Building and Maintaining a Whole Community Initiative: Health Communication in Practice with Be Well Communities^™

Abstract

The most effective health communication builds from evidence-based best practices and theory. In practice, health campaigns rely on considerations often under-discussed in health communication, such as consistent agency-style client service, image management, and community coalition-building. Health outcome progress often requires change at multiple levels, from individual cognition and behavior to policy creation. These multi-level needs further highlight the importance of effective practical health communication supporting a range of outcomes and building toward replication. This article covers the complexities of building and implementing a theory-informed health communication structure for a multifaceted, place-based cancer prevention initiative. Part of the overall process includes detailing the internal communications of a health communication group, interorganizational communication, engaging community partner support, the message creation process, and longitudinal efforts on program maintenance and assessment. Furthermore, this article seeks to offer an example of the client service role a health communication team can play to combine theory, empirical message development, and community goals in whole community efforts. Ultimately, the goal is to share experiences from seven years of program work to help guide future community-based efforts in other health contexts and foster progress in theoretical and practical understandings of health communication.

Introduction

Health communication campaigns can change behavior and improve real-world outcomes (Willoughby & Noar, 2022), though applying best practices and theory into localized, multifaceted health campaigns entails significant complexity. Applied campaigns rely on areas under-discussed in health communication, such as agency-style client service, image management, and community coalition-building. The research literature includes limited reflection on the complexities and processes of implementation, including how theoretically guided work moves from strategy to application while coaching community organizations on research-informed communication (Willoughby & Noar, 2022).

Time, money, and effort are stretched in local community initiatives, highlighting the need for understanding of how effective campaigns function and how to evaluate community-focused outcomes such as cultural change and trust in local institutions. Complexity arises, then, because the research literature often focuses on content choices and outcomes and less on implementation and replication (Getachew-Smith et al., 2022; Willoughby & Noar, 2022). Similarly, the majority of research examining persuasive strategies uses either messages without external validity (O’Keefe, 2015; Slater et al., 2015) or national campaigns (Noar, 2006).

This article covers the complexities of seven years implementing a theory-informed health communication structure for a multifaceted, place-based cancer prevention initiative. It lays out the interworking of health communication efforts, including inter-organizational communication, community partner support, message-creation, and longitudinal program maintenance. Furthermore, we offer an example of the clientservice role a health communication group can play to combine theory, empirical message development, and community goals in whole community efforts.

Be Well Communities

Be Well Communities^™ is a core program of the Cancer Prevention and Control Platform at The University of Texas MD Anderson Cancer Center, it is the institution’s place-based strategy for comprehensive cancer prevention and control working with communities to address modifiable risk factors for cancer including healthy eating, active living, sun safety, tobacco-free living, and preventive care (Rechis et al., 2021). Estimates suggest these factors account for at least half of cancer cases in the United States could be prevented (Islami et al., 2018). Be Well Communities has been implemented in three Texas locales: Pasadena, Baytown, and the Acres Homes neighborhood in Houston (see Rechis et al., 2021, 2024). Be Well Communities provides an ideal space to examine health communication practice because their approach brings together and bolsters individuals, schools, workplaces, government agencies, health care providers, and policymakers to plan to carry out sustainable, community-led solutions that are eventually sustained completely by local community organizations. Figure 1 indicates the timelines for Be Well Communities program development.

Figure 1.

Program timelines for be well communities.

The Be Well Communities backbone team

In all Be Well Communities implementation sites, evidence-based interventions are selected by and implemented with collaborating organizations from the community, supported by a multi-sector health coalition (a steering committee) largely made up of members of local organizations (M.D. Anderson Cancer Center, n.d.). Professionals from MD Anderson on the Be Well Communities team serve as the backbone team. Their role is to support and coordinate the steering committee and collaborating organizations to foster collaboration across sectors, build capacity of organizations, and align activities and programs toward shared, community-determined goals. The backbone team also evaluates the collective effort of the initiative (M.D. Anderson Cancer Center, n.d.), including associated health communication work (see Rechis et al., 2021, 2024).

Within Be Well Communities work, the Center for Health Communication at the University of Texas at Austin provides three levels of support, partnering on: 1) program identities for the overall Be Well Communities effort, 2) brand development for each community, and 3) health communication campaigns for collaborating organization efforts as well as community-wide interventions like infrastructure improvements. This work is further defined in Table 1 as well as Mackert et al. (2024).

Table 1.

Services provided by the center for health communication group for Be Well Communities.

Project management	Manage project timelines Coordinate with backbone team and collaborating organizations Coordinate scholarship, strategy, copy, and design Report on progress and brand management across programs Provide on-demand technical assistance and subject matter expertise
Strategy	Build and maintain program identities for all associated brands Applied and theoretical research for health campaigns with collaborating organizations, including advertising, public relations, and marketing needs Work with partners to distribute content across multiple media channels Assist with development of implementation plans for collaborating organizations Track and report on campaign implementation Monitor social and news media for Baytown and Acres Homes
Copywriting and design	Create original health communication campaigns for collaborating organizations, including advertising and public relations components Create branded products for collaborating organizations Create branded products for Be Well Communities
Scholarship support	Provide revision and editing support for Be Well Communities products Support evaluation design in line with program needs and theoretically guided assessment Support academic manuscripts using evaluation data

Building and maintaining the Be Well Communities identity

Fields such as brand management and advertising can be treated as separate from health communication (Basu & Wang, 2009; Mogaji, 2021), particularly in research spaces, but broad initiatives like Be Well Communities need to build brands and maintain program identities. Be Well Communities supports strategic campaigns led by collaborating organizations, and the program also needs communication assets of its own to sustain and grow the work. Therefore, guidance on program identities and image management is necessary alongside support for specific campaigns. Additionally, skills from the internal and organizational public relations fields are essential for team members to create theoretically informed health communication campaigns within community coalitions.

The creation of what is now known as Be Well Communities took time. The development of a branded program identity for Be Well Communities happened during more than a year of conversations to understand what community members would find meaningful; what would be a recognizable, distinct representation of community well-being; and what would also stand out from other related but different programs and institutions. Team members from MD Anderson’s institutional internal communications team, the Be Well Communities team, and the Center for Health Communication collaborated on drafts for discussion with steering committees and other key leaders.

Established best practices for health communication campaigns drove the formation of the Be Well Communities efforts, focusing initially on audience research and environmental scans of existing healthy communities work. Based on that foundational research, the initial branding ideas from the Be Well Communities team focused on health-oriented framing such as “Get Healthy” and “Be Fit.”

From there, conversations soon moved to ideas promoting well-being to encompass the broader nature of these healthy communities’ efforts. Additionally, building from research on other mediated health campaigns, the coalition’s work started giving priority to promoting self-efficacy. A well-being approach can present a low-stakes, gentle starting point for messages about incremental progress. It avoids ideas of fitness and healthiness that can be emotionally loaded for some people, creating reactance, especially when fitness is promoted too vigorously. Bearing all this in mind, the team began working with “Be Well, <city>” and “Go, <city>” branding options.

Following dialogue with a small group of partners and health communication experts across three months, the communication team created mock-ups of how “Be Well” and “Go” could be applied and took that to the steering committees for further community input over another two months. Community organizations agreed on “Be Well” as the preferred choice because the name is approachable, can include the full range of positive health behaviors, and sounds like a polite expression of good wishes to a fellow community member.

During the ensuing six months partner-focused work on message design, development, and placement continued before initial social-media content developed at the two-year point, marking the beginning of campaign-specific health communication work. The initial years were needed to foster community collaborations, define goals, develop contractual understandings between organizations, organize resources, and engage team members for project management, local engagement, and communication design. Year three brought significant health communication work, involving outdoor displays such as physical signage, more coordinated social media outreach shared by partners, digital displays in community locations such as building lobbies, and marketing materials like hats and T-shirts. Year four brought more consistent health communication work with brand management, focused campaigns, integrated media usage, message testing, and some assessment.

Program identities are a constant need because new programs and community partnerships develop frequently. The commitment to community partnership means that branded assets about programs develop in collaboration with steering committees, similar to the initial naming and logos. For example, the health communication team created tailored stylized impact maps to convey the reach of Be Well Communities efforts and build perceived efficacy of the program. Committee members generated requests about what to include, how to design the map, and how to represent their towns. For example, the Be Well Baytown steering committee requested that the map includes a local bridge, and the Be Well Acres Homes steering committee suggested adding a reference to a key bus line and the resulting neighborhood nickname, “the 44.” Also, Acres Homes steering committee members suggested including a horse and a barn to reflect the area’s agricultural heritage. Figure 2 shows the resulting impact maps for Be Well Baytown and Be Well Acres Homes.

Figure 2.

Impact maps for Be Well Baytown and Be Well Acres Homes.

Project timeline planning

An essential aspect of managing the complexity of multi-partner, multi-channel health communication work involves constructing the foundation for goal alignment, process creation, collective understanding, and organizational collaborations, especially for interventions across social-ecological levels. The process depends upon community leadership and allows for the substantial, up-front time that is needed for internal communications to foster trust such that many types of needed expertise can become integral to the overall work.

For example, community partners may have communication concerns that the health communication literature is capable of answering but is not yet part of published scholarship (e.g., implementation, timelines, and resources). Most excitingly, community partners often suggest creative ideas that fundamentally cannot be evaluated through traditional academic evidence appraisal, such as the charm of copywriting or appeal of visual communication. The evidence base of message effects can be useful to consult for broad strategy, like using gain or loss framing, but struggles to address creative concerns or local tailoring. No matter how great the evidence base becomes, formative research that takes in perspectives from the priority audiences will always be needed (National Cancer Institute, 2023; Noar, 2006; Willoughby & Noar, 2022). There is no substitute for community-driven creative work and message pre-testing in an environment of trust. Without it, initiatives risk not receiving honest input from local partners, which may cause enthusiasm for the initiative to wane.

Additionally, collective approval of communication content among larger institutions (e.g., local government, university, medical center) can require noteworthy investments of time and dialogue to develop norms and processes. Each institution brings its patterns and systems that need accounting for in the scheduling process. Local organizations must also respond immediately to their most emergent concerns, so upstream topics like cancer prevention can often be on the figurative back burner. COVID-19 urgencies show the impact on cancer prevention efforts at Lee College in the timeline in Table 2, which describes key moments in the creation of the campus sun safety campaign. Similarly, in the aftermath of Hurricane Harvey, a Baytown food distribution partner needed to reconfigure long-term cancer prevention to temporarily emphasize emergency assistance.

Table 2.

Timeline of the sun safety campaign at Lee College.

Aug. – Oct. 2018	CHC group supports content curation about sun safety
	Several sun safety articles created by the CHC are re-shared by Lee College on Facebook
Nov. 2018	Lee College promotes installation of sunscreen dispensers on Facebook
Dec. 2018 – March 2019	Overall Be Well Communities team curates additional content curation about sun safety
	Lee College re-shares additional sun-safety content on Facebook
Aug. 2019	Lee College creates and shares a CHC-designed graphic about sunscreen dispensers.
Nov. 2019	Lee College’s sun-safety website goes live
	The sun safety website is promoted by Lee College on Facebook
Dec. 2019	Sunscreen dispensers are promoted by Lee College on Facebook
Aug. 2020	Full sun-safety campaign designed with CHC is approved
Nov. 2020	Lee College begins implementing the sun-safety campaign
July 2021	New sunshade installed at Lee College
	Sunshade’s arrival promoted by Lee College on Facebook
August 2021 – Present	Sun-safety campaign in implementation phase
October 2023	Visual refresh of sun-safety campaign

The CHC and Be Well Communities teams must also think about logistics and capacity for each potential distribution channel, as some collaborating organizations know more about digital media than others and have different abilities to print physical materials. The health communication group invests a significant amount of time supporting collaborating organizations in building capacity to implement promotional assets. In one example, a CHC professional created a Q and A on their personal Instagram page to write a step-by-step tutorial on using the questions sticker feature while screenshotting every step so that a community partner could independently launch engaging social media content.

Creating and implementing health campaigns with collaborating organizations

Creating campaigns with the collaborating organizations and managing their implementation is given top priority each year. During fiscal year 2023, more than 90% of the communication assets produced by the CHC team were for campaigns created with collaborating organizations. Table 3 shows the final communication products delivered by the CHC in partnership with Be Well Communities in fiscal year 2023.

Table 3.

Final communication products delivered by CHC to Be well communities (FY23).

Products for promoting branded program identities
Be Well Communities	7
Be Well Acres Homes	3
Be Well Baytown	3
Health campaign products promoting cancer-prevention behaviors
Physical activity with local government	20
Physical activity with higher education	7
Sun safety with local government	21
Sun safety with public schools	58
Healthy eating with a local nonprofit	37
Total number of communication products	Total: 156

The products in this table include only final deliverables designed for external audiences. This list excludes internal process documents, meeting documents, implementation tracking, reporting, and the range of drafts typically needed to arrive at consensus.

Many in health communication scholarship are used to playing an outside adviser role. They often make recommendations centered around an ideal scenario and send them off as part of a research project or consulting role with a focus largely on short-term data gathering. In contrast, the CHC and Be Well Communities teams advise and see health communication projects all the way through from inception to implementation, engaging in daily client service. Practical health communication requires skills from health promotion, advertising, public relations, visual communication, and client relations to balance theory- and evidence-based recommendations in collaboration with community partners.

The emphasis on locally relevant messaging with collaborating organizations as the voices exists alongside the need to keep content as unified and consistent as possible so campaigns can be mutually supporting. At present, there is a broader strategy and copy-writing process involving drafting key visuals and messages to then tailor alongside each collaborating organization to support their voices and visual guidelines.

The sun safety work demonstrates the balance needed in these situations to span age groups, organizations, and languages. Figure 3 presents examples of sun safety campaign materials the CHC created for multiple collaborating organizations. The work incorporates the visual identities of each collaborating organization but maintains a recognizable consistency. The consistency required is primarily about information content and tone to ensure that the overall initiative is seen as a stable presence across communities with localization to respect preferences and amplify voices.

Figure 3.

Sun safety campaign materials for multiple collaborating organizations.

Additionally, many of the sun-safety visuals were designed to ensure that photos and photorealistic images, where used, represented significant portions of the local communities to benefit from homophily. The message placements also employed message content intended to build both self and response efficacy across the deliverables, such as focusing on people’s ability to invest in their future selves by seeking shade during peak sun hours and applying freely available sunscreen while also mentioning sunscreen’s effectiveness at blocking UV radiation and the utility of wearing hats, sunglasses, and clothing with sleeves.

Process and outcome evaluation

Another area of health communication that can benefit from practical lessons learned through Be Well Communities is evaluation. The program implements approaches to assessment appropriate for whole community initiatives while using evaluation data to improve programming and examine applications of health communication ideas.

Every collaborating organization implementing a communication campaign receives an implementation guide and tracking template which is completed on a quarterly basis. The CHC group helps create the tracking templates and also reviews and synthesizes the gathered data. In addition, the health communication specialists conduct independent monitoring and work with the backbone team to make changes based on the data.

For example, in fiscal year 2023 a local food access campaign was created and implemented. After several community events, the collaborating organization noted in a quarterly report that what was initially conceptualized as an online resource worked better as a print handout. In the next budget period, the online resource was re-designed to be a print resource (e.g., removing hyperlinks and changing color system). Further, after hearing about the collaborating organization’s reluctance to order from a print shop for timing and administrative reasons, a version was laid out for an office printer to produce half-sized, two-sided handouts with one side in English and the other in Spanish.

Sustainability and replication

The ultimate goals of this healthy communities’ initiative include independence and replication. Each aspect of the health communication work is designed to be handed off after initial development and training so that community groups have the capacity to be independent health communicators for subsequent work. Community partners need capability to design messages, select channels, maintain brands, assess communication efforts, and consider how outreach campaigns function in an integrated way, including with their own strategic priorities. Part of this means that the health communication work must operate at multiple levels, as suggested by the social-ecological model, because community health improves at individual, community, policy, and organizational levels. To meet this complex need, the health communication group has developed templates for organizations to use in social media platforms and community and internal presentations, established program identity guidelines, public relations guidance, one-to-one coaching on strategic communication best practices, and continued dialogue with steering committees and organizations responsible for maintaining coordination and future planning.

Discussion

The health communication work of Be Well Communities serves as an example of how communication can contribute to coalition development, capacity-building, and system activation in community health. The work also improves health communication’s knowledge as a field about how multifaceted communication campaigns serve people, organizations, and communities.

Coalition development

Coalition development is an essential area where Be Well Communities’ health communication work bolsters the initiative around a common vision. In particular, collaborating with a wide range of partners to develop the needed brands for credible outreach offers examples that can be borrowed by other community health programs; also, the lessons from the launch experience can help account for ways community-centric work may challenge traditional timekeeping and incentive structures for university partners.

Applied health communication work at this scale requires significant startup costs in terms of time and investments for relationship-building and process creation. Examples within Be Well Communities work, as discussed earlier in this manuscript, include creating the brands themselves as well as supporting the development of steering committees for each city and the backbone team to help guide overall direction.

Capacity building

Capacity-building within collaborating organizations also merits focus to ensure programmatic health communication work endures beyond any specific project or deliverable. Capacity-building in this way necessitates a client-service, trust-building mind-set similar to what strategic communication agencies offer. The organizations that collaborate on campaigns and the residents participating in programs are the clients, putting health communicators in position to align empirical evidence with community feedback and build up collaborating organizations in as many ways as possible to apply evidence-based communication.

The impact map development discussed above offers an example of capacity building where community members led editing with user-tailored messaging techniques, showing how participants in whole community programs can employ health communication best practices (Sundar & Marathe, 2010). Applied health communication like this where the research base meets community needs requires complementary elements that build from health promotion, advertising, public relations, visual communication, and client relations, all combining into an approach with potential across populations and health issues (see Table 4, which outlines the key considerations for strategic health communication in a whole community program). Be Well Communities work shows how brand identities, interwoven message placements, and community partnerships employ creativity and humanity to produce engaging, research-informed work capable of sustained, locally led impact.

Table 4.

Key considerations for strategic health communication in a whole community program.

1.	Time for coalition-building and goal alignment among coalition members
2.	Essential skills not always associated with health communication, including public speaking, public relations, and project management
3.	Program identities must be built and maintained
4.	Frequent, consistent client service needed to implement campaigns with local collaborating organizations
5.	Focus on building capacity of coalition members, requiring ability to teach new skills and provide on-demand technical assistance
6.	Thorough feedback process for communication products that engages all coalition members
7.	Space for responding to local priorities for products and project timelines
8.	Process for frequent engagement with implementation and outcome evaluation to adjust messaging content, placement, and coordination

System activation

System activation, defined as the process of messaging influencing “sectors of society” and then spurring actions at various social-ecological levels, is the explicit goal of a whole community health initiative like Be Well Communities. Hornik (2002) argued that system activation was the driving force behind positive health behavior changes associated with health campaigns but was often ignored by common evaluation methods because less thinking and attention are given to examining interventions with multiple inputs at specific moments in time. Further, the communication literature is broadly lacking evidence about effects beyond those at the individual level and effects over time (Cho & Salmon, 2007; Li & Cho, 2023), leaving space for a project like Be Well Communities to help fill needed gaps in conceptual understanding, particularly for multi-level work over time.

To study the way that various levels of activation interact, a different lens is required. Thus, an additional impact of the work with Be Well Communities is a sustained effort to closely evaluate the process of implementation alongside outcomes, all as a means of investing in deeper understanding of program and messaging improvement. Explanations of how process and outcome evaluation inform strategy are needed in the research literature, as a recent review found that less than half of the articles about process evaluation actually discuss how process evaluation influenced strategy (Getachew-Smith et al., 2022).

The first health communication-focused academic presentation building from Be Well Communities is an example of this impact. In that talk, Ghosh and Kriss (2023) showed that the perception that a local community college cared for its students positively moderated the relationship between sun safety campaign awareness and initial trials of sunscreen dispensers on campus. Focusing on a perception of care per Hornik’s (2002) assertion about “the underlying character of the way communication programs are meant to work” (p. 17) may represent a path forward to thinking and theoretically conceptualizing whole community approaches to health communication with innovative outcome evaluation (Peattie et al., 2016). The resulting knowledge can inform theoretical advances by offering external validity where academic concepts interact with practical environments while examining how key health communication ideas operate across social-ecological levels to support systemic activation.

Further, Be Well Communities’ contributions to coalition creation, capacity building, and system activation have driven noteworthy practical outcomes in partner communities such as Baytown and Acres Homes. Baytown’s focus involves 35 EBIs in five areas: healthy eating, active living, sun safety, tobacco-free living, and preventive care (see Rechis et al., 2021). The work in Acres Homes includes 23 evidence-based interventions focused on healthy eating, active living, sun safety, and tobacco-free living (see Anderson Cancer Center, 2023). During these efforts, Be Well Communities reached 83% of Baytown residents in its first five years with 48% of Acres Homes residents connected to an evidence-based intervention in the first two-plus years there.

More specifically, access to health care prevention resources make up a significant area of practical impact from Be Well Communities efforts, including Baytown clinical partners offering more than 5,900 breast, cervical, and colorectal screenings, for example. Additionally, in Baytown, more than 4,000 people attended 19 Pop-up Park events and 40,000 received sun safety information and resources. With school partnerships, more than 24,000 students benefited from a comprehensive coordinated school health approach focused on creating systems that support academic performance by integrating health education services into the school day and build healthy behaviors across the life course.

Similarly, in the first few years of Be Well Acres Homes, access to care and prevention has increased, such that more than 5,000 people in the community participated in physical activity programs and 2,000 received nutrition education. More than 5.7 million pounds of healthy food was distributed, and 82 garden beds in Acres Homes were rebuilt for community use. Ten community sunscreen dispensers were installed along with four shade structures at a community pool, accompanied by other infrastructure improvements at the pool complex.

Conclusion

This article maps the intricate, time-consuming process of building and implementing theory-informed health communication structures within the context of a multifaceted, place-based cancer prevention initiative. The findings highlight the often-overlooked challenges of translating theoretical insights into practical, community-focused outcomes, emphasizing the need for detailed understanding and documentation of effective processes across significant time. The program’s impact stems from its commitment to evidence-based practices and collaboration with community stakeholders. Similarly, the commitment to sustainability and replication as core to Be Well Communities reflects a forward-looking and integrated approach to health communication in community health initiatives. By sharing the experiences, challenges, and successes of health communication for Be Well Communities, this article helps show kinds of impact in ways that facilitate the progress of the field and guide future, impactful community-based initiatives.