Community-Based Participatory Research in an Obesity Prevention Media Campaign for Mexican Americans: Tu Salud ¡Si Cuenta!

Abstract

Background and Methods

To address obesity and related morbidities, community-based participatory research (CBPR) strategies were employed to design / evaluate a Spanish language media campaign promoting physical activity and healthful food choices among Mexican Americans. Qualitative evaluation strategies including content analyses on types and focus of media messages were conducted. Focus groups assessed appeal and trustworthiness of messages.

Results

All media campaign products feature role models and experts. Campaign messages primarily (98%) appear in TV morning show segments. Newsletters present individual and family role model stories. Majority of newsletters (68%) are distributed through churches and “promotora” outreach efforts.

Conclusions

CBPR lends itself to the selection and tailoring of evidence-based media campaigns. Moreover, CBPR guidance resulted in media messages that are credible and appealing to audience. Process evaluation strategies that gather information from the community provide solid evidence for how to modify the campaign to best meet audience expectations.

Introduction

Underprivileged Hispanics living along the U.S. – Mexico border, like other racial and ethnic minorities and persons with limited incomes, have disproportionately high rates of type 2 diabetes (T2D), obesity, cardiovascular disease, and cancer as compared to whites. In general, biological (family history), environmental (inequalities in income and education levels), and behavioral (physical inactivity and poor nutrition habits) factors contribute to these differences in incidence, and mortality and survival rates. Along the Texas – Mexico border, prevalence of obesity is higher than both the state and national averages (Faraji, Sanderson, Flores, Mier, & Millard, 2004); (Ogden et al., 2006). Overweight and obesity are highly correlated with type 2 diabetes, coronary heart disease (CHD), stroke, and some cancers and exacerbate the burden of other CHD risk factors (Mokdad et al., 2003) (US Department of Health and Human Services, 2001; Must et al., 1999). Although the etiology of obesity is multifactorial, excess weight gain is generally agreed to be the result of an imbalance between energy intake and energy expenditure over an extended period of time. Hence, two key behavioral determinants of overweight and obesity are physical inactivity and excess energy intake.

It is now widely accepted that community-based participatory (CBPR) research is an important aspect of understanding and protecting public health (Israel, Schulz, Parker, & Becker, 1998; National Institute of Environmental Health Sciences (NIEHS), 1997; National Institute of Environmental Health Sciences (NIEHS), 1997). CBPR equitably involves community members, organizational representatives, and researchers in all aspects of the research process to enhance understanding of a given phenomenon and the social and cultural dynamics of the community and to integrate knowledge gained with action to improve the health and well-being of community members (Israel et al., 1998). CBPR does not constitute a new and distinctive method for health promotion research; instead, it represents a more holistic research approach that focuses needed attention on the cultural, economic, political, and social aspects of health promotion. Because CBPR is a comprehensive method for public health research it is an effective strategy to address health disparities (e.g., obesity) among Hispanics from the Texas – Mexico border.

Community level interventions particularly theory-based media campaigns that are planned and operationalized in a culturally appropriate manner can help to reduce health risk and, eventually, eliminate health disparities among Hispanics (McAlister et al., 1992; Ramirez et al., 1995; Ramirez et al., 1999). Our media campaign uses behavioral journalism, the use of community role models and their stories to modify social norms and strengthen health-related proficiencies (Ramirez et al., 1999) to promote daily physical activity and healthful food choices. The purpose of this paper is to describe the program design, implementation, and process evaluation of a media campaign titled Tu Salud, ¡Si Cuenta! (Your Health Matters!) for Mexican Americans residing along the Texas – Mexico border.

Methods

Community-Based Participatory Research

Researchers collaborated extensively with community members to conduct a community assessment processes to determine the need for and potential content and scope of an intervention to address health disparities. Initially, nine focus groups were conducted with adult Mexican descent men and women living along the Texas – Mexico border to assess health care issues, media channels most often accessed for health information, and ideas regarding content of a media campaign. Based on these focus groups it became clear that both promotoras (lay community outreach workers) and mass media were seen as credible and accessible sources of health information. Additionally, physical activity and nutrition topics were of great interest to the population, particularly as they relate to obesity, diabetes, and cancer.

Discussions regarding these initial findings as well as epidemiological data regarding health issues in the local area led the collaborative group to select an evidence-based intervention to promote energy balance among Hispanic adults. The community advisory board with over 55 organizational partners including promotoras, healthcare providers, universities' representatives, community-based organizations, and religious organizations worked diligently to frame the campaign. Moreover, staff and community advisory members met with an additional 42 community leaders about the campaign including local community residents, physicians, city officials and faith-based organization leaders. The focus of these discussions was to obtain community leaders' opinions regarding the tailoring and implementation of such an intervention. Finally, staff and community advisory members worked closely with residents and community organizations in two underserved neighborhoods in the community to assess health issues and discuss intervention strategies. Information from the communities was obtained in promotora outreach discussions with leadership groups in the community and door to door canvassing. In the end, community and advisory board members gave input into the specific topics to be featured in the campaign, the name for the campaign (Tu Salud, ¡Si Cuenta!), role models to feature in the campaign, the media outlets to approach for implementation, the products to be featured in the campaign, and who to reach with campaign messages. The discussions with the community advisory board and other community leaders occurred during a one year period between August 2004 and 2005, prior to the pilot testing of the campaign.

The CBPR process between the community partners and the researchers determined that a Spanish language community-wide media campaign (Zaza, Briss, & Harris, 2005) for Mexican Americans, including information on physical activity and nutrition were appropriate. Moreover the process determined that the intervention would include environmental changes to support the increase of physical activity and nutrition in the local communities. A clear message from all the community partners was that if the university were to implement this media campaign that a strong commitment to keep the campaign in place for up to 10 years needed to be there.

Description of the Media Campaign

Evidence exists that systematically planned and implemented community-wide media campaigns reduce risky behaviors by adjusting perceptions of normative behaviors and by influencing individual's beliefs about those behaviors; and, in fact are a recommended intervention in the Guide to Community Preventive Services (Zaza et al., 2005). Several recent media campaigns have successfully prevented or reduced risk behaviors (Chou et al., 1998; Flay & Sobel, 1983; Flynn et al., 1994; Montgomery, 1995; Palmgreen, Donohew, Lorch, Hoyle, & Stephenson, 2001; Popham et al., 1994; Simons-Morton, Donohew, & Crump, 1997; Sly, Trapido, & Ray, 2002; Stryker, 2003; Worden, 1996). Moreover, research has repeatedly shown that media programs work best in conjunction with other community- or school-based programs, when consistent messages are conveyed through a variety of channels and in several different contexts (Flay et al., 1983; Maccoby, 1990; Schilling & McAlister, 1990; Sloboda, Stephens, & Alemagno, 1998; Worden, 1996). Testing the independent effects of media alone and media in combination with community or personal interventions is clearly warranted to further our understanding of media effectiveness.

Theoretical Foundation of Campaign

Behavioral theories suggest that a number of behaviors can be successfully influenced through the mass media (Maibach & Cotton, 1995). Behavior results from complex interactions among people's beliefs and motivations, and their social, cultural and physical environment (Bandura, 1986). In some situations, motivation to change is balanced between perceived benefits of the recommended behavior compared to the perceived social, cultural, or economic costs. In other situations, people desire to change their behavior but cannot because they lack the necessary skills or other resources. Understanding this balance is critical in understanding the potential effectiveness of media interventions.

The theoretical framework for our media campaign is Social Cognitive Theory with special and complementary emphasis on Behavioral Journalism and the Transtheoretical Model. Social Cognitive Theory (Bandura, 1986) addresses the psychosocial dynamics of health behavior and the best strategies to promote behavior change. The theory explains human behavior in terms of a triadic, dynamic, and reciprocal model in which behavior, social-environmental influences, and personal factors interact. Social Cognitive Theory has been applied in a number of practical settings with respect to health education interventions including AIDS education (Bandura, 1990) smoking cessation and cardiovascular programs, (Perry, Baranowski T., & Parcel G.S., 1990) and self-regulation of chronic disease (Clark & Zimmerman, 1990).

The use of media to promote health (eg., Behavioral Journalism) is a successful method for using mass media to stimulate social and behavioral change based on Social Cognitive Theory (McAlister et al., 1992). Behavioral journalism features identified role models (individuals who have made the specific health behavior changes) from the priority population in media materials such as television segments and newsletters. Scientific studies by McAlister and others have shown that behavioral journalism, combined with promotional outreach in the community, can influence personal health behaviors such as smoking cessation, weight loss and utilization of services to prevent deaths from breast and cervical cancer (Puska et al., 1985; McAlister, Ama, Barroso, Peters, & Kelder, 2000; McAlister, 1995; McAlister et al., 2000; Ramirez et al., 1999). By modeling necessary skills, behavioral journalism may also influence social change by identifying health-related [public] policies such restrictions on public smoking or elimination of barriers to preventive health care and by showing community members how those policies can be enacted. (McAlister, 1991)

Community role models were from Brownsville, Texas or Matamoros, Tamaulipas, Mexico and were identified by promotora outreach and program staff. Structured interviews ascertained level of behavior change (maintenance of specific physical and/or nutrition behavior change for at least six months) and preference of media venue in which to appear.

The media campaign under study includes role models appearing in both mass media outlets (daily television morning shows segments and occasional news segments) and a small media venue (monthly newsletters). The campaign features Hispanic role models and experts who discuss physical activity and nutrition. All communications are entirely in Spanish and the priority population is low socio-economic status adult females and males (aged 20-64 years) and their families.

Results

Evaluation of the Media Campaign

Our goal is to produce long-term healthful nutrition (primarily focused on eating 5 fruits and vegetables each day and reducing portion size) and increased physical activity (30 minutes of activity most days of the week with a particular focus on walking) resulting in energy balance using community-based participatory research processes. A quasi-experimental research design was used to test the hypothesis that psychosocial and behavioral changes among members of the two intervention communities in the US will be measurably larger than changes found among members in a comparison community receiving no media campaign messages. Additionally, qualitative and quantitative research methods are used to document the implementation strategies used in the campaign and to assess the effectiveness of the intervention study.

Because the media campaign is still in the early stages of implementation with just over one year completed, many measures of implementation were obtained including content analyses of media messages and newsletters, monitoring amounts of and locations for newsletters distribution, and focus groups with members of the priority population regarding content of messages.

Staff trained in content analyses examined each morning show and news segment for topics discussed, demographics of presenters discussing material, and length of broadcast. Reliability of analyses was ensured through multiple coders and comparison to pre-broadcast planning calendars. Content analysis of the mass media messages is depicted in Table 1. Total air time for our media campaign during the pilot year (August 2005-June 2006) was 7 hours, 25 minutes, and 17 seconds. Two-hundred forty-one different daily morning show segments and five news segments were aired during the 11 month period. Most daily segments lasted two to three minutes whereas the news segments lasted for four to five minutes. The main venue for the media messages was the morning show (98%); the gender (91.0% female) and ethnicity (99.2% Hispanic) of the personalities matched that of the morning show target audience, and, in order to establish “branding” of the media campaign, most of the media message presenters were health experts.

Table 1. Tu Salud, ¡Si Cuenta! Mass Media Content, 8/1/2005 – 6/30/2006.

	n	%
TV venue
Morning show	241 segments	98.0
News segment	5 segments	2.0
Gender of Personalities
Female	223	91.0
Male	19	7.8
Families	3	1.2
Ethnicity of Personalities
Hispanic	245	99.2
Other	2	0.8
Classification of Personalities
Role Model	78	30.0
Expert	155	63.0
Cook	11	5.0
Other	5	2.0
Air Time
Morning show	7 hours, 0 minutes, 11 seconds
News segment	25 minutes, 6 seconds
Total	7 hours, 25 minutes, 17 seconds

Monthly newsletters were in color, double-sided, and legal size (8.5″×14″). A total of eleven newsletters were created and distributed (one per month). The majority (55%) of the newsletters focused on both physical activity and healthy food choices in relation to health outcomes such as diabetes, cancer, or gender based health issues. All small media pieces featured one main role modeling message; a community member describing their health behavior change (Table 2). Three editions of the newsletter had additional community role model messages; quotes from these role models supplemented the content of the main role model story. In particular, two months (May 2006 and June 2006) featured several families as role models. A total of 19 community role model messages appeared in the 11 issues throughout the 11-month period of which all were of Latino origin. Main role models were predominantly individual females (63.7%, 7/11) aged between 20 and 50 years, and all additional role models consisted of families mostly of mother-daughter relationships (75.0%, 6/8, data not shown). Thirty-six individuals (26 females of all ages and 10 males of all ages, data not shown) were featured in the 19 role model messages. Health expert recommendations also appeared in most editions (90.9%, 10/11). These health experts (medical doctors, nurses, and others) were both men (50.0%, 5/10) and women (50.0%, 5/10) and all except one were Latino (90.0%, 9/10). Photographs or artwork illustrated and reinforced the content of newsletters. Other content areas of the newsletters included benefits of performing specific health behaviors (63.6%), advice on incorporating health behaviors into daily routine (100.0%), myths (9.1%), healthful recipes (54.5%), monthly calendars with reminders to set goals (100.0%), promotion of media partner and mass media segments (100.0%), recognition of sponsors (100.0%), and links to electronic resources (27.3%).

Table 2. Tu Salud, ¡Si Cuenta! Small Media Content^*, 8/1/2005 – 6/30/2006.

	n	%
Theme of newsletters (n=11)
Physical activity (PA)	2	18.1
Healthy Food choices (HFC)	3	27.2
Both (e.g., PA & HFC related to diabetes, cancer, women & men health)	6	54.5
Unit of all role model stories (n=19 in 11 newsletters)
Individual female	7	36.8
Individual male	1	5.3
Family	11	57.9
Ethnicity of all role model stories (n=19 in 11 newsletters)
Latino	19	100.0
Unit of main role model stories (n=11)
Individual female	7	63.6
Individual male	1	9.1
Family	3	27.3
Average no. of words	393
Age range of Main role models (n=11)
Individual females	20 – 50 years
Individual male	40 – 50 years
Families	1 – 50 years
Unit of additional role model stories (n=8 in 11 newsletters)
Family	8	100.0
Gender of expert (n=10 in 11 newsletters)
Female	5	50.0
Male	5	50.0
Average no. of words	131
Ethnicity of expert (n=10 in 11 newsletters)
Latino	9	81.8
Other	1	9.1
Credentials of expert (n=10 in 11 newsletters)
Medical doctor	4	40.0
Nurse	1	10.0
Other	5	50.0
Other content (n=11)
Benefits of health behavior	7	63.6
Tips** for health behavior	11	100.0
Myths	1	9.1
Healthful recipe	6	54.5
Monthly planner	11	100.0
Media partner promotion	11	100.0
Sponsorship logos	11	100.0
Links to electronic resources	3	27.3

^*Small media content refers to the messages contained in 11 newsletters.

^**Tips to incorporate health behavior into daily routine.

Small media distribution is described in Table 3. Staff recorded distribution locations and numbers of newsletters delivered each month. A total of 27,907 newsletters were disseminated in the 11-month pilot period of this project. Door-to-door delivery by promotoras or outreach workers (29.1%) and churches (38.4%) were the main forms of distribution. Promotora / outreach delivery included didactic interaction, regarding the newsletters, between the promotora and the community member at home. Furthermore, clergy at the churches also discussed the newsletters at the end of their religious services.

Table 3. Tu Salud, ¡Si Cuenta! Small Media Monthly Distribution, 8/1/2005 – 6/30/2006.

	n	%
Promotora/Outreach delivery	737	29.1
Churches	975	38.4
Community Centers	275	10.8
Early education centers	200	7.9
Businesses	200	7.9
Healthcare sites	150	5.9
Total	2537

In order to obtain audience feedback to the campaign, trained facilitators conducted six focus groups with people in the viewing area (Hidalgo and Cameron Counties in South Texas and Northern Mexico). Two groups were conducted in each of the intervention neighborhoods (four in the U.S.) and two groups were conducted in Matamoros, Tamaulipas, Mexico (the sister city of Brownsville, Texas) to assess attitudes towards the content, its cultural appropriateness, clarity and appeal of messages, effectiveness of marketing strategies and future ideas for use in the campaign. The focus groups lasted between 1 ½ - 2 hours. On average 9 people attended each session and were paid a $10 incentive for their time (total n = 57). Participants were recruited by promotoras. Written consent was obtained at the beginning of each focus group and a short demographic survey was completed at the end of each group. All participants reported they considered themselves Mexican American or Mexican. Majority of the participants (88%) reported that their primary language was Spanish. All but two participants were between the ages of 20 – 64 years, and most participants were female (77.2%). All focus groups were tape-recorded. All data analyses were conducted by staff using ATLASti software.(2005) Selected focus group participant statements are shown in Table 4.

Table 4. Tu Salud, ¡Si Cuenta! Selected Focus Group Participant Statements.

Relevancy of Subject Matter	Gender	Location
“Los temas son interesantes, reales.” (The topics are interesting, real.)	male	Matamoros
“Somos mujeres. Mamás y abuelas, y siempre nos interesa temas de salud familiar.” (We are women. Mothers and grandmothers, and family health is always of interest to us.)	female	Brownsville
Community & Expert Role Models
“Las personas de la comunidad están bien porque así es mas creíble.” (People from the community are fine because it is more credible.)	female	Matamoros
“Si motiva porque podemos decir que una persona sobrepeso o con obesidad también puede caminar y hacer ejercicio.” (It does motivate [us] because we can say that someone who is overweight or obese can walk and exercise.)	female	Matamoros
“Si ya no esta hablando correcto el español, ya no le ponen atención. Ya no proyecta lo que quiere la población.” (If they are not speaking correctly, then you do not pay attention. They do not project want the community wants [to see]).	female	Brownsville
“Que se memoricen un poco mas para que no tengan que estar leyendo.” (They should memorize [what they are going to say] so that they are not reading.)	female	Matamoros
Illustrations & Segment Length
“Deben de poner las graficas para cada tema.” (You should include illustrations for each topic.)	male	Matamoros
“Deben de enseñar video o fotos del ejercicio mientras están hablando.” (You should show video or photos of the exercise while talking.)	female	Matamoros
“Seria mejor menos dias y mas tiempo. Unos 10 minutos.” (Less days and more time would be better. About 10 minutes.)	female	Brownsville
“Estaba bien solo que le den mas tiempo para poder incluir mas información.” (It's fine but more time so that more information can be given.)	female	Brownsville

Focus group participants stated that the nutrition, physical activity, and related health topics in the mass media messages were relevant and appealing to them and salient others (family members, friends, and neighbors). Additional themes including family unity, family support, family medical history, and common chronic diseases such as T2D, heart disease, and cancer resonate well with this community. Participants from all of the focus groups reported that the use of role models was an effective method to demonstrate health behavior change. However, focus group participants stressed the importance of the use of role models who speak proper Spanish. The mix of English and Spanish, slang, or non-mastery of the Spanish language was unacceptable. Furthermore, it was recommended that personalities not read their statements rather they should memorize their commentary. In five of the six groups, participants stated that illustrations and photos clarified and summarized the health messages. Additionally, half of the focus groups stated that longer segments could provide more advice in detail (concrete steps) to make physical activity and nutrition behavior changes. Finally, the participants believed that the hands-on demonstrations (cooking segments, simple exercise movements, use of props, and samples) reinforced the health messages.

Results from the content analysis and the focus groups were then discussed with community partners and changes to the intervention have been proposed and implemented based on the findings. The modifications to the campaign include greater emphasis on promotora delivery of newsletters, moving to longer segments on the morning shows which feature more role models, increasing the coverage on the news, and more careful selection of personalities in the campaign based on Spanish language capacity.

Discussion

This paper described a Spanish language media campaign specifically designed to enhance the translation of currently recommended practices for physical activity and healthful food choices to Mexican Americans residing along the Texas – Mexico border. The Tu Salud Si Cuenta! community wide media campaign was designed and is implemented with a community-based participatory approach. This approach guides the basis for the type of intervention to implement and its tailoring to Spanish speaking individuals and families living along the US – Mexico Border. The involvement of the community in the campaign increases the projects devotion to shaping messages that are relevant for the population. Process evaluation results indicate that the media campaign products (television segments and newsletters) are showcasing role models and experts that are relevant and credible to the audience and that the messages provide information that is useful to them. Importantly however, the process evaluation and the discussions with the community partners also have guided changes to the campaign. Thus it became a true partnership between those most affected by the media, community members, and researchers who could provide evidence of what was or was not effective.

Future efforts to evaluate the media campaign include obtaining post test surveys in the two intervention communities and a single comparison community. Pretest data were collected in all three communities prior to full implementation of the campaign. These surveys include measures of behavior, self-efficacy, barriers, awareness of campaign, and built environment to support health.

Additionally, the future efforts of the campaign will continue to strive for strong community involvement in all aspects of the campaign including interpretation of survey findings, expansion of campaign to other media venues (radio, newspaper, bill boards) and funding.

Conclusion

This study suggests that community-based participatory research is a complementary strategy for the planning and implementation of community-wide media campaigns. CBPR creates the discussions and relationships around the formation of campaign messages, enhances the delivery mechanisms in the mass media (features role models) and in the small media (by vested individuals delivering newsletters), and supports the evaluation of the campaign through greater awareness and willingness to participate in process and impact level data collection efforts.