of your

S ALUD PARA SU C ORAZÓN – C OMMUNITY A LLIANCE W ORKING FOR H EART H EALTH

Composition

Originally, the Community Alliance Working for Heart Health consisted of 30 members of the Latino community. Membership included Latino health care professionals, health communication experts, health educators, public health experts, leaders of local Latino community-based organizations, and representatives from clinics and health centers, Spanish-language mass media networks, Latino businesses, and the NHLBI Ad Hoc Committee on Minority Populations. Also represented were State and local health departments and laypeople, such as local artists and public relations specialists from private corporations. As the program matured, the community alliance membership increased and its structure changed. Members pooled their extensive knowledge of community history, organizational resources, networks, and interorganizational relationships to work toward a common goal to improve heart health in their community.

Roles and Responsibilities

˛ Attend general community alliance meetings and selected committee meetings. ˛ Share expertise about the Latino community. ˛ Provide information on specific cardiovascular disease prevention needs in the Latino community. ˛ Help with the planning, development, implementation, and evaluation of the program. ˛ Serve as a representative of the community alliance to various audiences in the community.

Structure

Salud para su Corazón’s community alliance held quarterly meetings of all members. Committees met more frequently, ad hoc, and occasionally met by conference call when busy schedules would not allow meeting in person. Three committees were formed in the planning phase of the program: ˛ Outreach and Dissemination Committee ˛ Print Educational Materials Committee ˛ Mass Media Committee.

Stage 1 — Planning

S ALUD PARA SU C

ORAZÓN — C OMMUNITY A LLIANCE

NITIAL

T ACTICS

Outreach and Dissemination Committee

Objective: Support the Salud para su Corazón program in promoting heart health among Latinos in the Washington, DC, metropolitan area through outreach activities and the dissemination of materials.

Strategy 1: Establish sustainable linkages and work with the most appropriate channels for outreach and information dissemination to the Latino population.

Tactics: ˛ Identify resources in the targeted geographical areas and develop a Latino community resource directory. ˛ Identify suitable community events and develop a calendar of events relevant to the program.

Strategy 2: Develop a network for referrals to clinics and health education services for CVD prevention and control.

Tactics: ˛ Plan and conduct a survey of clinics available to the Latino population within the targeted geographic area. ˛ Develop and distribute a current list of referrals throughout program implementation.

Print Educational Materials Mass Media Committee Committee

Objective: Support the Salud para su Corazón program in promoting heart health among Latinos in the Washington, DC, metropolitan area through the development of print

Objective: Support the Salud para su Corazón program in promoting heart health among Latinos in the Washington, DC, metropolitan area through various media outlets.

educational materials.

Strategy 1: Assist with the development of culturally and languageappropriate print educational materials to promote heart health in the

Strategy 1: Establish linkages with local media outlets to obtain coverage of Salud para su Corazón events. Latino community.

Tactic: ˛ Draft manuscripts for the following materials: • Eight easy-to-read bilingual booklets

Tactic: ˛ Contact local media to cover events such as the poster contest, youth soccer tournament, and the premier event.

• Bilingual recipe booklet
• Bilingual group discussion (charla) guide.
• Health promoters manual and flipchart.

Strategy 2: Pretest print materials Strategy 2: Develop products for with the participating audience. television, radio, and local Spanishlanguage newspapers.

Tactics: ˛ Identify sites, recruit participants, and conduct pretesting of materials with participating audience. ˛ Incorporate changes to materials based on pretesting results.

Tactics: ˛ Develop two television programs. ˛ Develop 21 radio segments on heart health. ˛ Write articles for newspapers and newsletters.

˛ Develop a glossary of terms to be used consistently in all educational products.

Community alliance members participate in parade.

Keep communication flowing. Stay in close contact with the members of your community alliance. They are the “engine” of the program, because of their ability to distribute information within the community and their ability to help sustain the program over time. A community alliance newsletter is an effective way to announce activities of your program and new partnerships, and highlight the accomplishments and contributions of community alliance members.

I always looked forward to receiving Saludos. It was a very effective, upbeat, and personal way to find out what the other committees were doing.

• Felícita Bernier, R.D., Nutrition Consultant

Salud para su Corazón newsletter

Promote ongoing participation of alliance members. Work with alliance members to ensure that both their needs and the needs of the program are being met. Use your successes to encourage and motivate alliance members. Be sure to recognize and thank them for their contributions.

Seek new partnerships. To help sustain the program, identify candidates for new partnerships. As program planning is completed, community interest may increase. Organizations that serve the community but were not involved in the planning stage may see ways that they can now contribute. Cultivate this interest—new members will bring resources, ideas, and skills that will benefit your program.

Review the structure of the community alliance. As your program progresses, the roles and responsibilities of your community alliance members may have to be revised to meet changing needs. For details on how Salud para su Corazón restructured its committees as it entered the implementation phase, see page 50.

Recognition awards ceremony honors the Community Alliance Working for Heart Health.

Stage 1 — Planning

S ALUD PARA SU C ORAZÓN — L ATINO H EART - H EALTH P OSTER C ONTEST

Salud para su Corazón conducted a heart-health poster contest early in the planning stage to begin to publicize the program, to get community members involved, and to give the community alliance members a sense of progress. Latino children and young adults were invited to design a poster that would artistically interpret the concept of preventing heart disease. The Latin American Youth Center, a member of the community alliance, coordinated the contest, disseminated information throughout the community, and secured participation from a local art school, Centro de Arte, which sponsored the event. The activity began with presentations on heart health given at schools to provide background for students interested in participating. Press releases were sent to Spanish-language newspapers, radio stations, and local newsletters. Flyers were sent to local

Poster

clinics, schools with high Latino enrollment, teen centers, grocery stores, and other community businesses. Judges were selected from the community to determine judging criteria.

There were 46 entries submitted by Latino youths and young adults from Maryland, Virginia, and the District of Columbia. Winners were awarded prizes such as a free course at a school of art, a U.S. Savings bond, a gift certificate for art supplies, and others.

The winning entry was adopted as a poster for the Initiative. Its title, “Salud para su Corazón,” became the Initiative’s title. In addition, artwork from other entries generated ideas for the Salud para su Corazón mascot and logo.

Mascot Logo

PHASE 5: SELECT MESSAGES, CHANNELS, AND STRATEGIES

Use a multilevel approach. Using a variety of media channels and interpersonal strategies to “blanket” the community with similar messages will reinforce those messages and increase the likelihood of achieving your objectives. Each method has its own appeal. Some are more appropriate for particular messages and audiences. Consider the following:

˛ One-on-one communication (a health professional, lay health educator, family member, or friend provides information to another person)

˛ Group communication (charlas, promotora de salud trainings)

˛ Community events (health fairs; parades; activities held at churches, schools, malls, and other community locations; walkathons; and athletic events)

˛ Demonstrations (heart-healthy cooking demonstrations)

˛ Print materials (brochures, booklets, recipe books, posters, and fotonovelas)

˛ Mass media (radio, television, and newspapers)

˛ Electronic materials (telenovelas, audio- and videotapes, Internet, song or jingle)

˛ Promotional items (t-shirts, refrigerator magnets, bookmarks, pencils, key chains, and calendars)

Identify suitable channels and strategies. The information gathered in the assessment phase will help you determine which types of channels and strategies are best suited for your

program’s participating audience. Armed with this information, consider these factors in selecting communications channels:

˛ Participants’ preferences and usage

˛ Program budget and resources (such as personnel and equipment)

˛ Accessibility and credibility to the participating audience

˛ Acceptability to community leaders and other partners

˛ Appropriateness for your messages

Volunteers demonstrate heart-healthy cooking at the Desfile de las Américas.

Stage 1 — Planning

S ALUD PARA SU C ORAZÓN — C OMMUNICATION S TRATEGIES AND C HANNELS

Mass Media Channels

˛ Radio - A popular 3-minute daily health segment on a local Spanish-language station.

˛ Television - Two popular Spanish-language programs: an hour call-in health program on a local independent station and a 30-minute special-interest program aired on the local Univision channel.

˛ Newspapers - Four local Spanish-language weeklies were selected based on their circulation across the entire geographical area.

Print Educational Materials (Bilingual)

˛ easy-to-read booklets

˛ fotonovelas

˛ poster

˛ recipe book

˛ charla guide

˛ promotores de salud curriculum

Incentives

˛ refrigerator magnets

˛ key chains

˛ pencils

˛ t-shirts

˛ heart-healthy food samples

˛ personal appearances by professional soccer

players and autographed pictures

˛ tournament trophies

˛ blood pressure and blood cholesterol

screenings and wallet cards

Interpersonal Strategies

˛ charlas (educational sessions) on heart health facilitated by a physician, nurse, nutritionist, dietitian, or health educator

˛ promotora de salud (lay health educator) program (trains individuals to provide information on heart health to neighbors, friends, and relatives)

˛ heart-healthy cooking demonstrations

˛ parades and other community events

˛ screenings

Person-to-Person Contacts

˛ lay volunteers (to distribute materials at health fairs, grocery stores, and clinics)

˛ professional volunteers (to distribute materials and provide counseling to patients, conduct screenings at health fairs and community events, and facilitate charlas)

PHASE 6: DEVELOP YOUR PROGRAM PLAN

Write your plan. Before any activities are initiated, you should write a plan to provide structure for the program, using the outline developed in Phase 1. Your initial program plan will reflect the tasks accomplished in the previous phases. The written plan should state:

˛ Description of the problem—a brief synopsis of the health problem to be addressed, who it affects, and how the problem is currently being addressed.

˛ Participating audience—a detailed description of the population to whom your messages and activities will be directed.

˛ Goals—the broad aims of the program or what the program hopes to accomplish.

˛ Objectives—specific and measurable tasks designed to accomplish the goals. You began the planning stage with broad-based objectives that should now be refined in light of information gathered in Phases 2 to 5.

˛ Key strategies—activities that will be used to meet the program’s objectives.

˛ Resources required—estimated cost, staff time, materials, fees for services.

˛ Evaluation—methods to monitor and assess progress toward the stated objectives.

˛ Timeline—a list or table designed to keep the project on track and indicate specific deadlines or target dates. Be sure to schedule every task that you can think of from the planning stage through evaluation.

Use your plan. A written program plan provides structure for the program. It helps define the scope of your program and the types and amounts of resources (including human and in-kind resources) needed for your intended activities. The scope and scale of your program are determined largely by the funding and other resources available (see page 26). Use the plan to help you seek outside support as it documents the elements that potential sponsors or partners need to assess.

Update your plan. Expect to update your plan as the program matures and you learn from your own experiences. Do not be tempted to overlook this step. It is necessary to keep your program effective. A sample program plan based on Salud para su Corazón is provided on page 24.

PLAN FOR PROGRAM EVALUATION

Strive for an integrated plan. Evaluation should be an integral component of your plan from the beginning. Involve your own staff as well as the community alliance. It should not be viewed as separate or “extra.” Besides determining the success or failure of a program, evaluations are conducted to:

˛ Measure the effectiveness of a program.

˛ Identify the strengths and weaknesses of a program.

˛ Identify problems and barriers.

˛ Assess progress.

˛ Modify current program strategies.

˛ Justify program funding and requests for continued or increased funding.

˛ Plan future programs appropriately.

Stage 1 — Planning

Most community-based projects have limited funds and many believe that they cannot afford to include evaluation. All programs can and should include some form of evaluation, no matter how small.

Community-based health promotion programs rarely conduct impact evaluation because it is costly and requires long-term commitment. Thus, this guide focuses on formative, process, and outcome evaluation. Tips for pro-

gram evaluation are provided on page 23, and additional details concerning program evaluation are provided in the evaluation section of this guide (see pages 61 through 73).

FOUR TYPES OF PROGRAM EVALUATIONS (GREEN AND KREUTER 1991)

˛ Formative evaluation assesses the strengths and weaknesses of your materials and strategies before implementation begins. Methods include pretesting of printed materials and pilot-testing of outreach activities.

˛ Process evaluation examines the procedures involved in conducting and implementing the program. Information from process evaluation is used to guide program decisions.

˛ Outcome evaluation provides data concerning

Intercept interview in progress

short-term effects of the program, including increased awareness and knowledge, expressed intentions to make recommended changes, and responses to public service announcements. The measures can be selfreported (in interviews with the intended audience), observational (evident changes in the number of people being screened for a CVD risk factor at a local clinic), or comparative (comparing CVD knowledge of your participating audience and of a similar group that did not receive the intervention).

˛ Impact evaluation focuses on long-range results such as changes in numbers of deaths or cases of serious illness.

TIPS FOR EVALUATION PLANNING

˛ Start early. Plan evaluation when the program is being planned. This will enhance your overall program because it will ensure that you answer some basic, important questions, such as:

• What is the program trying to accomplish?
• What would need to happen to show that the program has succeeded?
• How will we know whether that has or has not happened?

˛ Decide what to evaluate. Since you cannot evaluate everything, determine what is most important to know.

˛ Identify the best available indicators of the success of your program. For health promotion programs, the strongest indicators are those that show behavior change. Other positive outcomes might include (1) an increased knowledge of CVD and its risk factors and behaviors that can reduce an individual’s risk of developing CVD, (2) adopting the belief that the recommended behaviors would be personally beneficial, and (3) sharing information with relatives and friends.

˛ Consider a variety of evaluation methods. Consider the personnel available, their skills, your program’s budget, and your timeline. Select methods that are compatible with your program and your participating audience. For example, if a number of people in your intended audience have limited reading and writing skills, you would not want to use a self-administered questionnaire. Instead, you might consider telephone interviews, intercept interviews, or focus groups in which a leader captures information on a flipchart, board, or paper.

˛ Consider using evaluation materials developed by other programs. If your evaluation resources (time and funding) are very limited, you may need to find materials that you can duplicate or adapt to meet your needs. Salud para su Corazón evaluation survey instruments are available on the NHLBI Web site.

˛ Establish an evaluation team.

• Involve community alliance members. Identify members with evaluation expertise to join the evaluation team. Involve community representatives in planning, developing, and implementing your evaluation.
• Establish links with groups that can offer technical assistance. Local universities, consortiums, and other academic and technical groups may be interested in offering technical assistance or guidance for your evaluation component.
• Carefully select interviewers. It is a plus to use someone from the community. If you conduct interviews, make sure that the interviewer can establish a rapport with the participants and that he or she is friendly, respectful, and professional.

˛ Remain flexible. As your program evolves, you may need to revise your evaluation plan. For example, you may discover unexpected outcomes that should be examined.

Stage 1 — Planning

S ALUD PARA SU C ORAZÓN — I NITIAL P ROGRAM P LAN

Program Goal: Promote healthy lifestyles among Latinos in the Washington, DC, metropolitan area, to reduce their risk of CVD.

Primary Objective: Increase the community’s awareness of modifiable cardiovascular risk factors (high blood pressure, high blood cholesterol, smoking, overweight, diabetes, physical inactivity) by 10 percent over the life of the program by demonstrating ways to adopt healthy lifestyle changes (that is, maintain a healthy weight; eat in a heart-healthy way; increase physical activity; and quit smoking).

Secondary Objective: Design a culturally appropriate community-based campaign; test the campaign by implementing it in the Washington, DC, metropolitan area; disseminate the model to other Latino communities.

Description of the Need: Latinos are the fastest growing segment of the U.S. population, accounting for almost 10 percent of the total population. By the year 2010, Latinos will be the Nation’s largest minority group. Studies show that the Latino population is disproportionately affected by cardiovascular disease and associated risk factors. Furthermore, Latinos are generally unaware of important lifestyle or behavioral changes that could prevent them from developing CVD. The population’s need for culturally relevant information and its relatively young age present an excellent opportunity for a CVD prevention intervention. The Washington, DC, metropolitan area has a large Latino community with many residents for whom existing heart-health materials are inappropriate.

Primary Participating Audience: Latino men and women ages Percent distribution of Latinos by county: Washington, DC

metropolitan area

Strategies:

˛ Establish the Community Alliance Working for Heart Health to encourage community involvement and acceptance of the program. ˛ Develop educational products for the Latino community. ˛ Disseminate program messages and materials to the Latino community through mass media channels, community events, and relevant networks.

C ONTINUED

Tactics:

˛ Conduct a contest to involve the community in designing a program poster. ˛ Develop bilingual print materials and disseminate these materials through existing community channels such as health fairs, community-based organizations, churches, clinics, and public health agencies. ˛ Develop a promotores curriculum for use in existing promotores programs. ˛ Develop a 21-segment radio series on heart health and broadcast it via a local Spanish-language radio station and a well-known and respected radio personality. ˛ Develop two educational videos. Broadcast these videos on the Spanish-language television network and integrate them into a charla program. ˛ Develop a Hispanic physicians network to aid in the dissemination of materials and messages. ˛ Sponsor a soccer tournament where free health screenings and information will be offered.

Third place Francisco Cervantes displays entry that won him first place in the poster contest.

Second place

Evaluation:

˛ Formative — Conduct focus groups and individual interviews; pretest bilingual print materials; pilot-test outreach strategies (such as charlas). ˛ Process — Conduct facilitated discussion groups and mail surveys to community alliance members. ˛ Outcome — Conduct pre- and postintervention community intercept interviews to assess changes in knowledge and intention to change behavior. Conduct telephone interviews with selected participants of outreach activities.

Timeline: Develop table with estimated start date and number of weeks or months needed to complete tasks.

Stage 1 — Planning

SEEK ADDITIONAL FUNDING AND OTHER SUPPORT

There are many ways private industry can help. Businesses always have targets to meet. It’s important to know the goals to establish mutually beneficial partnerships.

• Silvia Fajardo, CitiBank

Secure outside funding. Most programs need to secure outside funding through sponsorships or grants. Be prepared to provide potential funders information on what you plan to accomplish, the strategies you will use, how you will measure your success, the resources you have and those you need, and the timeframe for developing, implementing, and evaluating your program. As described in a previous section, these elements should be documented in your program plan (see page 21).

Solicit in-kind support. In-kind donations are an excellent way to stretch your program funds. Many businesses will print t-shirts, wallet cards for recording blood pressure and blood cholesterol readings, and educational materials, and lend equipment as well. Also, never underestimate the value of volunteer labor; it can be your greatest asset. Contact local schools and universities for interested students.

Consider multiple funding sources. When seeking sponsors, do not limit yourself to organizations and businesses that commonly support health education and health promotion programs. As noted in the discussion on partnerships in Phase 3, other types of organizations may be willing to sponsor an activity to benefit the community they serve. When exploring options for financial funding and other types of support, be sure to examine all alternatives and include your community

alliance’s ideas. Possible sources of funding for community programs or activities related to community programs include:

˛ Local, State, or Federal agencies

˛ Foundations

˛ Hospitals

˛ Pharmaceutical companies

˛ Nonprofit organizations

˛ Banks

˛ Airlines

˛ Utility companies

˛ Local chambers of commerce

˛ Food manufacturers

˛ National business chains

˛ Local businesses

• Restaurants
• Pharmacies
• Video stores
• Art supply stores
• Supermarkets

At the youth soccer tournament, the Washington Gas representative hands out trophies donated by the company.

S ALUD PARA SU C ORAZÓN — S OURCES OF F UNDING

The NHLBI provided leadership, technical assistance, and funding to develop and produce educational products to support the program implemented in Washington, DC. Community alliance members helped secure private funding and in-kind donations from businesses and community organizations. For example, the Washington Gas Company sponsored a youth soccer tournament and food-tasting at the premier event; Citibank sponsored a Latino Physicians Network meeting that helped recruit Latino physicians to participate in the initiative; Adventist HealthCare printed brochure holders to display Salud para su Corazón materials; and VITASTAT loaned automated blood pressure screening machines that were placed at community sites.

Adventist HealthCare donated the brochure holders.

The Happy Heart gets its blood pressure checked.

STAGE 2—DEVELOPMENT

STAGE 2—DEVELOPMENT

1. Assess Existing Materials
2. Develop Your Own Materials
3. Pretest Messages and Materials
4. Develop a Dissemination Plan

Once you have completed the planning stage, you are ready to produce messages and materials. However, before developing your own materials, you may want to assess existing materials to identify those that serve your needs. This will allow you to direct time and funding to other tasks. You may be able to find published materials that are appropriate for your program, or you may need to develop your own. Some programs do both.

This section discusses how to assess existing materials, and how to develop a framework for your messages and choose educational products appropriate for your participating audience. It also discusses why it is important to pretest and revise products before you move on to the implementation stage.

PHASE 1: ASSESS EXISTING MATERIALS

Consider Using Salud para su Corazón Educational Materials

Depending on your community’s needs, some or all of Salud para su Corazón’s educational materials may be right for your program.

These bilingual, easy-to-read materials were developed by the NHLBI in conjunction with the Salud para su Corazón Community Alliance Working for Heart Health. They were pretested in the metropolitan Washington, DC, Latino community. For a description of the materials and suggested uses, see the table on page 30. To purchase these materials, refer to the health education materials information on the last page of this guide.

Search Other Sources

Program developers often discover materials while conducting their community assessment. Some sources of relevant materials may include, but are not limited to:

˛ Volunteer organizations

˛ State and local health departments

˛ Federal agency information centers and clearinghouses

˛ Associations for health professionals

˛ Similar health education programs

˛ University or public libraries

˛ Internet sites (Healthfinder at the U.S. Department of Health and Human Services; U.S. Department of Agriculture’s Food and Nutrition Information Center http://www.nal. usda.gov/fnic/)

˛ Community health coalitions

˛ Colleagues

Stage 2 — Development

S ALUD PARA SU C ORAZÓN — E DUCATIONAL

Educational Materials Description

Educational Materials for Consumers

Salud para su Corazón poster Depicts heart-healthy lifestyle behaviors in a colorful and eye-catching way.

Eight easy-to-read bilingual Presents CVD prevention messages in booklets a practical and easy-to-read format. Topics include high blood pressure; smoking; high blood cholesterol; weight control; physical activity; salt and sodium; and dietary fat, saturated fat, and cholesterol.

Bilingual recipe booklet: Delicious Heart- Healthy Latino Recipes

Showcases 23 heart-healthy recipes from traditional Latin American cuisine. (Platillos latinos iSabrosos y saludables!)

Community Outreach Materials—Charla Guide Package

From Heart to Heart: A Bilingual Describes how to organize and

Group Discussion Guide (De corazón a corazón: Guía bilingüe para organizar una charla)

facilitate 1⁄2-hour heart-healthy educational sessions. The guide includes the videos described below and reproducible handout material.

A 25-minute educational video in Spanish: “Por amor al corazón” (“For the Love of Your Heart”)

Demonstrates how to make hearthealthy lifestyle changes, with an emphasis on nutrition and physical activity using dramatization, testimonials, and advice from a physician.

A 25-minute educational video, in Spanish: “Cocinar con su corazón en mente” (“Cooking With Your Heart in Mind”)

Provides important tips on how to select and prepare delicious hearthealthy Latino meals from acclaimed Latino journalist María Elena Salinas and nutritionist Felícita Bernier.

M ATERIALS

Suggested Use

Display in clinics, hospitals, health organizations, and other community settings; use as a teaching tool.

Discuss information with clients and help them develop a CVD prevention plan for themselves and their families. Can be used one-on-one at clinic visits, distributed at health education classes and community events, or used by media for local stories.

Prepare favorite recipes at hearthealthy cooking demonstrations to show how to prepare tasty, inexpensive, and heart-healthy meals. Can be distributed at clinics and community events. Media can reproduce recipes.

Use as a guide for community members who want to organize charlas on heart health at churches, community centers, clinics, and other settings.

Show as part of a charla or in clinic and hospital waiting areas, churches, health fairs, community centers, or in other community settings.

Show as part of a charla or in clinic and hospital waiting areas, churches, N AAT health fairs, community centers, or in other community settings.

ORAZÓN

Educational Materials

Promotores Training Package

Your Heart, Your Life: A Bilingual Lay Health Educators Manual (Tu corazón, tu vida: Manual para promotores de salud)

“Your Heart, Your Life” Flipchart

Five mini-telenovelas (videos) “An Ounce of Prevention” (“Más vale prevenir que lamentar”)

Fotonovelas and workbook (“An Ounce of Prevention” [“Más vale prevenir que lamentar”])

Materials for Program Planners

Latino Community Cardiovascular Disease Prevention and Outreach Initiative: Background Report

OfficeofPrevention,Education,andControl

Bringing Heart Health

SALUD PARA

SU CORAZÓN to Latinos: A Guide for

BRINGING

HEART Building Community

TO HE A LT H LAT I N O S

AGUIDE : Programs

BUILDING FOR

COMMUNITY PROGRAMS

NationalHeart, Lung, and Blo dInstitute

Bringing Heart Health to Latinos: A Guide for Building Community Programs (Video)

Description A comprehensive, user-friendly, ninelesson lay health educators manual on heart health. Includes hands-on, skillsbuilding activities and reproducible handouts. Also includes materials to train other lay health educators to teach the program.

Suggested Use ˛ Use as guide for lay health educator to teach full series of classes to small community groups. ˛ Train lay health educators on how to use the manual. ˛ Use ideas and activities as a basis for other teaching activities in the community.

Illustrations to visually reinforce key Use as part of “Your Heart, Your Life” messages in the “Your Heart, Your classes. Life” manual.

The 2-minute “health moments” that reinforce CVD prevention messages using a novela format. A colorful and engaging companion booklet reinforces heart-health

Show as part of “Your Heart, Your Life” classes; local Spanish-language television stations may air. Use as part of “Your Heart, Your Life” classes. messages highlighted in the telenovela series.

Provides a comprehensive risk factor profile of CVD among the Latino population in the United States. Presents ideas on how to plan, develop, implement, and evaluate a community-based heart-health promo-

Justify the need for culturally appropriate programs to promote heart health among Latinos. Use to plan and implement hearthealth programs for local Latino communities. tion program for Latino communities. Showcases strategies from the Salud para su Corazón pilot program that are easily adaptable for other Latino communities.

A 7-minute video that highlights Salud para su Corazón activities from the Washington, DC, pilot program and gives tips on how to replicate the

View for ideas on developing a local heart-health initiative. Show to colleagues, community leaders, and sponsors to gain ideas and support. program in other communities.

Note: Check the NHLBI Web page (http://www.nhlbi.nih.gov) in the Latino section for selected materials.

Stage 2 — Development

Obtain information about the materials. If you find materials appropriate for your program, contact the source. Explain how you plan to use the product and obtain permission, if necessary. It would be helpful to ask the program or agency that developed the materials:

˛ How they were developed

˛ If they were pretested

˛ Whether that program or agency found them effective

˛ What modifications would be made if the materials were being developed today.

USING EXISTING MATERIALS

Ask these questions:

˛ Do the materials convey your message?

˛ Is the information accurate?

˛ Are the language and reading level appropriate for your participating audience?

˛ Would your audience find the products visually appealing?

˛ Can your audience relate to the people shown in photographs or drawings or described in the text?

˛ Is there anything about the materials (wording, examples, design, and so on) that your audience might find offensive?

˛ Could the materials be adopted and/or reproduced economically?

PHASE 2: DEVELOP YOUR OWN MATERIALS

If available educational materials do not meet your specific program needs, you may need to develop new materials. Remember that the

product is the vehicle for your message. Consider which product can best convey your message. Think about the products that appeal to your participating audience. Consider your program’s budget. Do you have the resources you need to develop a particular type of product? A poorly developed or low-quality product can undermine your program’s credibility. You may need to choose a simpler way to convey your program’s messages. For example, if you do not have resources to develop a booklet, you could develop brief fact sheets or flyers. Follow the steps outlined below to develop your own materials.

Assess Your Participating Audience

Your program might develop messages to convey facts, change attitudes, modify behaviors, or perhaps capture all three. Message development also starts with assessment. Use the information gathered during the assessment phase to answer the following questions:

˛ What does your audience know about heart disease?

˛ What does your audience know about heart disease risk factors?

˛ What types of messages appeal to your participating audience?

˛ What would motivate them to make behavioral changes?

˛ How does your participating audience perceive the benefits of behavioral change?

˛ How does their lifestyle affect their willingness and/or ability to make behavioral changes?

˛ How do their values and beliefs affect their perception of health and their response to health-related messages and interventions?

Focus groups are another excellent way to gather information to answer the questions listed on page 32. The table on page 34

˛ At the same time, many people hold the opposite, fatalistic attitude that you cannot control your own fate. demonstrates how Salud para su Corazón used ˛ The average person does not understand the findings from preintervention focus groups to concept of risk or probabilities. develop its messages. ˛ Popular myths affect what people believe

Consider Health Perceptions When developing your messages, keep in mind that people perceive messages differently. The following list provides general charac-

and how they react to health concerns. ˛ Many immigrants have limited access to health care and rely on alternative or unproven means. teristics that you may consider. Choose those ˛ Many people, particularly low-socioecofactors that may apply to your audience. nomic-status groups, have trouble relating to ˛ The public typically believes that health problems that may occur in the future and risks do not apply to them personally (“It believe that you should “live for today.” won’t happen to me.”).

S ALUD PARA SU C ORAZÓN — M ATERIALS AND P RODUCTS D EVELOPMENT

Salud para su Corazón developed print materials (easy-to-read booklets, fotonovelas, recipe book, charla [group discussion] guide, promotores de salud [lay health educators] training manual); radio programs; television programs; and telenovelas. The text of the print materials was prepared by NHLBI staff, community alliance members, and consultants supporting the program. Professional artists and designers were hired to design the publications and produce the graphics. A local Latino artist was hired to design the graphics for the charla guide.

The scripts for the radio programs were written in Spanish by Dr. Elmer Huerta, a local Latino physician and community alliance member. The scripts were then translated into English and both texts were reviewed for scientific accuracy by the NHLBI.

A local Latino production company was hired to produce the television programs that were also duplicated in video format. The script, developed in Spanish, was based on information the production company gathered by holding informal focus groups with community members. Actors were engaged from a local Latino nonprofit theater group. The first program (“Por amor al corazón”) portrays the Gomez family as they make lifestyle changes after the father has a heart attack. It also includes testimonials from Latinos who have made heart-healthy changes, and it provides medical facts from a Latino physician, Dr. Huerta. In the second video (“Cocinar con el corazón en mente”), a community alliance member, Felícita Bernier, R.D., shows how Latinos can continue to enjoy the foods that they love by making simple changes in their shopping and food preparation habits. This video also features acclaimed journalist Maria Elena Salinas, who shares her personal experiences with making changes to a heart-healthy lifestyle.

Stage 2 — Development

S ALUD PARA SU C ORAZÓN — M ESSAGE P HYSICAL A CTIVITY

Focus Group Findings Participants indicated that they tend to overlook information that is very

Recommendations Develop simple and concise messages.

lengthy and that they are overwhelmed by messages that are too technical.

Participants associated “prevention” with avoidance. They understood what they should not

Focus on positive behaviors to prevent heart disease and demonstrate recommended health behaviors when appropriate. do, but were less clear on what they should do.

Many participants believed that their Emphasize that it is never too late to health is beyond their control. start making lifestyle changes that can promote heart health.

The majority of participants knew that a person needs to exercise to have a healthy heart. Participants

Reinforce correct information that is already known and introduce new information. did not know how much physical activity is recommended.

Many participants said they knew what they should do but daily pressures and stresses are the real barriers.

Address heart health promotion within the context of the audience’s lifestyle. Recommend concrete steps to promote gradual change and emphasize benefits to the individual and the family.

F RAMEWORK FOR

Sample Key Messages From Stay Active and Feel Better Booklet

˛ Get active—feel better!

˛ Start by adding movement to your daily routine:

• Get off the bus one or two stops early and walk.
• Use the stairs instead of the elevator.
• Dance to your favorite music.

˛ It’s never too late to make a commitment to a healthy heart. Physical activity is good for your whole family.

˛ Children and adults should do a total of 30 minutes or more of moderate physical activity each day.

˛ Take a 10-minute walk at lunch; walk another 10 minutes with your kids after work; and dance 10 minutes while dinner is cooking. Just make sure it adds up to 30 minutes a day!

˛ People want “a quick fix” and definite answers.

˛ Many people cannot relate to events beyond their immediate circle of family or friends. Unless the person or someone close to them experiences a health problem, it really does not exist.

˛ The average person does not understand scientific terminology and may not trust something they cannot understand.

˛ Many people hear mixed messages from family, friends, and the media, so that they do not know what to believe.

To overcome these barriers, consider the following tips:

˛ Make your messages short and concise.

˛ Be sure that your messages do not exceed the reading level of the participating audience.

˛ Develop messages that are clear and consistent.

˛ Focus on what your audience perceives as important.

Consider Values and Beliefs

As mentioned in the assessment section, people’s values and beliefs also affect how they view health and the types of behaviors they are willing to adopt. Most Latinos share core values and beliefs that your program should consider when selecting messages and strategies. The table on page 37 illustrates how Salud para su Corazón incorporated these values.

Select Educational Products To Convey Your Messages

Most programs use a variety of educational materials to accomplish their objectives. The information you gathered in the planning stage

of your program, including focus group findings, will guide you in choosing products and materials that will meet your program’s needs. Your community alliance committees can play an important role in choosing materials that will appeal to your participating audience and in developing and pretesting new materials.

CONSIDERATIONS FOR THE DESIGN OF PRINT MATERIALS

When developing print materials, consider the format and design as well as the text. Here are some tips that will help you develop “easy-to-read” materials.

˛ Use short sentences (no more than 25 words).

˛ Use headings and subheadings to break up the text.

˛ Choose a serif font for text.

˛ Use 12- to 14-point type for text

˛ Use upper- and lowercase letters; it is hard to read text printed in all capital letters.

˛ Leave generous amounts of white space.

˛ Avoid right-justification, except when type adjoins an illustration with a straight edge.

˛ Do not center text. Centered headers may be okay.

˛ Dark ink on a light surface is easiest to read; avoid reversed type (white type on a black background).

˛ Avoid long stretches of italics or bolding or underlining. Use these features sparingly, for emphasis.

˛ Avoid “widow” and “orphan” lines—either the first or last line of a paragraph appearing on a separate page from the rest of it.

˛ Avoid breaking a word at the end of a line.

˛ Try not to end a line with a single word from the next sentence.

˛ Pay attention to quality. If you plan to photocopy any material, always use a sharp master and do not copy from a copy.

˛ Use illustrations to reinforce words.

Stage 2 — Development

Reading Level of Materials

Assess the literacy level of your audience. During the assessment phase, you gathered information about the educational level of your participating audience. Be sure that you do not exceed their anticipated average reading level. There are several tests available to assess the reading level of individuals, such as the wide range achievement test. Remember that most people’s comfort level and retention level are lower than the actual number of years of schooling that they have attained. Most materials for the general public should be written at the sixth- to eighth-grade reading level.

One of the main reasons so many Latinos in the United States have heart disease is because we need more information that we can understand.

• Focus group participant

Assess the readability of materials. Readability tests estimate the educational level a person must have to understand the materials. To do this, they count the number of syllables in words or the number of words in sentences. Materials that include words of many syllables and sentences of many words require a high reading level. There are readability tests available that you can apply manually or with a computer to assess the reading level of your materials, such as the Wide Range Achievement Test.

Use your judgment. Although readability tests are a helpful tool, you must also rely on your professional judgment. Health materials may be harder to gauge with a readability formula because they often contain multisyllable words that you cannot replace (such as “cholesterol”) and that must be used several times in the text. The formulas also cannot measure flow, organization, jargon, or offensiveness of

terms. Readability tests are, however, relatively quick and inexpensive; they provide a tangible measure, their use can encourage the selection of words, and they can be used to compare products.

Spanish-Language Considerations. The format and design tips provided above are applicable for developing Spanish-language materials. However, reading assessment tests developed for the English language do not apply to Spanish. Until better tools are developed, reading levels can be approximated by the number of years of schooling that the individual has completed. Most readability tests use sentence length and number of syllables to determine reading level, but in Spanish, syllable counts are much higher. In addition, terminology is important in Spanish-language materials. Using universal/broadcast Spanish will help you avoid problems with terminology, and, as noted in the pretest section, you can pretest your materials with the intended audience to identify wording that may be offensive or difficult to understand.

PHASE 3: PRETEST MESSAGES AND MATERIALS

Pretesting your materials in draft form is essential in developing effective materials. Pretesting is a type of formative evaluation that will help you determine whether the materials are understandable, appealing, and useful to the participating audience. Some key areas to consider are:

Content—Can your audience understand and remember important points? Pretesting can help identify the strong points and weak points in the materials.

Appeal—Does the material attract attention and have sufficient appeal in ideas and graphics to get people to pick it up?

S ALUD PARA SU C ORAZÓN — V ALUES AND THE S TRATEGY F RAMEWORK

Value or Belief Familismo—the significance of the family to the individual

Recommendations Develop messages that focus on benefits for the family rather than the indi-

vidual. Select activities that include the family.

Simpatía—a need for positive, smooth Develop messages and select strateinterpersonal relations gies that promote healthy behaviors without being confrontational.

Personalismo—a preference for friendly and personal relationships with members of the same ethnic group Fatalismo—the belief that there is little an individual can do to alter his or her destiny

Use educational strategies that provide an opportunity for people to learn about heart health in a friendly setting with other Latinos. Stress that an individual can make simple but useful changes. Provide examples of what similar people have accomplished.

Respeto—deferential behavior toward others based on factors such as age and position of authority

Involve respected members of the community in your activities. Use characters that remind the audience of people they respect to convey messages.

Colectivismo—the importance Encourage sharing information with assigned to friends and members of friends and relatives. the extended family

B ELIEFS R EFLECTED IN

Example Strategies

Showed pictures of families engaging in various physical activities such as walking and dancing.

Used role-playing as a teaching method to help people feel more comfortable when implementing a recommended behavior in a real-life situation (for instance, asking a friend to not smoke inside the home).

Used charlas (group discussions) to teach Latinos about heart health. Trained promotores de salud (lay health educators) to demonstrate behavior changes that promote heart health.

Used testimonials from Latinos who had made heart-healthy behavior changes (such as having people who have successfully included regular physical activity in their life explain how they made this healthy change).

Developed radio programs delivered by a respected Latino physician. Created the character Doña Fela—a grandmother who shows her family how to make healthy behavior changes in fotonovelas and telenovelas.

Provided extra handouts at charlas for participants to share with friends and relatives. Trained promotores de salud to teach people in their social networks how to make healthy behavior changes.

Stage 2 — Development

Personal relevance—Does the audience feel the material speaks to them personally? Does the audience get any new information about health-promoting behaviors, and could they use the information?

Language—Are all Spanish terms understood by the reader and is the language culturally appropriate?

Pretesting usually involves a small number of people from your participating audience. Pretesting methods that are easier to do in the community include focus groups and questionnaires administered by an interviewer in a clinic or other community setting. Although focus groups are often conducted by a trained moderator in a professional focus group facility, there are many community sites that may work for you. Meeting in a familiar setting may also put your group more at ease, feeling open to discuss their opinions more freely. However, an individual’s responses are influenced by others in the group. Review Stage 1/Phase 1 for more information on focus groups.

Questionnaires administered by an interviewer on a one-to-one basis can help you assess the individual’s own opinions and comprehension. The following tips can help you develop your questionnaire:

˛ Keep the questions focused and simple.

˛ Use close-ended questions or multiplechoice questions when possible.

˛ Categorize answers to open-ended questions by similar responses to help analyses.

˛ Review other programs’ questionnaires and seek advice from community alliance members who have experience in this area.

If you are pretesting print materials, you can develop a draft or mockup. If your program is using radio announcements, you can record a test tape to pretest before you develop a studio

version. A television announcement or video can be tested through a review of storyboards or videotaped sketches with a voiceover, which the production agency can provide. Your community alliance members should be able to help you identify community-based organizations willing to help pretest your materials. This will save time and effort and ensure that your educational materials are tested in the community for which they are intended.

KEEP THESE LIMITATIONS IN MIND

In health communications, pretesting indicates how you may expect materials to be received by your audience. But it cannot predict the exact results. For example, if you include 20 people in your test group and 8 have trouble understanding the text, this does not necessarily mean that 40 percent of your participating audience will not understand the material. It does, however, indicate that you should consider revising the text to make it less confusing.

Pretesting complements the experienced judgment of a person familiar with your participating audience. Remember—you are dealing with human beings who may alter their response to please the interviewer (for instance, downplay a negative response so as not to hurt the interviewer’s feelings or show disrespect) or hide feelings they fear may be judged as wrong or unusual. These traits are common among Latinos. For this reason, it is important to examine and interpret responses carefully.

S ALUD PARA SU C ORAZÓN — P RETESTING OF E DUCATIONAL M ATERIALS

Salud para su Corazón also pretested five fotonovelas and the scripts for six telenovelas using two focus groups. They used sketches and text to demonstrate the products. As a result of these focus groups, two of the five fotonovelas and accompanying telenovelas were rewritten. The groups enthusiastically offered their suggestions on ways to make the stories more meaningful. Some even offered to act out their suggestions. The groups also suggested adding worksheets, which eventually were adapted for use in the promotores training manual. A major change was made in the fotonovelas that worked out very well: The focus group participants suggested that the artist draw the actors used in the telenovelas rather than use photographs.

The video and radio scripts were reviewed in English by the NHLBI, and representatives from the community alliance reviewed the Spanish versions.

Stage 2 — Development

S ALUD PARA SU C ORAZÓN — A NALYZING AND T ASTE - T ESTING R ECIPES

The recipes used in the Salud para su Corazón cookbook, Delicious Heart-Healthy Latino Recipes (Platillos latinos iSabrosos y saludables!), were community alliance members’ family favorites. The recipes were analyzed with the Minnesota Nutrition Data System for calories, total fat, saturated fat, cholesterol, sodium, calcium, and iron, and then modified for adherence to the criteria the NHLBI uses for its programs: less than 12 g fat; no more than 4 g saturated fat; less than 100 mg cholesterol; and less than 600 mg sodium. There are many other nutrition software programs available for analyzing recipes. If you need help locating software for your program, visit the USDA’s Food and Nutrition Information Center’s Web site at http://www.nal.usda.gov/fnic/ and search the Food and Nutrition Software and Multimedia Programs database in the recipe or nutrient analysis categories.

This dish looks great and the flavor is excellent. I like the fact that it is heart healthy.

• Taste-tester from Guatemala

The recipes included in the cookbook were taste-tested by the General Clinical Research Center in the Irving Center for Clinical Research, Columbia University, New York. A trained sensory test panel composed of the Salud para su Corazón participating audience evaluated each recipe on a 5-point scale (5 highest to 1 lowest) for appearance, texture, flavor, and overall quality. Recipes earning an average panel score of 4 were included. Those with scores less than 4 were modified and retested until they were acceptable. For help with taste-testing recipes, consider your local extension service and universities, culinary schools, and food compa-

Sensory evaluation panel member

nies in your area. tastes food sample.

PHASE 4: DEVELOP ADISSEMINATION PLAN

Think creatively. Prepare a plan to disseminate your materials. Expand your audience by considering avenues not used before. Include in the plan the methods you will use to promote and/or distribute materials, such as:

˛ Outreach and educational activities

˛ Health fairs

˛ Community events

˛ Direct mail

˛ Advertisements.

Be ready when opportunity knocks. Compile a list of organizations (such as grocery stores, clinics and hospitals, and community centers) that will display your materials and flyers. Be sure that your flyers include ordering information. Once you have generated a list of organizations to target, you will need to obtain mailing labels, request space in local newspapers for advertisements, and be able to handle requests for materials. You will also need to determine which materials, and how many, you send to each organization (see page 43 for Salud para su Corazón’s distribution plan). Outreach and education activities provide convenient opportunities for disseminating materials. In addition, the media can be helpful in distributing information.

Your distribution plan will help you determine the quantities of materials to print and the costs involved. It will help focus your efforts in reaching your participating population and allow for greater dissemination if community organizations are willing to assist you. Here is a list of things you should do before you begin your dissemination efforts:

˛ Focus your outreach efforts by identifying your priority groups.

˛ Construct several packets of materials that correspond to the needs of the priority group (for example, physician packets versus media packets versus consumer packets).

˛ Develop cover letters for each group that explain the contents of the materials packet.

˛ Develop an order form with guidelines for bulk quantities and a clear procedure for phone and data entry personnel on packets and order forms.

˛ Establish a procedure for tracking order forms received.

˛ Construct a timeline that coordinates materials dissemination with media coverage and complementary community events.

Television announcements that promote materials and tell viewers where they can get a free copy usually work. And if the public sees the same materials in the clinics, agency, or health fairs in the community, they will pick up copies to share with their family.

• Arturo Salcedo, Executive Director, Educational Video in Spanish

Volunteers assemble Salud para su Corazón materials for distribution.

Stage 2 — Development

Invest in training. Consider training for community volunteers or other groups who agree to distribute your educational materials. This gives an opportunity to establish a clear understanding of how, when, and to whom they will distribute materials. In addition, you can thank volunteers for their help and moti-

vate them to continue. To disseminate training manuals, consider “training the trainer.” For example, one way of disseminating the lay health educators manual is to teach a health educator how to train other health educators to use the manual.

Promotores de salud and others receive training for community activity.

S ALUD PARA SU C ORAZÓN — D ISSEMINATION P LAN FOR THE W ASHINGTON , DC, M ETROPOLITAN A REA

Salud para su Corazón developed materials for a variety of audiences: consumers, community workers, media, and program planners. See pages 30 and 31 for a full description. Distribution plans for each group differed.

Goal: Coordinate a communitywide distribution of Salud para su Corazón educational materials in the Washington, DC, metropolitan area.

Priority Areas

1 2 3 4

Spanish-language televi- Community alliance State and local health Cosmetics saleswomen sion stations members departments Latino clubs Latino radio stations Latino community- Women, Infants, and Latino grocery stores based organizations Children (WIC) Program Latino newspapers Latino music stores Social service agencies Expanded Food and Nutrition Education Health providers net- Program (EFNEP) work Nutrition Education and Health fairs and com- Training (NET) Offices munity events Head Start Programs Selected churches Hospitals

HMOs

Strategies:

˛ Mail package of selected materials to organizations with a cover letter. Provide telephone followup when needed. ˛ Provide large quantities of materials to targeted organizations in Virginia, Maryland, and the District of Columbia that conduct ongoing community events such as health fairs and charlas. ˛ Disseminate materials door to door to selected sites in the Washington, DC, area via health promoters from the Latin American Youth Center. ˛ Advertise the availability of materials at clinics and community agencies using a public service announcement on the “Línea Directa” television program. ˛ Provide large quantities of materials to community sites that offered to distribute materials in their ongoing activities. ˛ Train lay health educators to use program materials.

Outcomes:

˛ Record the number of materials distributed. ˛ Track the number of order forms. ˛ Learn how the dissemination strategies work for the local area to develop strategies for a dissemination plan at the national level.

MPLEMENTATION

STAGE 3—IMPLEMENTATION

1. Get Ready To Introduce Your Program
2. Launch Your Program
3. Conduct Activities
4. Sustain Program Interest and Involvement

PHASE 1: GET READY TO INTRODUCE YOUR PROGRAM

Congratulations. You have completed the major thrust of your program planning and development tasks. Now is the time to look at how far you have come and appreciate how much you have accomplished. It also is time to put your “kickoff” plans into place, encourage and thank everyone who is contributing to your program, look for opportunities to involve other individuals and organizations in your program activities, and identify opportunities to become involved in ongoing community events.

Formative research conducted during the planning and development stages will help ensure the success of your program. Before you conduct your activities you should:

˛ Increase involvement of your community alliance. The hard work that your community alliance members invested in the planning and development should be recognized and promoted. Use your successes thus far to encourage and motivate your community alliance as you prepare to carry out the pro-

gram’s activities. Mention the impact that your efforts will have on your participating audience and the potential to affect the Latino population as a whole. Keep your community alliance members well informed about all program activities, listen carefully to their opinions, and keep them actively involved in the intervention activities.

˛ Recruit other volunteers. At the beginning of the implementation phase, you can identify other individuals, agencies, health providers, health programs, and organizations that will be willing to donate time and services to help you implement your activities. Consider recruiting:

• Latino health professionals. Community alliance members can help you identify and recruit Latino physicians, nurses, nutritionists, and health professionals who are willing to donate their time to facilitate charlas, conduct cooking demonstrations, or provide blood pressure screening or nutrition counseling at community events. You may want to use the volunteer registration form shown on page 47.
• Community members. To ensure community ownership of your program, be sure to involve community members in your program. Identify key individuals who can help you organize and promote program activities such as charlas and cooking demonstrations in churches, tenant associations, workplaces, clubs, or neighborhood organizations’ meeting sites. You

Stage 3 — Implementation

may want to use the church and community organization contact report form included on page 48 to track locations and key contacts for community outreach activities. Community members may also help you hand out materials at health fairs and other community events or organize walking clubs in their neighborhood.

• Screening sources. You will provide a valuable service to your Latino community by offering blood pressure, cholesterol, and diabetes screenings. Be sure to contact local hospitals, pharmaceutical companies, service groups such as the American Red Cross, and other related health promotion programs that may be willing to provide personnel and equipment to conduct free screening services for your program. You may want to use the screening services tracking form shown on page 49.

˛ Develop a calendar of activities. Involve your community alliance and volunteers in developing a calendar of program activities.

Calendar of program activities

I like to volunteer because I like to give something back to my community. Our lives are hectic Monday through Friday, so on weekends I share my knowledge and experience with my community.

• Florentino Merced-Galindez, R.N., member of the local chapter of the National Association of Hispanic Nurses

˛ Participate in community events. Contact the sponsors of community events such as health fairs, parades, and festivals and ask about opportunities to collaborate on community events. Share what your program can offer with regard to screening services and educational materials.

˛ Increase direct involvement of the Latino media. The local Latino media can play a pivotal role in involving the community by informing residents about your program, attending and publicizing community events, disseminating program messages, and promoting your program’s materials.

˛ Involve other health education programs. Identify and work with groups that know how to use the materials your program has developed or appropriate materials developed by others in their health education programs. Encourage other organizations that serve the Latino community to use your materials to incorporate CVD education into their health-related programs.

It is important to take an opportunity to review all elements of your program plan before the implementation phase is in full swing. Make refinements, using information and insights that you have gathered along the way. It is much easier to make these adjustments now, than to wait until your interventions are under way. For example, as mentioned in Phase 3, you may need to modify the structure of your community alliance so that it can meet your program’s changing needs. The program refinement box on page 50 describes actions taken by Salud para su Corazón.

EGISTRATION

Volunteer name: Address: Telephone number:

Indicate your professional background: q Dietitian q Food service professional q Health promoter

Check the activities that you would like to volunteer for:

Fax number:

q Medical doctor q Nurse q Other

Organize a charla (Does not require teaching). Organizers will do everything to get it together— publicity, get facility, set up, take down chairs and tables, etc. Facilitate a heart disease prevention charla. Facilitators will be provided with an outline for their presentation and supporting educational materials. q Provide nutrition counseling. Take blood pressure readings. Volunteers will be required to bring their own equipment. q Other

Fill in the location(s) where you would prefer to volunteer:

Indicate the times and days that you are available to volunteer:

MONDAY TUESDAY WEDNESDAY THURSDAY

q Morning q Morning q Morning q Morning q Afternoon q Afternoon q Afternoon q Afternoon q Evening q Evening q Evening q Evening

Please fax or mail your completed form to:

FRIDAY SATURDAY SUNDAY

q Morning q Morning q Morning q Afternoon q Afternoon q Afternoon q Evening q Evening q Evening

Stage 3 — Implementation

C HURCH AND C OMMUNITY O RGANIZATION C ONTACT R EPORT

Date: Submitted by: Church/organization name: Address: Telephone number: Fax number:

Who is the main contact for Latino affairs (e.g., head of organization, pastor)?

Telephone number:

Are there any other key contacts (e.g., active lay individual, board member)?

Telephone number:

Schedule of worship services in Spanish or hours that services are provided.

Services or activities offered that can be used to implement Salud para su Corazón outreach activities (e.g., adult education classes, food service, nutrition classes).

Indicate which activities the church or organization might be interested in hosting or helping with:

q Hosting heart disease prevention charla q Hosting screenings q Hosting heart-healthy cooking class q Distributing educational materials

q Showing educational video q Publishing article in newsletter q Publishing article in newspaper q Other q Displaying poster

Please fax or mail your completed form to:

No

FollowupNeeded

Yes

No

Referred

Yes

No

On BP HEET MedicationYes

S

No

BP ElevatedYes

Age VALUATION

E 3

Other

AI/AN

API CREENING

S

White

Race/Ethnicity

Hispanic

Black

Female

Sex

Male

No. 1 2 3

3Specify ___________________ Page ____ of ____

2American Indian/Alaska Native

1Asian/Pacific Islander

4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 Date: ___________________4Referred by: _____________________________________________

Stage 3 — Implementation

S ALUD PARA SU C ORAZÓN — P ROGRAM R EFINEMENT

As the Salud para su Corazón pilot program entered its implementation stage, a general meeting of the community alliance was called to conduct a guided group discussion and self-assessment survey. This process evaluation exercise helped reorganize the community alliance, pinpoint strengths and weaknesses within the alliance, and propose solutions. It also initiated activities that assisted in the transition from planning and development to the implementation stage, and it was critical to the success of the implementation phase. Changes are described below.

˛ Saludos, a newsletter developed to communicate the alliance’s activities, was found to be a valuable tool for intercommittee communication and overall program coordination. Subsequently, the newsletter was published more frequently with added features such as community alliance member profiles, a timeline, and a calendar of events. These helped improve communication among committees about the project’s various activities.

˛ Committees were restructured and the specific roles of the committees were redefined, as follows, according to the new priorities and activities of the implementation stage:

• The Dissemination and Partnership Development Committee was charged with distributing Salud para su Corazón products communitywide, expanding the community network, and promoting sustainability of the project.
• The Education Committee was originally designated as the Print Educational Materials Committee; however, as the pilot program progressed, the role of this committee expanded, and it was asked to promote the program by overseeing special educational activities such as charlas and cooking demonstrations that were held at churches and other community sites.
• The Outreach Committee was designated to promote the Salud para su Corazón program through community events such as health fairs, sporting events, festivals, and desfiles (parades).
• The Communication/Media Committee was asked to develop and implement a communications plan to improve internal communication between the NHLBI and the community alliance as well as among alliance members. It was also assigned to strengthen the program’s external communication with the community and with media channels.

˛ To kick off the implementation stage, community alliance members recommended planning a media event specifically showcasing Salud para su Corazón to motivate and mobilize members and volunteers and to promote the program’s messages and materials. The premier event (highlighted in Phase 2 of this section) was planned with publicity provided by the program’s local Latino media contacts.

PHASE 2: LAUNCH YOUR PROGRAM

Launch your program with a kickoff event. A kickoff event can introduce your program to the participating audience; motivate and build enthusiasm among your staff, the community alliance members, and other volunteers; and provide an opportunity to involve the local media. Use creative and innovative themes to attract your audience; include food, prizes, games, and giveaways (such as t-shirts, buttons, and magnets) to spice up your activity; and have fun!

Before any event, ask the following:

˛ Have you prepared a program for the event?

˛ Are your educational materials ready for distribution?

˛ Are staff and volunteers trained?

˛ Have you identified the media channels that can best serve your program?

˛ Have your community alliance members enlisted support from their networks to help publicize and assist program efforts?

˛ Are your evaluation plans in place?

PHASE 3: CONDUCT ACTIVITIES

The Salud para su Corazón program has received wonderful responses from participants at healthy cooking demonstrations and health fairs. They enjoy taking home the booklets and cookbooks.

• Jane Durken, Cardiac Outreach Coordinator/Prevention and Wellness, Adventist HealthCare

Mobilize your community. Everyone looks forward to providing materials and conducting educational activities for participating audiences. This phase can and should be enjoyable and

SAMPLE

gratifying, but it also is MEDIA National Heart, Lung, and Blood Institute

ADVISORY National Institutes of Health v Public Health Services v U.S. Department of Health and Human Services

hard work! As you con- DATE: August 28, 1996

FOR IMMEDIATE RELEASE CONTACT:

duct your activities, you

LATINO HEART HEALTH CAMPAIGN HOSTS PREMIER EVENT

should continually exam- On Monday, September 9, community leaders, health officials and local media per-

sonalities will gather for a premier event celebrating the first ever comprehensive heart health campaign for Latinos in the Washington, D.C. metropolitan area. On

ine processes to ensure project will be shown in advance of public broadcast.that evening, sneak previews of the television and radio programs produced for this

Miriam Hernández of WUSA and Pablo Sánchez of Univision will co-host this cel-

that each activity runs as nership between the Community Alliance Working for Heart Health (a group ofebration of theSalud para su Corazónproject. The campaign is the result of a part-

local organizations and volunteers) and the National Heart, Lung, and Blood Institute and the Office of Research on Minority Health of the National Institutes of

smoothly as possible. Health.

Dr. Elmer Huerta, host of the popular program on Radio Borinquen, “Cuidando su Salud,” will preview a month-long series of shows on heart disease prevention

Each activity will have producer of “Linea Directa,” will present a special episode of that program calledwhich will air on weekdays beginning September 13. Arturo Salcedo, host and co-

“Por Amor al Corazón,” which will debut on September 22 at 6:30 pm on Channel

1. The half-hour drama will depict the impact of heart disease on one Latino fami-

logistical and administra- ly.

In addition, announcements regarding the availability of educational materials, programs and upcoming activities of

tive requirements, and Representatives from the Department of Health and Human Services, Members ofSalud para su Corazónwill be made.

Congress, local government officials and community leaders have been invited to this premier. The event will be held in the auditorium (Room 100A) of Our Lady

each involves working D.C., from 6:00 to 8:30 p.m.Queen of the Americas Church at 2200 California Street, N.W. in Washington,

###

with other people. This is true even when you 59

Sample press release

do not organize the event but tap into a community event or an activity conducted by another program.

Publicize your activities. When conducting your own activities, publicize them in a variety of ways. In the Latino community, word of mouth, television, and radio can be very effective.

Community Outreach Activities

A variety of activities can provide information about CVD to your intended audience and explain ways to prevent CVD risk factors such as high blood pressure and high blood cholesterol. For example, activities that demonstrate the benefits of adopting a healthy lifestyle can encourage people to make gradual changes that can help them live a longer, healthier life. Because the immediate and extended family is so important in the Latino community, activities that emphasize heart-healthy behavior benefits for the entire family are usually well received. Details about specific activities conducted by Salud para su Corazón are included in the sidebars and boxes.

Stage 3 — Implementation

S ALUD PARA SU C ORAZÓN — P REMIER E VENT AN O VERWHELMING S UCCESS

It was an unusually hot evening on September 9, 1996, but the warmer-than-expected temperatures did not dampen people’s enthusiasm as they gathered to launch Salud para su Corazón. Instead, physicians and business leaders who came directly from their offices simply loosened a collar or shed a jacket—but virtually no one left until the festivities were over.

The event, sponsored by the NHLBI, the Community Alliance for Heart Health, and the National Institutes of Health’s (NIH) Office of Research on Minority Health (ORMH), showcased the campaign’s products. The premier gave community alliance representatives an opportunity to see the materials they helped develop and to experience, firsthand, community reaction to these products.

Following the multimedia presentations by local

The premier event program

reporters, TV personalities, NHLBI officials, and community alliance members, the evening turned to fun and fellowship. Participants enjoyed music and a buffet of dishes prepared by a local restaurant using a selection of heart-healthy recipes from the Salud para su Corazón recipe book. Attendees were given t-shirts and copies of Salud para su Corazón materials to take home.

Attendees enjoy a heart-healty buffet at the premier event.

Charlas (group discussions). Charlas are group discussions that are typically moderated by a Latino health professional. During the charla, participants learn steps that they can take to prevent or lower their risks of developing heart disease and stroke. Group members then have an opportunity to ask questions and discuss how they can make the recommended lifestyle changes. After the group discussion, sponsoring organizations may offer one or more of the following services: blood cholesterol, blood pressure, or diabetes screenings; nutrition counseling; or food demonstrations.

I liked the charla because it helped me to become more health-conscious and motivated me to be more careful about my heart. The charla setting creates a sense of friendship and fellowship among all of us.

• Magdalena Gomez, charla participant

Magdalena Gomez, charla participant

CHARLA ACTION STEPS

˛ Secure a group discussion facilitator. If the charla is conducted in Spanish, the facilitator must be fluent in Spanish and, preferably, a Latino health professional.

˛ Find a site to hold the charla.

˛ Arrange optional activities, such as blood pressure and blood cholesterol screenings, nutritional counseling, or cooking demonstrations.

˛ Publicize your activity; enlist the support of well-known health care professionals and clergy.

˛ Encourage your community alliance members to contact their networks (such as local businesses and churches) and ask them to support the charla. They can post announcements, provide refreshments, or provide services such as babysitting.

˛ Arrange for a VCR and monitor, a flipchart, and markers. Make sure that you have plenty of copies of all educational materials.

˛ Locate or create a referral list of community doctors who work with local clinics and have it available at the time of the charla.

˛ Evaluate the charla. Provide a short questionnaire to assess the audience’s satisfaction with the program and the facilitator.

I believe that health professionals have a duty to keep in touch with the community, and Salud para su Corazón gives us the opportunity to deliver heart health prevention messages. Charlas are good vehicles to keep in touch with the community.

• Elmer Huerta, M.D., M.P.H., community alliance member

Stage 3 — Implementation

S ALUD PARA SU C ORAZÓN — C HARLA P ROGRAM

During the program’s planning stage, Salud para su Corazón focus group members indicated that group discussions are an effective way to provide health education to Latinos. The pilot program conducted 15 De Corazón a Corazón Charlas (Heart-to-Heart Group Discussions) from February to June 1997, reaching over 1,000 people. The charlas were conducted in church halls, community centers, worksites, and tenant associations in the target area. The 90-minute sessions described steps that Latinos can take to prevent or lower their risks of developing heart disease. Each was moderated by a Latino health professional.

The Salud para su Corazón pilot program developed a guide, From Heart to Heart: A Bilingual Group Discussion Guide, that outlines the steps and explains the activities for conducting a charla or group discussion. The program also developed two videos that were shown as part of the charla intervention (see health education materials and information on page 86).

The Salud para su Corazón charla program was successful, largely because of the assistance of community alliance members who were well connected and highly regarded in the community. For example, popular local physician and Latino radio show host Dr. Elmer Huerta gave two well-attended charlas. Padre José Eugenio Hoyos was also instrumental in rousing community support for the charla program. After publicly endorsing Salud para su Corazón at the premier event, Padre Hoyos promoted the charla program by announcing it from the pulpit of his local church and providing space for several charlas in his church hall and meeting room.

Youth soccer tournament flyer

Charla flyer

Lay health educators (promotores de salud).

Como promotores de salud, si nosotros ten-

Using lay health educators is a popular and

emos la ‘semilla de información,’ podemos

familiar way of passing along information in

sembrarla en nuestras familias, vecinas, y

the Latino community. Community members

nuestra comunidad para que las personas

are receptive to information received from one

logren poco a poco hacer cambios salud-

of their peers.

ables en su vida.

• Silvia Pérez, promotora de salud

S ALUD PARA SU C ORAZÓN — L AY H EALTH E DUCATOR P ROGRAM ( P ROMOTORES DE S ALUD )

During the implementation phase, the pilot program developed a curriculum to train lay health educators to teach other community members how to reduce their risk of CVD. The training manual, titled Your Heart, Your Life: A Bilingual Health Promoters Manual (Tu corazón, tu vida: Manual para promotores de salud), was pilot-tested at La Clínica del Pueblo in February and March 1998. The guide consists of nine components that include an introduction and an overview of CVD and its risk factors along with chapters that focus on:

˛ increasing physical activity ˛ reducing salt and sodium ˛ quitting smoking

˛ eating less fat, saturated fat, and cholesterol ˛ maintaining a healthy weight ˛ planning and budgeting menus

The curriculum explains behaviors that can help prevent health problems such as high blood pressure, high blood cholesterol, and diabetes, which increase a person’s chances of developing heart disease and stroke. The sessions feature fun, interactive activities that show participants that the recommended behaviors are things that they can do and that they can get their families to do. For example, hands-on activities are used to teach participants how to use the Nutrition Facts label, and how to use the Food Guide Pyramid to follow a heart-healthy lifestyle. Role-playing is used to help participants model desired behaviors.

The pilot training for 16 promotores de salud was a successful formative evaluation exercise that resulted in many helpful suggestions for revising the program before it was finalized. The pilot-test participants showed Salud para su Corazón staff members how lay health educators can use their ingenuity and knowledge of their audience to tailor a curriculum and make it more meaningful.

Graduates receive certificates for completing training.

Stage 3 — Implementation

Food demonstrations. Food demonstrations are a popular way to show that food can be prepared in a heart-healthy way and still be tasty. A food demonstration can be a simple activity (for example, showing how to skin chicken or skim the fat off the top of a can of soup), or it can be a more sophisticated activity (for example, showing how to prepare one or more traditional Latino dishes the hearthealthy way). Recipe books can be distributed as incentives to encourage participants to prepare food with less saturated fat, cholesterol, salt, and sodium. Food demonstrations are effective because the audience can see how the food is prepared, and they can sample the results. Your program may want to recruit volunteers from the local health department, local

S ALUD PARA SU C ORAZÓN —

restaurants or culinary schools, or the Cooperative Extension Service to help conduct the food demonstrations. The group discussion guide From Heart to Heart gives detailed steps for organizing a food demonstration, and Delicious Heart-Healthy Latino Recipes contains 23 recipes that were pretested in the Latino community. You can use recipes from this booklet for food demonstrations or you can order copies (see health education materials information on page 86) as an incentive for food demonstration participants to try healthier dishes at home.

F OOD D EMONSTATION T RAININGS

A group of community volunteers from churches and clinics and the Cooperative Extension Service’s Expanded Food and Nutrition Education Program were trained by a registered dietitian who had experience with food demonstrations. The following were key points:

Heart-healthy cooking and shopping (including reading Nutrition Facts labels) ˛ Organization ˛ Equipment ˛ Food safety

The attendees were then able to perform hearthealthy food demonstrations for their own organizations and programs.

Food demonstration participants sample heart-healthy food.

Community events. Many Latino neighborhoods organize events to celebrate their heritage. Community events such as health fairs, parades, and other festivities provide an opportunity to reach people in your target community without investing as many resources as needed for events that you plan and conduct yourself. You can distribute program materials, conduct screenings, conduct cooking demonstrations, or offer nutrition counseling to the participants. These community activities also present an opportunity to network with other organizations with similar goals.

Personal contact. One-on-one contact between a health care professional and a patient or between two community members (such as a promotora de salud and another person) is an effective way to transmit healthrelated information and encourage behavior change in the Latino community. Less intensive personal contacts can also make a difference. Consider youths and older people for activities such as passing out materials at community events, stores, or churches.

Mass Media Channels

Mass media offer an appealing way to reach large numbers of people. If you have the resources, you can develop your own programs and purchase air time. You also may explore opportunities to leverage free air time. With limited funds, consider these ways to make mass media work for you:

˛ Contact radio and television producers of public service shows to be a guest on their program. You can be interviewed or take calls about your initiative and provide information on heart health. For television, bring visuals or food samples to spice up your

S ALUD PARA SU C ORAZÓN

• P UBLICITY E VENTS

Salud para su Corazón found that the best way to publicize its activities was to identify influential individuals who were willing to publicize the program’s activities; for example, charlas held in churches or as part of a church event were announced from the pulpit by the minister or priest. In addition, the pilot program produced inexpensive, colorful flyers for placement in clinics, churches, community centers, stores, and other locations frequented by community members. Press releases were developed for major activities such as the soccer tournament and the premier event (see sample on page 51). The community alliance media committee developed a contact list of local Spanishlanguage newspapers and television and radio stations to receive copies of the press releases.

segment. Be sure to include an opportunity for the audience to obtain more information. Have a local telephone number available and send your program materials to interested callers.

˛ Contact local Latino newspapers and offer to write articles or submit heart-healthy recipes.

˛ Send press releases to radio and television stations and newspapers, and ask them to announce upcoming events as public service announcements on their community calendars.

Stage 3 — Implementation

S ALUD PARA SU C ORAZÓN — M ASS M EDIA A CTIVITIES

Television. Segments were developed for two television programs that are watched by a large number of Latinos living in the Washington, DC, area. Salud para su Corazón was featured in two segments of “Hablemos de Salud” (“Let’s Talk About Health”), a 1-hour talk show hosted by community alliance member Dr. Elmer Huerta. This program is shown on Sundays from 2 to 3 p.m. on WNVC, a local independent television station. The second show, “Línea Directa,” is a 30-minute public affairs program that airs on Sunday evenings on the Spanish-language television network, Univision. Two 25-minute Spanish-language shows produced by “Línea Directa” also are used as videos in conjunction with the charlas.

In addition, a series of public service announcements ran during the course of the program’s implementation phase on the local Univision channel, and a series of short vignettes produced in Spanish was developed to dramatize important messages to promote heart disease prevention. These vignettes are known as telenovelas because they are similar to the soap opera-type telenovelas that are popular programs on Spanish television channels. Telenovelas present a story with a “larger than life” flair and, in this case, the stories also are presented with a bit of humor. Salud para su Corazón’s telenovelas feature the Ramirez family whose abuelita (grandmother), Doña Fela, teaches the family how to reduce their risk of heart disease. They are being shown to major Hispanic markets nationwide through Univision.

Radio. “Un Mes de Prevención Contra las Enfermedades del Corazón” (“A Month of Prevention Against Heart Disease”), a 21-part, 5-minute series produced in Spanish, was aired three times daily on a popular Spanish-language radio station.

Newspapers. Several local Spanish-language newspapers provided free publicity for the charlas and the radio and television programs. These papers also published Salud para su Corazón messages and heart-healthy recipes. Special events such as the poster contest and the premier event were widely covered in the print media. Community alliance members also wrote newspaper articles about CVD risk factors and ways to reduce the risk of heart disease.

Community spokespersons. Latino health professionals and health promotion experts were recruited to respond to media requests for interviews. These individuals were provided information about the program so that they could respond to requests not only in the Washington, DC, area, but also in other areas as news of the program spread. A representative from this group, for example, was interviewed on the morning talk show, “Adelante Houston.”

PHASE 4: SUSTAIN PROGRAM INTEREST AND INVOLVEMENT

We are joining the NHLBI to form a nationwide partnership of Hispanic organizations and individuals that will make Salud para su Corazón a living project in all our communities.

• Yanira Cruz Gonzalez, Coordinator of Health Programs, National Council of la Raza

Link with other groups. Partnerships with the media and with other community organizations are key to a successful and effective program. As mentioned before, it is important that the structure of the community alliance remain flexible and fluid. Although membership may change, new ideas and energy will flow into the program, which increases interest and enthusiasm among all concerned.

Tips to expand and sustain your community alliance include the following:

˛ Assess the activities that are being planned in your community.

˛ Assess your local health care providers for their investment in heart-health programs.

˛ Explore opportunities for cosponsorship of educational events or reproduction of your materials.

˛ Involve local chapters or affiliates of national Latino organizations.

˛ Explore funding opportunities to sustain or expand your program.

Create new partnerships. To create new partnerships, explore the possibility of:

˛ Cosponsoring a health fair or other health event that is expected to be well attended. This can be especially beneficial if a partnering organization is a local chapter of a

national organization. If the scope of your program can be broadened to the national level, the partner can provide a network of potential outlets.

˛ Forming a new partnership with an organization or community group. To encourage participation and to expand your group to include new members, consider offering benefits such as continuing medical education (CME) credit at meetings.

˛ Keep members informed and interested by sending program materials as they are developed, and include them on your newsletter mailing list.

Stage 3 — Implementation

S ALUD PARA SU C ORAZÓN — P ARTNERING W ITH A G ROUP T HAT Y OU C REATE : T HE L ATINO P HYSICIAN N ETWORK

An educational seminar sponsored by the Citibank Medical Group was conducted with the dual purpose of helping physicians market their practice under managed care and establishing awareness of the Salud para su Corazón program. After the seminar, 18 physicians expressed interest in being involved with Salud para su Corazón and were enthusiastic about the opportunity to network with one another; thus, the Latino Physician Network was formed.

Members of the Latino Physician Network:

˛ Conducted charlas at churches and other community sites. ˛ Staffed booths at health fairs and provided free health screenings. ˛ Used Salud para su Corazón educational materials in their offices and clinics. ˛ Showed the Salud para su Corazón video in their office waiting areas. ˛ Recommended the Salud para su Corazón program to their colleagues.

Physicians, by virtue of their expertise, carry a lot of credibility in the community, and we should take advantage of that.

• Ernesto Africano, M.D., cardiologist

Physicians sign up for Latino physician’s network.

Physicians networking.

STAGE 4—EVALUATION

STAGE 4—EVALUATION

1. Prepare for Evaluation
2. Conduct Evaluation Activities
3. Prepare an Evaluation Report and Use Key Findings To Enhance Your Program

Evaluation should not be an afterthought. If properly planned, it can be used to enhance your program efforts and provide motivation for expansion.

• Hector Balcazar, Ph.D., Arizona State University

PHASE 1: PREPARE FOR EVALUATION

Planning for evaluation must be part of your initial program planning, and so it is covered in Stage 1. However, evaluation activities are conducted during the development and implementation stages or shortly thereafter. This section provides additional details about conducting program evaluation, illustrated with examples from the Salud para su Corazón pilot program. Evaluation is the key to making your program the best that it can be. You can use information from the evaluation to improve the program, develop future projects, or advise others who are conducting or are planning similar programs.

Before conducting any type of evaluation, review the evaluation plan that you developed

during the planning phase (see page 21) to decide whether any changes are needed. Carefully review what you decided to evaluate and your evaluation measures; the instruments you have developed, adapted, or adopted; and the staff selected to conduct each evaluation activity.

PHASE 2: CONDUCT EVALUATION ACTIVITIES

As noted earlier in this guide, there are several types of evaluation that you can conduct. Each provides different information to help assess aspects of program success.

Formative Evaluation

Formative evaluation is an ongoing process. The information collected through formative evaluation helps measure the strengths and weaknesses of your program. Formative evaluation is integrated in the planning, development, and implementation stages. It may include:

˛ Conducting assessment surveys

˛ Conducting a literature review

˛ Conducting focus groups

˛ Developing and refining program objectives and strategies

˛ Developing evaluation systems

˛ Pretesting educational materials

˛ Pilot-testing interventions

Stage 4 — Evaluation

PROCESS EVALUATION: YOUR COMMUNITY ALLIANCE

Process evaluation can help your program determine:

˛ What community alliance members find positive and negative about their involvement in program activities

˛ Whether their individual needs are being met and whether they have suggestions for improvement

˛ Whether their involvement in the alliance is benefiting their respective organizations and how they expect their continued involvement to affect their organizations

˛ Their recommendations for improving current activities and conducting successful future programs.

Process Evaluation

Process evaluation assesses procedures used to develop and implement your program and it allows you to make changes in the way your program operates to increase its chance of success. For example, you may want to assess how well your community alliance is functioning, whether the subcommittees are effectively accomplishing their goals, and whether the members are satisfied and willing to continue their support (see box on Community Alliance Evaluation on page 63). You might also want to examine your participating audience’s response to a particular methodology (see box on Charla Evaluation on page 64).

Process measures also help you monitor your program’s progress. You will want to record the number of materials distributed, meetings held, contacts made, and media channels used to determine whether your program’s objectives are being met. Tracking how well your program is working will reassure your organization, your staff members, your community

alliance, and any outside sponsors that your program is moving toward its goal.

Outcome Evaluation

When people think of evaluation, they most often think about outcome evaluation, which helps you determine whether you accomplished your objectives and reached your program goals. Some outcome evaluation measures provide a comparison of the participating audience’s awareness, attitudes, and behaviors before and after the program (see box on Intercept Interviews on page 66). This type of evaluation answers questions about whether a change occurred as a result of the program, such as:

˛ Did the activities increase awareness of CVD risk factors?

˛ Did the participants demonstrate/express intention for behavior change?

˛ Did participants make behavior changes?

Assess the impact of your activities. Additional outcome evaluation measures may include assessing the effectiveness of several program components, focusing on the impact of activities and educational products on the participating audience (see box on Charla Evaluation on page 64 and box on Radio and Print Materials on page 67). For example, outcome evaluation of your educational products and media activities will answer the following questions:

˛ How many people requested the educational materials after being exposed to your public service announcements?

˛ Did your educational materials increase awareness of CVD risk factors?

˛ What modality—print, radio, or television— influenced your participants to change their behavior?

˛ Did your interventions help people feel more confident about engaging in selected behaviors?

S ALUD PARA SU C ORAZÓN — C OMMUNITY A LLIANCE ( P ROCESS E VALUATION )

For Salud para su Corazón, the community alliance was a primary source of skills, resources, contacts, and ideas, and thus it was the focus of the program’s process evaluation. The long-term effectiveness of the community alliance was influenced by decisions made early on concerning the structure and processes. The process evaluation procedure allowed the initiative to assess how well the structure and processes were working and determine whether modifications were needed. It also helped determine if the members were realizing benefits that would sustain and motivate them as individuals and as a group.

The tools and techniques used for the community alliance process evaluation were:

˛ A guided group discussion that was completed before the implementation phase of the program

˛ Self-assessment surveys, also completed before the implementation phase

˛ One-on-one interviews with the NHLBI Latino Project Team and community alliance members

Guided Group Discussion

Community alliance members were asked to participate in a guided group discussion designed to identify the alliance’s strengths, weaknesses, and opportunities. This exercise provided a format for obtaining individual opinions and allowed the group to identify issues to be addressed. The feedback allowed the program to implement changes to increase member satisfaction. Recommendations included:

˛ Enhance communication among members.

˛ Keep current members involved and recruit additional partners.

˛ Change the subcommittee structure to accommodate the changing needs of the program.

˛ Secure involvement of the Latino media and the intended population to foster community ownership and program visibility.

Self-Assessment Surveys

Alliance members also completed a self-assessment survey. Questions were designed to assess the length of membership and participation in planning activities; to characterize communication among members and the committees; and to solicit suggestions for the implementation phase. Self-assessment surveys were mailed to those who were absent.

Key Findings

The majority of members:

˛ Were satisfied with the amount of time spent on activities.

˛ Cited sharing cultural expertise and participation in the planning of activities as important.

˛ Indicated they felt the community alliance was consistently involved in decisionmaking through consensus building.

˛ Expressed satisfaction with the decisionmaking process.

˛ Were satisfied with level of communication; the main recommendation was to publish the Saludos newsletter more frequently.

˛ Felt that there were few barriers to keep them from participating.

Stage 4 — Evaluation

ORAZÓN

O UTCOME E VALUATION

Self-Administered Questionnaire

A self-administered survey was developed to assess the participants’ overall satisfaction with the charla. The questionnaire, written in Spanish, was brief and easily comprehended by people with limited reading skills. Questions were mostly close-ended, and included Likert scales (scale of 1 to 5) for assessing overall satisfaction with the charla and the presenter. The instrument was reviewed by Spanish-speaking health professionals for content and readability and pretested with participants of three pilot charlas. Adjustments were made in content, format, and question order, based on participants’ feedback. Presenters at six charlas provided the questionnaire to participants, which resulted in 200 completed surveys.

Results showed that the majority of respondents were very satisfied with the charlas they attended and would consider changing their behavior after learning about the risk factors for heart disease. Other key findings were as follows:

˛ The majority of participants rated the charlas with the highest rating of satisfaction on a 5-point scale. The average rating across sites was 4.7.

˛ Among the three charla components, most respondents overall ranked the “video” as the number-one informative component. The “questions and answers” component was ranked second, and the “review” component third.

˛ The majority of respondents (98.9 percent) said that they planned to share information about CVD risk factors with family members, friends, neighbors, and other relatives who did not attend the charlas.

˛ Few differences were seen in responses when comparisons were made between sexes or age groups.

˛ Almost 50 percent of respondents said that they came to the charla to educate themselves and to obtain additional information.

C ONTINUED

Post-Charlas Participant Telephone Interview

A followup telephone survey was conducted to assess the effectiveness of the charlas and Salud para su Corazón print materials distributed to participants at the charlas. Structured telephone interviews were conducted in Spanish. The study sample analyzed consisted of 75 respondents. Men and women were equitably represented. A majority of respondents reported being very satisfied with the charla they attended and with the Salud para su Corazón print materials they received. Other key findings included the following:

˛ Almost two-thirds of the respondents (62 percent) gave copies of Salud para su Corazón print materials to other people to increase their awareness and knowledge of CVD risk factors.

˛ The majority of respondents said they shared information obtained from the charla (80 percent), from the eight booklets (82 percent), and from the cookbook (81 percent) with family, friends, neighbors, and relatives.

˛ Most respondents said that their behavior had changed since their participation in the charlas.

˛ Few significant differences were noticed among age groups for most survey responses. However, older charla participants used and shared Salud para su Corazón print materials more often than the younger charla participants did.

˛ Females used and shared their CVD prevention knowledge more often than males did.

Stage 4 — Evaluation

S ALUD PARA SU C ORAZÓN — I NTERCEPT I NTERVIEWS ( O UTCOME E VALUATION )

Salud para su Corazón conducted intercept interviews in three locations in the Washington, DC, metropolitan area (Arlington, VA; Silver Spring, MD; and the Adams Morgan community in Washington, DC) to measure changes in knowledge, attitudes, and behaviors related to reducing the risk of CVD. At each location, half of the interviews were conducted at churches that participated in the implementation phase of the program and that conduct mass in Spanish; half were conducted at grocery stores known to be frequented by Spanish-speaking Latinos. Before the implementation phase, 344 interviews were conducted; and 328 were conducted 6 months after the campaign began. Approximately the same number of interviews were conducted at each location each time. Potential respondents were approached after mass and outside the grocery store and screened for the following criteria:

Qualified respondents were given the full interview, in Spanish, by trained and experienced field interviewers.

The sample was designed to reflect the Latino population in the Washington, DC, metropolitan area; thus, respondents were recruited as follows:

˛ Half were male; half were female. ˛ Half were 18 to 34 years of age; half were 35 to 54 years of age. ˛ Of all survey participants, 30 percent were from El Salvador; 30 percent were from other Central American countries; 30 percent were from South America; 5 percent were from Puerto Rico; and 5 percent were from Mexico.

The survey instrument used multiple items to measure knowledge of risk factors and behaviors associated with CVD. The same questionnaire was used on both tests; however, two questions were added to the later test that probed awareness of the Salud para su Corazón program on the television show “Línea Directa” and/or Dr. Huerta’s radio programs. Several items were asked of respondents in both an aided and an unaided fashion. The survey instru-

Community members participate in

ment is available at the NHLBI Web site.

intercept interviews.

The relatively small sample size limits analysis of subgroups and does not meet requirements for determining statistical significance.

S ALUD PARA SU C ORAZÓN — R ADIO S ERIES AND P RINT M ATERIALS ( O UTCOME E VALUATION )

Methodology

Salud para su Corazón’s 21-segment radio series provided a unique opportunity to evaluate many of the program components. Radio is an extremely popular medium for Latinos, particularly at the local level. A tag line at the end of each of the 21 radio segments on heart health gave a telephone number that listeners could call to request free copies of Salud para su Corazón’s eight easy-to-read bilingual pamphlets and cookbook. The person handling the phone calls gathered information including name, address, telephone number, and age of each caller. More than 1,220 telephone requests were taken, illustrating the effective use of radio for reaching Latinos.

Approximately 1 month after the last request for materials, a stratified random sample of 100 callers was selected to participate in a 5-minute telephone survey to assess customer satisfaction with the Salud para su Corazón program’s eight-booklet series on CVD prevention and the recipe book. Customer satis-

Radio host Dr. Huerta meets

faction was measured through ratings of usefulness, listeners at community event. appearance, ease of comprehension, and overall quality. Other information gathered included print material likes and dislikes, how the recipient used the materials, with whom the recipient shared the materials, and a customer satisfaction rating of the Salud para su Corazón program’s 21-segment radio series.

Results

Most respondents used the Salud para su Corazón program’s print materials they received and were highly satisfied with the materials’ use, appearance, understanding, and quality. Other key findings:

˛ A majority of the respondents used the eight booklets and the cookbook to educate family and friends about CVD prevention and to prepare specific low-fat recipes.

˛ More than 85 percent of respondents shared their knowledge with either family members or friends—usually with at least one person.

˛ Most respondents (97 percent) rated the “Cuidando su Salud” radio program, which broadcasted the Salud para su Corazón radio series, as highly motivational.

˛ For the majority of survey responses, no significant differences were noted among age and gender groups.

To obtain a copy of the instrument, visit the NHLBI Web site.

Stage 4 — Evaluation

PHASE 3: PREPARE AN EVALUATION REPORT AND USE KEY FINDINGS TO ENHANCE YOUR PROGRAM

Build for the long term. Taking the time to document the results of your evaluation efforts is important. This step will help you:

˛ Identify areas of success.

˛ Identify areas where additional or different strategies are needed.

˛ Determine what types of modification are needed and the resources required.

˛ Document positive aspects of the program as viewed by the participating audience and/or the program planners.

˛ Plan future programs.

˛ Satisfy funding requirements and/or secure funding.

˛ Share the benefits of your experience with other programs having similar goals.

Write your evaluation report. The content of your report will vary according to its intent and its audience. For example, a report shared with people who have limited knowledge about the program will include more extensive background information. Much of the information provided in an evaluation report can be obtained from your program plan, provided you have kept the plan up to date as changes occurred and modifications were made. Most evaluation reports include some or all of the following:

EVALUATION REPORTS

˛ Background information on the problem addressed

˛ Description of the program’s audience (participating audience)

˛ Summary of program goals and objectives

˛ Description of the intervention

˛ Discussion of evaluation methods

• Research design
• Limitations
• Instrument development (with samples)
• Sample selection and recruitment
• Description of samples
• Data collection experience

˛ Presentation of data

˛ Analysis of data

˛ Plans for further evaluation

˛ Discussion of the implications of findings

˛ Next steps for program

Selected results and conclusions from Salud para su Corazón evaluation efforts are presented in the remainder of this section as examples of the types of information gathered through effective evaluation and the types of strategies that succeed.

S ALUD PARA SU C ORAZÓN — K EY F INDINGS F ROM THE I NTERCEPT I NTERVIEW E VALUATION

To evaluate the effectiveness of the pilot program, Salud para su Corazón administered a survey to Spanish-speaking respondents in October 1995, before the campaign began, and again in April 1997, after the primary intervention period. The pre- and postintervention samples were comparable in demographics and recruitment locations.

The main objective of the pre- and posttest intercept evaluation was to measure the impact of the program on awareness and knowledge of CVD risk factors and healthy behaviors. An outcome measure was a 10 percent increase in the proportion of the participating audience who could recall three or more of the five modifiable risk factors promoted in the campaign without prompting from the interviewer.

A report that documented the findings from this evaluation was prepared. The report focused on methods, findings, and application of the findings. Key findings and conclusions drawn from the evaluation are summarized below.

Awareness of CVD Risk Factors and Preventive Health Behaviors

˛ Knowledge of factors that can help prevent CVD increased. In the pretest survey, 28 percent of the respondents could identify three preventive behaviors, unaided. The number increased to 43 percent in the posttest survey.

˛ Trends were generally consistent across gender and age groups; however, the greatest effect was seen in the 35 to 54 age group.

Recall of Sources of Information (in Spanish) on Prevention of CVD in the Past 6 Months

˛ In the pretest survey, 46 percent of respondents could recall receiving information in Spanish on CVD prevention. The number increased to 58 percent in the posttest survey.

˛ Television and radio remained the sources of information most frequently cited by respondents (25 percent and 21 percent, respectively, pretest, and 41 percent and 35 percent in the posttest survey).

˛ Awareness of Salud para su Corazón was strongly associated with recall of information from television or radio programs (71 percent of those who were aware of the initiative could recall at least one source of information).

Current Behaviors To Reduce CVD Risk

˛ No differences over time were seen in the proportion of respondents measuring their blood cholesterol or blood pressure.

˛ Women were more likely than men to have cholesterol and blood pressure tests, both pretest and posttest; and a similar trend was seen for older people compared with the younger group.

Stage 4 — Evaluation

C ONTINUED

Awareness of the Salud para su Corazón Campaign

˛ In the posttest survey, 42 percent of respondents indicated an awareness of the Salud para su Corazón campaign. Females were more likely to be aware of the campaign than were males (47 percent versus 37 percent), and older respondents were more likely to be aware than were younger ones (50 percent versus 43 percent).

˛ Of those who were aware of the campaign, 65 percent had heard about it on the radio, and 63 percent had seen the show, “For the Love of Your Heart,” on television. About one-third had heard of the campaign at church.

˛ Men were more likely than women to have been exposed to the campaign on radio (74 percent of men versus 58 percent of women) and television (71 percent of men versus 57 percent of women). Women were more likely than men to indicate that they had heard of the campaign at church (39 percent of women versus 25 percent of men) and at local clinics (25 percent of women versus 8 percent of men).

˛ Although a considerably higher proportion of people 35 to 54 years of age were aware of the program than people 18 to 34 years of age, there were generally no differences in their sources of information.

˛ Television and radio were very effective channels and were most successful in reaching Latino men. Churches were a viable avenue for reaching this population, particularly women, but were less effective than radio and television. Clinics were somewhat effective in reaching women but not men.

Conclusions

An analysis of findings from Salud para su Corazón indicates the following:

˛ A community-based program can increase knowledge of CVD and preventive behaviors among Latinos residing in the Washington, DC, metropolitan area.

˛ Television and radio programs are an effective way to reach this population with health-related messages.

˛ Churches were not as effective as television or radio but reached a reasonable number of people— particularly women.

˛ Additional strategies are needed to reach men and younger people of both sexes.

˛ More effective strategies are needed to encourage male and female Latinos of all ages to seek preventive screening for CVD risk factors.

BRING HEART HEALTH TO LATINO COMMUNITIES

Program planners who wish to replicate the Salud para su Corazón pilot program can benefit from the following experiences that proved to be most successful.

Assessment strategies

˛ Know your participating audience. Having a clear picture of the Latino population at the national and local levels helped the program design products that would be useful to the local Latino population as well as to a wider audience throughout the United States.

˛ Involve the participating audience. Involving the participating audience from the beginning has been crucial for the development of key messages and products, the dissemination of printed materials, and the implementation of outreach activities.

Community empowerment

˛ Involve key community leaders and volunteers. This was critical to successful implementation. Maintaining communications between the NHLBI and the community alliance was a challenge. Several alliance meetings were conducted to keep the communication flowing. Activities were also organized in the community at different points of the development and implementation phase to keep the group motivated.

˛ Be flexible and patient. Flexibility to expand the network as needs or opportunities arose was important. Some community alliance members offered their expertise during the planning phase; other members joined the group as the initiative entered the implementation phase. Everyone was welcome and had a role to play.

Balance

˛ Find ways to balance the needs of the community with the program’s needs. Support other issues of importance in the community to encourage the inclusion of heart health in their agenda.

Educational materials development

˛ Use universal or broadcast Spanish and a bilingual format. Universal language and a bilingual format for printed materials enabled the project to reach a wider Latino audience, saving resources as well.

˛ Avoid literal translation of messages. To conform to the cultural norms, values, and practices of the participating audience, the program avoided literal translations. For example, the English-language side of the program pamphlets contains the popular saying, “An ounce of prevention is worth a pound of cure,” and the Spanish-language side contains the saying, “Más vale prevenir que lamentar” (“It is better to prevent than to lament”). Both sayings convey the same message, but a literal translation would not have given as strong a message.

Mass media product development

˛ Use multiple channels to deliver the same message. This was essential to have an impact and reach large numbers of people. For example, message reinforcement in local newspapers (articles and publication of recipes) and in television and radio broadcasts enhanced the initiative’s outreach.

˛ Use innovative ways to deliver the message. Songs and poems, for example, are nontraditional vehicles for health information.

˛ Use radio programs to disseminate materials and announce outreach activities. For example, a phone number was announced over the radio, which people could call to

Stage 4 — Evaluation

receive a free copy of the materials and recipe book. In 4 weeks, 1,224 callers requested copies of the materials.

˛ Invite members of the media to become part of the advocacy group. Local Hispanic news reporter Miriam Hernández from Channel 9 (Washington, DC) and Pablo Sanchez from Univision were masters of ceremony for the premier event that celebrated the spirit and accomplishments of the project.

Outreach and dissemination efforts

˛ Use low-budget, community-based methods for outreach. Charlas on heart health were well received in the community. Community-based organizations with tight budgets were interested in sponsoring charlas on heart health because they are informal gatherings, easy to organize, and require only a small amount of their staff time.

˛ Use physicians from the community in outreach efforts. Latino physicians facilitated the group discussions and answered questions from the audience. Participant responses demonstrated that doctors continue to be a respected source of health information for the Latino population.

˛ Offer appealing incentives for outreach activities. Free cholesterol and blood pressure screenings were incentives for charla participants. One way to get organizations to sponsor a group discussion on heart health was to offer screenings as part of their ongoing programs. They saw the group discussions as a way of expanding or enhancing their existing programs.

Partnerships

˛ Engage active partnerships. Think big to expand the reach of the program. Consider working with local, regional, or national community and business leaders, and media networks.

NHLBI and Univision announce partnership to air telenovelas nationwide.

Evaluation phase

˛ Use trained interviewers from the participating population. Response rate is good when people are approached by a trained Latino interviewer who is considered their peer.

˛ Use incentives for participation. T-shirts with the Salud para su Corazón logo were given to survey respondents.

˛ Share results of your evaluation with the participating audience to reinforce participation, acknowledge progress and obstacles, and set the stage for continuity and sustainability.

EXPAND THE VISION FOR HEALTHY LATINO COMMUNITIES

Salud para su Corazón works. It promotes healthy lifestyles and healthy communities through approaches that celebrate our cultural traditions and community ties.

• Rita Alcalay, Ph.D., University of California at Davis

We hope you feel prepared to implement a successful CVD risk-reduction program in your Latino community.

Whether you follow each step or modify the steps to suit your needs, the examples and illustrations from Salud para su Corazón will give you creative ideas and materials to begin your own program. To further assist you, a list of information centers and organizations is provided, and the attached appendices contain materials from Salud para su Corazón that you can use to implement your program and share ideas with others. See the health education materials information on page 86 to order additional educational products, such as the eight easy-to-read booklets, cookbook, and charla guide with two educational videos.

Everyone has fun when it comes to heart-healthy eating.

Salud para su Corazón event gets an early start on the next generation.

SHARE YOUR SUCCESS

Be sure to communicate your successes with others so that they will share our vision of increasing knowledge about CVD risk factors and encouraging heart-healthy behaviors among Latinos. We would like to hear about how you have used this guide in your community. Please send your feedback to: Matilde Alvarado, Office of Prevention, Education, and Control, National Heart, Lung, and Blood Institute, 31 Center Drive, Building 31, Room 4A-16, Bethesda, MD 20892.

RESOURCES

The NHLBI and the Department of Health and Human Services’ Office of Minority Health maintain a toll-free telephone number (1-800-282-9126) for the public to obtain a free copy of the eight easy-to-read materials. You may publicize this number in your local effort.

Complementary resources may be found in similar programs conducted in your community. The following list of resources may also help:

Office of Minority Health Resource Center P.O. Box 37337 Washington, DC 20013-7337 (800) 444-6472 (Se habla Español.)

Food and Drug Administration Office of Consumer Affairs HFE-88 5600 Fishers Lane Rockville, MD 20857 (301) 443-3170

National Association of Hispanic Journalists 1193 National Press Building Washington, DC 20045 (202) 622-7145

National Coalition of Hispanic Health and Human Services Organizations (COSSMHO) 1501 16th Street, N.W. Washington, DC 20036-1401 (202) 797-4328

National Cancer Institute Office of Cancer Communications Building 31, Room 10A-16 9000 Rockville Pike Bethesda, MD 20892 (301) 496-5583 or (800) 4-CANCER

National Clearinghouse for Alcohol and Drug Information P.O. Box 2345 Rockville, MD 20852 (301) 468-2600 or (800) 729-6686

National Council of la Raza Center for Health Promotion Suite 1000 1111 19th Street, N.W. Washington, DC 20036 (202) 785-1670

National Diabetes Information Clearinghouse P.O. Box NDIC 9000 Rockville Pike Bethesda, MD 20892 (301) 654-3327

National Federation of Hispanic Owned Newspapers 853 Broadway, Suite 811 New York, NY 10003 (212) 420-0009

Telemundo 2280 West 8th Avenue Hialeah, FL 33010 (305) 884-8200

Univision 1999 Avenue of Stars Suite 3050 Los Angeles, CA 90067 (310) 556-7676

REFERENCES

Balcazar H, Castro FG, Krull JL. Cancer risk reduction in Mexican American women: The role of acculturation, education, and health risk factor. Health Education Quarterly 1995; 22:61-84.

Keenan NL, Murray ET, Truman BI. Hispanic Americans. In: Centers for Disease Control and Prevention. Chronic Diseases in Minority Populations. Atlanta, GA: Centers for Disease Control and Prevention, 1992.

Kuczmarski RJ, Flegal KM, Campbell SM, Johnson CL. Increasing prevalence of overweight among U.S. adults. The National Health and Nutrition Examination Surveys, 1960-1991. Journal of the American Medical Association 1994; 272(3):205-11.

Mogelonsky M. First language comes first. American Demographics 10: October 1995; http://www.marketingtools.com/Publications/A D/95_ad/9510_ad/ad812.htm [accessed 9 Dec. 1997].

Moreno C, Alvarado M, Balcazar H, Newman E, Ortiz G, Forrest M. Heart disease education and prevention targeting immigrant Latinos: Using focus group responses to develop effective interventions. Journal of Community Health 1997; 22(3):435-50.

National Center for Health Statistics. Advance report of final mortality statistics, 1992. Monthly Vital Statistics Report. Supplement 43:6. Hyattsville, MD: U.S. Department of Health and Human Services, 1994.

National Center for Health Statistics. Anthropometric data and prevalence of overweight for Hispanics: 1982-1994. Vital and Health Statistics 11(239): 14-15. Hyattsville, MD: U.S. Department of Health and Human Services, 1989.

National Heart, Lung, and Blood Institute. Latino Community Cardiovascular Disease Prevention and Outreach Initiative: Background Report. Bethesda, MD: Public Health Service, National Institutes of Health, 1996.

Roslow P, Nicholls JAF. Targeting the Hispanic market: Comparative persuasion of TV commercials in Spanish and English. Journal of Advertising Research 1996; 36(3):67.

Strategy Research Corporation. 1994 U.S. Hispanic Market Study. Miami, FL: Strategy Research Corporation, 1994.

U.S. Bureau of the Census. Hispanic Population in the United States: March 1993. Current Population Reports, Series P20-475. Washington, DC: U.S. Government Printing Office, 1993a.

U.S. Bureau of the Census. We the American . . . Hispanics. Washington, DC: U.S. Government Printing Office, 1993b.

U.S. Bureau of the Census. 1990 Census of Population. Social and Economic Characteristics: United States. Washington, DC: U.S. Government Printing Office, 1993c.

APPENDICES

APPENDIX A: SALUD PARA SU CORAZÓN MODEL

APPENDIX B: SERVICE PROVIDER QUESTIONNAIRE (ENGLISH AND SPANISH)

APPENDIX C: WALLET CARD (SPANISH)

SALUD PARA SU CORAZÓN EVALUATION INSTRUMENTS ARE AVAILABLE AT THE NHLBI WEB SITE AT HTTP://WWW.NHLBI.NIH.GOV.

• FOCUS GROUPS PARTICIPANT INFORMATION FORMS
• COMMUNITY ALLIANCE SELF- ASSESSMENT FORMS
• CHARLA (GROUP DISCUSSION) PARTICIPANT ONSITE AND TELEPHONE SURVEYS
• RADIO INTAKE FORM

Appendix A — Salud para su Corazón Model

S ALUD PARA SU C ORAZÓN — M ODEL

The conceptual framework of Salud para su Corazón is drawn from various communication and intervention theories including ecological theories, social marketing theories, theories of behavior change, and the media channel framework.

Social Marketing and Media Channel Framework

Planning Development NHLBI/Community Cardiovascular Implementation Ecological Perspective Alliance Health Promotion Dissemination Evaluation

Behavior Change Theories

Individual Family Community

Theoretical Framework Culturally and Language-Appropriate Multilevel Interventions Outcomes

Ecological Perspective

˛ Integrates the individual, the interpersonal, and the environmental aspects of life.

˛ Incorporates cultural and social factors and relationships with groups and organizations that influence the individual, the family, and the community.

˛ Views behavior as being affected by the interplay of the factors mentioned above.

˛ Allows for replication of ideas and practices by other communities because of its multilevel interactive orientation.

˛ Can be applied to health messages dealing with multiple risk factors.

Social Marketing Perspective and the Media Channel Framework

˛ Consumer orientation — Allows for understanding what consumers are thinking and experiencing; pretest materials with target audience.

˛ Audience segmentation — Differentiate large groups of people into smaller homogeneous subgroups to determine behavioral, motivational, cultural, and other variables that may affect the communication strategies and messages chosen.

C ONTINUED

˛ Channel analysis — Determines appropriate methods to reach the target audience when they are most likely to be attentive and responsive to intervention messages.

• Combines broad-reach media (such as television) and high-involvement media channels (for example, face-to-face discussions and print materials) to reach as many people as possible.
• Uses multiple media channels simultaneously.
• Uses different media channels at different times for programs spanning long periods of time.
• Tailors messages to reach the intended audience.

˛ Strategy — Defines the overarching concepts that will focus the program planning to achieve the stated objectives.

˛ Program monitoring and revision — Establish mechanisms to monitor program process and incorporate feedback to refine or revise program.

Behavior Change Perspective

˛ Behavior change does not occur rapidly; intervention must be sustained in the community.

˛ Many exposures to information are necessary for behavior change.

˛ Consistent themes and messages and positive reinforcement at various points will enhance the effort.

˛ Activities must be relevant and acceptable to the intended audience.

SELECTED READING

Understanding health promotion theories, models, and practices can help you develop a successful program for your community. Sources of information include:

Flora JA, Saphir MN, Schooler C, Rimal RN. Toward a framework for intervention channels: Reach, involvement, and impact. Annals of Epidemiology Supplement 1997; 7(7):S104-S12.

Glanz K, Rimer BK. Theory at a Glance: A Guide for Health Promotion Practice. Bethesda, MD: National Cancer Institute, National Institutes of Health, 1997.

Green LW, Kreuter MW. Health Promotion Planning: An Educational and Environmental Approach. Second Edition. Mountain View, CA: Mayfield Publishing Company, 1991.

McKenzie JF, Smeltzer JL. Planning, Implementing, and Evaluating Health Promotion Programs: A Primer. Second Edition. Boston: Allyn and Bacon, 1997.

McLeroy KR, Bibeau D, Steckler A, Glanz K. An ecological perspective on health promotion programs. Health Education Quarterly 1988; 15(4):351-77.

National Cancer Institute. Making Health Communication Programs Work: A Planner’s Guide. NIH Pub. No. 92-1493. Bethesda, MD: Public Health Service, National Institutes of Health, 1992.

Stokols D. Translating social ecological theory into guidelines for community health promotion. American Journal of Health Promotion 1996; 10(4):282-98.

Appendix B — Service Provider Questionnaire (English)

COMMUNITY ALLIANCE WORKING FOR HEART HEALTH

SERVICE PROVIDER QUESTIONNAIRE

Cardiovascular Disease Prevention

Agency Name:

Address: Street

City State Zip

Contact Person: Phone Number: Fax Number:

Please indicate if your agency offers the following cardiovascular disease prevention and treatment services, if they are in English and Spanish, and if there is a fee for the service: SPANISH Screening Services Cholesterol Hypertension Weight Diabetes Treatment Services Cholesterol Hypertension Diabetes Counseling Services Smoking Cessation Weight Reduction Cholesterol Diabetes High Blood Pressure One-on-One Counseling Group Counseling Health Education Services Cooking Classes Health Classes Exercise Classes Videos Brochures and Other Print Materials Lay Health Educators Other

Does your agency have a sliding fee schedule?

Does your agency accept Medicaid?

Is your agency located near public transportation?

Does your agency have eligibility requirements for services?

Does your agency accept new patients/clients?

Can we list your agency as a resource in our educational materials?

Yes

Yes

Yes

Yes

Yes

Yes

No

No

No

No

No

No

Thank you for completing this questionnaire. If you would like information about the Community Alliance Working for Heart Health, please call .

Appendix B — Service Provider Questionnaire (Spanish)

ALIANZA COMUNITARIA PARA LA SALUD DEL CORAZÓN CUESTIONARIO PARA LOS CENTROS DE SALUD Prevención de las Enfermedades Cardiovasculares

Nombre de la agencia:

Dirección: Calle

Ciudad Estado

Persona a contactar: Número de teléfono:

Codigo postal

Número de fax:

Por favor indique si su agencia ofrece los siguientes servicios para prevenir y tratar enfermedades cardiovasculares, y sí éstos se ofrecen en inglés o español, y cuál es el costo de estos servicios:

(Marque a todo lo que aplique) SÍ NO Servicios de Control Colesterol Presión arterial alta Peso Diabetes Servicios de Tratamiento Colesterol Presión alta Diabetes Servicios de Consejería Para dejar de fumar Reducción de peso Sobre el colesterol Sobre la diabetes Sobre la presión arterial alta Consejería individual Consejería en grupo Servicios Educativos Clases de cocina Charlas sobre la salud Clases de ejercicio Videos Folletos y otros materiales escritos Promotores/educadores de la salud Otros

¿Tiene su agencia una escala de precios para los servicios y tratamientos?

¿Su agencia acepta el Medicaid?

¿Su agencia tiene buen acceso a los servicios de transporte público?

¿Su agencia exige requisitos de elegibilidad para obtener los servicios y tratamientos?

¿Su agencia acepta nuevos pacientes?

¿Podemos citar su agencia como un preveedor de servicios en nuestros materiales educativos?

ESPAÑOL INGLES GRATIS PRECIO

Sí

Sí

Sí

Sí

Sí

Sí

No

No

No

No

No

No

Gracias por responder a este cuestionario. Sí usted quiere mas información acerca del la Alianza Comunitaria para la Salud del Corazón llame al .

Appendix C — Wallet Card

Use for photocopy purposes only.

Back

Front "

Back

(fold)

Front " " "

Salud para su Corazón Health Education Materials

The NHLBI also maintains a World Wide Web site at http://www.nhlbi.nih.gov. Selected publications are also available on the NHLBI Web site.

†Set of Eight Easy-To-Read Bilingual Booklets on Preventing Heart Disease – #55-745.

†Delicious Heart-Healthy Latino Recipes (Platillos latinos ¡Sabrosos y saludables!)

• #96-4049.

From Heart To Heart: A Bilingual Group Discussion Guide (De corazón a corazón: Guía bilingüe para organizar una charla) (Includes two 25-minute videos, “For the Love of Your Heart” and “Cooking With Your Heart in Mind.”) – #97-4050.

An Ounce of Prevention: A Guide to Heart Health (Más vale prevenir que lamentar) – Available 1999.

Salud para su Corazón—Your Heart, Your Life: Lay Health Educator’s Manual (Salud para su Corazón—Tu corazón, tu vida: Manual para promotores de salud) (Includes flipchart and five mini-telenovelas.) – Available spring 1999.

Salud para su Corazón—Bringing Heart Health to Latinos: A Guide for Building Community Programs (Includes a 7-minute video.) – #98-3796. _____________

†Publications noted with this symbol are available on a disk that can be used by a professional printer to print unlimited copies.

To the beat of your heart

An ounce of prevention is worth a pound of cure, says Grandma Fela.

To the beat of your heart the world is walking. To the beat of your heart people are celebrating.

To the beat of your heart the world is walking. With rhythm, oh my, with such relish, Grandma is dancing.

She is one hundred years and one month old; she was born a century ago. Her heart has been pierced three times with love’s arrow.

How’s that? She eats rice and beans. What did you say? She walks every day. She does not like pork skin. For real? She is never out of tortillas.

She has never smoked in her life; she likes to play soccer. She is no friend of alcohol, beware the cholesterol.

What does she drink? 1% milk. For real? She checks her blood pressure. That’s why she is one hundred years old.

So Grandma dances to the beat. With flavor for the health of the heart, little salt and no lard. And how does Grandma care for her heart?

Salud para su Corazón Song

by Lilo González

Al ritmo del corazón

Más vale prevenir que lamentar, dice la abuela Fela.

Al ritmo del corazón el mundo esta caminando. Al ritmo del corazón mi gente esta celebrando.

Al ritmo del corazón el mundo esta caminando. Con ritmo, ¡Ay! ¡Con sabor! La abuela esta panchangueando.

Tiene cien años y un mes; nació el siglo pasado. Le han flechado el corazón tres veces se ha enamorado.

¿Cómo? Come habichuelas y arroz. ¿Qué dice? Camina todos los días. No le gusta el chicharrón. ¿De veras? No le faltan las tortillas.

Nunca ha fumado en su vida; le gusta jugar futbol. Del alcohol no es muy amiga; ¡cuidado el colesterol!

¿Qué toma? Leche al 1%. ¿De veras? Se chequea la presión. Por eso cumplió cien años.

Por eso baila este son. Salud para su corazón. . .con sabor, con poca sal y sin manteca. Y ¿cómo cuida su corazón la abuela? With fruits and vegetables, and whole wheat bread, watches her weight and enjoys her life.

Discrimination Prohibited:

no descuida de su peso y disfruta de la vida.

Under provision of applicable public laws enacted by Congress since 1964, no person in the United States shall, on the grounds of race, color, national origin, handicap, or age, be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity (or, on the basis of sex, with respect to any education program or activity) receiving Federal financial assistance. In addition, Executive Order 11141 prohibits discrimination on the basis of age by contractors and subcontractors in the performance of Federal contracts, and Executive Order 11246 states that no federally funded contractor may discriminate against any employee or applicant for employment because of race, color, religion, sex, or national origin. Therefore, the National Heart, Lung, and Blood Institute must be operated in compliance with these laws and Executive Orders.

NATIONAL LEADERS SUPPORT SALUD PARA SU CORAZÓN

Salud para su Corazón is a blueprint for Latino community outreach. We are pleased to be a partner with the National Heart, Lung, and Blood Institute to promote heart health in the Latino community. As a primary source of news and information for Latinos, our company has committed the resources of the Univision Television Group stations and the Galavision network to disseminate the critical health messages of cardiovascular disease prevention throughout the Latino community.

• Ivelisse Estrada Vice President Corporate and Community Relations, Univisión

“Creo que es muy importante que los periódicos Latinos consideren entre su material a publicar la valiosa información en apoyo al programa Salud para su Corazón, que tiene como fin reducir la incidencia de enfermendades cardíacas. El periódico es un vehículo importante para llegar al corazón de nuestros lectores con mensajes que les ayuden a vivir más y mejor.”

• Carlos G. Carrillo President National Federation of Hispanic Owned Newspapers

“While other diseases affecting the Latino community have gotten more attention and perhaps more focus, the real ‘silent killer’ of Latinos is heart disease. Over 25% of deaths among Latinos are heart disease related, making it the number one cause of death in our community. This initiative is long overdue and critically needed. We applaud the NHLBI for establishing Salud para su Corazón and we are committed to helping them reach out to the Latino community.”

Raul Yzaguirre President National Council of La Raza

“Salud para su Corazón ha creado importantes materiales educativos y de medios de comunicación que deseamos utilizar en nuestra campaña en México.

Dr. Julio González-Molina Organización Panamericana de la Salud México, D.F.

U.S. Department of Health and Human Services Public Health Service National Institutes of Health National Heart, Lung, and Blood Institute

NIH Publication No. 98-3796 November 1998