African-Americans have disproportionately higher rates of morbidity and mortality for cardiovascular disease, and hypertension than Caucasian-Americans do. Age-adjusted cancer mortality rates are much higher for men and women of minority groups, including African-Americans, than for Caucasian-American men (240.4 vs. 164.2 per 100,000) and women (123.5 vs. 103.5 per 100,000) (Campbell et al., 1998).

According to Centers for Disease Control and Prevention (CDC) statistics reported by the American Heart Association, the age-adjusted death rates in Caucasian-American and for African-American women are as follows:

• coronary heart disease (139.7 vs. 160.1 per 100,000)
• stroke (57.9 vs. 76.1 per 100,000); lung (43.0 vs. 42.0 per 100,000)
• breast cancer (28.0 vs. 37.7 per 100,000)

The estimated age-adjusted standard prevalence for elevated blood cholesterol (more than 200 mg/dl) of Americans from 20 to 74 Years is:

• Caucasian-American and African-American men (52% vs. 45%)
• Caucasian-American and African-American women (49% vs. 46%)

These health disparities have motivated numerous public health researchers to tailor health promotion interventions specifically for African-Americans in addition to other underserved groups. Questions about these health disparities remain among researchers, but they believe that lifestyle factors such as nutrition and physical activity play a role (Campbell et al., 1998).

There is mounting scientific evidence that fruit and vegetable consumption is linked with a lower risk of certain types of cancer and other chronic diseases (such as cardiovascular disease and diabetes) (Campbell et al., 1999, Stages of change). The National Cancer Institute's 5-a-day for Better Health campaign is based on the premise that consumption of fruits and vegetables can help lower Americans' risk of certain cancers and other chronic diseases, due to fiber, antioxidants, and other anti-carcinogenic compounds (Campbell et al., 1999, Fruit and vegetable). The goal for this campaign was for all Americans to consume five servings of fruits and vegetables each day by the Year 2000.

There are notable differences in the morbidity and mortality rates from chronic diseases such as cardiovascular disease, hypertension, and diabetes in African-Americans when compared with Caucasian-Americans and other ethnic and racial groups in the state. There is a large African-American population within the state. It is for these reasons that the state health department decided to plan and implement a health promotion dietary intervention with African-Americans in the state.

The state health department chief over chronic disease prevention considered inviting the following individuals to join the planning team to ensure that various perspectives were represented:

• state health department nutritionists,
• faculty members from several universities in the state with expertise in health promotion interventions, evaluation, and statistics,
• NAACP and other African-American organizations,
• key community members of predominately African-American communities in the state,
• the state cardiovascular health program manager,
• the 5-a-day state coordinator,
• local health departments from the state

The planning team determined that they wanted to target African-Americans in the state, but they needed more specific data detailing the problem. They worked with state health department epidemiologists and consulted with the National Center for Health Statistics of the Centers for Disease Control and Prevention to examine existing data to further describe the problem (http://www.cdc.gov/nchs/). They accessed health data from the State Behavioral Risk Factor Surveillance System regarding behavioral risk factors related to cancer and cardiovascular disease such as prevalences of tobacco use, overweight, and physical inactivity (http://www.cdc.gov/brfss/). They also obtained additional epidemiologic information from Centers for Disease Control and Prevention's website with health statistics information such as Women and Heart Disease: An Atlas of Racial and Ethnic Disparities in Mortality to gain a more detailed perspective about the problem (http://www.cdc.gov/dhdsp/library/maps/cvdatlas/atlas_womens/
womens_download.htm).

After learning from these data that the Eastern region of the state had a number of rural counties with 30% or more African-American populations, the university faculty members on the planning team devised a survey to gather baseline information about the anticipated target population.

The baseline survey, completed by African-Americans in the rural counties of the eastern region of the state, included questions regarding:

• estimated current daily consumption of fruits and vegetables,
• level of awareness about how consumption of fruits and vegetables can help protect them from cancers and certain chronic diseases,
• level of knowledge about how consumption of fruits and vegetables can help protect them from cancers and certain chronic diseases,
• level of self-efficacy or perceived ability to consume more servings of fruits and vegetables daily,
• demographic information about their gender, age, annual income, and education,
• status within the Stages of Change model, with regard to consumption of fruits and vegetables.

The data indicated notable disparities for certain types of cancer and cardiovascular disease for African-Americans in the state when compared with individuals from other race and ethnicity groups and Caucasian-Americans. Morbidity and mortality rates were much higher in the rural areas of the state, and the planning team hypothesized that the increased rates were related to lifestyle factors such as diet and physical inactivity.

The baseline survey data indicated that individuals in the ten rural counties in the state were predominately female (70.4%), 98% African-American, 1% multiracial, and 1% other race. The mean age was 51.4 years and most individuals were married (55%). Most individuals in the sample earned less than $20,000 annually (60%). One-third did not have a high school education, 33% had high school diplomas, and 33% received education beyond high school. Educational level was associated with individual's status in the stages-of-change. People with less than a high school education were mostly in the precontemplation and contemplation stages. The intervention counties had more individuals in the preparation stage and fewer people in the precontemplation stage. Individuals in the precontemplation, contemplation, and preparation stages consumed approximately 3.5 servings of fruits and vegetables per day in contrast with the people in the action and maintenance stages, who ate 6.5 servings daily. Individuals in the action and maintenance stages indicated a sense of self-efficacy for consuming five servings of fruits and vegetables daily (68%), but the people in the pre-action stages expressed lower levels of self-efficacy (60%).

The baseline survey indicated the following subgroups as defined by the Stages of Change (Campbell et al., 1999, Stages of change):

25% Precontemplation: This subgroup was 69.8% female, had an average age of 56.2 Years, 62.7% had a high school education or less, and 98.5% of this subgroup were African-American. This subgroup consumed an average of 3.5 servings of fruits and vegetables daily.

3% Contemplation/65% Preparation: This subgroup was 69.7% female, had an average age of 49.4 Years, 64.6% had a high school education or less, and 99.4% of this subgroup were African-American. This subgroup consumed an average of 3.5 servings of fruits and vegetables daily.

1% Action/6.8% Maintenance: This subgroup was 79.0% female, had an average age of 51.4, 55.8% had a high school education or less, and 99.3% were African-American. This subgroup consumed an average of 6.0 servings of fruits and vegetables daily.

The baseline survey also indicated that most individuals (76 to 78%) felt consuming more fruits and vegetables was likely (from very to somewhat likely) help them prevent a chronic health problem.

In comparison with other groups, African-American men and women in rural counties of the eastern portion of the state (that have 30% or more African-American populations) have much higher rates of mortality and morbidity from chronic diseases such as cancer and cardiovascular disease.

The baseline data indicated varying consumption levels of fruit and vegetable based on stages of change status:

Precontemplation: an average of 3.5 servings of fruits and vegetables daily.

Contemplation/Preparation: an average of 3.5 servings of fruits and vegetables daily.

Action/Maintenance: an average of 6.0 servings of fruits and vegetables daily.

Using the data already gathered in addition to the baseline data, the planning group decided to conduct six focus groups with individuals representative of the African-American target audience. The researchers inquired of these focus group participants their perceptions of fruits and vegetables, serving sizes, chronic diseases such as cancer and associated risk and protective factors, and appropriate channels for interventions. They asked what types of people should be included in a planning group and how the messages should be delivered to be culturally relevant.

These focus groups provided the following information about the target population:

• African-Americans within the state's rural counties perceive serving size as very different and more situational than dietitians do.
• African Americans are fairly to very active within their churches, so churches could be an appropriate channel for the nutritional intervention.
• It would be helpful to involve ministers in this intervention. They could incorporate scriptures into the intervention and could suggest people to help review materials and plan nutrition programs.
• Churches within communities have natural support people who are highly regarded for their support and advice on various life issues.
• They suggested not mentioning the word "cancer" in the messages. Instead, they stated it would be more effective to present the nutritional messages in a positive light rather than a fear-inducing one.

This information resulted in this new problem description:

Adult African-American men and women in the eastern rural counties of the state experience higher rates of morbidity and mortality when compared with other groups based on ethnicity and race. Lifestyle factors, such as consumption of fruits and vegetables may have a protective effect for these individuals, with regard to cancer and other chronic diseases such as cardiovascular disease.

Strengths: African-Americans were interested in improving their health status, especially with a community intervention that was culturally appropriate.

Weaknesses: There has been a hiring freeze within the state health department for the past nine months. It could be difficult to locate and hire the appropriate professionals to help with this project in a timely fashion.

Opportunities: The National Cancer Institute had funding for large-scale nutritional interventions within communities. They needed more information about how to offer health promotion interventions within underserved communities. Several potential partners were interested in planning and implementing a nutrition intervention, including the state health department, local universities, and the cooperative extension service. The opportunity is for a specific health promotion intervention targeted to African-Americans within rural counties, who could likely benefit from this health program. There are a large number of highly active church members within the rural counties of this state.

Threat: Within the United States, African-Americans have had some very negative experiences with government-planned health interventions (e.g., the highly publicized Tuskeegee experiment with African-American men with untreated syphilis). As a result, they have may less trust in the government and health care professionals.

The goals of this nutrition intervention aimed to address lifestyle factors to help prevent chronic diseases like cancer and cardiovascular disease in African-Americans. The planning team planned to:

• Increase the availability of fruits and vegetables in community stores, farmers markets, fruit stands, and at social functions.
• Assist the target population to begin consuming more servings of fruits and vegetables daily per person. This would move them towards consuming at least five fruits and vegetables per person daily.
• Increase the proportion of African-Americans who understand the importance of fruits and vegetables in cancer prevention.
• Evaluate the effectiveness of the nutrition intervention and share lessons learned.

The planning team considered utilizing constructs from the Stages of Change model or Prochaska's Transtheoretical Model, Social Cognitive Theory, Social Support, and the Health Belief Model when planning the intervention (http://cancer.gov/cancerinformation/theory-at-a-glance).

The Stages of Change model takes into consideration that individuals may be in various stages when approaching a health behavior change (Glanz & Rimer, Theory at a Glance, 1995, http://cancer.gov/cancerinformation/theory-at-a-glance).

For example, one individual may be consuming seven fruits and vegetables daily is in the action stage, whereas another person may be only consuming two servings per day. This person is merely considering increasing his consumption of fruits and vegetables and would likely be in the contemplation stage. Social Cognitive Theory incorporates the reciprocal relationship between an individual, his environment, and his behavior change. This theory includes a person's confidence in his own ability to make a behavior change, what benefits (or harm) may occur as a result of that change, and modeling of other people's behaviors.

The concept of Social Support can be instrumental when facilitating behavior change, since individuals perceive support from other people to change their health behavior. The Health Belief Model provided a framework when planning a health intervention. It includes constructs of perceived susceptibility to and severity of problems if one does not make a positive behavior change, perceived barriers and benefits for making a behavior change, and an individual's perceived capability to perform the desired behavior change.

Since this was a population-based strategy, it was also helpful to include constructs from the Social Ecological Model to provide policies and environmental strategies to support the targeted dietary changes (http://cancer.gov/cancerinformation/theory-at-a-glance).

(For more information about theories and intervention models please refer to Glanz, Lewis, Rimer (2000). Health Behavior and Health Education: Theory, Research, and Practice (2nd ed.). San Francisco: Jossey-Bass and/or the Communication Initiative's descriptions of theories and planning models at: http://www.comminit.com

Taking consideration of these models, theories, and suggested guidelines, the planning team felt it was important to:

Health Communication/Health Promotion

• Assess where the target population is with regard to their current intake of fruits and vegetables (i.e., their readiness for change).
• Assess their readiness in consuming more servings of fruits and vegetables or where they are with relation to Stages of Change model.
• Consider using peer helpers (based on constructs from Social Cognitive Theory) from the community in the intervention.
• Formal and informal guidelines for program interventions need to be informed by the Healthy People 2000 guide.
• Tailor health communication messages and products to move the target audience (and perhaps segments that are in the various Stages of Change) to the next stage of change.
• Increase awareness about the importance of consuming at least five servings of fruits and vegetables daily and its link with protecting against cancer and cardiovascular disease (related to the Health Belief Model).

Health Policy/Enforcement

• It would be helpful to work with local grocers and produce stand owners to ensure they offer a wide variety of fresh, affordable fruits and vegetables in communities. (This relates to the Social Ecological Model).
• Formal and informal guidelines for program interventions need to be informed by the Healthy People 2000 guide.
• It would be optimal to work through established channels that are trusted by African-Americans in their communities. (This concept relates to the Social Support model).
• Train health care providers how to work with different ethnic and racial groups to increase their sensitivity, which in turn, could improve the perceptions of medically underserved people towards the health care providers. (This change could encourage more use of health screenings, etc.). (This relates to the Social Ecological Model).
• Train health care providers about the role of fruits and vegetables in prevention of cancer and cardiovascular disease. (This relates to the Social Ecological Model).
• More funding and resources need to be allocated to decrease health disparities among ethnic and racial groups.

Health Communication/Health Promotion

Strengths
Health communication campaigns have improved awareness and knowledge about health behaviors. Increasing fruit and vegetable consumption by 0.5 serving daily is a realistic goal for a health communication campaign when combined with a program intervention.

Weaknesses
Health communication campaigns require resources in staff time and funding. A health communication campaign in isolation may not be sufficient to facilitate long-term behavior change in a target population.

Opportunities
Health communication campaigns can use creative channels to increase awareness and knowledge about health behaviors. When used appropriately, they can also positively influence the target population's views about a health promotion intervention. Even better, a campaign and intervention could improve the target population's views of the partners involved in the campaign (i.e., health care providers, nonprofit organizations, federal agencies, state and local health departments, etc.).

Threats
A community-based health communication campaign (in conjunction with a health promotion intervention) could negatively influence a target population if the campaign uses messages that are unacceptable to the target population. For example, if the messages and communication products are not pre-tested with focus groups representative of the target population, they could be culturally inappropriate for that audience. Culturally insensitive messages could cause more damage to perceptions of the planning team (including health care providers, nonprofit organizations, federal agencies, state and local health departments) because it appears that these groups are nonresponsive to the community's needs.

Ethics
If the health communication campaign and health promotion intervention are conducted in a way that communicates that all chronic diseases are totally preventable by consuming more fruits and vegetables, this message could harm individuals and their families who have chronic diseases such as cancer and cardiovascular disease. Why? Because the message stated that these diseases are largely preventable when a person consumes the proper amount of produce. This message places blame and judgment on individuals and could do more harm than good in this situation. It would be wise to frame the message that while consuming more fruits and vegetables can help to prevent certain chronic diseases, it is only a part of the larger picture.

Mindful of the ethical considerations of this intervention, the planning group formed a materials review group. These individuals were representative of the target population and reviewed and provided feedback on all materials prior to their distribution.

Health Policy/Enforcement

Strengths
Establishing health policies and environmental strategies can help support the health communication campaign and health intervention, creating a synergistic effect for facilitating the proposed behavior change.

Weaknesses
If done inappropriately and/or without input from communities of the target population, health policies and environmental strategies could backfire and cause more harm than intended good in the communities. It is vital that some members of the target population are provided an opportunity (or opportunities during the process) to provide input into these decisions.

Opportunities
The establishment of health policies and environmental strategies could provide a tremendous opportunity to build partnerships within the community to increase community capacity. This process could empower the community members to continue planning and implementing health communication and health promotion interventions within their community. It could improve trust and credibility of the planning team partners.

Threats
As stated previously, if the planning team without any input from community members (who are part of the target population) determines health policies, the health communication campaign and intervention could cause more harm than good. If done in a culturally inappropriate manner, this could also cause great mistrust in the process and toward all partners involved in the planning.

Ethics
It would be ethically improper to plan, implement, and evaluate a health communication plan and intervention without some community input. Given the historical context of the federal government's treatment of African-Americans in the Tuskeegee experiment, it is vital to create a health intervention that elicits more good than harm in the target population.

In addition to the partners mentioned earlier, the planning group decided to also include the following as partners: local church ministers, a grocers organization, and individuals who serve as lay leaders at local churches.

Additional resources came from a research grant from the National Cancer Institute (NCI) to support evaluations of the program in addition to the existing grant from the Centers for Disease Control and Prevention (CDC) supporting cardiovascular health in the state.

After much deliberation, the planning group decided to invite the following individuals and organizations needed to be partners in the planning process:

• state health department nutritionists,
• faculty members from several universities in the state with expertise in health promotion interventions, evaluation, and statistics,
• the cooperative extension service,
• key community members of predominately African-American communities in the state,
• a minister with a public health expertise,
• the state cardiovascular health program manager,
• the 5-a-day state coordinator,
• local health departments from the state,
• a media specialist, and
• a health communication specialist.

Once the planning team was formed, the planning team members decided to meet with partners on a monthly basis to communicate with planning group. Staff meetings occurred weekly.

The program coordinator produced and distributed a report that highlighted discussions, critical issues to be addressed, and who and by when they would be resolved.

The program coordinator also provided briefings/public meetings to gather input about the program plan.

In an initial meeting, the program coordinator led a discussion in which the planning group determined the roles and responsibilities with partners and what resources will be used for certain components of the program.

The planning team determined that communication was needed to support the larger intervention, which was a health promotion program. They based this program on the Stages of Change model and Social Cognitive Theory, including the use of nutrition action teams and lay health advisors for each intervention church. Nutrition action teams coordinated activities for their churches, such as gardening classes, health cooking classes, and potluck dinners with healthy fruit and vegetable dishes.

These individuals were trained about how to plan and implement health programs, especially related to nutrition. The lay health advisors received training in nutrition and cancer prevention. They provided nutritional counseling to church members and helped them get support for increasing their fruit and vegetable consumption.

The intervention included establishing policies in the community environment to support increased consumption of fruits and vegetables.

Communication components included tailored church bulletins, brochures, recipe booklets, posters, banners, idea sheets for programming, church bulletin inserts, educational materials, and sermons with a health promotion component.

There are approximately 2.5 million residents in the state. The target audience was African-American adults (as active church members) in the eastern rural region of the state.

Although the baseline survey data indicated that there were individuals within the Precontemplation, the Contemplation/Preparation, and Action/Maintenance stages, there were no segments large or unique enough within the rural African-American population in the eastern region of the state that warranted separate communication interventions.

The communication goals for the selected audience segment were to:

• Increase awareness about how consumption of at least five fruits and vegetables daily can help improve the health of individuals (and may help prevent cancer, cardiovascular disease, and other chronic diseases, but this part was not used in the actual communication products based on focus group data).
• Motivate the target population to consume more servings of fruits and vegetables daily.

The theories and models relevant for this proposed intervention included: the Stages of Change model, Social Cognitive Theory, the Social Support model, and the Social Ecological Model.

(More information about these theories and models can be found in the National Cancer Institute's Theory at a Glance http://cancer.gov/cancerinformation/theory-at-a-glance).

The planning group utilized focus groups conducted with African-Americans representative of the target population. These groups helped the planning team learn more about communication channels to use, appropriate messages and use of social networks within communities, and how to generate relevant and culturally appropriate messages and health communication products. Interviews were conducted with church pastors to generate similar information.

The focus group and interview data indicated that churches would be an excellent communication channel for this program intervention. Interviews with church ministers and the focus groups suggested that working within the churches, through ministers and church members, would be optimal.

Participants recommended the formation of nutrition action teams, with the minister and several active members and a designated program coordinator, to plan and implement the programs. They also recommended that a review panel of the minister and several church members review all communication products prior to their use and distribution to ensure their clarity, relevance, and appropriateness. They also recommended using lay health advisors, with training, to provide advice and counseling for church members involved in the program intervention.

The lay health advisors also provided feedback to interested church members with regard to their current consumption of fruits and vegetables, their beliefs in cancer prevention, overcoming barriers to increasing their consumption of fruits and vegetables, and how to establish support for this change.

The planning team decided to tailor the health communication messages and program intervention for the audience who was in the preparation stage to move them toward the action stage.

The planning team's specific communication objectives were:

• To increase participation in nutrition-related activities by 25% during Years 2 and 3 of the intervention.
• During the intervention period of 24 months, to move 30% of the individuals from the preparation stage to the action stage within the 24-month intervention.
• To increase 50% of the individuals' in the intervention counties daily consumption of fruits and vegetable servings by 0.5% within the 24-month intervention.

Target Audience: African-American adults who are active church members within ten rural counties of the eastern region of the state. They fall into the following subgroups (Campbell et al., 1999, Stages of change):

Precontemplation: This subgroup was 69.8% female, had an average age of 56.2 Years, 62.7% had a high school education or less, and 98.5% of this subgroup were African-American. This subgroup consumed an average of 3.5 servings of fruits and vegetables daily.

Contemplation/Preparation: This subgroup was 69.7% female, had an average age of 49.4 Years, 64.6% had a high school education or less, and 99.4% of this subgroup were African-American. This subgroup consumed an average of 3.5 servings of fruits and vegetables daily.

Action/Maintenance: This subgroup was 79.0% female, had an average age of 51.4, 55.8% had a high school education or less, and 99.3% were African-American. This subgroup consumed an average of 6.0 servings of fruits and vegetables daily.

The communication goals for the selected audience segment were to:

• Increase awareness about how consumption of at least five fruits and vegetables daily can help prevent cancer, cardiovascular disease, and other chronic diseases.
• Motivate the target population to consume more servings of fruits and vegetables daily.

Communication Objectives: The objectives of this nutrition intervention were, during the intervention period, to:

• Assist the target population to begin consuming 0.5% more servings of fruits and vegetables daily per person. This will move them towards consuming at least five fruits and vegetables per person daily.
• Increase the availability of fruits and vegetables by 10% in community stores, farmers markets, and fruit stands.
• Increase the proportion of African-Americans by 20% who understand the importance of fruits and vegetables in cancer prevention.

Key Promise: If I consume more fruits and vegetables daily, I will be healthier and can prevent myself from getting sick.

Support Statements/Reasons Why: Eating at least 5 servings of fruits and vegetables daily can help protect from cancers and other chronic diseases, but the terms "cancer" and "chronic diseases" will not be used in the actual messages.

Tone: Communications about this intervention, consuming more fruits and vegetables daily, needs to be positive and upbeat. It should not include the words "cancer," or "chronic disease," or "cardiovascular disease."

Media: Church-related communications products such as bulletins or newsletters, posters, flyers, bulletin boards in churches, and brochures

Openings: Churches and church-related events such as potluck dinners and classes, grocery stores, farmers markets,

Creative Considerations: Communications need to be culturally relevant and coincide with scriptures and religious teachings.

The planning group discussed the proposed intervention and health communication plan with the relevant stakeholders from the community. They discussed how they would use evaluation to check how the intervention was being implemented as well as the outcome from it.

Upon consulting with the state health department, they determined that grant money would be available from the National Cancer Institute (NCI) and the Centers for Disease Control and Prevention (CDC) to conduct these evaluations.

The planning team drafted a timetable to determine their budgetary needs and they proposed that the nutrition intervention project would last for four Years. They proposed the following timeline to coincide with the funding award dates (they anticipated receiving funding in June of Year One):

Year One: The planning group would determine sampling and data collection plans and begin collecting baseline data by October. They would conduct focus groups and key informant interviews to develop and test concepts, messages, settings, activities, and materials from August until February, to ensure adequate feedback from their target audience.

Years Two and Three: The actual intervention and health communication campaign would occur during the second and third Years of funding. From June to May of Year Two, the planning team would facilitate training for individuals of the nutrition action teams and the lay health advisors. The churches would also begin developing capacity for nutrition programs during this time. An implementation or process evaluation would occur during this time.

Year Four: The fourth Year would primarily consist of collecting post-intervention data, to determine whether any changes occurred in the target population, related to the intervention. An outcome evaluation would occur during this time.

The planning team proposed the following budget for the four-year intervention:

Based on feedback on the creative concepts, the planning team developed ten messages based on the Stages of Change model, to facilitate movement of the intended audience to progress towards more active stages (to begin consuming more fruits and vegetables). The planning group wanted to utilize accurate messages that were: clear, culturally appropriate, credible, and consistent for the target audience. The focus group facilitators solicited input from the focus group participants regarding the proposed messages, and learned that participants perceived messages aligned with Biblical scriptures as highly motivating, culturally appropriate, and credible. The focus group data informed the selection of the messages to be used in the actual intervention.

The planning team decided that they would work through churches, as this channel would provide a familiar and influential context for the intervention and its accompanying communication efforts. It also fit the planning team's time and budgetary constraints. Most importantly, the planning team felt that churches would be the most conducive setting for this proposed intervention given the high percentage of African-American individuals in the state who were active church members.

The planning group decided to test the church setting by sharing their proposed messages (and the larger intervention idea) with two ministerial associations in the state. In an informal meeting, the planning team shared their ideas with members of the ministerial associations. They asked for their input and received enthusiastic responses to their idea of working through the churches.

The planning team needed to select channel-specific communication activities as a part of the larger intervention. They wanted to work at a group- and organizational-levels so that this intervention and the proposed behavior change (of consuming more fruits and vegetables) would be supported within their social networks. Once the planning team agreed that working in church settings in the five counties would be optimal for this campaign, they began selection of specific communication activities. The planning team proposed and tested the following activities as an integral part of the program intervention (and learned that a majority of church members in the test churches perceived them positively):

• Offer gardening classes for church members.
• Encourage farmers markets and produce stands, and grocery stores to provide a variety of fresh produce on a regular basis.
• Provide information for ministers to incorporate nutrition messages into their sermons occasionally.
• Provide lay health advisors who could counsel and encourage individuals to begin consuming more fruits and vegetables.
• Offer educational cooking sessions.
• Assist church members in the modification of their favorite fruit and vegetable recipes to include in a church cookbook.
• Encourage women and men church members to bring more fruit- and vegetable-based dishes to church pot luck dinners.
• Develop nutrition-related inserts for the weekly church bulletins.
• Provide nutrition-related articles for church newsletters.
• Create and offer nutrition planning packets for the church team leaders with posters, banners, brochures, recipes, and ideas for potential programs and church bulletin boards.

The planning team also established a review team to provide feedback about the messages and communication products intended for the intervention. The planning team solicited input about the proposed communication products prior to the communication products' production and dissemination.

The communication implementation plan follows.

Background and Justification
African-Americans in the state have high morbidity and mortality rates associated with chronic diseases such as cancer and cardiovascular disease. Research indicates that lifestyle factors such as nutrition can play a role in the development (or prevention) of these diseases. The National Cancer Institute supports program interventions in community settings to promote individuals consuming at least five or more servings of fruits and vegetables daily.

Audiences
The target audience for this intervention and its associated communications is predominately African-American women who reside in the eastern rural region of the state.

Communication Goals and Objectives
The communication goals for the selected audience segment were to:

• Increase awareness about how consumption of at least five fruits and vegetables daily can help improve the health of individuals and may help prevent cancer, cardiovascular disease, and other chronic diseases, but based on feedback from focus groups, this part was not used in the actual communication products
• Motivate the target population to consume more servings of fruits and vegetables daily.

The planning team's specific communication objectives were:

• During the intervention period of 24 months, to move 30% of the individuals from the preparation stage to the action stage within the 24-month intervention.
• To increase 50% of the individuals' in the intervention counties daily consumption of fruits and vegetable servings by 0.5% within the 24-month intervention.

Messages
Based on pretesting data, messages were positive, supportive, and incorporated Biblical scriptures. Sample messages are: "Why God wants you to eat more fruits and vegetables" and "A prayer and a healthy breakfast are a great way to start the day."

Settings and Channels for the Messages
The planning team selected churches within the eastern, rural region of the state for the setting. The planning team chose group and organizational channels for the communications and intervention components. For an example of the group channel, the planning group chose several lay health advisors from each intervention church to provide counsel and support for church members working to consume more fruits and vegetables. The organizational channel was each church in the intervention, which had a nutrition action team coordinating nutrition-related activities and communications. For example, each team distributed brochures, flyers, and church bulletin inserts.

Activities

• Offer master gardening classes for church members.
• Encourage farmers markets, produce stands, and grocery stores to provide a variety of fresh produce on a regular basis.
• Provide information for ministers to incorporate nutrition messages into their sermons occasionally.
• Provide lay health advisors who could counsel and encourage individuals to begin consuming more fruits and vegetables.
• Offer educational cooking sessions.
• Assist church members in the modification of their favorite fruit and vegetable recipes to include in a church cookbook.
• Encourage women and men church members to bring more fruit- and vegetable-based dishes to church pot luck dinners.

Available Partners and Resources
The partners involved in this process were:

• state health department nutritionists,
• faculty members from several universities in the state with expertise in health promotion interventions, evaluation, and statistics,
• key community members of predominately African-American communities in the state,
• the state cardiovascular health program manager,
• the 5-a-day state coordinator,
• local health departments from the state local church ministers,
• a grocers organization, and
• individuals who serve as lay leaders at local churches.

Resources primarily came from a research grant from the National Cancer Institute (NCI) to support the program.

The planning team identified the relevant stakeholders related to the nutrition program intervention. They were: high-level managers from the state health departments, staff coordinating the program intervention, the planning team members, a leader from a local grocers association, a member of a state ministerial organization, and officials from the county government. They also designated key individuals from the funding sources as stakeholders, from the Centers for Disease Control and Prevention and the National Cancer Institute.

The planning team invited the stakeholders to a meeting to discuss the program intervention and the need for evaluating it during and after the intervention occurred.

(The following explanation in phase five explains an implementation evaluation, or process evaluation, and an effects evaluation that occurred in conjunction with the program intervention).

In the meeting just described, the stakeholders discussed the program intervention and agreed that it would be quasi-experimental. There are numerous churches, both small and large, in the eastern rural counties that have predominately African-Americans as members. Within each county, the planning team decided to select 2 small churches (less than 100 active members) and 3 large churches (more than 100 members) to participate. Then, they randomly selected a county to be in either the intervention or the delayed intervention. Five counties would receive the nutrition intervention to encourage the target population to increase their servings of fruits and vegetables daily. Five counties would receive the delayed intervention. The primary audience would include adults, especially women, within this African-American population who actively attend church.

The planning team discussed the proposed larger program intervention, including the health communication components associated with it, its overall purpose and objectives. After lengthy discussion, it became obvious that they were clear in their understanding about the program and its intended audience. They synthesized this discussion into a summary document to describe the program intervention. Several of the stakeholders from the local universities agreed to assist in the process and effects evaluation designs and in the data collection and analysis processes.

The implementation evaluation would measure how the nutrition activities and communications were implemented. The planning team sought to learn more about the number of people who were aware of the intervention, how many people attended the events related to the intervention, how they learned about them, perceptions about the success of the activities, and barriers, if any, were encountered in planning the activities.

The planning team designed the effects evaluation to discern to what extent individuals increased their fruit and vegetable consumption, to what extent their awareness was raised about the importance of consuming fruits and vegetables, and if awareness of the intervention was related to increased fruit and vegetable consumption.

After this meeting, the planning team discussed what occurred in this stakeholder meeting. They concluded that inclusion of the relevant stakeholders was instrumental in getting support from them, even from individuals who were originally resistant to the program intervention and its evaluation.

The planning team held a second meeting with the stakeholders to clarify what kinds of information they wanted from the implementation evaluation and the effectiveness evaluation and when. First, they talked about the types of evaluation questions to ask in the evaluation.

Implementation Evaluation Questions

1. How many people in the intervention churches were aware of the intervention?
2. How many people attended the nutrition-related events?
3. How did they learn about the events?
4. How were intervention activities planned?
5. What activities were perceived as successful?
6. What barriers were encountered in planning activities?
7. Did individuals anticipate that these activities would continue after the funding ceased?

Effects Evaluation Questions

1. To what extent did individuals increase their consumption of fruits and vegetables as a result of their involvement in the intervention?
2. To what extent did individuals become more aware of the importance of consuming fruits and vegetables for their health?
3. Was awareness of the intervention related to increased fruit and vegetable consumption?

They talked about the timeline, when data collection would begin and conclude, and data analysis. They planned a meeting to discuss the implementation evaluation findings and agreed that during that meeting they would provide recommendations for how to improve the program delivery. They also felt that compiling a report about the program and its process evaluation would help similar programs in the future. Next, they discussed the effects evaluation and its timeline. It was important for the stakeholders to get a snapshot of what occurred as a result of the program intervention and why. They planned a meeting as the data analysis was completed, to again discuss the analysis and provide recommendations for future programs.

The stakeholders discussed the originally agreed-upon goals and objectives for the nutritional program intervention. They used these goals and objectives for their intervention standards. As a reminder, these goals were:

• Increase awareness about how consumption of at least five fruits and vegetables daily can help improve the health of individuals.
• Motivate the target population to consume more servings of fruits and vegetables daily.

The intervention objectives were:

• Increase participation in nutrition-related activities by 25% during Year Two and Three of the intervention.
• During the intervention period of 24 months (Years Two and Three), to move 30% of the individuals from the preparation stage to the action stage.
• To increase 50% of the individuals' in the intervention counties daily consumption of fruits and vegetable servings by 0.5% within the 24-month intervention (Years Two and Three).

The planning team also relied upon the evaluation standards specified in the Centers for Disease Control and Prevention's (CDC's) Framework for Program Evaluation (MMWR, 1999, volume 48 (RR-11)) to ensure that the evaluation was ethical, appropriate, and produced credible information. (The actual standards are utility, feasibility, propriety, and accuracy, http://www.cdc.gov/mmwr/).

The planning team contacted all eligible churches within the rural eastern counties of the state (smaller churches with 100 active members or less and large churches with more than 100 active members) to inquire about their interest and willingness to participate in the program intervention. Of the available churches, 50 churches indicated a willingness to participate. (One church later decided to remove itself from the intervention, citing reasons unrelated to the intervention). The planning team also established a review team to provide feedback about the messages and communication products intended for the intervention. The planning team solicited input about the proposed communication products prior to the communication products' production and dissemination.

Based on the focus group data, the planning group decided to use the church as the primary communication channel for this intervention. They planned to work through the main program coordinator to establish a nutrition action team in each church with the help of the ministers. Once formed, these nutrition action teams would begin planning their own church activities. The main program coordinator worked with the planning team to develop a booklet of suggested program activities, health communication products (flyers, banners, brochures, recipe booklets, special church bulletin inserts, etc.) for the nutrition action teams to use.

The planning team designed an evaluation plan that included both an implementation and an effects evaluation. Their evaluation was a quasi-experimental design in which there were 5 counties in the intervention and 5 counties with a delayed intervention (and used for comparison purposes). The intervention counties and the delayed intervention counties both received a baseline survey assessing their awareness of consuming fruits and vegetables daily, their status with regards to the Stages of Change model, and their current consumption of fruits and vegetables in Year One. In Years Two and Three, the intervention occurred in the five intervention counties only. An implementation evaluation occurred during Years Two and Three to assess how the intervention was being delivered. In Year Four, individuals in the intervention and delayed intervention counties received a (posttest) survey assessing their awareness of consuming fruits and vegetables daily, their status with regards to the Stages of Change model, and their current consumption of fruits and vegetables.

The evaluation team (a smaller part of the planning team) from a local university was solely responsible for coding, entering, and analyzing the data. They agreed to meet with the planning team and relevant stakeholders after data analysis for both the implementation and the effectiveness evaluations so that they could discuss the findings. They used Cochran-Mantel-Haenszel chi-square tests for the categorical variables and F tests for the continuous variables to determine statistical significance (Campbell et al., 2000). They used a 0.05 level of significance, divided by the number of tests, for multiple comparisons (Campbell et al., 2000). To analyze the qualitative interviews, two researchers on the planning team coded the data according to how churches planned and made decisions about intervention activities and how and why activities were perceived as successful, and whether intervention activities were institutionalized within the churches. They utilized NUD*IST software to analyze the qualitative data (Campbell et al., 2000).

The planning and evaluation teams decided to provide presentations and evaluation reports at two points around the intervention. They first developed presentation and an evaluation report to explain their findings with regard to the programs-awareness of the programs, attendance at the programs, and perceptions of how the programs went and could be improved. The second evaluation report was written and distributed to stakeholders, program partners, and the planning team after the effectiveness evaluation was completed. They also offered a presentation where the stakeholders, program partners, and the planning team could learn more about the results first hand and ask questions to the evaluation team.

In a large meeting that occurred prior to the intervention kick-off event, the planning team and the relevant stakeholders agreed to allow several evaluation experts from a local university (also referred to as the evaluation team) to carry out the evaluation, including the design of the instruments, data collection and analysis, and reporting the results. However, the planning team clarified that they wanted opportunities to provide input and feedback into the evaluation process. The planning team and the stakeholders also asked that the newly formed evaluation team update them in quarterly meetings and with a monthly newsletter.

Each year the project received a total sum of approximately $580,000. Approximately $120,000 of this amount was used for the evaluation components annually.

Baseline Data Collected:	Fall, Year One
Partner Training:	Winter, Year One
Campaign Launched:	Winter, Year Two
Implementation Evaluation Began:	Spring, Year Three
Effects Evaluation:	Data collected with baseline survey in Fall of Year One and the survey distributed again in Fall of Year Three with the addition of church activity reports and church coordinator interviews.
Data collection and analysis:	Concluded in Year Four

The planning team designed an evaluation plan that included an implementation (or process) and an effects evaluation. This evaluation implementation plan included:

Implementation Evaluation Questions (Occurred during Years Two and Three)

1. How many people in the intervention churches were aware of the intervention?
2. How many people attended the nutrition-related events?
3. How did they learn about the events?
4. How were intervention activities planned?
5. What activities were perceived as successful?
6. What barriers were encountered in planning activities?
7. Did individuals anticipate that these activities would continue after the funding ceased?

Effects Evaluation Questions (Occurred during Year One and Four as baseline and post-test data)

1. To what extent did individuals increase their consumption of fruits and vegetables as a result of their involvement in the intervention?
2. To what extent did individuals become more aware of the importance of consuming fruits and vegetables for their health?
3. Was awareness of the intervention related to increased fruit and vegetable consumption?

They used intervention goals and objectives for their intervention standards. The goals were to:

• Increase awareness about how consumption of at least five fruits and vegetables daily can help improve the health of individuals.
• Motivate the target population to consume more servings of fruits and vegetables daily.

The intervention objectives were:

• Increase participation in nutrition-related activities by 25% during Years Two and Three of the intervention.
• During the intervention period of 24 months (Years Two and Three), to move 30% of the individuals from the preparation stage to the action stage.
• To increase 50% of the individuals' in the intervention counties daily consumption of fruits and vegetable servings by 0.5% within the 24-month intervention (Years Two and Three).

Each year the project received a total sum of approximately $580,000. Approximately $120,000 of this amount was used for the evaluation components annually.

Once the planning and evaluation teams finalized the communication and the evaluation plans, they planned a kickoff event. It was important that program partners were also invited to this program kickoff, so that they would be more likely to support the project. The planning team invited the press to attend a latter portion of this meeting, so that they could publicize the program intervention.

To prepare for the kickoff meeting and press conference, the planning team ensured that they had adequate printed materials of the summary communication plans, the program team was fully briefed and prepared to positively and clearly present the appropriate messages about the program intervention. They also compiled a list of newspaper and television reporters, and sent them press releases prior to the event.

The program intervention coordinator tackled unexpected events and problems.

She made sure to brief the planning and evaluation teams as the program moved towards its objectives.

She held weekly meetings with her staff to troubleshoot as a team, to keep them motivated and cognizant of the program's progress and problems.

She also checked the established quality control procedures for program and communication coordination, to make sure that the planning team, the nutrition action teams, the lay health advisors, the program partners, and the stakeholders were kept informed about the program's challenges and progress.

As the program intervention progressed, the planning staff and the program intervention coordinator made notes of ways to improve the program and its communication.

They also gathered this information as the implementation evaluation occurred, to keep records of logistical procedures for communication and implementation of the program.

They organized program-related documents such as newsletters, meeting notes, and communication products into a "how to" guide for similarly structured future program interventions.

The program intervention coordinator and her staff modified their communication procedures with the planning and evaluation teams as well as with the stakeholders, based on feedback about the program.

They learned that not everyone was able to attend their regularly scheduled meetings, and some stakeholders were not receiving their newsletters in a timely fashion. As a result, these stakeholders felt out of the communication loop, which was not helpful for the program itself. Thus, the program intervention coordinator offered the option of teleconference calls for people who could not be present in the meetings and made sure her staff kept an updated mailing list of all involved persons in the program.

The program intervention coordinator learned from the implementation evaluation that some of the nutrition action teams were not able to plan and coordinate regular programs within their churches. So, the intervention program coordinator made sure that the nutrition action teams had enough people who could help with the programs, and that the teams had the supporting materials (flyers, banners, bulletin board supplies, etc.) in enough time to adequately plan and promote their nutrition-related events.

The planning team realized the importance of sharing what they learned from their experiences with the nutrition program intervention, since it was a precedent-setting one in a church setting.

They brainstormed how to disseminate what they learned. The planning team agreed to submit several manuscripts to peer-reviewed journals describing the intervention in detail.

They also felt it was important to share this information in professional presentations at national conferences, such as the American Public Health Association.

In addition, they wanted to share this information on a community level. They compiled a manual and a newsletter to distribute in a public meeting, and invited stakeholders, the participants in the intervention, and the program partners to attend. At this meeting, the planning team shared information about the program and the successes. The highlight of the evening was when various participants shared their personal experiences with the program and its positive impact on their lives. The conclusion of the meeting was a potluck dinner, with lots of fruit and vegetable dishes in addition to traditional Southern dishes.

Lastly, a report was prepared for publication targeted to state and local health departments. This report detailed the essential elements of the program intervention, outlining how it was collaboratively planned and evaluated.

References

• Campbell, M.K. et al. (2000). The North Carolina Black Churches United for Better Health Project: Intervention and process evaluation. Health Education & Behavior, 27 (2): 241-253.
• Campbell, M.K., et al. (1999). Stages of change for increasing fruit and vegetable consumption among adults and young adults participating in the national 5 -a-Day for Better Health Community Studies. Health Education & Behavior, 26(4), 513-534.
• Campbell, M.K., et al. (1999). Fruit and vegetable consumption and prevention of cancer: The Black Churches United for Better Health Project. American Journal of Public Health, 89(9), 1390-1396.
• Campbell, M.K., et al. (1998). Stages of change and psychosocial correlates of fruit and vegetable consumption among rural African-American church members. American Journal of Health Promotion, 12(3), 185-191.
• Campbell, M.K. et al. (1996). Assessing fruit and vegetable consumption in a 5 a Day study targeting rural blacks: The issue of portion size. Journal of the American Dietetic Association, 96(10), 1040-1042.
• Campbell, M.K. et al. (1994). Improving dietary behavior: The effectiveness of tailored messages in primary care settings. American Journal of Public Health, 84(5), 783-787.
• Campbell, M.K., Polhamus, B., Jackson, B., Cowan, A., Demark, W. (1997). Culturally sensitive dietary assessment in a rural African American population. American Journal of Clinical Nutrition, 65(Supplement), 1346S-1347S.
• Demark-Wahnefried, W., Hoben, K.P., Jennings, J., Miller, M.W., & McClelland, J.W. (1999). Utility of produce ratios to track fruit and vegetable consumption in a rural community, church-based 5 A Day intervention project. Nutrition and Cancer, 33(2), 213-217.
• McClelland, J.W., Demark-Wahnefried, W., Mustian, R.D., Cowan, A.T., & Campbell, M.K. (1998). Nutrition and Cancer, 30(2), 148-157.