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					          Live Well, Live Long: Steps to Better Health—Blueprint
         Health Promotion and Disease Prevention for Older Adults

                Changing Behaviors and Changing Communities

Introduction
The Healthy People 2010 initiative, a national strategy for promoting the health of all
Americans, recognizes the intertwined relationship of the community environment with
individual health. When adopting healthy behaviors, people are motivated by more than a
simple desire to be healthy. This chapter will address change based on factors such as
illness and community environment. Beginning with a discussion of individual change, the
chapter will then address community responsibilities for providing healthy environments.

Table of Contents
                Changing Individual Behavior
                      Introduction
                      Resistance to Change
                      Stages of Behavior Change
                      Ripening the Conditions for Change
                      Tools and Techniques for Developing Conditions for Change

                Changing the Environment to Support Healthy Behavior
                      Introduction
                      Strength-based Assessment and Community Development
                      Conducting Culturally Appropriate Needs Assessments

                Health Literacy
                      Introduction
                      Determining Client Literacy
                      Tools for Improving Health Literacy
                      Resources




Live Well, Live Long: Steps to Better Health                                           1
          Live Well, Live Long: Steps to Better Health—Blueprint
         Health Promotion and Disease Prevention for Older Adults

                Changing Behaviors and Changing Communities


Changing Individual Behavior

Introduction
 At any age, fear of change is a normal reaction. For older people, who have engaged in
certain habits and life patterns for many years, change can be seen as:

               A threat to feeling competent
               A possibility for embarrassment
               A peril to living independently
               A source of fear or loss

        The behavior you may see is resistance to change.

Table of Contents
                Resistance to Change
                Stages of Behavior Change
                Ripening the Conditions for Change
                Tools and Techniques for Developing Conditions for Change


Resistance to Change—Internal Factors
―Why should I change? I‘ve lived this way all my life and I‘m still here.‖

This statement rings true for many older adults faced with changing health behaviors, for the
following reasons:

Their Experience of Chronic Diseases or Illness

Older adults may have lived for years with health habits that cause or contribute to the slow
progression of chronic diseases. Many of these conditions may not have surfaced yet, which
creates a false sense of security. With increased longevity, chances are good that these
conditions will eventually emerge.

The current generation of elders is the first to experience extended life with chronic illness.
Their parents probably lived with ―a few aches and pains,‖ but shorter life spans did not
allow for many examples of long-term treatment and prevention efforts.



Live Well, Live Long: Steps to Better Health                                                      2
Eighty-eight percent of today‘s older population will develop one or more chronic illness.
Older adults can greatly mitigate this condition by adopting health-promoting behaviors
before symptoms surface. As the aging population grows in number, more older people
will have the opportunity to change their behavior to improve their health. Until more
older adults accept the possibility of successful change, many will remain reluctant to
make health changes.

Care of Chronic Illnesses

Because chronic illnesses do not have a single cause or treatment, no single behavioral
change can bring about a radical improvement. Older adults may not appreciate the value of
new behavior if one behavior change does not dramatically improve their health.

The Nature of Habits

Long-held and often unhealthy habits are comforting when life becomes difficult.
Changing or giving up a habit is a loss that is added to the many others experienced in
later life. So older adults may resist changing a familiar habit. Even if they do make a
change, they naturally may feel grief. The depth of the grief depends on the importance
the older person places on a habit.


After deciding to make a change, these factors still face the older person:

Deciding on a Regular Program

Establishing new habits can be stressful and requires a great deal of personal adjustment.
Making a commitment to begin to exercise, eat healthy foods or quit smoking is a matter
of tipping the scale from keeping comfortable old habits to responding to deeper needs.
These needs form important motivations that can include:

               The fear of disease
               Social pressure
               Financial incentives
               Peace of mind or stress reduction
               A sense of accomplishment
               A desire for fun

Continuing the Chosen Program

Self-doubt about adopting the new behavior weakens the balance between the desire for
comfortable past habits and the desire for change. Perhaps the change did not succeed in
a timely manner, or meet unexpected challenges. For example, you begin a program of
avoiding nighttime snacks, and your evenings seem to crawl by. Over the next weeks,
the craving gradually disappears until you receive an upsetting phone call. This triggers a




Live Well, Live Long: Steps to Better Health                                               3
craving for comfort that snacks may represent, and challenges your health commitment.
Although triggered by an outside element, the test is internal.

Overcoming Interferences That Disrupt the Healthy Behavior Lifestyle

Circumstances may also interrupt your new behavior. For example, a twisted ankle may
require rest from exercise for a week. The setback results in losing ground in reaching
your health goal. Your challenge comes in returning to the exercise routine. All the
work seems to have been wasted and a built-in excuse has formed.

Resistance to Change—External Messages
Older adults struggle not only with personal barriers to healthy changes, but also with
barriers created by the external world. Societal norms play a major role by encouraging
the following beliefs:

1. Life should be comfortable and easy, especially for older people.

               Instead of exercise, services provide drive-up convenience for our lunches,
                our banking errands, our outgoing mail, and even our religious practice
               Ready-made meals are available to save time, with minimal preparation
                but maximum salt and fat content
               Entertainment is instantaneous, providing a means to pass the time rather
                than a fulfilling time. Television consumes an average of four hours of
                older adults‘ attention each day. Aside from documentaries and some
                game show programming, easy entertainment does not bolster mental
                fitness.

2. Everything is bad for you.

    The authors of the 2001 National Blueprint for Increased Physical Activity in Adults
    Age 50 and Older report that many messages related to physical activity are unclear
    and at times inconsistent. This confusion occurs regarding other health behaviors, as
    conflicting reports appear on topics like butter vs. margarine, eggs and cholesterol,
    and the health aspects of drinking wine. Older adults confused by conflicts often put
    little credence in official health guidelines and become resigned to fate.

Resistance to Change—Personal Motivators
Successful health behavior change stems from a complex interplay of motivating factors
such as:

1. Perceived threats

Many of us believe that an illness or unintentional injury ―could not happen to us.‖ We
may feel little motivation to act when the danger seems remote. The situation changes


Live Well, Live Long: Steps to Better Health                                                4
when a family member, a friend or even a national figure falls victim to an illness. The
heightened sense of threat begins to tip the scales toward action. However, a situation
that is too threatening may result in denial or an attitude of fatalism. For example, a
person with a family history of diabetes may take no action to treat the disease, in the
face of its seeming inevitability.

2. Perceived benefits

An appeal to achieving a valued goal can also move people to action. The possibilities
for independent living, savings in healthcare costs, or feeling part of a favored group may
break down the ambivalence toward change. The benefits of taking action outweigh the
barriers.

3. Beliefs

Building on people‘s beliefs about their personal skills, their ability to change and their
ability to overcome barriers (such as transportation, inconvenience, cost, or fear of
potential discomfort) plays an important role in motivation. For example, beliefs in
complementary and alternative medicine have moved 35 percent of the older population
to pay for treatments not covered by health insurance.

Stages of Behavior Change
Ten years ago, James O. Prochaska developed a stage model to explain the experience of
change to his patients. Prochaska found that understanding the difficulty of changing
profoundly helped his clients. He then refined his model to include five stages.

Precontemplative

Description       Motivational Issues Techniques for Moving to     Descriptive Time
                                      Next Stage                   Phrases
The individual    The individual        Especially defensive when I won‘t      This stage
is not thinking   may be unaware of     presented with Action                  may be
about change,     the health issues,    Statements such as ―quit               extended
and may not       demoralized over      smoking.‖                              over months
even want to      past failures,        Family or friends                      and years.
know about the    negative aspects of   expressing how this                    People may
health issue.     the change are        behavior affects them may              leave and
Defensive.        more evident than     effect change. Individuals             return to this
                  the benefits.         may be emotionally moved               stage.
                                        by the death of a loved one
                                        from a similar illness.
                                        Success in changing one
                                        behavior may influence
                                        changing others.




Live Well, Live Long: Steps to Better Health                                                  5
Contemplative

Description     Motivational       Techniques for Moving to Next    Descriptive Time
                Issues             Stage                            Phrases
The             An individual    Reinforcement for change from I may           This stage may also
individual is   may not know     all sectors.                                  take a long time.
thinking        how to change                                                  People may cycle in
about           the behavior or                                                and out many times.
change, but     how to begin the
still           change.
ambivalent.
Problem
behavior is
under
examination.

Preparation

Description     Motivational       Techniques for Moving to Next    Descriptive Time
                Issues             Stage                            Phrases
The             There may be       Often coming to classes and      I will     Action comes within
individual      fear about ability seeking information supports the            a month. Again,
begins          to enter the       change.                                     time varies
weighing the    action phase or                                                depending on
pros and        there may be                                                   moving to another
cons. As the    grieving.                                                      stage and returning.
pros become
more
compelling,
the person
begins to
think about
the
advantages
of behavior
change. Plan
of action
unites with
intent.




Live Well, Live Long: Steps to Better Health                                              6
Action

Description    Motivational        Techniques for Moving to Next     Descriptive          Time
               Issues              Stage                             Phrases
The            A need to           At this point, making         I am now                 This stage lasts
individual     specify the terms   environment as encouraging as                          approximately 6
begins to      for success         possible to reach success is                           months and may
perform the    becomes             most important.                                        be cycled in and
behavior       important to see                                                           out of by the
and feels in   the advantages                                                             individual.
control.       of the behavior.
Individual     Develop specific
frequently     goals such as 20
turns to       minutes of
others for     exercise 3 times
assistance     per week.
and support.

Maintenance

Description       Motivational Techniques for Moving to Next       Descriptive     Time
                  Issues       Stage                               Phrases
Individual is     .             Providing rewards and         I have               Doing the behavior for
preventing                      incentives and sharing                             more than 6 months.
relapse to past                 successes help to encourage                        Lapses may occur, but
habits.                         continuation of the new                            generally the individual
                                healthy behavior. Incentives                       maintains a health
                                can include becoming a                             routine.
                                teacher for this particular
                                behavior change or serving as
                                a role model.




Live Well, Live Long: Steps to Better Health                                                     7
Example 1—The Senior Wellness Project

Abstract
The Senior Wellness Project is a low-cost participant-directed health behavioral change
program. Its core component is a research-based health-enhancement program. The
project also includes exercise programs and classes on self-management of chronic
conditions.

Background
In 1994, the Northshore Senior Center initiated a physical activity program as part of a
research study, funded by the Centers for Disease Control (CDC). It was conducted by
the Northwest Prevention Effectiveness Center (formerly known as the Health Promotion
Research Center) at the University of Washington in Seattle. The results of the study
showed decreasing physical pain and depression among participants in the program,
which became the Lifetime Fitness program.

This exercise program has become one component of a comprehensive wellness model
that has expanded to over 35 sites.

Health Enhancement Program
A University of Washington study formed the basis for the Health Enhancement
Program. Participants, referred from various local sources, work with a Registered Nurse
and social worker. The process starts with:
    A health self-evaluation
    A motivational interview with the nurse practitioner to identify self-determined
       health goals. The nurse facilitates the meeting and records information using a
       specialized software program that outlines the participant‘s health action plan—
       goals chosen, how they will be achieved, test scores related to the goals, and how
       the program will support the participant. Every six months a health action
       program is updated and printed out for the participant and his or her physician

The nurse and social worker are available to provide health education, and to address
questions and concerns that the participant‘s physician may not be able to cover.

Each participant may also choose to be matched with a health mentor, a trained
community-based volunteer who may accompany the participant to exercise classes,
provide weekly calls and support, or other activities supporting the participant in reaching
health goals. Some graduates of the program have in turn become mentors.

The program is supported by the local Area Agency on Aging, the local health
department, hospitals, and private and public foundations. The health department pays
for a nurse at five sites and local hospitals provide additional funding or staffing.
Foundations fund the program at four public housing sites, partly for interpreter services
in many languages. The fee is a sliding scale donation only.



Live Well, Live Long: Steps to Better Health                                                 8
A University of Washington geriatrician assists in evaluating the program. Program
outcome data is analyzed separately at the University. The results of the study found a 72
percent decrease in length of hospital stay and a 38 percent reduction in cases of
hospitalization.

Lifetime Fitness
Lifetime Fitness is designed to accommodate settings without exercise equipment. The
program‘s success is demonstrated by increased physical activity in participants also with
socialization. Certified fitness instructors who have received a four-hour training on the
program curriculum teach one-hour sessions three times a week for five weeks at senior
centers and public housing buildings. The exercise routine consists of
             Warm-ups
             Balance exercises
             Strengthening routines (using hand and foot weights)
             Stretching
             Endurance or cardio-fitness activities
             Cool-down

Classes are individualized and continue seamlessly from one five-week session to the
next. Exercisers who stay for the five weeks generally become long-term participants.
Fees vary.
http://depts.washington.edu/hprc/Current_Projects/Lifetimefitness.htm

Chronic Disease Self-Management Program
This program, based on Kate Lorig‘s 1996 Stanford University research model of self-
management for chronic conditions, is a six-week course, taught by a trained facilitators,
typically older adults with chronic conditions. Briefly, the course helps participants
develop short-term goals; provides information on nutrition, exercise and relaxation
techniques; and acts as an educational group for all chronic conditions. It is designed to
enhance regular treatment, and also to educate older adults on techniques for managing
chronic conditions. The workshop is given for two-and-a-half hours per week for six
weeks in community settings such as senior centers, churches, libraries and hospitals.
Sessions are founded on the participation process, in which mutual support among
participants promotes confident and effective self-management.
http://www.stanford.edu/group/perc/

Contact: Susan Snyder, M.S., Director, Senior Wellness Project
Senior Services of Seattle-King County
1602 2nd Ave., Suite 800
Seattle, WA 98101
Phone: 206-727-6297
E-mail: SusanS@seniorservices.org




Live Well, Live Long: Steps to Better Health                                                 9
Example 2—OASIS Health Promotion Model

Abstract
The OASIS Wellness program is a core curriculum of courses developed and used by the
OASIS senior adult education program sponsored by May D&F department stores. The
curriculum is based on James Prochaska‘s Stages of Change—precontemplative,
contemplative, preparation, action and maintenance. The Stages of Change model
recognizes that different stages of readiness need different incentives. Courses are
designed to assist participants in moving from one stage to the next to achieve self-
identified behavior goals.

Background
OASIS has about 350,000 members in 26 cities nationwide. OASIS conducts a number
of educational and activity programs for older adults at the May D&F stores or with
partner facilities.

Currently, each site has a local health sponsor, such as a hospital or HMO, which helps
provide health programming. The core curriculum developed by OASIS is supplemented
at each local site by lectures, health screenings and other available programming, such as
the Arthritis Foundation class based on Kate Lorig's ―Living a Healthy Life with Chronic
Conditions‖ course. Each curriculum includes lesson plans, handouts and overheads.

Core Curricula
The program is based on the following core courses, beginning with an overview of
healthy behavior to build awareness that will lead to choosing goals and planning actions.
The course catalogs offer a range of courses designed to help individual meet specific
goals ranging from exercise and nutrition to mental health and memory.




Live Well, Live Long: Steps to Better Health                                           10
    General Health              Taking Charge of your         An overview of healthy
                                Health                        behaviors with a healthy
                                                              lifestyle assessment, setting
                                                              specific, measurable goals,
                                                              referral to a team professional
                                                              such as a dietitian, and an
                                                              annual reunion for
                                                              reinforcement
                                Healthy Body, Healthy
                                Mind                          A general health promotion
                                                              program

    Physical Activity and       Choose Your Move              A sampler of various fitness
    Fitness                                                   programs, from yoga to
                                                              aerobics to Tai Chi

                                                              Beginning exercise for those
                                Exerstart!                    who have never exercised

                                Tai Chi                       Intermediate and advanced
                                Yoga                          instruction for each class

    Nutrition                   Personal Eating Plan          Basic nutrition and individual
                                (PEP)                         goal setting

                                PEP Plus                      More information on diet,
                                                              recipes, cooking
    Memory                      Memory Dynamics               Describes normal aging and
                                                              memory, provides memory
                                                              training

    Mental Health and           Outlook: It's the Thought     Introductory mental health
    Wellness                    That Counts                   course



                                Positive Attitude/ Positive   Four modules on mental
                                Aging                         wellness: self-esteem,
                                                              relationships, time
                                                              management, empowerment

    Bone Health and Fall        Building Bones                Osteoporosis education and
    Prevention                                                exercise program




Live Well, Live Long: Steps to Better Health                                                 11
                                Improving Your Balance       Exercise program to teach
                                                             balance skills and exercises

                                Staying on Your Feet         Fall prevention strategies

    Sensory Health              Staying Active: Managing     Under development
                                Changes in Vision and
                                Hearing

    Disease Management          Exercising Control:          Under development
                                Managing Your Diabetes

                                Medication Matters           Under development
    Continued Motivation        Health Coach Training        Trains peer health counselors
                                                             for many of the classes where
                                                             they act as mentors/coaches.
                                                             Training curriculum includes:
                                                                 Normal aging
                                                                 Goal setting
                                                                 Prochaska‘s change
                                                                   model

                         OASIS courses contribute to the health education of older adults
                          in these ways:
                 1.   Awareness—screening, referrals from other classes
                 2.   Knowledge—two-session courses on understanding the facts
                 3.   Skill Building—six-week sessions providing active work on health
                      goals
                 4.   Maintenance—six-week class sessions for ongoing support

                     Evaluations are also built on Prochaska‘s change model.
                 1. Awareness—Effort is made on outreach. Success is based on how
                    many older adults attend
                 2. Knowledge—Pre- and post-tests are given
                 3. Skill Building—The movement from one stage of change to another
                    is recorded and efficacy assessed
                 4. Maintenance—Individuals are tracked over one year to determine if
                    the behavior has become a habit

     Contact: Helen Lach, R.N., C.S., M.S.N.,
     Health Education Consultant
     Division of Geriatrics and Gerontology
     Washington University School of Medicine
     Phone: (314) 862-2933




Live Well, Live Long: Steps to Better Health                                                12
Ripening the Conditions for Change
People may recycle through the precontemplative and contemplative stages of change
many times before choosing healthier behavior. Three conditions must exist before
people adopt new behavior.

             Recognition of the importance of the change
             Confidence in the ability to change (self-efficacy)
             Readiness to change

Recognition of the Importance of Change

Until people place a value on changing behavior and give that value a high priority, they
will not have enough motivation to tip the scales toward action. The priority given to the
value of a behavior change is determined by a number of ingredients.

               Social Influences
               Personal Exploration
               Timing

Social Influences

The process of increasing a change‘s priority can be accomplished through social or
spiritual networks. For example, the Seattle-King County Department of Public Health
sponsored a program, ―Health Education Through the Churches.‖ It responded to
people‘s spiritual, emotional and physical needs in order to promote their overall health,
by recruiting and training faith community members to identify health concerns and
encourage healthy behaviors among their peers.

Personal Exploration

        1. Health Assessments

Health assessments or interviews can help older people examine their values and their
priorities regarding change. In one example, an assessment might ascertain that an older
person knows the benefits of exercise in improving his diabetic symptoms, but that
beginning an aerobics program is not as important to him as reducing fried foods from his
diet. The assessment has helped him identify his health goal.

Assessments take a variety of forms.

               The Aquatic Park Senior Center in San Francisco sponsors a weekly
                men‘s group with informal, freewheeling discussions as its centerpiece. In
                this casual atmosphere, many of the men have opportunities to discuss
                their values regarding healthy living. Although it is an unusual interview
                technique, through conversation the men crystallize their values, gain


Live Well, Live Long: Steps to Better Health                                             13
                 additional information about health and begin to realign their priorities.

                Seattle‘s Senior Wellness Project (see 1.2c, Example 1) takes a more
                 formal approach of one-to-one sessions to explore the goals and priorities
                 of change contemplators.

    2. Scaling Questions

One assessment tool for determining priorities is scaling questions. Ask the older person to
pick a number on a scale from zero to ten, with ten indicating the strongest incentive,
priority and sense of confidence to change. For example:

                 Older Person: I give the degree of importance to quit smoking as a five.
                 You:          Why not a six?
                 Older Person: Most of my friends still smoke. If I quit, I may not be able
                               to spend time with them.

You and the older person can now develop strategies to overcome this barrier to quitting
smoking. The use of scaling allows you to avoid giving advice and to rely on listening
for cues to barriers. Another question to help develop strategies for change could
include, ―What would it take to for you to move from a five to a seven? How exactly
would you see this happening?‖

Timing

If the older person places a low priority on a behavior change and has a low level of
confidence that the goal can be met, delay the attempt. Turn to another area of change
that is better positioned for success and confidence-building. After you make headway
on achievable goals, plan a time to discuss the delayed change, to avoid discouragement
about the delay.

Confidence in the Ability to Change

Confidence varies from one situation to another. For example, an older person‘s
temptation to eat high-fat foods may vanish during the day. In the evening, when his
family comes home for dinner, they request their favorite fried foods. Then he faces
temptation on two fronts—the high-fat meal itself, and the desire to enjoy it with his
family. This double bind threatens his confidence, and he needs to develop strategies to
strengthen his resolve.

The process of building confidence consists of four steps:

            1.   Identifying behavior patterns
            2.   Making a commitment
            3.   Creating a helping environment
            4.   Evaluating accomplishments or failures



Live Well, Live Long: Steps to Better Health                                                  14
Identifying Patterns

Self-monitoring assists the older person to systematically identify patterns of behavior.
Understanding a typical day or week requires a specific observation period.

The following are two models for self-monitoring: a checklist tool and a diary.

           In her work on osteoporosis at Tufts University, Miriam Nelson developed a
            daily reporting food log. The log outlines the amount of calcium, vitamin D,
            soy foods and fruits and vegetables consumed each day. The participant
            records the amount by simply making checkmarks.

           Using a diary to determine eating patterns, for example, it is useful to record:
                   o The food you consumed
                   o The time of day that you consumed food
                   o Where you ate the food
                   o If you ate alone or with others
                   o How you felt emotionally when you were eating

Self-monitoring improves awareness of triggers for unhealthy eating patterns and of
supports for maintaining a commitment to health.

Making a Commitment

People engaged in changing behavior can cement their commitment by developing a
health contract—a signed, written agreement to accomplish a health goal previously
established through discussion and negotiation.

Contracts provide three features:

    1. Clearly defined activity

            Good contracts outline the behavior, the location, who is involved in
            accomplishing the activity

    2. Visibility

            Contracts act as reminders when hung on the refrigerator or other conspicuous
            location

    3. Familiar tools
         Contracts can use a familiar format like a calendar or check sheet




Live Well, Live Long: Steps to Better Health                                                15
Example–Health Contract Calendar

Named as a 2001 Best Practice by the National Council on Aging Health Promotion
Institute, the health contract calendar is a flexible tool for summarizing a health
assessment and outlining goals in an easy-to-follow format. Developed for older adults,
at the University of Texas School of Applied Health Sciences, the contract provides space
for:
        1. Realistic goals
        2. Benefits that will motivate the older person
        3. Barriers and a brief plan to overcome them
        4. A month-long calendar to record accomplishments
        5. A signature area

The period of a month gives older adults enough time to incorporate the new behavior
into a routine. This tool works effectively for older people either in a counseling session
or to complete on their own after learning realistic goal-setting techniques.


Creating a Helping Environment

        Family and Partners

Understanding from partners, family and friends certainly helps to maintain the
momentum for change. A 1997 study determined that targeting activities and
information to a couple rather than an individual resulted in greater reduction of
cardiovascular risk. With age and loss of a spouse or partner, friendships play an
increasingly important role in support.

        Community Health Advisors

Lay health advisors work effectively with elders in Texas, Arizona and Washington State.
Acting as information sources and friendly follow-up visitors, lay health advisors fill the
role of trusted and supportive neighbor in many cultures. Regular contact helps to keep
the new behavior on track.

        Support Groups

In numerous programs, follow-up calls, visits or group meetings maintain healthy
behavior as a high priority. The Longmont (Colorado) Senior Center Pan y Café
program provides an informal setting for community education as well as health
information. The sessions begin with culturally appropriate music, food and decoration.
The group setting is a comfortable and supportive environment for Latino elders to
discuss problems and learn about community services. The program‘s success resides in
the culturally appropriate environment and staff, and in personal invitations to the
participants.


Live Well, Live Long: Steps to Better Health                                             16
Dr. David Haber of the University of Texas includes support groups in his grant-funded
health promotion programs. Participants in some of these groups have continued to meet
for years after the programs have ended, to socialize and provide practical assistance.

Evaluating the Accomplishments or Failures

        Rewards

The continued efforts of people who are maintaining their new behavior are inspired by
acknowledging to themselves their short-term accomplishments or discovering the
benefits from their changes. With personal health gains no longer the primary goal,
gratification must come from other areas. Becoming a group leader, instructor or health
mentor can inspire their continued compliance with healthy behavior.

Examples—Rewards

A prime example of a program that inspires maintenance of health goals, the National
Senior Games, an annual sports event for older adults, motivates the physically active to
reset their training goals yearly in order to compete.

For the less active, many communities turn to older adult walks or fun runs. By treating
participants at every level as elite athletes, these communities inspire continued
commitment to health. The San Francisco YMCA, as part of the community-wide ―Bay
to Breakers‖ run, sponsors an older adult program ―Bay to Breakfast.‖ A two-pronged
event, the health fair portion builds health awareness and participation in the walk
rewards active elders with healthy snacks at the finish line.

The Senior Health Alliance Promoting Exercise (SHAPE), a volunteer consortium of
Chicago-based organizations, spearheads the Get in SHAPE Chicago! Senior Health &
Fitness Walk. National Senior Health & Fitness Day is celebrated with a health activity
exclusively for older adults, with prizes and award ceremonies. Awards are given to
those who complete the three-mile lakeside walk, and the organizers encourage training
for annual event. In the first year, over 1,000 elders participated, and the second year
3,000 walkers and wheelchair participants are anticipated. The health fair at the finish
line, featuring live music, encourages participants to continue their routines by joining
exercise programs throughout the Chicago area.

The Chicago Department of Aging has encouraged multicultural participation through
outreach into ethnic community senior centers. The affordable $4 registration cost
entitles participants to lunch, a T-shirt and goodie bag.




Live Well, Live Long: Steps to Better Health                                            17
        Failures

Confidence erodes with repeated failures or recycling into earlier stages of change. Yet
failure gives us important information in planning for future success. Working with the
disheartened should feature:

               Affirming hard work and persistence
               Emphasizing strengths rather than difficulties
               Discussing solutions
               Avoiding overly positive statements. Failure is a loss. Allow some grief,
                but try to incorporate lessons from the failure into a solution

When brainstorming during the solutions discussion, emphasize that:

               Many courses of action lie ahead; this unsuccessful attempt was only one
                course
               No one can take a guaranteed course to success. Health educators can
                provide direction from what has worked for others
               Only the person making the change can recognize the best course that will
                fit personal strengths

Readiness to Change

Unlike an on-off switch, readiness to change appears in degrees. Early levels of
readiness begin with a shift in the perceived importance of the change. Eventually the
pros will outweigh the cons. In the later stages, eroding confidence in changing can
reduce its level of importance.

For example, an older person understands, and places great importance on, adhering to a
healthy diet. But if she has 1) little confidence in being able to avoid poor food choices
(in social settings or the family dinner table), or 2) doubt in her own ability to cook a new
way, the resulting feelings give improving her diet a low priority. This ambivalence
about change can take a person on a roller coaster ride of guilt, elation, depression and
optimism.

The ambivalence is reflected in the balancing of costs and benefits. The following chart
weighs the costs and benefits of changing diet.




Live Well, Live Long: Steps to Better Health                                              18
   Costs of Not Changing                            Benefits of Not Changing
       Fear of heart disease and diabetes             Not concerned with what to eat
       Reduction of activities                        Eating with family and friends
       Difficulty in finding clothes                  Eating favorite foods

   Costs of Changing                                Benefits of Changing
       Continual thinking about what to eat           Feeling healthy
       Giving up favorite foods                       Reducing healthcare costs
       Giving up social situations                    Feeling accomplished
       Learning to cook new diet                      Participating in more activities with
       Not eating out as often                          family, partners and friends
                                                       Feeling confident in finding nice
                                                         clothes


   Summary Chart
   The following chart summarizes each of the three conditions.
             
             
             Key Questions        Sample Questions              Resolution
Importance     Why?                How severe is               the   If the following conditions are
of the         Why should I do it? problem?                          met, there is reason to change:
Change         What      are    theWill it hurt me?                  1) The disease seems harmful
               benefits?           What is the risk for me?          2) The person‘s susceptibility
               What are the costs? Is it likely that this will       is high
                                   affect me?                        3) The benefits are worthwhile
                                   What are the advantages to        4) The pros outweigh the cons
                                   changing my behavior?
Confidence     What? How?          What are the barriers to          If a person believes that he or
in the         Am I able to do changing?                             she is capable of
Ability to     this?               What will make it                 1) making the change and
Change         How can I do this? difficult?                         2) coping with the difficult
               What will change?   Am I able to make this            aspects, it is likely that the
                                   change?                           person will change.
                                   Will I be able to follow
                                   through?
Readiness      When?               When are the changes              The older person must:
to Change      At what time?       easiest and most difficult        1) Feel prepared to make the
               What are my         to make?                          change
               present priorities? What makes this change            2) Decide when
                                   important now?                    3) Give it a priority




   Live Well, Live Long: Steps to Better Health                                               19
Tools and Techniques for Developing Conditions for Change
Confidence in one‘s ability to successfully change grows through:

               Mastering skills
               Seeing examples and options for change
               Persuasion from others
               Self-monitoring

Mastering Skills

    1. Practice. Success is best achieved through practice, beginning with short-term
       goals made up of smaller, achievable ends. The most successful programs raise the
       bar gradually, moving to more difficult tasks.

Example 1—Tai Chi Project

Associated with a number of hospitals in the Denver area, the Tai Chi Project builds on a
model of experience. Founder Joseph Brady, who practiced and taught gymnastics for
many years, believes in enhancing readiness to change by teaching skills and making an
activity fun. If people enjoy the activity, they will continue.

Part of enjoying the activity is feeling competent to perform. The class formula changes
with the specific needs of participants, and always includes time to rehearse the
movements many times during the hour session. Repetition over a number of sessions
each week and participation in a group cue learners to remember the movements
cognitively, which over time becomes ―body learning.‖

The success of the program is demonstrated in numbers. The project has over 200 older
learners participating on a regular basis.


Example 2—Associative Learning

Dr. David Haber of the University of Texas champions the benefits of associative
learning, or partnering a new health habit with established daily routines. For example,
working out on an exercise bike during a favorite television program or thinking about
stress-reducing affirmations while waiting in a grocery line eliminates the question of
whether to do the activity. The health behavior becomes as automatic as brushing teeth.


    2. Mastery Aids. Mastery aids (―crutches‖) encourage accomplishment of difficult
       tasks and can be removed in the future. Graduating from the crutches comes with
       practice and is part of the skill mastery plan. An example is a nicotine patch.




Live Well, Live Long: Steps to Better Health                                           20
Example—Nicotine Patch

The physical symptoms associated with nicotine addiction create a major barrier to
quitting tobacco products. The nicotine patch, allowing gradual reduction of the drug,
can, when used in combination with behavioral or emotional strategies for change, help
eliminate the tobacco habit.


    3. Record Keeping. Recording accomplishments inspires practice.

Example—Get Fit-Stay Fit Challenge

In Phoenix, Arizona, Get Fit-Stay Fit Challenge invites older adults to participate in their
favorite activities such as swimming, dancing or walking, and complete a designated
number of exercise days. Participants record the number of days they exercised for at
least 30 minutes. Each person list the days in both a personal log and a community log.
Individuals work toward a challenge goal for prizes, and also compete for trophies as part
of community teams.

Participants complete an exercise readiness screening, receive guidelines for creating a
safe and beneficial routine, and commit to exercising at least three days per week.

Each year, the Challenge picks a famous hiking trail as a theme. Each recorded day of
exercise equals ten miles of the simulated hike. For example, the Arizona Trail wanders
through 750 miles of scenic and historic landscape. By recording a day‘s worth of
exercise, the participant can check information on the location that he or she just
completed on the simulated leg of the hike.

Motivation to continue comes from the individual recording of accomplishment, social
participation in teamwork, tangible prize rewards and visual satisfaction from ―traveling
through‖ natural scenery that symbolize the process.


    4. Role Playing. Practicing new behaviors through role play is less tedious than
       constant repetition. Some older adults may find role-playing uncomfortable and
       confrontational. An alternative is to assign the older person an observer position,
       giving direction to the actors demonstrating the new skill.




Live Well, Live Long: Steps to Better Health                                               21
Example—Health Action Team

In San Francisco‘s Tenderloin District, the nonprofit organization, Planning for Elders in
the Central City, took the issue of affordable home care as a major campaign issue. To
raise awareness of the problem, Planning for Elders created the Health Action Team
(HAT) to conduct performance education—skits or familiar tunes with words to fit the
campaign. HAT uses the skits, featuring older adults as actors, to raise awareness about
health care issues. At one public performance that attracted the media, the organization
recruited 30 older volunteers to assist with the campaign. Volunteers gained an
awareness of the health issue, and watching their peers gave them confidence that they
too could participate.

Contact: Meg Cooch, Planning for Elders in the Central City
Phone: (415) 703-0188 ext.304


Seeing Examples and Options for Change

    1. Building on Past Successes. Strategies or skills already learned are models for
       new behavior. Strength comes from recognizing innate abilities and nurturing
       self-confidence.

Example—HELP, Healthy Eating for Life Project

In most senior centers, registration for cooking classes outpaces nutrition education. The
undeserved negative connotation of nutrition education often stems from a fear of being
punished for one‘s eating habits. Dr. Mary Clarke Barkley has taken the punitive notion
out of her classes. She has also developed a program for ―at-home learning,‖ allowing a
more comfortable and familiar setting.

Challenge sheets are a keystone of her education process. The classes are discussions
rather than lectures, and each class features the results of challenge sheets, which are
given as homework. The assignments may include a traditional recipe using a healthy
component such as reduced fat, or a description of how the participant prepared a type of
food group that week. The successful completion of the sheet generates a reward and
eligibility for a weekly raffle drawing. The classes build on the accumulated successes of
completing the challenge sheets, and culminate in a reward banquet.

For the instructor‘s manual for the program, you may preview the program at
http://www.oznet.ksu.edu. Use the search feature to find ―Healthy Eating for Life
Project.‖




Live Well, Live Long: Steps to Better Health                                             22
    2. Using Role Models. Witnessing the accomplishments of others can inspire self-
       confidence, if a respected person models the behavior. If public figures are used,
       they must represent the community of friends the older person sees in everyday life.

Example—Eat Well, Live Well (EWLW) Nutrition Program

The EWLW delivered a dietary change program through peer educators to low-income
African American women. Although not geared specifically to older women, the
community-based program addressed the ineffectiveness of earlier attempts to promote
dietary changes targeted at diabetes and cardiovascular disease found in older adults. By
using peers as models, the program encouraged adherence to dietary recommendations,
because the information received came from a credible source. Using peers encouraged
confidence because the role models are real people who mirror the lives of participants.


    3. Using Many Models. A single example may imply there is only one ―correct‖
       path to success. Using several approaches to mastery will show variety without
       being overwhelming. For example, the OASIS program (see Example 2)
       encourages staff who have not participated in physical activity classes to join a
       ―sampler‖ class. Participants can try swimming, Tai Chi, yoga or light aerobics.
       Without a great investment of time and money, older adults can experience their
       options and determine which most interests them. The examples should
       demonstrate coping and show skill mastery, essential and practical elements for
       changing behavior.

Persuasion from Others

    1. Using Realistic Messages. Messages should emphasize the importance of effort
       and persistence. Feedback should provide honest and compassionate information.

Example—Office of Cancer Control Ad

The Office of Cancer Control pre-tested two different versions of television public
service announcements to promote exercise. Program planners learned that the message
showing runners talking about their own exercise experiences was remembered more
often than a message using special visual techniques and a voice-over announcer.

A realistic scenario that viewers could relate to had greater impact than an announcer
reading facts.


    2. Using Praise. Praise effort and persistence, as well as success in developing
       skills and accomplishing goals.




Live Well, Live Long: Steps to Better Health                                             23
    Example—Haber Model

    Using praise as a reward from a health professional can significantly contribute to
    continued motivation, according to Dr. David Haber of the University of Texas.
    Having conducted many older adult wellness programs, he also highly recommends
    self-generated ―reinforcers.‖ The participants deliver their own praise and rewards
    for new behaviors until the behaviors reinforce themselves. One method of achieving
    the reinforcement of self-praise comes from affirmations, substituting positive
    thoughts for self-defeating criticism.


    3. Using Balanced Messages. Messages should not be overly critical or
       enthusiastic.

Example— Motivational interviewing

Motivational interviewing technique demonstrates effective use of balancing messages.
Components of motivational interviewing include:

               Careful listening to clients‘ descriptions of their behavior
               Providing factual, nonjudgmental observations about these descriptions
               Curious questioning of the client to clarify understanding of the situation
                so that the client arrives at a personal interpretation of facts

Especially effective in addiction work, the motivational interview relies on the exchange
of information. Overpraising, or the other extreme, criticism or fear tactics, fail to
encourage behavior change.


Self-Monitoring

    1. Using Rewards. Teach older adults to create concrete self-monitored strategies
       for maintaining interest in their behavior change.




Live Well, Live Long: Steps to Better Health                                              24
Example—SilverStriders

SilverStriders, a North Carolina walking club for people age 50 and over, offers a
logbook for tracking progress, gifts and awards, and an annual report of
accomplishments. As a local part of North Carolina‘s Senior Games competition,
SilverStriders Funwalks allow participants to qualify for the State Finals Funwalk. The
free logbook encourages participants to self-monitor their progress. Additionally, the
logbook documents achievements that qualify for prizes, an external reward system. For
more information, contact:

Contact: SilverStriders
PO Box 33514
Raleigh, NC 27636


    2. Addressing Unmet Goals. Devise strategies to help the older person cope with
       falling short of goals. Emphasize a message of persistence.




Live Well, Live Long: Steps to Better Health                                         25
          Live Well, Live Long: Steps to Better Health—Blueprint
         Health Promotion and Disease Prevention for Older Adults

                Changing Behaviors and Changing Communities

Changing the Environment to Support Healthy Behavior
Table of Contents
                Introduction
                Strength-based Assessment and Community Development
                Conducting Culturally Appropriate Needs Assessments

Introduction
Healthy behavior can be influenced by factors outside an older person‘s direct control.
Not all people have the same opportunities for positive change. Conditions in their social
environment may depend on public policies, accessibility of services and economic
opportunities. The new public health model calls for efforts to move from the individual
lifestyle change to the creation of a supportive environment for healthy living.

Support from family, friends, neighborhood associations and the community can
dramatically affect the individual health of older adults. Support can take the form of:

               Adequate housing
               Financial security
               Adequate transportation
               Safety and security

Strategies for individual behavioral change, described in the previous chapter, emphasize
personal obstacles for the older person. A healthy community is created by a partnership
between individuals taking responsibility for their personal care and the community
working to provide healthy environments. The complex healthcare needs of older adults
require a comprehensive approach that combines both elements.

Two steps lead to creating the partnership:

               Assessing the strengths and gaps in service provided by the neighborhood
                environment
               Building programs through community development and collaboration




Live Well, Live Long: Steps to Better Health                                               26
Strength-based Assessment and Community Development
Survey the local environment for existing programs, services and resources, and identify
the social strengths of members of the community. By relying on the problem-solving
capacities of local residents, associations and institutions, you can build on the
relationships among these three elements. These community building blocks are:

               Individual skills and experience
               Association maps
               Institution assets

After your inventory of these building blocks, you can create or recreate important
community connections. Your goal is to identify a bank of resources and their most
productive interrelationships for creating communities that support older adults‘ healthy
behaviors.

Individual Skills and Experience

Begin by identifying who may be helpful, either through skills or resources, to contribute
to a health promotion project.

               List skills developed at home or at work
               Identify the kinds of community work the person has done in the past and
                might be willing to do in the future
               Ask about interests or past work experience
               Collect contact information

Association Maps

The association map lists local associations that influence the community, including:

               Artistic, business and civic organizations
               Charitable groups
               Religious organizations
               Ethnic associations
               Older adult and youth groups
               Special interest clubs (e.g., biking, jogging)
               Local media
               Men‘s and women‘s groups
               Self-help groups
               Political associations
               Service clubs
               Sports leagues
               Veteran‘s groups




Live Well, Live Long: Steps to Better Health                                                27
These groups represent potential collaborators in health promotion programs and
activities.

Institution Assets

Make an inventory of local institutions and the assets they bring to the community:

               Facilities
               Materials and equipment
               Purchasing power
               Training
               Teachers
               The financial capacity to receive and generate funds

Assessing Older Adults’ Strengths

As a part of identifying individual skills and experience, include older adults in the
community assessment.

A strength-based approach, developed through a 1997 study conducted by Boulder
County (Colorado) Aging Services, is to assess the number of assets each older person
brings to daily life functioning and mental wellness. Interventions can then support and
reinforce those strengths.

These strengths can be:

               Personality characteristics
               Community support

Building on existing strengths rather than deficits results in greater life satisfaction and
perceived health. The strength-based approach enhances the feeling of self-efficacy and
confidence needed to make healthy behavior changes. For example, in the Boulder study,
older adults with 19 of 22 strengths designated in the study experience a threefold
decrease in self-identified problems compared to those with six strengths or fewer.

The following are the major strengths that older adults identified in the study.

    Social        Participation in Health and          Personal           External
  Supports            Activities      Wellness        Strengths          Strengths
Supportive        Creative         Good             Positive self-     Adequate
family            activities       physical         image              housing
                                   health
Supportive        Community        Good mental      Sense of           Financial
friends           service          health           purpose            security
Caring            Church/spiritual Functional       Positive view      Adequate
neighborhood      activities       status           of the future      transportation


Live Well, Live Long: Steps to Better Health                                              28
Community       Formal or       Adequate         Sense of    Safety/security
recognition and informal groups health care      empowerment
respect         or clubs
                                                 Good
                                                 interpersonal
                                                 skills
                                                 Willingness to
                                                 ask for and
                                                 accept help

The steps in assessing older adult strengths:

               Take into account how these specific strengths are demonstrated in present
                living situations
               Determine how the strengths can be supported for use in health promotion
                activities
               Strategize about community interventions that can enhance or develop
                additional assets

1. Strategies to Expand Personal Strengths

Personal strengths continually interact with community support and the environment.
Community support provides access to opportunities for creative activities or to
appropriate healthcare. For example, community-supported senior centers provide art,
dance or drama classes. The community may also sponsor specialized screening clinics
for older people.

Environment can also significantly affect behavior. For example, lack of a physically
safe and secure environment or transportation may restrict an older adult‘s involvement
in community activities or independent living tasks such as grocery shopping.

Both of these external elements, support and environment, contribute to a positive self-
image, a sense of purpose and empowerment.

The change to healthy behaviors requires a positive self-image to make the effort seem
worthwhile. A sense of personal empowerment and confidence in the ability to change
are also essential ingredients. Community and environmental support reinforce the
individual‘s desire to change and, as a result, health educators and planners are becoming
more involved in improving these areas to better the health of older people.

2. Support and Assistance from the Community

Maintaining the balance of health—physical, mental, social and cultural—is a complex
interaction involving both the individual and:

               The local community


Live Well, Live Long: Steps to Better Health                                               29
               The cultural community
               The social service system
               Society at large

Two strategies for integrating service systems and the social and cultural community are:

               Empowerment education

Example—San Francisco Tenderloin District

Empowerment education in communities evolved from adult education practices.
Education begins when learners see its importance to their lives. In public health
promotion, the community defines the problems and develops solutions. Community-
derived programs, like those for local crime prevention or developing walking paths, are
more readily supported than an agenda imposed from outside the neighborhood.

Empowerment education was used extensively by University of California at Berkeley
Public Health School professor Meredith Minkler in her work with hotel residents in San
Francisco‘s Tenderloin District.

Beginning with informal meetings in the lobbies of the neighborhood‘s older hotels,
elderly residents voiced concerns about housing costs and food quality. Most grocery
shopping was done at corner convenience markets offering few choices of fresh fruits or
vegetables. The group learned to unite their efforts to convince these markets to offer
more fresh foods.

With assistance from Dr. Minkler‘s students, they created a cookbook for older people
who do not have access to cooking facilities or who only have hot plates. These older
Tenderloin residents defined the problems and participated in creating solutions.




               Coalition building

By working with community groups on issues, partners can achieve successful results in
supporting healthier older adults who are functioning to their maximum abilities.

See Coalitions Chapter




Live Well, Live Long: Steps to Better Health                                            30
Example—Health & Beauty from the Inside Out

UTMB HealthCare Systems, a nonprofit managed care organization that provides clinical
health services to Houston elders on Medicaid, partnered with Fifth Ward Missionary
Baptist Church (FWMBC) in Houston to provide elderly parishioners with essential
information concerning breast health. Community health statistics show that older
African American women have the highest mortality rates from breast cancer because of
late detection.

The partnership seeks to increase awareness and provide culturally sensitive education
that comes from this community from influential sources to whom community members
already turn. The program depends on strategic alliances with organizations that are
ready for change and that have strong infrastructures to support the program‘s community
work. The Fifth Ward was chosen because the church had a health ministry in place but
needed the tools to move forward. Shirley Branch, the program coordinator, is a retired
nurse and, serving as the in-house expert, helped select the lay health educators. The
volunteer lay educators from the congregation work with older adults to reinforce the
educational efforts of healthcare providers, to help individuals with other social needs
that are difficult for healthcare professionals to address, and to mobilize community-
based resources to sustain support.

Lay educators also work with the community to ensure the program‘s consistency with
these women‘s traditional values and beliefs, while trying to dispel the myths that prevent
older people from accessing appropriate healthcare.

The program is run on the proverbial shoestring. UTMB provides the cost of
development and materials (which can be replicated for additional programs). Because it
takes place within the community, there is no overhead.

Conducting Culturally Appropriate Community Needs Assessments

Using a strength-based model, while appropriate in most settings, works best for needs
assessments in culturally diverse communities. The traditional model that entails
gathering information and assessing needs, isolated from involvement with the ethnic or
cultural community does not appropriately reflect the subtleties of the culture. Ideally,
the culturally appropriate assessment should combine:

               Gathering of demographic and health information about the target
                community
               Relationship mapping that defines the influences of human interactions in
                the older person‘s life

Gathering demographic and health information is important for the following reasons:




Live Well, Live Long: Steps to Better Health                                            31
               It enables community members and advisory groups to make decisions
                based on statistical information
               It provides funding organizations and program supervisors with a more
                trusted means than anecdotal information to evaluate the potential for
                program development and financial support

The chart below describes information-gathering procedures for mapping a community‘s
demographic information. New information can be gathered through surveys and focus
groups.

The relationship model places importance on active advisory groups and community
member involvement. This method can be very time-consuming in comparison to
traditional needs assessments, but the next stage in developing programs and campaigns
becomes much more effective with community involvement from the beginning of the
study inherent in the relationship model.

Traditional                                      Relationship/Strength-based
Background Information Gathering:                Background Information Gathering:
Where: Census statistics; social services lists; Where: Census statistics; social services lists; health
        health department statistics             department statistics; community gathering places;
What: Size of target audience                    special events; listings of local associations; churches
      Economic information                       and businesses from the phone book
      Epidemiological information                 What: Size of target audience
                                                        Economic information
                                                        Epidemiological information
                                                        Identification of informal caregivers and
                                                         gatekeepers
                                                        Identification of key leaders
                                                        Identification of important businesses
New Information:                                 New Information:
What: Survey asking what people want             What: Identify community assets, including informal
How: Mailed, in newspaper, telephone,                    helping networks
        door-to-door, local gathering place              Hold discussions with older adults in the
                                                         community
                                                         Review evaluation of individual case
                                                         assessments from service agencies to
                                                         determine daily living conditions
                                                  How: Informal group discussions, informal
                                                        conversations with gatekeepers
                                                        Check service agencies for patterns of referral
                                                        needs
                                                        Incorporate community members into design
                                                        and information gathering process




Live Well, Live Long: Steps to Better Health                                               32
Assessment:                                   Assessment:
How: Numbers gathered and presented at a      How: Gather information for presentation at
      community hearing. Plan developed              community focus group meetings, advisory
      from feedback of attendees                     group meetings and community forums to
                                                     receive feedback and for community-generated
                                                     solutions to problems
Pitfalls:                                     Pitfalls:
 Information is assumed to be the definitive  Ensuring that the appropriate people provide the
    community desire                              relevant information
 Information does not reflect the             Less formal, so the ―hard data‖ is not as clean as
    community‘s perception of need                funding agents might wish
 Creates wants instead of assessing needs  Can cost more than a traditional assessment,
 Creates expectations for service                especially if planners assist the community in
 Unclear on who is spokesperson for the          developing solutions
    community
Advantages:                                   Advantages:
 Demonstrates some commitment to caring  Information is more accurate
    for community elders                       Solutions are more client-centered
 Provides the hard numbers that funders       More ownership of solutions, both in bringing in
    want from grant writers                       outside resources and in building support within
                                                  the community
                                               Greater trust built in the community by working
                                                  closely with the formal and informal leaders
                                               Demonstrates to funders and planners that the
                                                  community is supportive of planning efforts
                                                  guided by the assessment


Community Relations

Many cultural communities complain of researchers coming into a neighborhood, asking
personal questions and then leaving, with no follow-up. Repeated studies over the past
years have left cultural community members and rural elders reluctant to share
information with outsiders because they see no direct benefit to the community.




Live Well, Live Long: Steps to Better Health                                         33
Example—The National Asian and Pacific Islander Center on Aging (NAPCA)

When developing an assessment for the Administration on Aging in 1999, the National Asian
and Pacific Islander Center on Aging (NAPCA) conducted large community forums with
translators in three languages to share survey results with the older adults who had
participated. In addition, the survey participants formed working groups to actively
participate in solutions to problems they identified. Involvement in the assessment phase has
made a difference in developing community-based information gathering programs to solve
identified problems.


In the relationship model, resistance has lessened as funding organizations recognize the
importance of community capacity building. Many researchers incorporate more
community involvement in their methodology by creating advisory groups to review
questionnaires, methods and translations, and by hiring community members to conduct
research and interventions.

Example 1—UCSF

At the University of California, San Francisco, researchers involved in a Vietnamese
breast cancer study used an advisory committee extensively in evaluating its
methodology and in the language used for the campaign and intervention. Additionally,
they hired Vietnamese women to conduct the intervention.


Example 2—Staying Healthy Project

American Society on Aging researchers for a study of elders engaged in risky
consumption of alcohol met with members of the Chinese community, to understand
drinking habits unique to their culture. The study incorporated a written survey on health
habits translated into Chinese. The translators advised the researchers to specifically call
out specific alcoholic beverages familiar to older adults, such as plum wine, instead of
categories, such as cocktails or hard liquor. Using common examples, rather than an
unfamiliar list of beverages, captures a more accurate reflection of alcohol consumption
among this population.


For the final step in successful assessment design, include an additional public
information effort after the final report has been developed. This final information effort
assures participants that their input will benefit the community. To build bridges for
future campaigns and programs, you must take responsibility to leave a positive legacy in
culturally diverse communities.




Live Well, Live Long: Steps to Better Health                                             34
          Live Well, Live Long: Steps to Better Health—Blueprint
         Health Promotion and Disease Prevention for Older Adults

                Changing Behaviors and Changing Communities

Health Literacy

    Table of Contents
                Introduction
                Determining Client Literacy
                Tools for Improving Health Literacy
                Resources

Introduction
The 1992 National Adult Literacy Survey (NALS) reported that 21 percent of American-
born adults cannot read the front page of a newspaper and 48 percent cannot decipher a
bus schedule. Applied to U.S. health systems, this low functional literacy translates into
low health literacy.

What is Health Literacy?
Health literacy includes:

               The ability to obtain, interpret and understand basic health information
                and services
               The competence and motivation to apply generalized information to
                personal health situations

Low functional literacy is not endemic to race, class or even level of education. Even if
individuals can read and understand materials with familiar content, they may still have
difficulty comprehending materials that contain unfamiliar vocabulary and concepts.

How does low functional literacy affect health promotion campaigns and care?

Health Education Information Materials
Most health education programs rely on printed materials. The materials may indeed be
simplified, but health literacy requires not only the ability to read and understand the
content, but also the ability to apply generalized information to personal situations.
Health literacy is necessary to:

               Understand precautions for disease prevention
               Seek out healthy lifestyle choices in foods, exercise options and
                intellectual stimulation
               Follow directions for care of illnesses or health conditions



Live Well, Live Long: Steps to Better Health                                               35
Medication Instructions
People who cannot read directions for prescription drug or over-the-counter medications
may inappropriately take or mix medicines. People with low literacy levels may also be
responsibility for monitoring medications for spouses or parents, doubling the risk of
medication misuse.

Health Care
Patients with low literacy are twice as likely to be hospitalized and twice as likely to
report poor health. Low literacy is associated with less understanding and use of
mammography. Prostate cancer patients with low literacy skills begin care with more
advanced stages of the disease. People with low literacy also find it difficult to interact
with healthcare or health promotion professionals. Interactive health literacy requires:

               Confidence for engagement in the healing process
               Independent decision-making based on informed actions
               Partnerships with professionals

What other effects of low health literacy should be considered?
Feelings of shame affect almost half of people with low literacy.

               67 percent of patients had never told their spouses
               53 percent had never told their children

Limited health literacy results in:

               Silence
               Shame
               Limited participation
               Lost entitlements
               Lost rights
               Exclusion
               Compromised healthcare
               Compromised health

Determining Client Literacy
Many people hide their low literacy level. They may feel vulnerable as well as ashamed.
These feelings discourage them from seeking information or asking questions. Asking
older adults to take formal literacy assessments may increase their distrust. However,
informal assessments of all participants in a program may aid health professionals in
selecting the most appropriate and effective healthcare information for them.




Live Well, Live Long: Steps to Better Health                                                  36
Example—To Help Everyone (T.H.E.) Clinic

In this Los Angeles, California, clinic, nurses and healthcare professionals take time to
determine which learning style is appropriate for each person—written materials,
pictures, verbal counseling, or demonstrations. Their next step is to put the appropriate
staff and resources in place.

Contact: Sylvia Drew Ivie, J.D.
T.H.E. Clinic
 Phone: (323) 295-6571 ext. 3004



Tools for Improving Health Literacy
One-to-One Assistance

In addition to helping people gain a better understanding of the healthcare system and
their own health problems, this approach can foster trust between you and your clients.
You can include discussions about:

               What a healthcare provider said during an appointment
               Dosage and timing of medications
               Concerns and questions about care and healthy lifestyles
               Learning styles and memory cues, such as pictures or color coding

Model programs developed throughout the country provide education sessions that are
followed up with a telephone call or home visits by volunteers.

Example 1—The Lafayette Adult Reading Academy (LARA)

One–to-one assistance for people with low functional literacy skills is also provided in
settings other than clinics and hospitals.

The Lafayette Adult Reading Academy, an adult basic education program in Lafayette,
Indiana, uses an interactive approach between its adult learners and pharmacy students to
ensure that prescription medications are taken correctly.

For six years, 10 pharmacy students recruited from Purdue University‘s pharmacy
department received academic credit to meet on a weekly basis with adult learners who
have chronic conditions. During the sessions, pharmacy students:

               Count all medications, both over-the-counter and prescription
               Record them on a medication sheet, along with data from the pharmacy
                label
               Conduct a three-step oral interview that uses open-ended questions to


Live Well, Live Long: Steps to Better Health                                                37
                assess the client‘s habits and perspectives

This successful program assisted 50 to 100 older adults each semester to better
understand their medications through individualized sessions. Among all the adult
learners over the years, none reported medication errors due to misuse or compliance.

Contact: Joanne Vorst
Lafayette Reading Academy
Phone: (765) 476-2920




Example 2—Brownsville Community Health Center

Volunteers at the Brownsville Community Health Center, known as promotoras, conduct
door-to-door visits within their Brownsville, Texas, community.

Promotoras are generally women between the ages of 40 and 67 who have families and
grown children. They visit people‘s homes to answer questions such as where to go for
healthcare or how to get transportation to the doctor‘s office. They often accompany
people to the doctor‘s appointments.

Promotoras can also provide information on healthcare rights or eligibility for programs
that offer financial assistance for healthcare.

Contact: Paula Gomez
Brownsville Community Health Center
Phone: (956) 548-7400
E-mail: psgmzanz@juno.com


Group Assistance

A group assistance environment allows older adults to obtain information from educators
and from the answers to questions asked by others in the group. Partnering with
hospitals, area agencies on aging or senior centers, a health educator can present sessions
on issues of importance to older adults, accompanied by questions-and-answer sessions.

Example—Kaiser Permanente-Denver
        At a community clinic, older patients with chronic conditions were invited to take
part in a group doctor‘s appointment. In this ongoing program, 15 people attend a
monthly one-and-a-half-hour session. The sessions follow a set agenda:
             Trust building—Through reminiscence techniques, members of the group
                share their memories based on the topic for the day
             Education—The doctor presents a brief health talk followed by questions


Live Well, Live Long: Steps to Better Health                                             38
                relevant to the talk or other health-related questions
               Blood pressure screening and medication refills—The doctor begins at one
                end of the table filling prescriptions and finding out who needs a personal
                appointment, while a nurse at the other end takes blood pressures and asks
                about personal appointment needs
               Final questions—Final questions about health issues or healthy lifestyles
                are answered
               Private appointments—After completing the session, those in need of
                more personalized care file into the examination rooms

Both written and verbal options are available to older adults to match their learning
needs.

Contact: John Scott, M.D.
Kaiser Permanente Hidden Lake Medical Offices
Westminster, CO
Phone: (303) 338-4545


Visual Tools

Visual tools can be used as supplements to one-to-one or group assistance. Visual tools
are designed to simplify concepts that may be too complicated to understand in written
word form. Most people, even those who read well, rely on visual clues to reinforce
learning. Here are some tips:

               Supplement text with pictures
               Tailor medication schedules or health promotion activities to fit a person‘s
                daily routine, using daily events as reminders
               Use clear captions, ample ―white space‖ and pictures or diagrams to attract
                the reader‘s attention and reinforce the message
               Limit a publication to one or two educational objectives
                    o What the reader will learn
                    o What the reader will do after reading the publication

When developing visual tools, emphasize what the reader will do rather than medical
facts. Readers find it difficult to relate abstract statistics to their own experience.




Live Well, Live Long: Steps to Better Health                                              39
Example 1—The Johns Hopkins Pictograph Research Project

The project developed hundreds of pictographs that show how to manage certain
conditions and how to understand medications and treatment of chronic conditions. A
pictograph is a picture that represents an idea. The goal is to develop effective and
efficient ways to communicate complex ideas to people who cannot read or who have
limited reading skills.

The results of the evaluation from the pictograph research project show that pictographs,
combined with spoken explanations, increase the understanding of available to people
who must manage symptoms and problems related to illness. An average of 85 percent
of the people in the study had immediate recall of the pictograph meanings. Four weeks
later an average of almost 3/4 of the people (71 percent) still recalled the meanings. Most
people, including those with low literacy levels, can remember most pictograph meanings
for at least four weeks. For samples of pictographs, go to
www.med.jhu.edu/cancerctr/ptfamsvc.

Contact: Peter Houts, Ph.D.
Johns Hopkins University
Phone: (717) 566-1610
Email: psh2@psu.edu


Example 2—Southside Area Health Education Center

The Southside Area Health Education Center, in Farmville, Virginia, uses a simple
method to reduce confusion about medications. A health educator color-codes the bottles
of medications at the center. On a cardboard clock, she places the color of the bottle at
the time that a certain medication is to be taken.

Contact: Beth Poore-Bowman, R.N., P.H.P.
Southside Area Health Education Center
Phone: (804) 395-2863
E-mail: bethp@tiger.hsc.edu
Reprinted with the permission of the Center for Medicare Education.



Resources
Baker, D.W., Gazmararian, J.A., Sudano, J., and Paterson, M. (2000) "The Association
Between Age and Health Literacy Among Elderly Persons." Journal of Gerontology,
Social Sciences 55B(6):368-374.




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Baker, D.W., Parker, R.M., Williams, M.V., Clark,W.S., and Nurss, J. (1997) ―The
Relationship of Patient Reading Ability to Self Reported Health and Use of Health
Services.‖ American Journal of Public Health 87(6):1027-30.

Baker, D.W., Parker, R.M., Williams, M.V., Pitkin, K., Parikh, N.S., Coats, W. and
Imara, M. (1996) Medicine 5(6):329-334.

Baker, D.W., Parker, R.M., Williams, M.V., Pitkin, K., Parikh, N.S., Coats, W., and
Mwalimu, I. (1996) ―The Health Experience of Patients with Low Literacy.‖ Archives of
Family Medicine 5:329-334.

Bennett, C.L., Ferreira, M.R., Davis, T.C., Kaplan, J., Weinberger, M., Kuzel, T., Seday,
M.A., and Sartot, O. (1998) ―Relation Between Literacy, Race, and Stage of Presentation
Among Low Income Patients with Prostate Cancer.‖ Journal of Clinical Oncology 16(9):
3101-3104.

Center for Health Care Strategies, Inc. (August 2000) ―Strategies to Improve Patient
Education Materials—Fact Sheet.‖ Retrieved March 4, 2001 from Center for Health
Care Strategies, Inc. on the World Wide Web: http://www.chcs.org

Davis, T.C., Arnold, C., Berkel, H.J., Nandy, I., Jackson, R.H. and Glass, J. (1996)
―Knowledge and Attitude on Screening Mammography Among Low Literate, Low
Income Women.‖ Cancer 78(9):1912-20.

Food and Drug Administration (January 4, 2001) ―Easy to Read Publications.‖ Retrieved
from the FDA Publications Catalog on the World Wide Web:
http://www.fda.gov/opacom/lowlit/englow.html

Goodwin, S., Ovnic, K., and Korschum, H. (February 11, 1998) ―Lack of ‗Health
Literacy‘ May Affect Treatment Outcomes for Many Senior Citizens.‖ Retrieved March
19, 2001 from Emory University on the World Wide Web:
http://www.emory.edu/WHSC/HSNEWS/releases/ feb99/021199literacy.html

Houts, P.S., Bachrack, R., Witmer, T.J., Tringali, C.A., Bucher, J.A., and Localio, R.A.
(1998) ―Using Pictographs to Enhance Recall of Spoken Medical Instructions.‖ Patient
Education Counseling 35(2):83-8.

Kilker, K.(2000) ―Considering Health Literacy.‖ Center for Medicare Information Issue
Brief 1(6), 1-8.

Maine AHEC Health Literacy Center (January 2001) Low Literacy Communications
Skills for Health Professionals-Summer Institute. Retrieved March 16, 2001 from the
University of New England on the World Wide Web:
http://www.une.edu/com/othrdept/hlit/index.htm




Live Well, Live Long: Steps to Better Health                                               41
Morley, G. (1997) Functional Health Literacy: A Primer. Princeton, NJ: Center for
Health Strategies.

Parikh, N.S., Parker, R.M., Nurss, J., Baker, D.W., and Williams, M.V. (1966) ―Shame
and Health Literacy: The Unspoken Connection.‖ Patient Education and Counseling
27:33-39.

Rudd, R.E., Zacharai, C., and Daube, K. (1998) Integrating Health and Literacy: Adult
Educators’ Experiences. The National Center for the Study of Adult Learning and
Literacy Report #5. Cambridge, MA: Harvard Graduate Schools of Education.

Rudd, R.M., Daltroy, L., DeJong, W., Greenberg, J., Kocj-Weser, S., and Kaphingst, K.
(January 2001) Health Literacy Overview. Retrieved March 16, 2001 from the National
Center for the Study of Adult Learning and Literacy on the World Wide Web:
http://www.hsph.harvard.edu/healthliteracy/slides.htm.

Weiss, B.D., Hart, G., McGee, D.L., and D‘Estelle, S. (1992) ―Health Status of Illiterate
Adults: Relation Between Literacy and Health Status Among Persons with Low Literacy
Skills.‖ Journal of American Board of Family Practice 5(3):257-64.

Williams, M.V., Baker, D.W., Parker, R.M., and Nurss, J.R. (1998). ―Relationship of
Functional Health Literacy to Patient‘s Knowledge of Their Chronic Disease. A Study of
Patients with Hypertension and Diabetes.‖ Archives of Internal Medicine 158(2):166-72.

Williams, M.V., Parker, R.M., Baker, D.W., Parikh, K., Coats, W.C., and Nurss, J.R.
(1995) ―Inadequate Functional Health Literacy Among Patients at Two Public
Hospitals.‖ JAMA 2714(21):1677-1682.




Live Well, Live Long: Steps to Better Health                                             42
          Live Well, Live Long: Steps to Better Health—Blueprint
         Health Promotion and Disease Prevention for Older Adults

                     Developing Health Promoting Campaigns

Introduction
It is important not to undervalue the process of preparing your organization and your
community to develop health promotion campaigns and programs. It is as crucial to
success as patiently creating the conditions for individual behavior change as described in
the previous chapter.

Organizing successful health promotion campaigns relies on involving community
partners in:

               Sharing time, expertise and resources
               Bringing health messages to older people in many community settings

Community collaborations are an essential part of health promotion program
development, as they increase the stability and longevity of programs and activities.

This chapter provides an overview of successful program preparation and planning. Each
section provides sample formats, forms and promotion materials as convenient, time-
saving tools.

Table of Contents
                Community Capacity Building: Developing Consortiums for
                Programs and Advocacy
                      Introduction
                      First Steps: Organizing Community Consortiums
                      Next Steps: Implementing Community Capacity Efforts
                      Implement the Plan: Getting to Work
                      Potential Problems and Solutions
                      Consortium-Building Tools

                Preparing for Your Program
                      Introduction
                      Steps in Planning
                      Coordinating the Program
                      Coordinating a Screening
                      Developing a Local Community Referral List
                      Publicizing the Program
                      Presenting the Workshop
                      Program Evaluations


Live Well, Live Long: Steps to Better Health                                            43
                         Screening Evaluations

                Program Presentation
                      Introduction
                      Distribution of Materials
                      Opening Welcome
                      Presentation
                      Discussion Following Presentation
                      Closure
                      Evaluations




Live Well, Live Long: Steps to Better Health              44
          Live Well, Live Long: Steps to Better Health—Blueprint
         Health Promotion and Disease Prevention for Older Adults

                     Developing Health Promoting Campaigns

Community Capacity Building: Developing Consortia for Programs and
  Advocacy

                Table of Contents
                         Introduction
                         First Steps: Organizing Community Consortiums
                         Next Steps: Implementing Community Capacity Efforts
                         Implement the Plan: Getting to Work
                         Potential Problems and Solutions
                         Consortium-Building Tools

Introduction
What is a community consortium?

A community consortium or coalition is a group of agencies, organizations, community
leaders and consumers that come together to address a special concern or accomplish a
specific task. The task often includes influencing people's behavior; coordinating
community services; and developing new public policy or making changes to existing
policy.

Key elements of a successful community consortium:

               Establishes dialogue
               Increases community knowledge about a concern
               Establishes consensus
               Generates community involvement and interest
               Shares resources and information
               Formulates and implements strategies and interventions
               Develops long-term solutions
               Promotes institutional change
               Secures host organization to facilitate the effort
               Receives commitment of resources by host organization and others

Advantages of community consortia:

               Identify and mobilize organizations and individuals who can apply their
                diverse knowledge, expertise, approaches and resources to solve a
                community concern and enhance existing service delivery and outreach



Live Well, Live Long: Steps to Better Health                                              45
               Minimize duplication of effort and services while coordinating and
                expanding service delivery
               Increase an organization‘s power to bring about change
               Build trust within communities by establishing a partnership of "equals,"
                not ownership by one organization
               Provide resources to increase information about the community through
                collection and analysis of data and evaluation of interventions
               Expand promotional and outreach activities
               Increase the number of organizations and groups supporting a community
                initiative
               Provide greater visibility and exposure for an organization and increase its
                credibility in the community


First Steps: Organizing Community Consortiums
1. Assign an Individual from Your Organization to Institute and Staff the
   Consortium

Identify and designate a person who will have ongoing organizing and staffing
responsibility for the group. Consortium activities must have support and commitment
from the host organization‘s leadership.

The assigned staff member should be familiar with the community and service providers
in the target area. Ideally, the staff person‘s background or skills should be in community
organizing.

The individual should be given the authority to represent your organization and commit
resources in support of consortium activities.

2. Identify Issue or Concern to Be Addressed

Begin by identifying an issue or concern of importance to your organization and others in
the community. A consortium is most effective when it concentrates on a single issue or
purpose.

Be sure that you are selecting a concern on which the consortium can successfully make
an impact. Encountering a defeat before the individuals from participating organizations
can develop effective working relationships with each other guarantees their reluctance to
work together on future projects.

Undertaking an issue that is too broad can also impede progress resulting in
discouragement or lost credibility.




Live Well, Live Long: Steps to Better Health                                              46
3. Prepare Data to Document the Problem

Organize the information that you gathered in your issue identification process. Define
the scope of the issue by including relevant data and factual knowledge—rather than just
perceptions and beliefs. Factual knowledge justifies the allocation of resources by
consortium partners. Information sources can include:

               Your organization‘s database and knowledge
               City, county and state health departments
               National sources such as the Centers for Disease Control and Prevention
                (CDC)
               Regional and state planning bodies
               Community hospitals and their community health resources, e.g., clinics
               National, state, and/or local organizations dedicated to a specific issue

4. Identify Community Groups, Organizations and Individuals Working on the
    Same Issue

Determine if other coalitions or community consortia are already working on this issue.
If so, check to see if you can combine your efforts or establish a collaborative effort.

5. Determine the ―Working‖ Size and ―Political‖ Size of the Consortium

Not all members of a consortium will be able to participate and contribute on an equal
basis. The full consortium, by necessity, will be composed of a "working" group and a
"political" group.

The "working" consortium generally consists of 10 to 20 members who commit to
regular participation in consortium activities. It includes groups or individuals who have
skills and/or resources to move the consortium‘s agenda forward.

The "political" consortium includes those whom the group calls to assist when needed.
These people can identify or provide resources, lend visibility or credibility to the group,
promote an issue at the governmental level, or access community members to support the
issue.

Prime candidates for the ―political‖ arm of the consortium come from elected offices, the
media, faith communities, government departments, local businesses, community elder
councils and educational institutions.

Treat the members of the "political" group as regular participants, keeping them informed
of all activities as if they were attending every meeting.




Live Well, Live Long: Steps to Better Health                                                47
6. Identify the ―Key Players‖ or ―Stakeholders‖ Who Would Support Your Issue

When determining whom to invite to join the consortium, consider these factors:

               Whether the person will be a ―working‖ or ―political‖ member
               Purpose and desired size of the consortium
               Diversity and cultural inclusion in the community
               Geographic representation
               Types of collaborative activities that might be planned
               Specialized expertise and influence needed

Compile a list of potential consortium members relevant to the issue. Include
representatives from these sources:

1. Government

               City, county or state health department
               Area Agency on Aging (AAA)
               Federal agencies such as the Food and Drug Administration, Substance
                Abuse and Mental Health Services Administration, or the National
                Institute on Health
               State Units on Aging (SUA)
               Administration on Aging (AoA) regional offices
               Public hospitals
               Veteran‘s Administration health clinics and hospitals
               Local elected officials
               Regional or state planning entities
               County extension service
               Recreation and park service

2. Healthcare organizations

                   Home healthcare agencies
                   Rehabilitation providers
                   Local healthcare providers
                   Hospitals, medical schools, disease research centers
                   Pharmaceutical companies

3. Social service organizations serving the target audience

           Public, nonprofit and for-profit community-based organizations
           Local chapters of national organizations such as the American Cancer Society,
            the American Heart or Diabetes Associations



Live Well, Live Long: Steps to Better Health                                           48
           Organizations that have received grants from federal agencies to address your
            issue
           Faith-based organizations, such as Catholic Charities, Jewish Family Services,
            Lutheran Family Services

4. Academic institutions

           Universities or community colleges
           Schools of nursing, social work, public health and administration

5. Consumers

           Support groups or caregiver organizations
           Community leaders and advocates
           State and local AARP chapter
           Senior centers

6. Other potential advocates

               Elected officials
               Media representatives
               Local foundation staff
               Religious leaders
               Local business owners


7. Identify Internal and External Resources to Support the Community Consortium

The assumption that consortia operate at no cost is one of the biggest barriers to success,
especially in communities where scarce resources limit community services or
organizational operations. A community consortium requires funds, staffing or product
donations to complete its mission. Identify resources to advance your programs and
operations within your organization.

As a rule of thumb, the host organization provides internal resources—staff and
administrative support, meeting rooms, refreshments, meeting notices and minutes.
External resources—reproduction of brochures, booklets or posters, public relations and
financial support for a community event—come from members‘ contributions, grants,
revenues from fund-raising events or special community drives.

Next Steps: Implementing Your Community Consortium Effort
1. Meet with Potential Consortium Members

Phone or visit potential members to establish rapport and mutual interest. Have prepared



Live Well, Live Long: Steps to Better Health                                             49
materials on the scope of your issue, purpose of the consortium, the possible time
commitment, and other interested organizations.

2. As the Host Organization, Convene and Staff Consortium Activities

Staffing ensures continuity, an accurate flow of information and a record of group
activities. Keep everything in writing in order to foster a shared knowledge base for the
consortium.

Provide refreshments for meetings. Food invites participation, especially when members‘
schedules are tight. Food also sets a welcoming tone. Be attentive to the special
preferences of cultural groups with dietary restrictions.

Convene the organizational meeting. Create a mailing list of the potential members who
expressed interest. Select an accessible, comfortable and mutually acceptable location.
Set the meeting agenda and mail, fax and/or e-mail meeting notices two to three weeks in
advance. Include a fax or e-mail return form to confirm attendance and continued
interest. Make reminder follow-up calls.

        Agenda

Cover the following points during the organizational meeting:

               Outline an identified problem or issue
               Review and discuss available data and information on the problem
               Propose a role the community consortium can play
               Discuss the roles and responsibilities of participating members
               Inventory what resources and capabilities of individual members can be
                directed toward addressing the problem
               Establish an initial timeline
               Review key success factors

Establish convenient dates and times for subsequent meetings. When older adults are
included, daytime may be more attractive, and transportation availability may warrant a
more accessible location than your agency. Group consensus determines time and
location. Be sensitive to those who wish to participate but cannot attend at the
determined time. Make accommodations by recording meetings, conducting special
update phone calls, or rotating times. Ideally, maintain continuity in location and time.

3. After the First Meeting, Follow Up on Other Tasks

Develop a grid of members—list their services and specific capabilities, and how they
can assist in accomplishing the consortium‘s goals. Evaluate whether other members
should be recruited to perform activities.




Live Well, Live Long: Steps to Better Health                                             50
Draft and try to secure letters of participation or memoranda of understanding (MOUs)
between each member and your organization, listing roles and responsibilities of the
participating member and consortium staff. Clarifying the roles upfront maintains
relationships throughout the course of the project. If staff from participating
organizations change, the relationship is documented for future members.

4. Organize the Consortium’s Structure and Direction at Future Meetings

Define the organizational structure by:

           Selecting the chairperson or co-chairpersons.
                o Consider a well-respected person who is not perceived as carrying out
                    a personal agenda and who bridges the interests of most members
           Establishing working committees and chairpersons to identify issues such as
            needs and barriers, action options and access
           Developing promotions and resources

Formalize the community consortium mission statement. Formally commit your
organization‘s mission and goals for this project. The mission statement, which reflects a
shared vision of the consortium members, will guide and maintain focus. The statement
should be concise but broad enough in scope to allow for expansion or changes in
purpose. The mission statement describes the general purpose of the consortium and
what it specifically hopes to accomplish.

        Example: The Breast and Cervical Cancer Consortium is established to improve
        the health status of Latino women over the age of 50 by increasing the level of
        screening coverage in the city of Pine Grove.

Establish specific and realistic objectives. Objectives should coincide with the mission
statement and be achievable using available resources.

        Example: Within the next six months, increase by 25 percent the number of
        breast and cervical cancer screenings of Latino women over 50 years of age
        within Pine Grove.

Develop work plans outlined by action steps—with dates, tasks, expected outcomes and
responsibilities. Identify potential causes of the problem (e.g., service gaps, accessibility,
cultural barriers) to be addressed. The plan should consist of realistic and doable action
steps. Create some steps that will produce "quick" successes that you can celebrate early
in the process. Early successes will help maintain interest among members and bring
visibility and credibility to the consortium.

        Example: Launch a breast and cervical cancer outreach plan targeting Latino
        women over 50 years of age in Pine Grove with an information booth at the
        community Cinco de Mayo celebration.




Live Well, Live Long: Steps to Better Health                                               51
Implement the Plan: Getting to Work
1. Implement the Work Plan

Monitor, on a regular and formal basis, the progress in achieving your objectives.
Regular oversight and evaluation will allow for early identification of problems and the
opportunity to make adjustments.

2. Maintain Community Ownership

Promote ownership by encouraging members to:
          Own and be responsible for addressing the identified problems
          Select their own leadership and set their own agenda
          Respect all members as equal partners, regardless of the size or capacity of
             their organization
          Maintain interest among participating members by carrying out an active
             communication strategy (e-mail, newsletter, phone trees, etc.). Never
             assume consortium members or the community-at-large are aware of
             everything

3. Maintain Interest in and Involvement with the Consortium

               Set realistic and achievable short-term goals
               Produce visible and quantifiable results. At each meeting, present an
                accomplishment
               Celebrate and publicize achievements
               Reward and recognize members freely and often. Use cards, letters,
                certificates, plaques, humorous gifts, products or an item of beauty (art,
                music, nature)
               Share the spotlight
               Act as a clearinghouse of information related to your subject area
               Expand community consortium membership as appropriate
               Demonstrate that the top leadership of your organization is interested in
                consortium activities

Potential Problems and Solutions
Remember to always seek the wisdom of the group in addressing issues and problems.

        1. Lack of direction or focus

                 Solution:         Clearly define the mission statement and goals
                                   Set realistic and measurable objectives

        2. Turf battles and competition


Live Well, Live Long: Steps to Better Health                                                 52
                 Solution:         Try personal contact and mediation
                                   Focus on the benefits of the consortium
                                   Include influential community members from competing
                                    organizations

        3. Past histories with unsuccessful collaboration or personality conflicts

                 Solution:         Clearly outline the duties and anticipated results
                                   Always follow up on assigned duties and meet deadlines
                                   Include influential community members who can mediate
                                    difficulties
                                   Develop a distinct and separate job for difficult personalities,
                                    minimizing conflict

        4. Failure to plan and/or act

                 Solution:         Assess the value of incentives/benefits to action and adjust
                                    accordingly
                                   Identify barriers to action and develop objectives to overcome
                                    them

        5. Poor links to the community

                 Solution:         Include influential community members at all stages, from
                                    determining the problem to planning the actions of the
                                    consortium

        6. Minimal organizational capacity

                 Solution:         Initiate the consortium only when a host organization provides
                                    staffing
                                   Develop leadership for future staffing
                                   Dissolve the consortium if staffing is not available

        7. Too little funding

                 Solution:         Create a development committee to seek funds
                                   Reduce goals and objectives to match the level of funding
                                   Seek more in-kind donations

        8. Failure to develop and maintain leadership

                 Solution:         Share information and decision-making
                                   Evaluate the workload for each leadership position if recruitment



Live Well, Live Long: Steps to Better Health                                                 53
                                    is the problem
                                   Develop co-leadership positions
                                   Groom new leaders

        9. Unequal sharing of responsibility and decision-making

                 Solution:         Analyze the cause
                                   Change leadership
                                   Review expectations for leadership and adjust as needed

        10. Time conflicts

                 Solution:         Outline time commitment expectations on a regular basis and
                                    renegotiate if necessary
                                   Maintain active communications, even when members cannot
                                    attend meetings

        11. Lack of ongoing staff/member training

                Solution:          Maintain active communications
                                   Develop new system for training new members

        12. Burnout/unrealistic demands on staff or members

                Solution:          Review expectations and adjust as appropriate
                                   Maintain active communications
                                   Extend deadlines
                                   Redistribute duties
                                   Take time for socializing
                                   Have a formal recognition and appreciation program

Consortium-building Tools
This section will provide samples of tools to assist you in determining the composition of
your group as well as building and evaluating its effectiveness.

               Sample mission/goal, objectives, actions
               Sample grid of members’ and consortium needs
               Sample invitation letters
               Sample meeting notice
               Sample agenda
               Memorandum of Understanding/Participation
               Sample evaluation form
               List of resources for data and information on subject area



Live Well, Live Long: Steps to Better Health                                                 54
Sample Mission/Goal, Objectives, Actions

Mission: The mission of Healthy People 2010 is to outline a comprehensive, nationwide
health promotion and disease prevention agenda committed to promoting health and
preventing illness, disability and premature death.

Goal: Improve health, fitness and quality of life through daily physical activity.

Objective: Reduce the proportion of adults who do not engage in leisure-time physical
activity by 20 percent by the year 2010.




Live Well, Live Long: Steps to Better Health                                            55
Sample Grid of Members’ and Consortium Needs

                      Organization             Potential Collaboration Resources
Aging Network         Meals on Wheels          Access to: local frail older adults
                                                           food preparation facilities
                                                           volunteers
                      Senior Center            Access to: older adults
                                                           meeting, recreation, dining or
                                                           kitchen facilities
                                                           newsletters
                                                           volunteers
                                                           family members
                      Van Services             Access to: transportation services
                                                           public visibility
                                                           older adults
                      Assisted Living          Access to: older adults
                      Housing                              family members newsletters
                                                           corporate sponsors
Health                Hospital                 Access to: health experts
                                                           newsletters
                                                           healthcare services
                                                           medical facilities
                                                           sponsors
                      Public Health Clinics    Access to: healthcare services
                                                           health demographics
                                                           patients
Community             Local Sports Clubs       Access to: fitness facilities
                                                           customers
                                                           fitness professionals
                                                           sponsors
                      Civic Groups             Access to: members
                                                           volunteers
                                                           businesses
                                                           sponsors
                      Ethnic Associations      Access to: trusted ethnic community members
                                                           translation
                                                           outreach
                                                           volunteers
Legal                 District Attorney        Access to: legal referrals
                                                           consumer information services
                                                           sponsors
Faith-based           Councils of Churches,    Access to: meeting and program facilities
                      Synagogues, Mosques                  congregations
                      and Temples                          trusted leaders
                                                           volunteers
                                                           social services


Live Well, Live Long: Steps to Better Health                                       56
Sample Invitation Letters
Invitation Letter 1

March 9, 2001

St. Mary‘s Church
2137 Anywhere
Somewhere, CO 80534

Dear Reverend,

We see the church as an important center of the lives of many older people, acting as a
focal point for activities, social contact, and support. As part of our project, we would
like to include you in planning support programs and assisting in reaching out to your
older parish members as part of your ministry.

The American Society on Aging, in collaboration with the American Diabetes
Association, is planning a health promotion program for older adults in Greatview.
Because we are concerned about the number of older people in our community who have
been diagnosed with diabetes, our groups are hosting an organizational meeting of
concerned community associations and faith-based groups.

Time: 2:00 P.M.
Date: March 30
Place: Greatview Community Center meeting room
       2425 View Dr.

Our goal is to address ways we can assist the older people throughout the city in
controlling this potentially disabling condition. We hope you can send a representative
from your church to this meeting.
If you have questions, please call me at (xxx) xxx-xxxx.
If you are planning to attend, please confirm by returning the enclosed response card.

Sincerely,



Follow-up Call Script

Hello, my name is ____________ and I‘m with the American Society on Aging. About a
week ago we sent you a letter. Did you receive it? Do you have any questions about the
meeting that I may answer? Are you planning to attend?
Thank you for your time.




Live Well, Live Long: Steps to Better Health                                                57
Invitation Letter 2




February 7, 2001

NAME
ADDRESS

Dear NAME:

Each year brings forth new and effective strategies to promote health and prevent disease
and morbidity. One way to ensure that this developing knowledge is applied effectively
is to organize it into a systematic program or model of Health Promotion/Disease
Prevention (HP/DP) strategies that is replicable across a variety of settings and providers.
We are writing to offer you the opportunity to be part of a model effort.

To organize a systematic program, the American Society on Aging, the Roybal Institute
for Applied Gerontology and the Centers for Disease Control and Prevention are
collaborating to provide community agencies and organizations tools for effective health
promotion and disease prevention campaigns for older adults. The project will assist
local health promotion staff to conduct outreach, disseminate of information, deliver
services, engage in staff training and develop a better understanding of the changing
health and social service needs of an aging and more diverse population. In addition to
disease specific messages, the model will address consortium building, use of the media,
culturally sensitive approaches, and effective strategies for working with older adults and
the aging network.

An Internet site devoted to this project will offer a cafeteria-style option to customize a
health promotion manual containing downloadable information, resources and model
projects that address local community health needs. Hard copies of the materials will also
be available for those who do not have Internet access.

Opportunities for Participation
A collaborative network of national organizations and associations representing potential
end users has been created to assist in creating useful tools for frontline staff and
planners. Network participants will:
      Review and comment on the model
      Assist with dissemination and promotion of the model within their networks,
        including incorporation into web pages and publications
      Provide a venue for training sessions at their meetings

Based on your innovative programs and/or your network contacts, we are inviting you to
join the Collaborative Health Promotion Network. We want to formalize this agreement


Live Well, Live Long: Steps to Better Health                                             58
through a Memorandum of Understanding, which we have enclosed. Please review, sign
and return it to ASA no later than the end of February.

If you have further questions, please contact Nancy Ceridwyn, ASA‘s Project Manager, (xxx)
xxx-xxxx, nancyc@abc.org.

Sincerely,


Patrick Cullinane, MS
Associate Director of Research and Special Projects
American Society on Aging




Live Well, Live Long: Steps to Better Health                                           59
Sample Meeting Notice
                                        LETTERHEAD


             NATIONAL COALITION ON MENTAL HEALTH &AGING

                                       MEMORANDUM

DATE:           September 13, 2001

TO:             Coalition Members

FROM:           Bob Organizer

RE:             Next Meeting

The next meeting of the National Coalition on Mental Health and Aging will meet:
                                   October 4, 2001
                                  AARP Boardroom
                                1600 Government Ave.
                                Washington, DC 2xxxx
                                    xxx-xxx-xxxx

Enclosed you will find the proposed agenda and a copy of the member roster. Note that
we will be given an update on the November 15th event to be held as part of the
International Year of the Older Person. For your convenience, an RSVP fax form is also
enclosed.

If you plan to share resources during the member update portion of the agenda, please
bring approximately 25 copies to circulate. You may also wish to bring a brief written
announcement to be included in the meeting summary report. Please call Mr. Sam
Adams @ xxx-xxx-xxxx if you have any questions.

We look forward to seeing all of you soon in Washington, D.C.
________________________________________________________________________
________________________________________________________________________

                                  Fax Reply Form
                        National Coalition on Mental Health
             Fax to Nancy Ceridwyn at (xxx) xxx-xxxx by October 1, 2001

Name:______________________________________________
                     Please print

E-mail:_____________________________________________


Live Well, Live Long: Steps to Better Health                                       60
Phone: _____________________________________________

I ___ will ___will not be attending the National Coalition on Mental Health and
Aging meeting on October 4, 2001.

Changes in mailing address, title, organization? Please let us know.


______________________________________________________________________


______________________________________________________________________


______________________________________________________________________




Live Well, Live Long: Steps to Better Health                                      61
    Sample Agenda
                         National Coalition on Mental Health and Aging
                                         October 5, 2001
                                    9:30 A.M. to 12:30 P.M.
                                   Proposed Agenda Topics


9:30    Welcome and Introductions                                        B. Organizer

9:45    Legislative Update                                               Members

10:15 Update from the Council on Social Work Education                   J. Smith

10:30 Report on the National Council On Aging Project                    F. Jones

10:45 Report on AARP-Center for Mental Health Services Project           J. Doe

11:00 Break

11:10 International Year of Older Person Planning Committee              B. Frank

11:30 Other Issues
      --Older Adult Mental Health Consumer Advocacy
      --Role of the Coalition                                            B. Organizer

12:15 Member Update                                                      Members

12:30 Adjourn for Lunch




Live Well, Live Long: Steps to Better Health                                        62
Memorandum of Understanding/Participation
                              LETTER OF PARTICIPATION


The ______________________________________________________ will
                              (Agency Name)
participate in the Health Promotion/Disease Prevention Network organized by the
American Society on Aging (ASA) and the Roybal Institute for Applied Gerontology,
California State University, Los Angeles (Roybal Institute).

The overall goal of the project is to develop a model of strategies and materials to
increase the level of awareness and enhance the capacity of national, state and local
organizations in serving the health promotion and disease prevention (HP/DP) needs of
the older adult population. The project will enable local health promotion staff to use an
Internet site to create, in a cafeteria style, a customized manual containing downloadable
information, resources and model projects that address local community health needs.
Hard copies of the materials will also be available for those who do not have Internet
access.

Participation in the Health Promotion/Disease Prevention Network (the Network) allows
the organization to receive information and progress reports on the status and availability
of the project‘s products. Participants may comment on the content of the materials
before publication.

Participants agree to disseminate information about the model in newsletters or other
regular communications to the organization‘s staff, members and/or interest groups.


_____________________________________                   ___________________
Agency Representative                                                   Date

_____________________________________
Title

_____________________________________                   ___________________
Contact Person                                                         Phone




Live Well, Live Long: Steps to Better Health                                             63
    Sample Evaluation Forms
    This evaluation form is designed to assist us in checking our progress in meeting the
    needs of the community. Please take a few minutes to invest your time in building a
    better organization responding to community needs.

    The mission of this group is to respond to health concerns of the residents of the
    Avondale neighborhood through health screening, advocacy and promotion of healthy
    behaviors.
     1. How effectively do you see this group fulfilling its mission?
    Circle one number
    1             2                    3                      4                 5
Very Effective Effective         Somewhat Effective   Often Not Effective   Not Effective

    2. What are the most pressing needs in the community?
    ____________________________________________________________________


    3. What projects should the group be addressing?
    ____________________________________________________________________


    4. What are the possible barriers to accomplishing the mission?

    __________________________________________________________________


    5. What changes would you like to see in the coalition for improved effectiveness?
    ___________________________________________________________________




Live Well, Live Long: Steps to Better Health                                                64
List of Resources for Data and Information on Subject Area
American Society on Aging (1997) The Blues, Not a Normal Part of Aging:
Coordinator’s Manual. A program kit. San Francisco.

Arthritis Foundation (1999) Speaking of Pain. Program Manual. A program kit.
Washington, DC.

Center for Substance Abuse Prevention (1994-1998) Technical Assistance Bulletins:
Guides for Planning and Developing Your ATOD Prevention Materials. Rockville, MD:
Division of Public Education and Dissemination.

Edward R. Roybal Institute for Applied Gerontology, California State University (1998)
La Mamografia. A program kit. Los Angeles.

Freudenberg, N., Eng E., Flay, B., Parcel, G., Rogers, T., and Wallerstein, N. (1995)
―Strengthening Individual and Community Capacity to Prevent Disease and Promote
Health: In Search of Relevant Theories and Principles.‖ Health Education Quarterly
22(3):290-306.

Green, L.W., and Kreuter, M.W. (1991) Health promotion planning: An educational and
environmental approach. Mountain View, CA: Mayfield.

Kretzmann, J.P., and McKnight, J.L. (1993) Building Communities from the Inside Out.
Chicago: ACTA Publications.

Maloof, P. (1998) Girl Neighborhood Power! Building Bright Futures for Success,
Coalition Building. A presentation at the Girl Neighborhood Power Grantees Meeting,
October 23, 1998, Alexandria, VA.

Minkler, M., ―Health Education, Health Promotion and the Open Society: A Historical
Perspective.‖ Health Education Quarterly 16(1):17-30.

Minkler, M. and Wallerstein, N. (1996) ―Improving Health Through Community
Organization and Community Building.‖ In Glanz, K., Lewis, F.M., and Rimer, B.K.,
eds., Health Behavior and Health Education: Theory, Research, and Practice. San
Francisco: Jossey-Bass Health Series.

Office of Disease Prevention and Health Promotion (2000) Healthy People 2010
(Conference Edition, in Two Volumes). Washington, DC: U.S. Department of Health and
Human Services.

Williams, K. (1997) Reaching Out: A Guide to Effective Coalition Building. Washington,
DC: Emergency Medical Services for Children National Resource Center.




Live Well, Live Long: Steps to Better Health                                            65
          Live Well, Live Long: Steps to Better Health—Blueprint
         Health Promotion and Disease Prevention for Older Adults

                     Developing Health Promotion Campaigns

Preparing for Your Program

Table of Contents
             Introduction
             Steps in Planning
             Coordinating the Program
             Coordinating a Screening
             Developing a Local Community Referral List
             Publicizing the Program
             Presenting the Workshop
             Program Evaluations
             Screening Evaluations

Introduction
Presenting well-received programs that have an impact on the audience demands
thoughtful and active preparation. Besides setting the stage for an event, preparation
determines its success.

Planners generally follow seven basic steps when planning a presentation:

               Reviewing program materials
               Planning logistics
               Identifying and recruiting a presenter
               Coordinating the program
               Developing a referral list of community resources, handouts or packets
               Publicizing the program
               Planning the evaluation and follow-up

Steps in Planning a Presentation

1. Reviewing Program Materials
The coordinator and presenter should preview visual material earmarked for the program
and carefully read all written information. Adjusting presentations to the type of
audience, the available audiovisual equipment or brochures available through
collaborative sponsors will add to the desired impact of the program materials.




Live Well, Live Long: Steps to Better Health                                             66
2. Planning Logistics
Begin planning your program well in advance to ensure its overall success and value to
the participants. Depending on the scope of the program, six months to a year may be
necessary.

Assign an organizing committee appropriate to your topic or purpose to help coordinate.
Hold an initial planning meeting three months prior to the presentation in order to share
ideas and delegate tasks.

The Planning Meeting
The following tasks should be discussed and assigned during your planning meeting:

Selecting the date, time and location for your presentation
Consider traffic at that time of day as well as convenient public transportation stops near
the location of the meeting. Weekday meetings in the morning or early afternoon attract
older adults who prefer to travel in daylight and avoid rush hour traffic congestion. For
older adults dependent on family members for transportation, consider holding programs
on the weekends.

Hosting the program
Consider linking the program to other scheduled events such as:

   Programs of local chapters of AARP, the National Retired Teachers Association, the
    National Association of Retired Federal Employees, or civic groups
   Home gatherings of coffee klatches or book clubs
   Church group meetings
   Community events such as health fairs

Reserve a comfortable meeting room that is accessible to an older adult audience.
Familiar locations such as restaurants, churches, senior centers or community centers that
local community members frequent for other functions are often more inviting than
formal classrooms or auditoriums.

Planning appropriately for staffing needs
If a large audience is expected, participants may require assistance in finding seating,
locating restrooms, receiving handouts or evaluation forms, or having general questions
answered.

Assigning responsibility for the publicity campaign
Leaving the publicity until the last minute guarantees a poor turnout. Publicity must be
well-planned, well-timed and appropriate to the target audience.




Live Well, Live Long: Steps to Better Health                                               67
               Contacting community groups to discuss the possibility of co-sponsoring
                the event broadens publicity opportunities. Informing older adults through
                organizations that they are involved in and trust increases outreach
                capability into the community
               Good sources for co-sponsors include senior centers, hospitals, retirement
                groups, older adult clubs, aging networks, local businesses, professional
                associations, synagogues/churches or fraternal organizations

Photocopying all handout materials
Overheads may be difficult to see in large rooms, so have handouts available.

               Having copies assists audience members in following the presentation
               Handouts are also convenient for participants who wish to review the
                information later at home or to share it with others


3. Identifying and Recruiting a Presenter
Recruit a professional, ideally from the health field, who is knowledgeable about older
adult health and especially the specific session topic. The hosting agency may want to
recruit additional professionals to answer questions and/or offer private consultations
after the program. In some instances, a panel of resource people may talk about the wide
range of services available or address questions reflecting a wide range of concerns.

A presenter who is a health professional can:
 Provide credibility to the health message
 Answer audience questions knowledgeably during open discussions
 Make appropriate referrals to community health systems

Choosing Health Professionals

A presenter who is a health professional can:

           Provide credibility to the health message
           Answer audience questions knowledgeably during open discussions
           Make appropriate referrals to community health systems

The following are health professionals who could be appropriate as presenters,
depending on the topic:
           Staff from national or local health organizations, such as the American
              Heart Association or the Arthritis Association
           Physicians with the appropriate specialty
           Licensed clinical social workers
           Psychiatrists (particularly geriatric psychiatrists, who are physicians
              uniquely trained to address the complex issues associated with diagnosing
              and treating late-life mental illness and co-morbid medical illness)



Live Well, Live Long: Steps to Better Health                                           68
                   Neuropsychologists who address dementia issues
                   Psychologists
                   Nurses
                   Nurse practitioners
                   Physician assistants
                   Employee assistance professionals
                   Certified counselors (e.g., marriage and family therapists)
                   Pharmacists
                   Nutritionists
                   Physical, occupational or activity therapists
                   Health educators

To find a presenter, contact local hospitals, health plans, physical therapy offices or
professional associations such as the Black Nurse‘s Association or the American Medical
Association. Some area agencies on aging, state units on aging, state departments of
health services, aging and mental health organizations, or universities may have health-
education-oriented staff knowledgeable about aging health conditions. Other sources
include:

               Geriatric education centers (usually located in a university medical school)
               Chapters of national health or disease-specific associations

When speaking with a prospective presenter, discuss the following:

               The session's focus on older adults and the specific topic
               Date, time and location of the session and directions to the location
               The nature of the audience (e.g., older-adult group, nursing home
                residents) and anticipated attendance
               His/her specific role (e.g., present the program and/or conduct a screening)
               Handouts
               Evaluations

Discuss any controversial topics or questions that might arise from the program
participants, or any community issues or sensitivities that may emerge during the
discussion.

Speakers may require a speaking fee or honorarium and travel expenses. First, try to
include these expenses in your budget. Physicians usually accept from $200 to $500 for a
one- or two-hour engagement plus mileage.

If your budget is severely restricted, explore partnering with a hospital or clinic that can
call on one of its medical staff, to use as a promotional program for its healthcare system.
You can also find a sponsor such as a bank or local industry to pay the honorarium. Of
course, some healthcare professionals will make presentations at no cost to you.




Live Well, Live Long: Steps to Better Health                                              69
Ask the presenter for an overview of his or her educational and professional background
(highlighting any experience working with older adults) so you can give a brief but
thorough introduction of the presenter at the program.


Coordinating the Program

1. Communications
Although many people try to avoid meetings, they may be a necessary evil when
coordinating programs. Make the meetings short and always have a written agenda.
Take notes that can be shared with the group as reminders for task assignments.
Even a conference call to ―touch base‖ on the progress and needs of all the committees
should take place regularly. Unexpected problems often crop up, which may require
particular solutions. The planning group, for example, may be able to use special
contacts to facilitate better publicity, or find alternative resources in order to reduce
printing costs.

2. Logistics Checklist

               Ensure adequate seating for participants, and tables for displaying
                educational materials. Chairs with arms that are not too low or cushioned
                are easiest for older adults to sit in and get up from. Avoid visual glare by
                arranging the chairs to face away from windows.
               Check the heating and cooling system to ensure that a comfortable
                temperature can be maintained in the room.
               Secure audiovisual equipment (e.g., VCR and monitor). Prior to the
                presentation, ensure that all equipment is available and working. This
                saves time at the start of the program and presents a more professional
                image to the audience.
               Obtain additional educational materials for distribution. Participants
                appreciate accurate and well-presented information. Many healthcare
                associations have exceptional materials available for distribution. Adding
                new partners to the program is an opportunity to provide participants with
                this additional information. Each of the programs (modules) in this
                learning series will have suggested handouts or contacts for obtaining
                resources.
               Secure a microphone and podium (if necessary). The ability to hear
                speakers is crucial for success. Even if the speaker has a loud voice,
                microphones are always preferred. If there is a question-and-answer
                portion of the program, either have questions asked at the microphone or
                have the moderator repeat the questions.
               Make arrangements for refreshments (budget permitting). Food plays
                an important role in attracting participants and improves satisfaction with
                programs.
               Set up an area where participants can sign in, receive a name tag, and
                pick up information on coordinating organizations and the day's health


Live Well, Live Long: Steps to Better Health                                                70
                promotion topic. Have name tags, pens and a wastebasket available at the
                registration table.

Coordinating a Screening

As a community health promotion activity, screening:

               Helps detect any risks for disease or debilitating conditions
               Provides a baseline of wellness for future comparisons
               Builds awareness of health promotion activities

Many argue that screening has no value when there are few affordable or accessible
resources to treat a particular disease. However, screening results do provide
documentation of the number of elders at risk. Documentation serves as a strong
objective justification when advocating for services.

Screening also raises awareness of health risks and can increase the motivation to seek
more information or to change behavior.

Organizing and conducting a screening does not necessarily require in-house resources.
Needed resources can come through:

               Collaborations with disease-specific advocacy and research organizations
               Local health plans or ancillary health profession training courses

When contacting the organizations that could potentially conduct the screening:

               Describe your program
               Ask if they will volunteer one or more clinicians to conduct the screening
                at your facility
               Specify that the attendees will be mostly older adults and therefore a
                qualified professional with geriatric experience is preferable

Screening sessions often begin with an educational presentation. A volunteer clinician
may also be recruited to present an educational program.

The following organizations may be able to help organize and/or conduct your screening
or identify additional resources:

               Area Agencies on Aging: To obtain contact information for the local
                AAAs, call the Eldercare Locator line at 1-800-677-1116
               State Units on Aging: To obtain contact information for a SUA office in
                your area, call the National Association of State Units on Aging at
                (202) 898-2578




Live Well, Live Long: Steps to Better Health                                              71
Developing a Local Community Services Referral List
You should have a referral list available in case:

               Questions arise requiring more in-depth answers
               Audience members present symptoms needing further examination

A referral list should be distributed to all participants at the beginning of the
presentation.
This list should include:

               Names of facilities
               Contact person(s)
               Phone numbers
               Addresses
               Office hours
               Insurance services (e.g., Medicare)

Make a note on the referral list for participants:
          To contact their primary physician for a complete evaluation
          To contact several facilities to determine which best meets their needs

Contact the agencies and individuals you plan to list in advance to confirm their
availability to perform follow-up evaluations and treatment.

Depending on the topic, information on local community resources could include:

               The sponsoring facility's services
               Private practitioners (e.g., geriatric psychiatrists, geriatricians, case
                managers)
               Health and mental health centers
               Aging networks (e.g., adult daycare centers)
               Nonprofit and publicly funded state, county, and local facilities that
                provide free and/or sliding-scale treatment
               General hospital(s) offering services or clinics for older adults
               Specialty hospitals
               Support groups for the topic discussed in the presentation
               Local pastoral counseling centers or parish nurse programs
               Family service agencies




Live Well, Live Long: Steps to Better Health                                                72
You may be able to obtain an existing referral list of geriatric health resources in
your community by contacting:

               Local Area Agencies on Aging (request copies of their "Information &
                Referral Directory" which includes local facilities, programs, and
                professionals)
               Local advocacy groups on aging
               The recruited presenter
               Local hospital(s)

Publicizing the Program

If your organization decides to open the program to the general public, you can increase
the attendance of older adults by executing a virtually cost-free publicity campaign to
notify individuals/groups of your program and intended audience.

The following are recommendations for publicity and promotion.

Distribute Flyers

Develop a flyer outlining the following:

               Location
               Time and date
               Topic and presenter information
               Cost
               Sponsoring groups

Either mail or hand-deliver flyers throughout your community to:
           Local offices/chapters of national health organizations (e.g., the American
              Mental Health, Heart, Diabetes or Arthritis Associations)
           AARP chapters
           Local Area Agencies on Aging
           Hospitals and health clinics
           Senior centers, older adult clubs, and retirement groups
           Libraries, schools, colleges
           Churches, synagogues, mosques, temples
           Civic groups and local businesses
           Laundromats and grocery stores
           YMCAs
           Restaurants frequented by older adults
           Nutrition sites
           Housing sites




Live Well, Live Long: Steps to Better Health                                           73
Contact/Pitch Local Media

        Create a media list of all local print and broadcast media that includes:

               Contact names
               Phone/fax numbers
               E-mail and mailing addresses

        Step 1. Create a list of the area's media using your local telephone directory.

        Step 2. Call each media outlet and obtain the name of the appropriate reporter or
        editor to whom you should send your announcement/release.

        Step 3. Confirm regular mailing addresses and fax numbers during these calls.

        Step 4. Mail or fax a calendar announcement and media release with a cover letter
        to the appropriate reporters/editors at the local radio, TV and cable stations, as
        well as newspapers, magazines and community organization newsletters.

        Step 5. Follow up with a phone call to confirm receipt of the notices and to
        encourage media outlets to broadcast or publish the information.

        Tip
        The more lead time you give the media, the better your chances of getting
        publicity.

The following media are appropriate campaign targets:

    Daily Newspapers
            Community calendar editor
            Medical/health editor and reporter
            Features editor
            Age-beat reporter

    Weekly/biweekly Community Newspapers and Magazines
           Editor

    Newsletters (e.g., hospital, senior organization, HMO member newsletters)
           Editor
           Radio stations
           Community calendar editor
           Program director
           Assignment editor
           Medical/health reporter




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        TV Stations (e.g., PBS, cable programs)
           Community calendar editor
           News director
           Assignment editor
           Medical/health reporter

Presenting the Workshop
When opening the presentation:

               Welcome the audience
               Introduce yourself and the presenter
               Give an overview of the program
               Recognize sponsors and partner organizations
               Point out that the session is geared for the audience and encourage
                involvement throughout the program

Program Evaluations
For a more complete picture of the effectiveness of a program, conduct a three-level
evaluation of the event. Ask:

               Participants
               Organizers or partners
               Staff

Develop the evaluations before the event following these three steps:

               Define the elements to be evaluated. Formulate the questions to ask or the
                activities to record
               Define the best vehicle for response and collection of information
               Design the evaluation and present it to the target audience

A staff member has developed a talk on healthy aging for a local housing site.
Evaluation questions may include:

               Was the speaker a good presenter and was the program effective?
               Was the speaker clear?
               Were examples easy to understand?
               Was the presenter‘s style interesting when providing information?
               Was the presenter organized, knowledgeable in this field?
               Was time allowed for questions?
               What could be improved?




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What basic elements would indicate that the presentation developed new awareness of a
health issue and perhaps motivated participants to consider developing healthy
behaviors? These might be:

               How will the participants use the information?
               Did the information presented expand on what the audience already
                knows?
               What additional information would be helpful in the presentation?

Tip
        Program evaluations should take no more than five minutes to complete or
        participants will leave most of the answers blank. Because of the time limit, these
        surveys will give only a quick picture of the effectiveness of the presentation in
        building awareness or changing behavior.

Evaluation of Screening
Any screening that takes place during the program should also be evaluated. This
evaluation should include:

               Evaluation of the screening tool
               Number of referrals that resulted from the screening
               Ease of administering the tool by professionals
               Ability to recruit appropriate professionals to administer the screening
               Community response to the screening




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Sample Evaluations
                             American Society on Aging
Hosting Organization Program Evaluation

Company/Organization_________________________________________________

Person completing the evaluation form ___________________________________

Presenter‘s name______________________________________________________

Topic __________________________________              Date______________________

Number of individuals attending ________________

Please take a moment to rate the presentation by circling the appropriate number for each
question.

                                               Strongly                   Strongly
                                               Agree                      Disagree
1. The presenter was knowledgeable.             5         4   3      2       1

2. The presenter was organized.                 5         4   3      2       1

3. The presenter provided the information
   in an interesting, enthusiastic and
   articulate manner.                           5         4   3      2       1

4. The presenter understood the audience
   and accommodated the presentation to
   the audience‘s needs.                       5          4   3      2       1


5. Comments:

_________________________________________________________

_________________________________________________________

_________________________________________________________




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                             American Society on Aging
Participant Program Evaluation

Presenter‘s name_________________________________________________

Topic __________________________________             Date______________________

Please take a moment to rate the presentation by circling the appropriate number for each
question.

                                                   Strongly                     Strongly
                                                   Agree                        Disagree
1. The presenter was knowledgeable                   5        4          3    2      1

2. The presenter was organized                       5         4         3    2     1

3. The presenter provided the information
   in an interesting, enthusiastic and
   articulate manner.                          5      4       3           2   1

4. The presenter allowed time for questions.   5      4       3           2   1

5. The presenter added to my knowledge
   about the topic.                                      5     4         3    2     1

6. I plan to use the information from the
   presentation.                                         5     4          3   2     1

7. Comments:

_______________________________________________________

_________________________________________________________

I would be interested in future presentations on the following topics:

________________________________________________________

_________________________________________________________
                        Thank You!




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Debriefing

Right after the event, plan a debriefing session with the collaborative partners and staff.
Include in the debriefing:

               Elements that presented problems, solutions that were found, and thoughts
                about how to solve the problem for future programs
               Comments from the presenter on the organization of the day, feedback on
                logistics such as room set-up or equipment needs, and the presenter‘s
                perceptions of audience receptivity
                A list of organizations and individuals who should be acknowledged for
                their roles. Assign a group to write letters or make thank-you calls
               Celebration of successes. Keep the team engaged by acknowledging
                effort and creativity




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          Live Well, Live Long: Steps to Better Health—Blueprint
         Health Promotion and Disease Prevention for Older Adults

                     Developing Health Promoting Campaigns

Program Presentations

Table of Contents
                2.4a     Introduction
                2.4b     Distribution of Materials
                2.4c     Opening Welcome
                2.4d     Presentation
                2.4e     Discussion Following Presentation
                2.4f     Closure
                2.4g     Evaluations

Introduction
After the presentation is prepared, a few simple tips will assist in keeping the event
engaging and effective.

The following is a recommended sequence for presenting a program.

               Distribution of materials
               Welcome and program overview
               Activity (screening, icebreaker, true /false quiz about the topic)
               Presentation
               Evaluation

Distribution of Materials
As participants arrive, have a staff member greet them and distribute a packet of materials or
handouts.

        Tip
        Generally, participants like to walk away from a program with information and any
        additional materials obtained through aging and/or participating organizations.

The handout packets for participants should include the following:

               Facts about health promotion
               Answers to common questions
               Resources on the topic
               Local referral list


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           Educational brochure(s)

Set up an information/resource table offering additional brochures and other older-adult
educational materials, such as aging services directories.

        Tip
        Such materials can often be obtained free by contacting the local aging network,
        hospitals, professional associations, mental health organizations, and national
        organizations addressing the day‘s topic.

Welcome and Program Overview
Consider opening the session with an icebreaker exercise to help put the participants at
ease. For example, ask people to turn to their nearest neighbor and introduce themselves.

The sponsoring organization‘s program coordinator should provide a welcome to
participants, an overview of the program, and an introduction of the presenter.

Sample Coordinator’s Script

        Welcome to our program [Topic Title]. I am [name, title] of [sponsoring
        organization] and we look forward to sharing the next 60 to 90 minutes with you
        as our presenter discusses [the topic].

        The main goals of this program are to dispel the common myths and
        misinformation about [the topic], and to increase your understanding of symptoms
        and the treatments. We will discuss how you can:

                    1. Benefit from the information you‘re given today
                    2. Increase your odds of avoiding [the topic]
                    3. Improve your quality of life by better managing [the topic] based on
                       the activities developed during this session

        The final goal is to inform you about appropriate resources in our community, and
        to provide you with a referral, if necessary.

        I‘ll now turn over the session to [presenter‘s name, title, affiliation, background]
        who will present this program.

Presentation
Sample Activity

To capture the attention of the audience, participation in an activity—such as a screening,
a quick risk questionnaire or a self-scored true/false quiz about the topic—generates
interest through a sense of discovery.


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Presentation

The presenter can follow a simple outline to maintain direction and to stay within the
presentation time limit of no more than 45 minutes. Save the last 15 minutes for
questions and answers.

        Tip
        Since the adult attention span generally begins to waver at 20 minutes, change the
        tempo and solicit audience participation at intervals to keep the audience engaged.

Sample Presenter’s Outline

               Incidence of condition
               Description of symptoms
               Current information and myths
               What is normal aging?
               Health promotion activities and benefits
               Treatment options
               Actions that audience members can take

Discussion Following the Presentation
The presenter can receive questions either on cards handed in by participants during or
after the talk or by people raising their hands.

Use a microphone whenever you address an audience of more than 25 people. When
possible, have the audience use the microphone when making comments or asking
questions.

    Tip
    Remember to repeat the question if a microphone is not available to the audience.

Answer questions as if there are no ―stupid‖ questions. Value can be found in most
audience comments or in the spirit in which participants present their stories. Giving
audience members respect engenders respect for the speaker and the information
conveyed in the talk.

Closure

               Try to allow time for participants to ask more questions following the
                formal presentation
               Have resource people available to assist with some questions or concerns
               Close the program with a thank-you to the participants and speaker(s)
               Announce follow-up or future sessions



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Evaluations
Evaluations benefit your programs by:

               Providing a blueprint for improving future programs
               Giving feedback on how well the goals of the program were met
               Showing the audience and the speaker respect for their time by soliciting
                opinions of the program
                Providing accountability for the performance of goals

Accountability to boards, funders, administrators and the community generates trust and
sets the foundation for ongoing relationships, the key to effective health promotion.

When distributing evaluations to participants:

               Ask the participants to complete evaluations before they leave
               Make sure to have pencils or pens for them to complete the form and
                collect them as they leave

Evaluations by presenters give a clearer picture of the success of the logistics and process
involved in organizing the event.

Staff debriefings following the program contribute to improving the process and
teamwork for future events.




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          Live Well, Live Long: Steps to Better Health—Blueprint
         Health Promotion and Disease Prevention for Older Adults

                               Working with Mass Media
Introduction
Mass media offer many opportunities for health messages including:

                Public service announcements (PSAs)
                Mentions in news programs
                Entertainment programming
                ―Magazine" and interview shows (including radio audience call-ins)
                Live remote broadcasts
                Editorials (television, radio, newspapers, magazines)
                Health and political columns in newspapers and magazines
                Internet pages and links

Each format offers a particular advantage, and each may reach a different audience mix.
As you plan and implement your health promotion campaign or activities, incorporate a
variety of formats and media channels, always choosing those most likely to reach your
target audiences.

Table of Contents
                 Advantages and Disadvantages of Print and Broadcast Media
                 Ensuring Good Media Coverage
                 Working with Local Publications for Older Adults
                 Getting the Best from Rural Media
                 Using the Internet




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          Live Well, Live Long: Steps to Better Health—Blueprint
         Health Promotion and Disease Prevention for Older Adults

                               Working with Mass Media

Advantages and Disadvantages of Various Types of Media
Television

The purpose of television is generally to inform and entertain, not to educate. Still, there
are advantages to using television for your health messages.

    The advantages are:

                Visual as well as audio presentation makes emotional appeals possible,
                 and provides an easier way to demonstrate a behavior
                Television can reach audiences not as likely to turn to traditional health
                 sources for help
                Opportunity exists to include health messages via news broadcasts, public
                 affairs/interview shows, dramatic programming

Disadvantages include:

                The passive consumption of information by TV viewers usually does not
                 move them to action
                Viewers must be present when the message is aired. Choosing the right
                 time and the right channels is expensive
                Since television often does not require the viewer‘s full attention, the
                 message can become obscured by commercial "clutter"
                PSAs could potentially reach the largest range of audiences, but they are
                 not always aired at optimal times. Deregulation ended government
                 oversight of station broadcasts of PSAs and public affairs programming
                PSAs can be expensive to produce and distribute

        Tip
        Paid advertisements may be more affordable on local cable channels, but the
        audience may be limited

Radio

Advantages for radio are:

                The various formats presented on radio offer potential for more audience
                 targeting than television
                Opportunity exists for direct audience involvement via call-in shows


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           Audio without visual images may make messages less intrusive
           Audio without visual images can engage the imagination to visualize personal
            health better than fixed images portrayed on television
           Radio can reach people who do not use the health care system

Disadvantages include:

           Although more targeted, radio may reach fewer people than TV
           Radio generates generally passive consumption. Interaction with the audience
            is possible, but the target audience must be listening to the program when it is
            aired
           Deregulation ended government oversight of station broadcasts of PSAs and
            public affairs programming, which has reduced the opportunities for each of
            the radio formats
           Feature placement requires making a lot of contacts, which may be
            time-consuming

        Tip
        Creating live copy is flexible and inexpensive, while PSAs must fit station format
        and may have limited airtime for the effort

Magazines

Magazines can offer full-length articles that explain complex issues and behaviors, so
they are a good medium for providing healthcare information.

Advantages are:

               Because there are so many special-interest magazines, you can more
                specifically target segments of the public (e.g., seniors with an interest in
                health, ethnic groups)
               Print may lend itself to a more factual, detailed, rational message delivery
               The audience has a chance to clip, reread and contemplate material
               Magazine format permits active consultation, allows information to be
                easily passed on and can be read at the reader's convenience

Disadvantages include:

               Although there are no requirements for PSA use and they are inexpensive
                to produce, PSAs are more difficult to place in magazines
               Ad or article placement may be time-consuming
               Because articles are generally longer here than in newspapers, you must
                generate commitment from the reader, either through graphics,
                exceptionally engaging stories or a currently relevant news topic




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Newspapers

Newspapers provide easy audience access to in-depth issue coverage.

    Advantages are:

               Newspapers can reach a broad audience rapidly
               Newspapers can convey health news and breakthroughs more thoroughly
                than TV or radio and more quickly than magazines. Feature placement is
                possible

Disadvantages include:

               PSAs are virtually nonexistent
               The short shelf-life of newspapers limits rereading and sharing with
                others, with the exception of some feature articles

        Tip
        Small newspapers may take public service ads, but the ad must contain a
        newsworthy item, e.g., a free screening or lecture.




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          Live Well, Live Long: Steps to Better Health—Blueprint
         Health Promotion and Disease Prevention for Older Adults

                               Working with Mass Media

Ensuring Good Media Coverage
Why seek good media coverage?

Good media coverage contributes to effective promotion efforts. Understanding the whys
and hows of media relations will smooth the way to working with editors and reporters
and can help ensure good media coverage in all settings.

Step 1. Give a Local Slant to Your Story and Communicate Early with Media
Personnel

               Involve media personnel in developing the local angle during the planning
                stage of a health promotion campaign
               Contact media sources ahead of time instead of building a whole
                campaign that cannot be covered because of space or airtime limitations.
                Editors and radio managers do not want to be the last to be called
               If possible, make any first contact with a reporter, editor, or manager in
                person

        Tip
        Remember that everything told to a reporter is ―on the record.‖ Don‘t say
        anything that cannot be quoted, and never disparage another person‘s or
        organization‘s promotion of your message.


Step 2. Prepare Fact Sheets

Fact sheets with information about the organization or program are helpful to all
reporters—television, radio, and newspaper. The fact sheet should include the following
information about your organization:

               Founding date
               Logo
               Statement of purpose
               Community services
               Achievements
               Contact person and phone number for the reporter to call for more
                information.

The fact sheet may not generate an immediate story, but it makes the organization‘s name


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familiar and sets the stage for a story on another occasion. The fact sheet also allows the
organization to provide favorable background information for a story.

Step 3. Have a Spokesperson Available at Any Hour

Select and prepare a spokesperson to represent your organization or program. But
remember that the media are more likely to use information on an organization when they
do not get the runaround. A spokesperson must be available at any hour, and media
representatives should have the spokesperson‘s office, home, car phone and fax numbers.
Give the media a direct line to the spokesperson‘s office. He or she is the designated
person to speak to the media and participate in television and radio talk shows.

Step 4. Make Sure Your Media Relations Are Proactive

Frame health promotion/disease prevention issues in ways that compel media coverage.
Consider the following:

               Use an angle or ―hook‖ that makes information compelling or
                controversial
                   o Cyclical, calendar-based events can help get the message across.
                       Holidays lend themselves to feature stories connected to promotion
                       messages
                   o Look for national hooks for a story. For example, link national
                       discussions on new findings, such as increase in diabetes cases to
                       local health programs or screenings. Use that information to bring
                       in local coverage. For example, get a local person to talk about
                       using prevention and treatment
                   o Keep up-to-date on government releases as well as publications
                       like the New England Journal of Medicine. If a national source
                       issues a report, be ready to call the local assignment editor with
                       figures localizing the national story

               Find an unusual method of delivery. For example:
                    o To promote a local campaign to stop alcohol- and drug-impaired
                       driving, a popular drive-time radio disk jockey was presented with
                       a breakfast basket tied with red ribbons
                    o An environmental group sent its press release glued to a large
                       plastic container. The station could not help but see it and read it!

               Find an out-of-the-ordinary association with something already in the
                news. For example:
                    o When traces of poisonous substances were found in Chilean
                       grapes, tobacco control activists pointed out that even larger
                       amounts of the substances are found in a single cigarette

               Present an ―opportunistic‖ exploration or elaboration of an issue


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                    o    A local story can catch the eye of a national TV editor. Television
                         news often seeks a local organization for an angle on a news story
                    o    Look for ways to turn a negative story into a positive promotion
                         focus

              Use the telephone reactively
                   o Although this strategy is not used often, it can be effective
                   o When there is a breaking story, call the news outlet and offer an
                       expert or an opinion
                   o Offer not only information on the problem involved, but also
                       present someone who has been looking at the problem in the
                       community

Use News Releases and News Advisories Effectively

Sample Calendar Announcement and Media Release
Sample Calendar Announcement

For Immediate Release                                  Contact: Nancy Ceridwyn
April 11, 2001                                         (xxx) xxx-xxxx or nancyc@abc.org


                                               CALENDAR NOTICE

                                   The American Society on Aging presents:


                MEMORY RETENTION: FITNESS FOR THE BRAIN

City College of San Francisco
Downtown Campus
April 5, 12 and 19, 2001

Three half-day workshops exploring aspects of memory and normal aging, current research
on learning and the brain, and prevention activities to maintain mental fitness or slow
memory loss. Designed for people 50 and over.

For more information, contact the American Society on Aging, XXX Market Street,
Suite XX, San Francisco, CA 94103-1824; telephone (xxx) xxx-xxxx; fax (zzz) zzz-zzzz;
E-mail: info@abc.org; website: www.xxx.org.

                                                     ###




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Sample Media Release

For Immediate Release                                Contact: Nancy Ceridwyn
March 30, 2001                                       (xxx) xxx-xxxx or nancyc@abc.org

       The American Society on Aging to Present a Series on Memory Retention


The American Society on Aging (ASA) will present the series Memory Retention: Fitness
for the Brain at City College of San Francisco, Downtown Campus on April 5, 12 and 19,
2001 from 9:00 a.m. to noon.

ASA will sponsor the series of three half-day workshops exploring aspects of memory
and normal aging, current research on learning and the brain, and prevention activities to
maintain mental fitness or slow memory loss. Designed for people over 50, the series is
one of ASA‘s most popular educational programs conducted by experts in the field.

Leading the first session, ―Let‘s Start with the Brain,‖ Dr. XXXXX from the University
of California, San Francisco Geriatric Education Center, will discuss normal aging and
memory. Unlike all other organs in the body, which are basically formed at birth, the
brain uses experiences from the environment to build itself. The more input the brain
receives from the outside world, the more brainpower it develops. ―The brain is capable
of rewiring itself at any age,‖ Dr. XX explains. He will outline the current research on
memory and describe how memory and learning take place.

Dr. YYYYY from the Stanford Geriatric Education Center will address challenges to
memory retention. The second session, ―Am I Losing My Memory?‖ will describe
genetic, environmental and medical reasons for memory loss—many of which are
treatable.

―Putting Action into Lifelong Learning: From Research to Learning‖ is the final session
of the series led by ZZZZZZZ, Ph.D. from Excel, Inc. This practical session will provide
the audience with specific techniques and exercises to enhance and retain memory.

Registrants can attend one or all programs in the series to meet individual interests and
schedules. Registration fees are $8 per session or $20 for the series. Registration forms
are available at all San Francisco Senior Centers or by calling ASA at (xxx) xxx-xxxx.

                                               ###




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News Release

What are the types of news releases?

A news release can be written:

               In advance of an event (to encourage media coverage and public
                awareness)
               Concurrent with an event (to make sure that key points are highlighted)
               Following an event (to inform the public of what happened)

Major media generally use advance or concurrent news releases; weekly newspapers
often use all three types.

How can my news release catch the attention of the editor?

Most media organizations are inundated with news releases. A release is more likely to
be read and taken seriously when it is:

               Typed on the organization‘s letterhead or letterhead specifically developed
                for news release
               Prepared in the standard format:
                o      Top of the page
                              ―For immediate release‖ (and the date of the release)
                              ―For more information contact‖ (and the name and
                               telephone numbers of the contact)
                    o Informative headline or title
                    o Paragraph 1
                    o Dateline
                              What (the event or subject)
                              Where (the location)
                              When (the time)
                              Who (the principals or major players)
                    o Paragraph 2
                        More information about the event or activity
                        A quotation by a spokesperson
                    o Following and final paragraphs
                        Additional information, if necessary
                        Generic text that describes the organization or program (choose
                           a standard descriptive closing paragraph for all news releases)
                        If it continues to another page, place ―-more-‖ at the end of
                           each page
                        Paragraphs are not continued to succeeding pages
                        Place identifying information at the top of each page
                        At the end of the release, place ―-30-‖ or ―###‖



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                Dropped off with the assignment editor (whom you have already met),
                 with a backup copy to the health editor. Be sure to follow up with a phone
                 call.
If the release is turned down after a follow-up call, ask the editor to keep the organization
or program in mind for future stories related to health promotion issues.

        Tip
        Include evening and weekend phone numbers in addition to work numbers,
        because editors and reporters often work on weekends and after 5 p.m. If they
        cannot reach an organization or program to verify an upcoming event or get a
        quote, they may bypass the release.

News Advisory

When and how do I use a news advisory?

A news advisory—an invitation no longer than a page in length—can be used instead of a
news release to alert the media to a news conference or media event worthy of coverage.

Use the following format:

               Typed on letterhead or news release stationery
               Prepared in the standard format:
                o      Top of the page
                        ―For immediate release‖ (and the date of the release)
                        ―For more information contact‖ (and the name and telephone
                           numbers of the contact)
                        Informative headline or title
                        List the essentials in outline form: who, what, where, why and
                           when
               Place ―-30-‖ or ―###‖ at the end.

        Tip
        When using an advisory, always distribute a more detailed news release at the
        event or on the day of the event, and send copies to reporters who were not
        present.

Distributing News Releases and News Advisories

What distribution methods are most effective?

For small community media, hand-deliver mail or fax.

To guide distribution efforts, find out and follow deadlines for daily and weekly
newspapers (and any Sunday editions), television and radio stations, and magazines.




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Hold News Conferences and Briefings

When do you use a news conference or briefing?

A news conference takes a more formal format than a news briefing. A news conference
usually begins with a basic presentation followed by an opportunity for attendees to ask
questions.

Media kits are distributed before the presentation and should contain:

               A fact sheet (two-page maximum)
               A biographical sketch of leader(s)
               A current news release
               Examples of news coverage
               A copy of the PSA (if distributed to radio/television)
               Black-and-white photographs

A news briefing allows an organization to bring the media together informally and
answer questions away from the spotlight. Responses are also ―on the record,‖ but more
background information can be communicated.

When do you use a news conference or briefing?

News conferences or briefings are best used:
          When the organization or program has important news to announce—like
             the results of a study or the kickoff of a special campaign
          Sparingly, because attendance requires a major time commitment for news
             media
          As an opportunity to provide the media to capture a visual or a live audio

        Tip
        Use a checklist for preconference, conference day, and follow-up activities for:

               Rooms
               Speakers
               Budgets
               Media kits
               Refreshments
               Transportation
               Equipment
               Microphones and electrical outlets

Prepare Letters to the Editor and Op-Ed Articles

Most newspapers devote at least one page to opinions, presenting them in, for example,



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editorials, letters to the editor, regular columns (both local and nationally syndicated),
political cartoons, and contributed articles.

               Letters to the Editor
                   o If the local newspaper does not provide instructions, call the
                       newspaper editorial department and ask for any specific rules that
                       should be followed (for example, how to address the letter and its
                       maximum length)
                   o Type the letter and include the full name of the author and a
                       telephone number the newspaper can use to check authenticity
                   o Monitor published letters to get a feel for their style and tenor
                       before starting to write
                   o Make sure the letter says something different from those already
                       published
                   o If the letter is a response to an article, editorial or letter published
                       in the newspaper, do it quickly—before the momentum of the story
                       is lost—and refer to it by headline and date
                   o Encourage volunteers, clients or other supporters to write letters
                       about a health promotion
                        Different letters on a single topic will strengthen your case
                        Form letters or any indication of an organized letter-writing
                            campaign will weaken the effort

        Tip
        Discuss errors in articles in a telephone call to the reporter, rather than in a ―set
        the record straight‖ letter to the editor. Writing a correction letter is a step to take
        only when other avenues have failed.

               Op-Ed Articles and Guest Editorials
                The op-ed section, usually on the page opposite the newspaper‘s editorial
                page, generally presents regular columnists (national and local), but there
                may be opportunities for a guest columnist
                   o Ask the editor for submission guidelines. An op-ed piece—usually
                       three double-spaced, typed pages—provides more space than a
                       letter to address issues from the health promotion perspective or to
                       present the organization‘s or program‘s position when it differs
                       from that endorsed by the newspaper
                   o Be succinct, and avoid going off on tangents that detract from the
                       main theme
                   o Have another person with writing skills review the article before
                       submitting it
                   o Opportunities for expressing opinions on broadcast media are few,
                       but some television and radio stations air editorial opinions and
                       invite opposing viewpoints. Using such an avenue when available
                       makes it possible to reach a wider audience with a message




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Public Service Announcements

What are public service announcements?

In the past, the Federal Communications Commission required radio and television
stations to donate a certain number hours to public service announcements. Since
deregulation, each station has its own policy regarding donation of free commercials
(usually aired in off-hours).

Some PSAs are presented as the joint effort of the sponsoring agency and the station. For
example, a PSA might close with: "This message is brought to you as a public service
from the American Cancer Society and Station WXXX."

Public service campaigns include a combination of:

           Television and radio PSAs
           Public service transit ads and billboards
           Print publications such as booklets and posters
           Specially planned events
           Health education activities

Two types of messages are used in these campaigns:

               General messages urge behavior changes (e.g., quit smoking). Many
                general message PSAs are nationally produced and feature celebrities or
                are created by major advertising and production firms. Work with your
                community station to localize the national PSAs with the telephone
                number of your organization or program
               Specific announcements give details of upcoming events or activities (e.g.,
                come out for next Saturday‘s smoke-out)

How do I get PSAs aired?

               Find out station policies:
                   o Stations often predetermine PSA themes
                   o See if the station conducts meetings about their formats, timelines
                       and other essential information, and get on the mailing list
                   o To keep the PSA off the bottom of the pile, find out the format that
                       the radio station prefers—announcer-read ―live copy‖ or
                       prerecorded on cassette, record, or reel-to-reel
                   o Many stations prefer announcer-read PSAs because they draw
                       attention to their on-air personalities and do not compete with
                       prerecorded paid commercials
                   o Some all-news and talk stations prefer prerecorded PSAs with
                       music backgrounds as a change of pace



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                    o    Television stations use announcer-read PSAs, accompanied by one
                         or more slides and prerecorded film or video spots. Some stations
                         will request slides or photographs to accompany the PSA; others
                         prefer to produce their own slides
                    o    Hand-deliver PSAs for radio and television at least 2 to 3 weeks
                         ahead of time—more if possible. Include the length of the PSA
                         and a word-for-word written text with prerecorded PSAs. For all
                         PSAs, include a beginning date and an ending or ―kill‖ date. A
                         maximum of three months is a good idea

        Tips for developing TV PSAs:
                   o Keep messages short and simple—just one or two key points
                   o Be sure every word works
                   o Repeat the main message as many times as possible
                   o Identify the main issue in the first 10 seconds in an attention-
                       getting way
                   o Summarize or repeat the main message at the close
                   o Superimpose the main point on the screen to reinforce the oral
                       message
                   o Recommend a specific action
                   o Demonstrate the health problem, behavior, or skills (if relevant)
                   o Provide new, accurate, straightforward information
                   o Present the facts in a straightforward manner
                   o Use a memorable slogan, theme, music, or sound effects to aid
                       recall
                   o Be sure that the message presenter is seen as a credible source of
                       information, whether an authority, celebrity, or target audience
                       representative
                   o Use only a few characters
                   o Select an appropriate approach (e.g., testimonial, demonstration, or
                       slice-of-life format)
                   o Make the message understandable from the visual presentation
                       alone
                   o Use positive rather than negative appeals
                   o Emphasize the solution as well as the problem
                   o Use a light, humorous approach, if appropriate, but pre-test to be
                       sure it works—and doesn't offend the audience
                   o Avoid arousing fear, unless the fear is easily resolved and the
                       message carefully tested
                   o Be sure the message, language and style are considered relevant by
                       the intended audience
                   o Use 30- or 60-second spots to present and repeat the complete
                       message; use 10-second spots only for reminders
                   o If the action is to call or write, show the phone number or address
                       on the screen for at least five seconds, and reinforce it orally
                       (phone calls require less effort than writing)



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                    o    Check for consistency with campaign messages in other media
                         formats

Step 5. Identify Media Spokespersons for Your Organization

Who do people want to hear?

In some cases, the person who handles media relations may speak officially, but usually
reporters want statements from persons with more rank.

Therefore, the media relations person generally does the behind-the-scenes work, and the
organization‘s executive director, president or chairperson is the designated
spokesperson.

How do you keep the story focused?

Having many people talk with reporters is not a good idea, unless it is within a tightly
structured environment like a news conference.

When reporters talk to different people at different times, the stories may not match
exactly, and the resulting story may be negative.

To make sure everyone is ―reading from the same script,‖ limit media relations to a
maximum of three people.

If the media want to talk to ―rank-and-file‖ people, select in advance those who will
discuss the program rather than letting the reporter choose.

        Tip
        Realize that journalists do not share their stories before publication for proofing or
        positive or negative tone.

                        Have your facts correct on all handouts
                        Develop an appropriate relationship with the press—helpful and
                         respectful

Step 6. Develop and Maintain Media Lists

To customize your contact information, create an up-to-date media list.

Media lists are available for purchase, but become outdated quickly, and often overlook
small, new and transient publications and programs.




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How do I create a media list?

               Use the local library‘s reference books on local and national media. The
                Internet and the telephone book are also good sources. Check your
                sources regularly to maintain the accuracy of the list
               Keep the detailed media list in a loose-leaf binder, using one page per
                media outlet

What should be included in a listing?

               For a daily or weekly newspaper, include the following information:
                   o Name
                   o Format
                   o Circulation
                   o Distribution area
                   o Publication date(s)
                   o Street address
                   o Mailing address
                   o Telephone number
                   o Owners and chain affiliation
                   o Names of key staff, including publisher, managing editor,
                       community service director, advertising manager, news and public
                       affairs directors, and columnists
                   o Relevant deadlines for submissions
                   o Public service advertising, news release and calendar policy
                   o Whether the newspaper contains a letters-to-the-editor section
                       and/or an op-ed page, prints public service news releases, or has a
                       calendar listing

   For a radio or TV station, include the following information:
                   o Name
                   o Location on the dial
                   o Format
                   o Audience
                   o Broadcast area
                   o Hours on the air
                   o Street address
                   o Mailing address
                   o Telephone number
                   o Owners and network affiliation
                   o Names of key staff, including general manager, news director,
                      editorial director, public service director, advertising manager
                   o PSA policy and accepted format (announcer-read or prerecorded
                      on cassette, record, or reel-to-reel tape)
                   o Whether the station has on-air editorials (and provides
                      opportunities for editorial responses)


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                    o    Whether the station has locally produced news programming and
                         staff reporters (or is fed through a network affiliation).

        Tip
        Be sure the media list includes:

                College and university radio stations
                Public radio and television stations
                Wire services
                Local bureaus of national newspapers, magazines and broadcasters

Step 7. Track Your Progress by Monitoring and Measuring Media Coverage

In general, media coverage can be placed in three categories:

                Coverage that is generated through media relations efforts
                Coverage of an organization‘s or program‘s specific issues that is
                 generated independently
                Coverage of a health and prevention issue that is not specific to one
                 program

Why should I monitor media coverage? If I just get it in, I’ll be lucky.

                Knowing how the organization and issues are covered allows for a better
                 appraisal of media relations and helps guide future contact with the
                 media.
                Monitoring helps you to:
                    o Correct misstatements and errors
                    o Identify persons in the media attuned to health promotion/disease
                        prevention issues
                    o Classify issues that are regularly covered
                    o Position your organization or program properly with respect to
                        national and regional stories
                    o Replicate successful media strategies
                    o Identify areas that need more media coverage

How can I find time to monitor media coverage?

Clipping services provide an excellent resource for monitoring stories that appear in
newspapers and magazines. However, no clipping service can track all the stories, and it
may take up to several weeks before you receive the clips. Clipping services are also
expensive. Check for free clipping services on the Web, which will also be faster. Other
options may be available. For example, the Los Angeles Times offers a keyword search.
Other major newspapers may have a similar service.

Review the major community dailies and weeklies regularly for stories on your


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organization or program and on health promotion in general. Clip relevant articles.
Volunteers who keep up with local news can assist in scanning the local papers.

Broadcast monitoring services provide video and audio copies of television and radio
reports, but they tend to be expensive. Use them when an important story is breaking and
complete coverage is needed. Another idea is to ask staff or volunteers to tape the
programs. Such homemade tapes will not have the same quality, but the only cost is for
blank tapes. Sometimes the station will make a copy for you.

How do I measure media coverage?

Media coverage can be measured in terms of quantity, placement and content. Quantity
and placement measures are relatively objective; content measures are more subjective.

   Quantity. How much did the story get?
                o For print, quantity is measured in column inches
                o For electronic media, quantity is measured in seconds or minutes
                   of airtime
                o Convert the amount of free publicity into dollars by calculating
                   how much the amount of space or time would cost.

   Placement. Where was the story placed?
                o Certain placements—including the front page or above the fold of
                   a daily newspaper, and the opening of the evening television
                   news—reach the largest numbers
                o For specific audiences, other placements may be more effective.
                   For example, the editorial and business pages of the local
                   newspaper usually have high readership among local opinion
                   leaders

   Content. Is the story positive, negative or neutral?
              o Consider the totality of the coverage in measuring content. For
                  example:
                       Often the headline grabs attention, but the article itself is
                          reasoned and more neutral
                       A fact or two may be wrong, but on balance the reporting is
                          accurate and positive




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          Live Well, Live Long: Steps to Better Health—Blueprint
         Health Promotion and Disease Prevention for Older Adults

                               Working with Mass Media

Working with Local Publications for Older Adults
What opportunities are there for contributing to these publications?

In the past, two types of publications have targeted older adults:

               Newspaper and magazines
               Resource directories

The newspapers and magazines are usually free monthly publications that depend on
advertisements to generate revenue. One or two writers cover the events of the region,
often relying on professionals from service agencies to provide news releases or even run
regular articles.

Annual printed resource directories feature articles on topics ranging from housing to
health, usually followed by a directory related to the topic. Again, revenue is gained
through advertisements or sponsorships. Local publishers are looking for experts to
submit articles.

How are the publications distributed?

        Many of the newspapers are distributed monthly to:

               Senior centers
               Grocery stores
               Nutrition sites
               Housing sites

Directories are distributed to similar sites, as well as:
            Physician‘s offices
            Banks
            Case management agencies
            Businesses with family elder care programs

How do I submit information?

For either of these types of publications:

               Make personal contact either by phone or appointment
               Share past writing samples


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               Explore with the publisher or editor his or her copy needs and ideas for
                content
               Do your research:
                o Find out editorial deadlines
                o Ask about editorial guidelines for articles
                o Provide calendar items in the requested format

What other publications reach older adults?

Consider membership groups and associations that have publications or newsletters.
These might include:

               Unions
               National organizations with local chapters such as AARP, National Retired Federal
                Employees
               Advocacy groups such as the Gray Panthers or Older Women‘s League
               Service groups such as Rotary or Kiwanis
               Granges (rural communities)
               Veterans of Foreign Wars
               Fraternal organizations such as the Masons, Elks or Moose

Many of these groups have monthly newsletters that list coming events. Some will print
short articles that you have written.

How do I submit information?

The first step to include these newsletters as part of your information campaign begins
with contacting someone on the local governing council of the target organization. Talk
with the president or the person in charge of program planning or special events, who can
put you in touch with the newsletter editor.

Step two entails discussing with editors their content, publication dates and compelling
reasons that your program will benefit their members. Develop a rapport with each
editor. Provide each publication with information in their format and style.

Step three looks to the future. Stay in contact even after the publication has printed your
information. These are new allies that can help with future events and activities.




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          Live Well, Live Long: Steps to Better Health—Blueprint
         Health Promotion and Disease Prevention for Older Adults

                               Working with Mass Media

Getting the Best from Rural Media Sources
Rural and small-town media represent a unique area of American journalism. Their
special characteristics provide growing opportunities for expanding print, radio, and other
electronic media coverage. Rural and small-town media meet the needs of their
audiences—and of health promotion programs—in a way that no other media can.

Realizing the Benefits of Rural and Small-Town Media

               Try to capitalize on the opportunities that rural and small-town media
                present, instead of seeing this viable market as a second choice among
                communication sources.
               Use rural and small-town media to initiate programs that are models for
                other health promotion advocates in larger market areas. Working with
                smaller media outlets provides an opportunity to play a creative role in
                developing health promotion messages and campaigns. The smaller the
                market, the more opportunity there is to try something new

What are the best strategies to ensure effective results?

               Develop good relationships with media staff
               Give a local slant to your story and communicate early with local
                media personnel
               Prepare fact sheets
               Create a regional information network
               Emphasize community relations
               Use local celebrities
               Have a spokesperson available at any hour
               Understand the structure and characteristics of rural and small-town
                media resources

Develop Good Relationships with Media Staff

Given the presence of the media in small communities, editors and managers are actually
some of the most influential members of a community. They often also serve as
executives in community and civic organizations such as the chamber of commerce, as
well as in other social and fraternal organizations.

Seize all opportunities to meet and interact with local media personnel in social rather
than professional settings. For example:


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               Get to know editors and radio managers personally by inviting them to
                lunch
               Find out what your organization can do to receive airtime or space in the
                newspaper. But do not expect an immediate response. It takes time and
                patience to build good media relationships

Give a Local Slant to Your Story

               Just as in metropolitan areas, the best story in a rural or small-town market
                is a local one

Create a Regional Information Network

Collect, record, and publicize statistics about the incidence of diseases or certain
situations in your area. Such information captures the reader‘s attention and provides an
excellent lead for messages on the importance of prevention.

Emphasize Community Relations

A well-attended awareness event can appeal to a television or radio station as a
community relations opportunity and a news story.

               Meet with the marketing or community affairs director of a television
                station and get him or her involved as a co-host of the event
               Develop promotional goods, such as T-shirts and hats with the television
                or radio station‘s logo, to use at a collaborative event with the station
                providing ads for the event
               Try to use one of the station‘s personalities in the promotion (e.g., a news
                anchor, sports anchor, or weatherperson)

Use Local Celebrities

Enlist a local celebrity to lend support and credibility to your event.

               Newspapers and television and radio stations will go out of their way to
                cover, for example, the university basketball coach, the governor, or a
                local person who has achieved national recognition in his or her field
               Use the right celebrity to present the health message or represent the
                campaign

        Keep in mind the advantages:

               Celebrities can be effective if the audience directly associates them with
                your message (e.g., an ex-cancer patient, a pregnant woman, an ex-
                smoker)


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               Celebrities speak for themselves and their image, and will make a firm
                agreement about their role and what they will and will not say
               Celebrities can increase attention to your message from audiences and
                from editors or producers who determine the newsworthiness of issues

        And disadvantages:

               The appearance of a celebrity may compete with your message for
                attention
               Some audiences may not react favorably to certain celebrities
               A network or radio station may not use a top star from a rival station
               Production schedules will be built around the celebrity's schedule, which
                could result in production delays or a need to reschedule, increasing
                production time and costs
               The celebrity may practice health habits or hold health-related opinions
                that could later contradict your own messages
               Celebrities live in the public eye; a change in their popularity or personal
                lifestyle could affect the acceptability of your message

        Tip
        A local celebrity or well-known person may be more credible for some audiences
        than a national figure

Understand the Structure and Characteristics of Rural and Small-Town Media
Resources

        Print Media

In general, rural print media concentrate their limited resources on local news coverage
and rely on wire services or newspaper syndicates for national and state news.

        Daily Newspapers

               Like their urban counterparts, daily newspapers in rural areas want ―hard
                news‖ within an established deadline, such as Thursday at noon for
                Sunday coverage. Get to know those deadlines
               In pitching a story about a state or national observance or event with a
                local slant, describe the event in 50 words or less and answer these
                questions:
                             Whom does it affect locally?
                             When will it happen?
                             Why is it timely?
               When presenting hard news to the editor of a rural daily, remember that
                statistical information about the local market is a strong lead
               To get to know him or her, hand-carry the first few press releases to the
                city editor, managing editor, or assignment editor


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               When working with a daily newspaper that is large and well-staffed, offer
                camera-ready art (logos or illustrations) for use in articles and make a
                photo opportunity available so the editor will assign a photographer or
                reporter
               Remember that a reporter covering an event wants to interview someone
                in the sponsoring organization to get more information and to collect
                quotes that will give the story more human interest. Have the contact
                information for these people available for the reporter

        Weekly Newspapers

               In terms of getting space for a story, weekly newspapers are usually the
                hardest to access, but they have more freedom in content
               Rural papers often operate with only one writer who also serves as the
                editor. Cater to the editor and help him or her develop a comprehensive
                story about your organization or event
               Weekly papers lose some stories because news becomes old quickly, so
                they may be looking for feature articles and human-interest stories
               Weekly newspapers are filled with a variety of regular columns that may,
                for example, include news on civic groups, volunteer opportunities, a
                calendar of church gatherings, and personal news about local residents.
                Use the personal news approach by telling your story through a local
                resident
               Including a photo and a graph or a logo will help the story‘s chances of
                ―getting some ink‖ in the paper. The photos and artwork do not have to be
                professionally done, but they do have to conform to the guidelines and
                standards of the news organization
               Create a presence at county festivals and older adult events—high
                priorities for rural media—by providing print materials and people who
                can answer questions. Such contributions may provide an opening to
                convince the editor of the worth of a weekly column on health promotion
               See if the paper saves money on printing costs by using a holding
                company that prints three or four other small county newspapers. A
                regular column published in one weekly could be published in the others
                and ultimately cover a much larger circulation area

        Biweekly and Tabloid Newspapers

               In contrast to the emphasis on breaking news at daily newspapers,
                biweekly and tabloid newspapers—like weekly newspapers—emphasize
                feature stories
               Any press release going to a biweekly or tabloid newspaper should include
                quotes, different opinions, testimony, and good photos
               Call ahead—usually four weeks—to find out if the biweekly or tabloid
                wants an information sheet on a health promotion campaign or event



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        Other Publications

               Consider contributing to:
                   o Church bulletins
                   o Employee newsletters
                   o Communications among members of fraternal, social or civic
                      organizations

        Electronic Media

        Radio Stations

               Get to know the station managers, if possible, and always know the
                receptionists. In many cases, it is the receptionist who has primary
                responsibility for community relations for the station, and can be an
                advocate for including news on health promotion efforts or events in the
                station‘s programming
               Arbitron ratings may be available to help identify the station with the most
                relevant audience. However, radio station salespeople can usually be
                relied upon to know their listening audiences. Ask for handouts on
                listener demographics by age grouping and keep them on file for quick
                reference
               The format generally determines which station is best for a specific age
                group or for a particular health promotion message. Look for a format
                with a more eclectic approach—playing big band music or special
                language programs—to get the message to your target audience

        Television Stations

               Each rural television station, like every radio station, runs PSAs. Stations
                vary in their commitment to PSA development, so make sure the PSA is
                easy for the stations to use. A tape that is ready to go will receive more
                airtime
               Seek out interview opportunities on public service shows or within
                newscasts. Work directly through the producer and offer your
                spokesperson as a resource on those particular issues
               Try to access the medical segment of local television news programs.
                Health reporters at television stations develop stories from the constant
                stream of calls, letters, and faxes they receive from companies and
                organizations. A prevention-related health report can enlighten people
                about how to take care of themselves, and the news organization receives
                credit for being interested in public well-being
               Due to deadline pressures, television reporters need to have stories spelled
                out to them quickly—they have limited time for research. Try to allow at
                least two hours before broadcast for a story to be completed.
               They need a story that is visual and action-oriented


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               Once contact has been made with a person at each television station, begin
                monthly phone conversations with them so they will not forget your
                organization

        Public Radio and Television Stations

               In many rural areas, public television and radio stations offer the largest
                viewing audience. Because of the recent increase in channels available
                through cable, public channels are perceived as having fewer viewers than
                commercial channels, but it is not true
               If commercial television is not a viable option, look into public media
                resources: their audience often not only includes a large number of regular
                viewers but also covers a wide geographic area
               To gain access to public media resources:
                    o Write news releases for radio delivery by using short sentences that
                       can be read easily. For a timely event, news personnel often
                       follow up to get a taped interview to go with the regular radio
                       news. Give the news bureau time to respond to a news release—at
                       least a week
                    o Ask about newsbreaks on nationally syndicated radio programs
                       such as ―Morning Edition‖ and ―All Things Considered‖
                    o Volunteer for televised fundraising events over public television.
                       Staffing telephones to take information on call-in contributions
                       provides an opportunity for your organization to be visible while
                       you are helping a community media resource
                    o Ask the public television programming director if he or she is
                       seeking new ideas for an original production in the station‘s
                       studios. Grants often make a production about a worthy
                       community service possible
                    o Volunteer to serve on the public television advisory council

        Cable Access Channels

Many rural cable companies, which depend on the city or county government‘s
agreement with the company, designate up to 5 percent of their income from cable fees to
a community access channel.

These channels are not sophisticated in their visual approach to programming, but they
offer a large segment of the population an opportunity for access.

A community access channel views itself as a service to the community and so it is an
opportunity for health promotion activities. Personnel from rural community access
channel often encourage groups and individuals to use the facility and, sometimes, the
equipment for the creation and cablecast of unique programming.




Live Well, Live Long: Steps to Better Health                                             109
        Cable Television Ads

Cable companies have appreciably lower advertising rates than commercial television
stations. The Cable Spot Advertising Directory is available through most cable company
ad departments if they are members of the Cable Television Advertising Bureau
(telephone (212) 751-7770).

The directory contains information on:
 The market—geographic area served
 Areas served—cities, villages and townships
 Homes served—actual number
 Penetration—percentage of the total number of homes in the area served by cable
 Rates—based on 30-second ad airtime, determined by time of day aired. Ask about
   access to CNN, ESPN, TNT, USA, and TNN
 Sales contact—name and telephone number

A word of caution: Salespeople are available to take orders in any locale in the country,
but because cable advertising is so new, the sales staff is often difficult to reach. To save
time and frustration, if your organization or program has a 30-second spot on Beta Cam
available, ask one of the more accessible cable advertising sales staff to broker the ad to
designated cable companies.

Tips for Accessing Rural Media Successfully

   Remember that good ideas are appealing to rural newspapers. Talk to the
    advertising personnel to get financial backing from area businesses for a special health
    promotion effort.
   Rural media outlets tend to be operated by small staffs—sometimes they are one-
    person operations. Timing your visit will be very important—get to know their
    deadlines and hours of operation. It might take some work (repeated visits and
    telephone calls), but the outcomes can be varied and interesting.
   Make a personal visit to the managing editor or radio manager for editorial support of
    your project. Rural media sources often support pet causes: try to determine what the
    editor‘s special concerns and interests are. Then pitch your information to the editor‘s
    special concerns or interests.
   Piggyback a health promotion message on exercise by sponsoring a sports team.
    More and more communities are developing team sports for older adults. The reporter
    will write sponsorship identification into the story every time the team plays.
   Pitch a creative special-feature story idea to the city editor that will enhance hard
    news stories. Allow four to six weeks for planning.


The most successful communication efforts in rural markets are often the result of
networking with other organizations, both nonprofit and profit. Know when to piggyback
on other efforts in the community and when to release a story individually.



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Special Considerations in Developing Rural Media Relations

               Accessibility. The smaller newspaper has an accessible newsroom. Walk
                through it and talk with reporters, editors, and layout personnel. After a
                few well-timed visits, your organization or program may get called upon to
                provide input for stories.
   Circulation. Most rural newspapers have a circulation of 25,000 or less for a Sunday
    issue. Often the readership is 16,000 to 20,000. Getting a prevention message to a
    large audience requires planting the story in more than one media outlet.
   One editor. Most rural print sources have one person who makes decisions on placing
    stories. Find out who that person is and establish a good relationship with him/her.




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          Live Well, Live Long: Steps to Better Health—Blueprint
         Health Promotion and Disease Prevention for Older Adults

                               Working with Mass Media

Using the Internet

Table of Contents
                Introduction
                E-mail
                Web Sites

Introduction
Why use the Internet?

               Using the Internet increases outreach to traditional and non-traditional
                audiences. Growing numbers of older adults and caregivers are Internet-
                savvy
               For public relations and educational campaigns the Internet offers two
                major communication tools—e-mail and websites

                E-mail sends messages almost instantly to parties connected to the Internet
                who have their own mailboxes or accounts. Unlike faxes, the message
                transfers electronically and may be copied directly into a document,
                newspaper story, newsletter or television script.

                Websites have the advantage of providing extensive, timely information to
                Internet users who wish to access it at any time of day or location, and of
                allowing content to be printed or copied to other documents.

Who is our target audience?

                   On the Internet we have two major target audiences: older adults and
                those who care for them—their families and other caregivers

    Older Adults

               Of all computer users, 24 percent are older adults, most between the ages
                of 60 to 69, 14 percent are people age 70-79 and 4 percent are 80 and over
               Almost as many older adults have searched the Internet as use computers
               More than half of the older Internet surfers are looking for strategies to
                maintain independent living




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    Families and Caregivers

               One-quarter of American women who work outside the home provide
                caregiving to a family member and, as of May 2000, more women are
                online than men
               The Internet has becomes an important resource for information on
                medical conditions and products and services to assist in better care

E-mail
Advantages

Using e-mail for promotion and publicity complements the standard marketing
techniques. The advantages of using e-mail are:

               Ease in reaching the media through the Internet. Many editors and
                journalists have turned to e-mail as a contact point
               Low cost. After paying for online service ($20 to $50, depending on
                modems and cable connections), the more e-mail you send the less
                expensive it is to use
               Record of communications. By saving the e-mails sent, you have a
                written trail of communications
               Less intrusive. E-mail offers a less intrusive means than a phone call to
                convey information. The editor or journalist can read it or delete it at a
                convenient time
               Improved quality of presentation. Unlike voice mail, the sender has more
                time to construct and present the main points of the promotion
               Timely. E-mail can instantaneously send and receive communications. If
                you respond to deadlines in a timely manner and provide an already typed
                format that can be easily edited, you will save journalists time and effort

Disadvantages

The downsides to e-mail distribution of news releases and information are:
          The inability to send group releases

                Many organizations are using new "anti-spam" software (software that
                prevents hackers from overloading an e-mail system with multiple copies
                of messages or advertisers from sending offers indiscriminately), which
                may limit the number of e-mails that can be sent at one time.

                The software either searches subject or sender lines for keywords or
                blocks e-mails that are sent in groups. An error message is usually
                returned. Some formatting tips sometimes ―trick‖ the system. (See the
                section on formatting news releases.)



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               The lack of personal connections to reporters and those receiving
                information

                The personal connections can often encourage publication of the
                campaign‘s information or speed a news release insertion.

E-mail news releases only complement the traditional public relations methods and,
although the process is not as time-intensive, it still requires thoughtful preparation and
execution. Follow-up with media contacts through phone calls is still advisable.

Steps in E-mail Promotions and Publicity

    Development of E-mail Media Lists

    Structure

               Develop contact lists and create a database of e-mail addresses. A simple
                database includes contact information and date of the last contact. Here‘s
                a sample record:

                  Name                           Steve O‘Keefe
                  Address                        http://www.wiley.com/compbooks/
                  Topic/ publications            Publicist for Dr. Seussville
                  Last update                    5/97

               Categorize each listing to ensure appropriate messages go to appropriate
                contacts. You can do this by turning to your database program. For
                example, in Access, the database creation wizard asks you what ―fields‖
                you want to use: name, address, organization, media. When you select
                any one of these fields as you enter the basic information, you have
                created categories. When you ask your database for information, you can
                reference any of the categories or fields

               For developing national contacts, include http://www.nbc.com for media
                contacts. Use http://www.Four11.com/ as a phone book on the Internet to
                find e-mail addresses of people online. This voluntary directory may help
                you to look up a journalist by name
               For local contacts, adapt registration materials for any of your programs or
                news briefings to capture e-mail information
               Create your print media list by:
                1. First, identify your target publications
                2. Check the "staff box" in the magazine or paper you wish to contact
                    and look for the @ sign, which indicates an e-mail address
                3. Check the bylines or end of articles for addresses that include an @
                    sign



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                4. Develop a list of freelance writers who cover the ―age beat,‖ since
                    more print media are contracting for articles and features
               For broadcast media, scan the credits of television programs to find the
                show producers or listen for the names of special program producers on
                the radio. Public radio often gives an e-mail address to contact the station

For local broadcast media, call the station and ask for the e-mail address of the news
director.

    Maintaining the Media List

               You will want to track responses to your e-mails
               Continually groom the list to eliminate bad addresses and refine effective
                contacts. To promote good business relations, remove contacts‘ names
                when they ask to be taken off the list
               Be aware that e-mail addresses may change often, so keeping your
                database current is an ongoing process.


    Formatting E-mail News Releases

An e-mail news release consists of two parts: the address section and the message
section.

    Address Section

               The address section includes an area for you to enter e-mail addresses and
                to complete a subject line
               The address lines include the primary address, carbon copy (cc) and blind
                copy (bc) fields. The recipient does not see who received the blind copies

                Often you can avoid "spamming software" by putting group addresses in
                the blind copy box instead of the "To" box. This tactic also keeps your
                contacts confidential.

                Placing the addresses in the blind copy field also keeps the e-mail list
                short (sending the names of 350 journalists in the "To" field could result in
                19 pages of addresses before the message even begins—an immediate
                candidate for the delete button).

                Since you are not putting your media list in the "To" box, put in your own
                address or type "News Release."

    Subject Line
            Get the attention of the reader without using cheap tricks to entice the
               recipient into opening the e-mail


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                Dramatics or "cute" phrases call into question your credibility as a reliable
                 source of news
                Be honest and concise. Limit the subject to 25 characters, since most
                 fields will not hold more
                Good examples are:

                     News Release or ―News‖ and a short promotion of unique
                     characteristics of your story

    Avoid:

                "Check out my Web site." It has been overdone
                Using all capital letters in the subject line. It's the equivalent of shouting
                 on the Internet, and the mark of a beginner

    Message Section

    Content

The message should contain no more than three paragraphs:

                Paragraph one is the hook. Offer a relevant story associated with another
                 current news story or national event
                Paragraph two is the pitch. Make the pitch a brief description of the event,
                 the promotion or the campaign
                The final paragraph provides the contact information. Entice the reader to
                 reply and ask for a media kit or sample, or to register for an event

    Formatting for Professional-looking Copy: Solutions to Common Problems

                Line justification
                 E-mail software allows only a certain number of characters for each line.
                 Different software allows different line lengths. When you write your e-
                 mail, the text looks as if it is goes to the end of the line and "wraps"
                 around to the next line.

                 But, if the reader's software allows fewer characters per line than yours,
                 your reader will receive an e-mail that goes to the end of a line and then
                 includes only a few words on the following line, before beginning a new
                 long line. This "jagged edge" makes text difficult to read and tips off the
                 reader that a beginner is sending this message.

                Quote marks
                 When you use quotes, dashes or possessive single quotes, the reader's e-
                 mail may display them as asterisks, greater/less than signs or the symbol
                 for ―equals.‖


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               The solution to both of these formatting problems is to:
                   o Write the message using word processing software such as Word
                       or Word Perfect, that has a 60-character line length.
                   o Save the file in ASCII format. (Go to ―File Type‖ and choose
                       ASCII format)
                   o Check the file for problems and run the spell check
                   o Copy and paste the text into the message section of your e-mail.
                   o Save a copy of the message in the original format (Word or other
                       software). If you want to use this original copy for additional
                       releases or reports, it is easier to edit and cut and paste if the text is
                       in the usual software forma.

    Signature Section

               It is best to eliminate the signature in an e-mail news release

               The signature is text that automatically follows the message. Most people
                use this feature to include contact information. However, it may have
                similar formatting problems to the message section and most people will
                contact you with the reply feature of the e-mail

    Testing

You will want to check your news release:

               To ensure the e-mail addresses remain hidden
               To see how the lines break in the text
               To make sure that the signature feature is turned off
               To correct bad addresses

Send variations of the release to yourself or a friend using other e-mail services, such as
America Online or CompuServe.

Websites

               Before you consider creating a website, consider attaching your
                promotional materials to another site. Partnerships avoid the technical
                work of putting together a site

               Your community may have a local site to which you can attach
                information. Contact your city, parish or county public relations office or
                office of the mayor or commissioners




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Developing a Website

The complete story on how to develop a website is beyond the scope of this website, but
here are some basic tops for making a site more accessible to older readers.

    Balance the text and open space

               Increase readability by including some empty space around your smaller
                blocks of text. Good web designers use a column format, which can
                include a wide margin on either the left or right side of the page

                Current designers leave a wide margin of one to two inches on the right
                side of the page. The wider margin accommodates various monitor types
                or window sizes. However, this can produce longer text.

               The longer the text on each page, the more the reader will need to "scroll
                down" or move the cursor or mouse down the page to reach the end

                Scrolling can lose the reader's attention. Instead, develop hyperlinks,
                which allow the reader to click on a topic and skip to more detailed
                information or another section

    Divide topics into manageable sections

               Many people prefer to print documents to read at their leisure or give to
                others. A large document often requires printing more information than
                desired

                Breaking topics into smaller sections maintains the reader‘s attention
                better and is more convenient for printing

    Avoid animation and complex graphic images

               Flashing, blinking or moving objects or banners pull the reader away from
                the text and are visually distracting
               Animation and complex graphic images may take a long time to load,
                which is frustrating for the visitor to your site

    Justify paragraphs

               Justify the text to the left-hand side to improve ease in reading
               Full justification (to both the left and right margins) can produce irregular
                spacing between words and letters, causing visual confusion
               Centered text is the least readable and should only be used for titles




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    Use color judiciously

               Bright, fluorescent or vibrant colors are distracting and tiring to the eye
               Difficult-to-read text colors include yellow and combinations of blue and
                yellow or red and green
               Colorblind people may have difficulty with red and green combinations

    Create contrast

               Due to the yellowing of the cornea and eye fluids that occurs with age,
                seeing light colors becomes more difficult
               High contrast between foreground and background colors helps to make
                the text more visible
               Select dark type on light or white backgrounds
               Strong or highly textured background patterns make reading the text
                difficult
               Maintaining contrast between text and a neutral background makes text
                more readable to everyone, especially older people
               It is best to use no pattern at all for background

    Use fonts that are legible on computer screens

               Avoid dramatic fonts such as Old English
               Choose serif fonts like Times New Roman, Courier or Century School
                Book
                Times New Roman
                Courier
                Bookman Old Style
               Drop shadows on text also make text difficult to see.
                They are used to give words the appearance of depth

    Use fonts judiciously

               Use the same fonts throughout the site to create continuity

               Bold type adds impact, but any design element loses emphasis if used all
                the time. Use bold only to emphasize a title or a keyword

    Choose an appropriate font size

               Twelve- and fourteen-point type are the best font sizes for body copy.
                Make headlines and titles two or four points larger
               Make sure your font sizes are consistent




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    Provide adequate white space

               Include enough space between paragraphs and sections to allow the eye to
                rest
               Pages busy with copy look so daunting that the reader is inclined to skip
                over them
               Use extra space to highlight important text or change of topics

    Avoid words in all capital letters

               The eye has difficulty distinguishing rapidly between capital letters
               Use a capital letter only at the beginning of each word to set off a title or
                section or when grammatically correct

    Maintain format consistency and special features

               Underline all links (jumps to another part of your site or another site). This
                is a convention used throughout the Web

                Reserve underlines as cues to the reader that an underlined phrase is a link.
                Don‘t use underlining for any other purpose

Website Best Practices

Family Caregiver Alliance
www.caregiver.org

Abstract
Family Caregiver Alliance (FCA) is a non-profit organization. By creating a website,
FCA expanded its outreach beyond northern California communities. The site
demonstrates a number of principles for good Web presentation—use of white space,
visual organization, and ease of reading and navigating.

Site Presentation
Use of White Space

               FCA has divided the pages on the site into a two-inch index column on the
                left, and a four-inch column containing facts and information

                This division dedicates almost one-third of the page to white space. The
                text is better highlighted and easier to read.

               Colors are used for lines, titles and links. The colors act to highlight the
                text information presented in black, and reproduce well when downloaded
                and printed


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Visual Organization

               Using bullets and bold type and italics enhances the impact of each point
                the document addresses
               With the headings clearly marked at the top of the page, the topic of each
                page is clearly designated. Lines connect the index topics creating a path
                for the eye to follow. Links to other parts of the site are highlighted in the
                left column with a line dividing the links from the text

Ease of Reading

               Sentences are kept to two lines of the text block
               Within the fact sheets, terms are defined before the reader moves further
                into the descriptions of facts, symptoms and diagnosis and treatment.
                Technical terms, when used, are followed by a brief explanation in
                parenthesis

               The writing level is appropriate for a seventh grade reading level
               Typeface lends itself to easy reading as a ―serif‖ font (or ―book‖ font).
                Some of the titles are capitalized, but most of the text uses the easier-to-
                read upper and lower case format found in book print

Ease of Navigating

               Readers can navigate to any part of the site by clicking on a topic at the
                top left of a page or at the bottom of the page




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AARP
www.aarp.org/wellness

Abstract
As part of a new appeal to the next generation of older adults, AARP recently created a
website to provide not only health information, but also prevention tips and consumer
advice. AARP demonstrates what larger aging organizations can do with Web presence.
The site demonstrates a number of principles for good Web presentation—use of white
space, visual organization, appropriate use of graphics, ease of navigating.

Site Presentation
Use of White Space

               As with FCA, AARP has divided its pages into a two-inch index column
                on the left, and a five-inch column containing facts and information. This
                division dedicates almost a quarter of the page to white space. The text is
                better highlighted and easier to read

Visual Organization

               Each topic is highlighted in a light-colored title box. Under the title box
                fall the topics contained in that section. Visually, the page appears to be
                organized in discrete boxes addressing discrete topics
               AARP has capitalized on past articles that have appeared in its magazines
                and on the website. The AARP web designer has bulleted the articles
                related to a topic such as staying fit. Clicking on a descriptive article title
                sends the reader to another well-organized page with title boxes, bold
                heading for short descriptions or action steps and bulleted links. The
                consistency of the design throughout the site guides the reader to expect a
                similar format for each page
               With the headings clearly marked at the top of the page, the topic of each
                page is clearly designated. Lines connect the index topics creating a path
                for the eye to follow. Links to other parts of the site are highlighted in the
                left column with a line dividing the links from the text

Appropriate Use of Graphics

               The AARP designers have not overdone the placement of graphics

                Each page has a contemporary picture at the top right. At the left, the
                designers have incorporated a topic logo in the two-inch directional
                column. In some of the reproduced articles, cartoons or drawings appear.
                The drawings avoid stereotyped images.




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Ease of Reading

               Sentences are kept to two lines of the text block. The text reads like a
                magazine. Technical terms are defined but rarely used
               The sans-serif font (typeface without the short lines extending from the
                upper or lower strokes of a letter) is used extensively in the text. Visually
                attractive, the font can become difficult to read over time
               Colors are used for title boxes, titles and links

                The color highlights the titles. Black lines divide each page. The white
                background makes the black text easy to read. The colors on the screen
                reproduce well when downloaded and printed.

Ease of Navigating

               Readers can return to the home page by clicking on ―wellness‖ in the left
                directional column

                Other topics can also be accessed.

            o The search feature at the top of each page is also an advantage when
              navigating to other parts of the site. A link to the top of the page is
              strategically placed throughout articles or indexes. Related topics can also
              be found in the left directions column


Other Considerations

    Consider hand-eye coordination

               For users who have not grown up using a mouse or those with diminished
                motor capabilities, double-clicking or scrolling can be awkward and
                frustrating
               Make all links that require clicking the mouse large and static
               Increase the borders surrounding a link so that the button is better targeted
                and easer to hit




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    Archive past publications

               If you have newsletters or articles that may be of interest to people
                researching a topic covered in your health promotion campaign, develop an
                area on your site for these past articles
               Archives are especially important if links from your site to other websites
                were made. It is frustrating for readers who think they have found the
                perfect article on their subject to receive an error message that the page
                cannot be found
               Redirect the old links to the archive directory page so readers can look for
                the archived article in your table of contents. This page should be organized
                in a logical format by year or topic

    Provide search capability

               Search features give the reader the ability to search the site using a
                keyword, topic or title

    Avoid using tables

               If readers are downloading tables, some printers will not include the table
                format
               As an alternative, provide a text-only version of the page

Web Page Resources

               Laura's Web Zone
                http://www.lne.com/web
                Author of "Teach Yourself Web Publishing with HTML"
               Web Reference.Com
                http://www.webreference.com
                Book reviews, legal considerations, software and graphics
               Michael Shea's Internet Page http://justice.loyola.edu/~mshea/html/internetpage.html
               Conceptual approach to Web design—planning designing, maintaining and
               testing
              ―Contentious‖
                http://www.contentious.com
                Online writers and editors magazine and meeting ground
              WebWord.com
                 http://www.webword.com
                 Articles and original material on variety of content issues




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                Webgrammar
                 http://www.webgrammar.com
                 List of resources for Web writers
                Content-Exchange
                 http://www.content-exchange.com
                 Resource for online editors and writers, including a database job bank
                Jakob Neilsen’s AlertBox columns
                 http://www.useit.com/alertbox
                 Biweekly column on Web usability
                The Usability Methods Toolbox
                 http://www.best.com/~jthorn/usability
                 James Horn‘s collection of usability tools
                Info.Design
                 http://www.infodn.com
                 Website of two Washington, DC-area information architects
                Web Review Archive
                  http://www.webreview.com/archives
                  Archive of ―Web Architect‖ articles written for Web Review
                  (online magazine self-styled ―Cross Training for Web Teams‖)
                Web Review Content Section
                 http://www.webreview.com
                 Website‘s section on content
                Bobby.com
                 http://www.bobby.com
                 Web-based tool that analyzes Web pages for their accessibility to people
                 with disabilities.
                Web Monkey IA tutorial
                 http://www.hotwired.lycos.com/webmonkey
                 ―The Web Developer‘s Resource‖
                Columbia Guide
                 http://www.columbia.edu
                 Guide to online writing and text style
                Dave’s Site
                 http://www.davesite.com
                 Html tutorial
                Builder.com
                 http://www.CNET.com
                 Web Builders‘ section on accessibility

Promoting Your Website

There are many ways to promote your website once you have developed and tested it, and
have finally gone online.




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    Search Engines

               Search engines are software programs that help Internet users look for
                information

                Considered the "card catalog" of the Internet, the search engines ask you
                for keywords that describe the topic you want to know more about

                They then search their databases for matches. Many search engines post
                websites at no cost

    Registration on Other Sites and Search Engines
    Spiders

               Also referred to as web crawlers, spiders are search engines that use
                automated programs to scan sections of the Internet. They follow
                hyperlinks and search web pages for specific terms that can guide users
                looking for sites on specific topics. Examples are Alta Vista and Lycos

               You do not need to register your site with these search engines because the
                spiders search automatically

    Directories

               Directories are based on descriptive words, also known as key words,
                submitted by the Web page designer to characterize the information found
                on a site
               Unlike the spiders, directories are controlled by humans who wait for Web
                designers or sponsors to register their sites
               The information requested includes:

                         Name
                         Contact
                         URL (or Internet address)
                         Title of the site
                         Categories and headings
                         Keywords
                         25-word description of the site

    Registration Sources

               The number one resource for gaining visibility is
                http://www.siteowner.com. Registering your site will take you less than
                two minutes and will almost instantly increase the number of visitors
               In the ―Submit it! Free‖ box, type the URL of your site and click the
                ―Submit it!‖ button. Your site will automatically be listed in six of the


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                most popular search engines—Excite, HotBot, Lycos, AltaVista, InfoSeek
                and WebCrawler

               The following are other important search engine sites:
                        Google                www.google.com
                        Northern Light        www.northernlight.com
                        Yahoo!                www.yahoo.com

           You can also scan the listings on the Yahoo! Web Directory
                       1. Go to www.yahoo.com and enter the words ―search engines‖ or
                           ―web directories‖ in the search field.
                       2. From this listing, you should be able to identify specialized
                           search engines and web directories in your subject area.

    Linkage Campaign: Seeding the Internet with Links

To increase traffic on your site, you can also determine what other sites might be
attractive to your target audience and have a link placed on that site to yours. These are
called hyperlinks.

               Hyperlinks allow readers to click on a button or address listed on a page
                and jump to another site. More formally, hyperlinks direct the browser to
                open another file containing your site

               To approach the webmaster or designer of another site about a linkage,
                prepare a link letter

                Send the letter by e-mail to sites of like interest to your target audience.
                In the letter, provide your website address and a description of the site.

               If the link is accepted and implemented, you will want to know how the link
                affects traffic on your site

                You can code the links to determine the most useful sites. This operation is
                fairly technical and will require the help of a webmaster.

Incentives To Use the Site

        Make sure your site is technically “fit”

               Technical difficulties in reaching your site frustrate the reader and can
                result in lost credibility

                To ensure your site is technically "fit," check to see if all pages, buttons and
                links work.



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                 Plan regular tests of each page‘s operation and the links within the site and to
                 other sites.

                Keep your information current. It is easy to continue to develop new pages
                 and forget that the pages you developed six months ago need updating

    Incentives

Since you want viewers to return to your site, develop incentives to return.

        These can include:

                A daily news feature presenting three or more one-paragraph news items
                A calendar of activities
                Online newsletters
                Posting new health promotion presentations recently offered in the
                 community or at conferences
                Resource pages with links to other sites of interest to your target audience

        A library of resources can include frequently asked questions about a health
        promotion topic or provide supportive materials to the home page message.




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          Live Well, Live Long: Steps to Better Health—Blueprint
         Health Promotion and Disease Prevention for Older Adults

Creating Culturally Sensitive and Effective Health Promotion Materials

Introduction
When projecting growth in the aging of America, demographers anticipate:

               25 percent of the population will be over 65 by 2030
               25 percent will be nonwhite
               In some areas of the country (the Southwest and some regions of
                California), the nonwhite population will make up the majority of elders

Today, the aging population is more diverse than ever in terms of race, gender, sexual
orientation, ethnicity and language, immigration history, socioeconomic levels and
education.

In this changing demographic mosaic, in order to best serve all elders, the care provided
by health and social service programs must also change.

This section highlights examples of programs working within the cultural
framework of a community. Some may or may not be applicable to your programs.
The purpose is to provide a spectrum of possibilities and opportunities for you to
understand and test the concepts for your particular community.

Table of Contents
        The Role and Importance of Culture
               What is culture?
               How does culture affect medical care?
               Where do I start in developing appropriate health messages and services?
        Targeting Messages
               Attitudes, Values and Behaviors
               LGBT Experience
               Variations within Cultural Groups
               Language and Translations
               Racial and Ethnic Terms
               Sexual Orientation Terms
               General vs. Targeted Messages
        Steps to developing Culturally Appropriate Messages
        Common Mistakes in Developing Culturally Appropriate Messages
        Resources




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How does culture affect medical care?

Culture impacts the understanding between provider and client in relation to:

                   Symptoms
                   Treatment
                   Compliance
                   Basic information important in making healthcare decisions

Culture shapes behaviors, beliefs and attitudes about care related to:

                   Diet
                   Recreation choices
                   Residential choices

Culture governs beliefs about:

                   Health
                   Societal response toward illness
                   Definition of causes and treatment

Healthcare and social service providers must understand the effects of cultural
components such as ethnicity, language, race, immigration and historical experiences,
and use this knowledge in designing appropriate health communications and programs.
Culturally sensitive health promotion programs can:

               Reduce misunderstandings based on cultural belief systems between
                providers and consumers
               Empower older adults and their families, partners and friends to
                successfully navigate through the healthcare system
               Assist older adults in making better decisions about personal health
               Contribute to improving the health status of the nation‘s racial and ethnic
                communities, making outreach efforts more effective

There is no magic formula for health promotion that works for all older people.

               Each region of the country often has differing customs, dialects, beliefs
               Each region of the country has differing laws and levels of acceptance
                regarding sexual orientation
               Older people have various levels of identification with their culture,
                history, gender, sexual orientation or generational values
               Development of guidelines often reinforces stereotypes rather than
                focusing on the desires, strengths and needs of the older person




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A few points are universal, however. When developing messages and materials:

               DON‘T simply substitute multiracial faces for white faces
               DO create an information flow that is viewed and accepted as part of the
                culture
               DO carefully assess particular communities through:
                    o Focus groups
                    o Discussions with key leaders
                    o Collaboration with organizations already successful in that
                        community

This section highlights examples of programs working within the cultural
framework of a community. Some may or may not be applicable to your programs.
The purpose is to provide a spectrum of possibilities and opportunities for you to
understand and test the concepts for your particular community.




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          Live Well, Live Long: Steps to Better Health—Blueprint
         Health Promotion and Disease Prevention for Older Adults

Creating Culturally Sensitive and Effective Health Promotion Materials

The Role and Importance of Culture
What is culture?

               Culture provides people with a framework for living and for interpreting
                their environment
               Culture can emerge from ethnicity, language, nationality or religion,
                sexual orientation or gender identification, but it is not synonymous with
                any of them
               Culture incorporates:
                            o Language
                    o Shared values
                    o Traditions
                    o Norms and customs
                    o The arts
                    o History
                    o Folklore
                    o Institutions
               Culture shapes how people see their world and structure their community
                and family life

    Where do I start in developing appropriate health messages and services?

    Whether you‘re talking about a midwestern farm community or San Francisco‘s
    Chinatown, culture affects how people respond to messages communicated through
    various channels:

               Mass media
               Community events
               Family discussions
               Person-to-person encounters

Step 1. Considerations When Designing Targeted Disease Prevention Messages

               Beliefs about health are often based on folk wisdom, traditions and
                customs
               Beliefs about health services and care can be based on legal sanctions
               Beliefs, customs or traditions may reinforce old patterns that no longer
                work



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               Older adults may have modified customs or traditions, engaging new ways
                of coping with our rapidly changing American culture




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Examples—Health Beliefs

In Boston, for example, a study found that many Chinese elders turn to traditional
medicine for care of chronic conditions and rely on Western medicine for acute care.

Health beliefs among various ethnic groups may have shared qualities.

Studies conducted by Harborview Hospital in Seattle found that many first-generation
immigrants from Vietnam believe there are three causes of illness:

             1. Natural occurrences such as spoiled food
             2. Supernatural powers, meting out punishment or retribution
             3. The imbalance of yin and yang or hot and cold

Similarly, curanderismo, a belief system of some Mexican American elders in Colorado,
embraces five elements:

            1.   Humoral theory of illness (related to air, water, wood)
            2.   Personal characteristics that relate to susceptibility to illness
            3.   Naturalistic folk conditions such as empacho (intestinal distress)
            4.   Mystical causes such as fate or the evil eye
            5.   Magical causes brought on through witchcraft or hexing. Prayer, herbs,
                 diet and ritual contribute to healing and maintaining health

But remember, even though these cultures may share some beliefs, approach each
culture carefully to avoid a stereotypic response. Ask about treatments, and where
the older person receives care. Listen and learn.



Step 2. Considerations When Creating Preventive Care Programs

          The essence of a culture is frequently expressed through its proverbs and traditional
   sayings. The African saying, “It takes a village to raise a child” expresses community
   support for persons outside the nuclear family to become directly involved with disciplining
   and directing a child. An Asian proverb says, “The nail that stands up gets hammered
   down.” This proverb conveys disapproval of displays of wealth or achievement and
   emphasizes community progress. In many communities, then, it is important for those
   planning health promotion campaigns to place high priority on understanding cultural
   relationships and their impact on the campaign.

                Use the positive strengths of traditional beliefs
                Incorporate new health practices into traditional beliefs




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    Example1—The White Crane Wellness Center

    The White Crane Wellness Center in Chicago serves Russian, Romanian, Korean and
    Japanese elderly immigrants and refugees, as well as African Americans and
    Hispanics. The center has been successful in prevention by developing small
    informal groups to discuss and share health experiences, and by integrating its nurse
    educator‘s knowledge with traditional practices.

    Staff has adopted culture-specific strategies for cultivating trust. A successful
    method integrates healthy diet for older adults with traditional recipes. For example,
    the staff dietitian gathered soup recipes from older Russian women in an English-as-
    a-second-language class. She then substituted healthier ingredients and
    demonstrated the modified dishes during class. Through the instructor‘s
    interpretation, and a shared meal, the Russian women attending the class accepted
    the modified recipes.

    The White Crane Evaluation Committee found that participation increases in classes
    when traditional culture is understood by the staff and incorporated, like the food
    demonstrations, into program content.



     Example 2—Healthy Path for Navajo Elders

     Community and research partner organizations developed culturally relevant
     instructional modules for Navajo elders, to address the epidemic numbers of diabetes
     cases found in the Navajo community. The partners included the following
     organizations:

                             University of New Mexico
                             Navajo Area Agency on Aging
                             Crownpoint Healthcare Facility-Community and Prevention
                              Health Division
                             Navajo Nation Council on Aging
                             Eastern Navajo Health Board

     Two effective program components drew on traditional cultural activities—cooking
     and walking with a Navajo leader.

     As in the Russian program at the White Crane Wellness Center, program staff
     modified traditional Navajo recipes. In this project, the older adults complained that
     the healthier food did not taste as good. Staff developed a strategy of reducing the
     modifications but emphasizing portion control. This incremental change proved to
     be more effective.




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     To increase physical activity among older adults, the program staff organized a
     morning walk for older adults, joined by Navajo community leaders. The incentive
     of walking with their leaders and sharing ideas and asking questions resulted in
     significant participation in the walking program.

     The partnership also created health messages based on cultural phrases. When
     referring to success in life, ―It‘s up to you‖ is a familiar theme in Navajo stories.
     When developing materials related to healthy aging, the program planners inserted
     the phrase ―It‘s up to you‖ to encourage behavior changes.




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          Live Well, Live Long: Steps to Better Health—Blueprint
         Health Promotion and Disease Prevention for Older Adults

Creating Culturally Sensitive and Effective Health Promotion Materials

Targeting Messages
Attitudes, Values and Beliefs

Culture permeates many of our personal attitudes, values and behaviors, including:

               Whether primary importance is placed on the individual or on the
                community
               What roles for women, men, and children are generally accepted
               Whether the preferred family structure is nuclear or extended, one
                generation or multigenerational
               How important folk wisdom, life experience, ―mother wit‖ and common
                sense are in comparison to formal education and advanced degrees
               How wealth is measured—in material goods, like money and property, or
                in personal relationships, like children, extended family support systems
                and friendships
               Whether we revere our elders as the repositories of wisdom
               How time is used and valued—for example, the importance of being on
                time
               Whether people are tradition-bound or open to experimentation
               How religious life and/or spirituality and secular life are linked
               What foods we favor and which are forbidden
               How we dress and adorn ourselves
               What body language means, particularly whether touching or close
                proximity is permitted in specific situations

When developing the background information for your messages and programs, you can
also view cultures as ―high context‖ or ―low context.‖

               High context cultures tend toward nonverbal cues and messages. Fewer
                words are spoken. Asian, Native American, Arab, Latino and African
                American cultures tend to be more high Context communicators
               Low context cultures focus on precise, direct, logical and verbal
                communication, demonstrated among Anglo-Americans, Germans and
                Scandinavians

The following chart shows more extensive characteristics of these two types of cultures.




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High Context                                   Low Context
ASSOCIATION                                    ASSOCIATION
 Relationships depend on trust, build up       Relationships begin and end quickly.
  slowly, and are stable. Appropriate            Many people can be inside one‘s
  respectful gestures and language               circle; the circle boundaries are not
  determine status. One distinguishes            clear.
  between people inside and outside             Things get done by following
  one‘s circle.                                  procedures and paying attention to a
 How things get done depends on                 goal.
  relationships with people and attention       One‘s identity is rooted in oneself and
  to group process.                              one‘s accomplishments.
 One‘s identity is rooted in groups            Social structure is decentralized;
  (family, culture, work).                       responsibility is not necessarily
 Social structure and authority are             concentrated at the top.
  centralized; responsibility is at the top.
  The person at the top works for the
  good of the group.

INTERACTION                                    INTERACTION
 High use of nonverbal elements; voice         Low use of nonverbal elements. The
   tone, facial expression, gestures, and         message is carried more by words than
   eye movement carry significant parts           by nonverbal means.
   of the conversation.                         Verbal message is explicit. Context is
 Verbal message is implicit; context             less important than words.
   (situation, people, nonverbal elements)      Verbal message is direct; one spells
   is more important than words.                  things out exactly.
 Verbal message is indirect; the point of      Communication is seen as a way of
   the discussion is embellished but not          exchanging information, ideas or
   explicitly stated.                             opinions.
 Communication is seen as an art               Disagreement is depersonalized. One
   form—a way of engaging someone.                withdraws from conflict with another
 Disagreement is personalized. One is            and gets to the task. Focus is on
   sensitive to conflict expressed in             rational solutions, not personal ones.
   another‘s nonverbal communication.             One can be explicit about another‘s
   Conflict must either be solved before          bothersome behavior.
   work can progress or be avoided
   because it is personally threatening.




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TERRITORIALITY                                 TERRITORIALITY
 Space is communal; people stand close         Space is compartmentalized and
  to each other, share the same space.           privately owned; privacy is important,
                                                 so people are farther apart.


TEMPORALITY                                    TEMPORALITY
 Everything has its own time. Time is          Things are scheduled to be done at
  not easily scheduled; the needs of             particular times, one thing at a time.
  people may interfere with keeping to a         What is important is that activities are
  set time. What is important is that the        done efficiently.
  activity gets done.                           Change is fast. One can make a
 Change is slow. Things are rooted in           change and see immediate results.
  the past, slow to change and stable.          Time is a commodity to be spent or
 Time is process; one‘s time belongs to         saved. One‘s time is one‘s own.
  others as well as to the natural world.

LEARNING                                       LEARNING
 Knowledge is imbedded in the                  Reality is fragmented and
  situation; things are connected,               compartmentalized. One source of
  synthesized and global. Multiple               information is used to develop
  sources of information are used.               knowledge. Thinking is inductive,
  Thinking is deductive, proceeding              proceeding from specific to general.
  from general to specific.                      Focus is on detail.
 Learning occurs by first observing            Learning occurs by following the
  others as they model or demonstrate a          directions and explanations of others.
  skill, and then by practicing the skill.      An individual‘s orientation is preferred
 Groups are preferred for learning and          for learning and problem solving.
  problem solving.                              Speed is valued. How efficiently
 Accuracy is valued. How well                   something is learned is important.
  something is learned is important.

Remember again, the purpose of this framework is to provide a spectrum of
possibilities and opportunities for you to understand and test the concepts for your
particular community. Let the chart guide you to listen and learn from the older
adults in your community.

Incorporating these concepts into messages and materials can be quite subtle.




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Examples—Cultural Contexts

In a number of Hispanic cultures, a hug is a demonstration of affection, while among
first-generation Japanese, outward physical displays of affection are considered
inappropriate. How the characters in a television public service announcement interact
physically can be as powerful a cultural message as the actual dialogue between them.

In many African American, Asian, and Hispanic cultures, young people lower their eyes
when spoken to by adults, as a symbol of deference to authority. However, other
cultures, particularly those with roots in Western Europe, see lack of eye contact as an
indication that the person is being untruthful.


Lesbian, gay, bisexual and transgender (LGBT) people represent a diverse group dealing
with a range of sexual orientation and gender identity issues. This diversity encompasses
race, ethnicity, age, education, political affiliation, income, and the degree to which
individuals identify with other LGBT people.

Past and current experience have given LGBT people a relationship to the healthcare
system that differs significantly from other ethnic and cultural groups.


LGBT Experience
Experts estimate that between 1.75 million and 3.5 million Americans ages 60 and over
are lesbian, gay, bisexual or transgender. Existing research suggests that older LGBT
adults are satisfied with their lives. The concerns they express about aging are often the
same as those that other older people typically report.

Since 1973, all major medical and psychological associations in the United States have
considered homosexuality a normal variation of human sexuality. In other words, being
gay, lesbian, or bisexual is perfectly healthy, requiring no treatment or behavior change.

Yet even the limited available research on older LGBT adults highlights several issues of
particular importance for LGBT elders, reflecting differences in their healthcare needs.

Stigma

As in the experiences of some immigrant populations, discrimination and hate crimes
have threatened many LGBT people.




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Hate crimes may include:

               Property crimes (like robbery)
               Threats
               Intimidation
               Actual acts of physical violence

Hate crimes differ from other crimes because they:

               Send messages to a particular group of people, their families and other
                supporters that this group is unwelcome and unsafe in particular
                communities
               Are committed by otherwise law-abiding young people, often believing
                that they have societal permission to engage in violence against this group
               Leave behind extensive psychological damage. Although any type of
                victimization carries psychological consequences, the American
                Psychological Association has determined that hate crime victims suffer
                the symptoms of post-traumatic stress for up to five years, in comparison
                to two years for victims of non-bias-related crimes. They may also suffer
                from depression, anxiety, fear, stress and anger.

On top of stresses related to age, sexual orientation/identification stigma adds more
emotional charge to growing older. In their search for adequate healthcare, LGBT elders
often encounter the double stigma of declining vigor and of homophobia.

Mental Healthcare Encounters

Conversion therapy:

               Many older LGBT people either experienced ―reparative" or conversion
                therapies or know someone who did
               Popular in the 1950's and continuing to the present, these therapies
                attempted to change a person‘s sexual orientation, either voluntarily or
                through family coercion
               Treatments once employed such techniques as electric shock or drugs that
                induce vomiting to create an aversion to same-sex orientation. Now, more
                commonly, LGBT elders face therapy grounded in religious-based talk
                sessions
               In the overwhelming majority of cases studied, attempts to change a
                person's sexual orientation failed
               Reported side effects to these therapies include significant levels of stress,
                post-traumatic stress disorder, anxiety, shame, depression and even
                suicidal thoughts or behaviors




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To the credit of the mental health professional community, all the major medical and
psychological organizations have weighed in against conversion therapy, and actively
oppose its practice in the United States.

        "For nearly three decades, it has been known that homosexuality is not a mental
        illness. Medical and mental health professionals also now know that sexual
        orientation is not a choice and cannot be altered. Groups who try to change the
        sexual orientation of people through so-called ‗conversion therapy' are misguided
        and run the risk of causing a great deal of psychological harm to those they say
        they are trying to help."
        -American Psychological Association

        "Most of the emotional disturbance experienced by gay men and lesbians around
        their sexual identity is not based on physiological causes but rather is due more to
        a sense of alienation in an unaccepting environment. For this reason, aversion
        therapy is no longer recommended for gay men and lesbians. Through
        psychotherapy, gay men and lesbians can become comfortable with their sexual
        orientation and understand the societal response to it."
        -American Medical Association

Reluctance to address sexuality:

               As in all older adult populations, LGBT elders seek care for depression,
                stress or addictions and may have difficulty discussing sexuality concerns
               Internalization of negative social attitudes may inhibit seeking help related
                to intimacy, sexual problems, and other adjustment difficulties

Healthcare Encounters

The healthcare system has traditionally refused to recognize homosexuality as a normal
human variation.

               LGBT people generally receive less healthcare than the population at
                large, partially due to negative past experiences and mistrust of the
                medical profession
               LGBT elders visit healthcare providers less often than other older adults
               Discussion of health issues with providers can be guarded for those who
                fear that ―coming out‖ will lead to discrimination

This inability to communicate honestly with a healthcare professional negatively impacts
treatment.




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Sensitivity to LGBT Populations

               The healthcare system often denies the existence of homosexual
                partnerships, even though individuals may be living in life-partner
                situations for many years
               Some hospitals bar visits to their loved ones or disallow participation in
                healthcare decisions with their life partner or in funeral arrangements
               Some healthcare providers make assumptions about the health risks LGBT
                people face and may provide inadequate care (e.g., fear of HIV)
               Healthcare facilities usually lack staff capable of treating transsexual
                people, especially those in transition from one sex to another. Health
                systems have not placed a high priority on addressing transgender people‘s
                needs for hormone therapy, pain relief associated with sex reassignment
                surgery, continued pap smears and prostate exams or supportive mental
                health services. Hormone regimens can result in bone loss in the jaw and
                reduced saliva production, increasing the risk of gum disease and the need
                for oral health

Avoiding healthcare systems can be compounded by other factors:
               Financial reasons contribute to fewer medical visits, since most public and
                private health insurance programs do not recognize same-sex partners as a
                category for receiving family coverage
               Health professionals may not have the knowledge of resources to make
                referrals for older adults exploring their same-sex orientation for the first
                time as an older person



Variations Within Cultural Groups

Messages and materials must also respect the variations within cultural groups.

               Racial and ethnic groups are not monolithic
               People within any racial, ethnic, national or religious group are not
                homogeneous, even though they may hold many cultural beliefs, practices
                and institutions in common
               Some of the major areas of difference within groups include:
                   o Educational level/literacy
                   o Occupation/role in the family
                   o Income
                   o Citizenship, immigrant, or refugee status
                   o Adherence to folk customs and beliefs
                   o Age
                   o Gender
                   o Sexual orientation



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                    o    Geographic area
                    o    Presence or lack of disabling condition
                    o    Health status
                    o    Preferred language

 Race, ethnicity and culture are not the only factors that can be used to identify an
audience. However, take these elements into account when developing messages that
will be targeted toward specific populations, such as women, gays, agricultural
workers or the poor.

Consider your methods of targeting groups in two dimensions:

               Based on culture and linked to race, ethnicity, language, nationality, and
                religion
               Based on additional elements, such as age, gender, sexual preference,
                education level, occupation, and income

Language and Translations

Language often acts as a conveyer of cultural values. However, having the same
language does not automatically mean that a people share the same culture. For example,
Spanish-speaking people in the Americas represent three distinct cultures:

               European (Hispanics with ancestry from Spain)
               African (Hispanics generally with ancestry from the Caribbean and parts
                of Central and South America)
               Indian (Hispanics whose ancestors lived in the Americas before the arrival
                of Columbus)

       Similarly, among French-speaking individuals, the cultures are quite distinct for:

               French Canadians
               Haitians
               Vietnamese
               Immigrants from France

Use of messages and materials in languages other than English can be valuable, but they
should be developed and tested with particular care.

Guidelines for translations include:

              Hiring professionals who understand the nuances and context of the
               language as well as its formal structure
              Avoiding word-for-word translation, which often misses key elements of
               the intended message and communicates wrong or confusing information



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              Seeking references for translators within the target population. Fluency in
               a language other than English, particularly if the language was learned in
               a classroom, does not always guarantee the insight into the culture that is
               necessary for an effective translation
              Reflecting the special history and culture of the population with a specific
               dialect. Avoid heavy-handed use of slang phrases and poor grammar.
               Use appropriate phrases and word images that have special meaning to
               target audiences
              Pre-testing carefully with the target audience to avoid messages and
               materials that are insensitive, insulting, or unintentionally humorous
              Translating the materials back to English. A good rule of thumb
               acknowledges a 95 percent consistency in the reverse translation with the
               original English-language material as an appropriate indicator of an
               accurate translation

Racial and Ethnic Terms

Words are very important in the development of culturally sensitive messages and
materials. Terms that refer to race and ethnicity often have both overt and hidden
meanings. For example, many people of color resent use of the words ―minority‖ and
―nonwhite.‖ Whenever possible, use the descriptive term preferred by the majority of
that specific group. This may be based on nationality—such as ―Japanese‖ or ―Lakota‖
—or a may be a broader term, like ―persons of color.‖ In some instances, it is preferable
to use a combination of accepted terms. The key point is to listen and learn what terms
are appropriate for your target audience.

Sexual Orientation Terms
Two significant concerns can attract or discourage LGBT older adults from acting on
health messages.

Privacy and Confidentiality
Many LGBT people experience discrimination and sometimes violence. Targeted
messages must convey a nonjudgmental stance, respectful of individual preferences and
identity. Additionally, an appropriate tone should impart a safe environment, especially
if the message promotes services, courses or community activities.


Welcoming Language
In creating health messages, culturally appropriate language, whether relating to race and
ethnicity or to sexual orientation, can create trust and credibility for your target audience.
Use neutral terms such as ―domestic partner‖ instead of heterosexual-relationship
language (married, single, family, husband/wife) when describing relationships on intake
forms or in promotional materials.




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Also, ensure that you distinguish between gender identity and sexual orientation.
Transgender people have a gender identity; their sexual orientation may fall anywhere
within the range exhibited by nontransgender people (i.e., lesbian, gay, bisexual).
People call on a variety of terms when describing themselves. If a person uses a term that
you have heard as insulting—for example, ―fag‖ or ―dyke‖ —ask what word they would
like you to use. This avoids stiff or euphemistic words that convey discomfort or
disapproval.

General vs. Targeted Market Messages

Until quite recently, the preference for many programs was to try to reach everyone with
a basic message rather than target specific groups. The rationale for this broad-brush
approach includes:

               The feeling that we all respond to the same elements of American culture
               The belief that a good health promotion message is so powerful that it will
                reach all groups equally
               The perceived divisiveness of doing separate (―segregated‖) messages and
                materials for different groups
               Lack of time, money and expertise to develop separate, culturally specific
                campaigns and the risk of omitting some groups entirely
               Lack of information and experience in developing successful and relevant
                targeted campaigns

Generally, persons with roots in other cultures can understand messages that use the
images, symbols, and language of the primary culture of their resident nation. But they
may not absorb the message as completely as they would if the communication had
specific meaning for their own culture.

        Tip
        Messages geared toward specific cultural groups are often far more effective than
        general market messages in changing attitudes about healthy behaviors.

Broad messages are still important for media that reach a wide audience, such as
television and daily newspapers.

Augment the general market approach, whenever possible, with more specific messages
targeted at designated audiences.

When using both methods, cultural sensitivity should still be part of the design of any
general market messages. Keep in mind that:

               Every general market health promotion message does not require each
                target group to be represented visually




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 All messages and materials should be inclusive, and none should contain elements that
are offensive or inappropriate to any segment of the population




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          Live Well, Live Long: Steps to Better Health—Blueprint
         Health Promotion and Disease Prevention for Older Adults

Creating Culturally Sensitive and Effective Health Promotion Materials

Steps for Developing Culturally Appropriate Messages and Materials
Step 1. Gather General Information on the Issue You Plan to Address

For example, are there particular ways that illnesses or conditions have historically been
viewed within the culture? Do your homework before you approach the community for
help in designing a program. Listen and learn.

Step 2. Consider the Specific Issue, Aspect of an Issue or Problem You Will
       Address

Sharpen your focus on strategies to use as a starting point for discussion, for example:

               Dietary change
               Ongoing screening
               Avoiding certain foods
               Community action to improve food selection in neighborhood stores


        Tip
        Your ideas should not be set in stone, because the community may have its own
        perspective on the most important problems it sface.

Step 3. Define and Understand Your Specific Target Audience

              Identify key characteristics such as race, ethnicity, nationality, educational
                level, socioeconomic status, religious preference, geographic boundaries,
                age, gender, sexual preference and cultural preferences. Be as specific as
                possible.
              Don‘t assume that national data can truly describe your population
              Involve knowledgeable community leaders in a needs assessment process,
                so that you know exactly whom you are targeting with proposed
                messages.

Step 4. Develop Preliminary Concepts in Concert with People Who Are
        Representative of Your Target Audience

Begin by identifying members of the target population who are respected and influential
in the community. Enlist their help in the planning process. Remember, these




Live Well, Live Long: Steps to Better Health                                               148
individuals may not always be high profile or have the most stature in mainstream
society.

The types of people who are leaders will vary from one group to another. They may:

           Hold formal rank within the religious structure
           Operate within informal spheres of influence
           Serve as teachers or counselors
           Have leadership positions within a group or club
           Be elders who are seen as wise men and women throughout the community.

Gaining the support of people who represent your target audience can provide invaluable
insight into the needs, beliefs, and customs of the audience

Step 5. Test the Preliminary Concepts with the Intended Audience

Even though representatives of the target community were involved in the development
of your concepts, it is still important to test those concepts to check the cultural
appropriateness and potential effects on the issue or problem you are addressing.

        Testing can be done through:

               Focus groups
               Interviews
               Questionnaires

When testing, use skilled and knowledgeable individuals who accurately understand the
community (and are preferably from the community) to ensure that the information truly
reflects the community‘s beliefs.

Step 6. Target Media Channels

Identify media channels that best reach various racial, ethnic, sexual orientation and other
specific audiences. Find out how they are actually used by the audience.

Choosing the appropriate channels can be complicated.

               Most of the target audience views general market media such as television
                and daily newspapers
               The target audience often places more credibility in media owned or
                controlled by members of its own group

Combine general market and target market media to increase the number of times your
message is seen or heard and the number of people it reaches.




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Examples of other channels that are effective in reaching a specific audience with a
health promotion message are:

                Church bulletins
                Flyers posted at the corner grocery store
                Community beauty salons and barbershops
                Laundromats
                Group meetings
                Printed T-shirts
                Women‘s bookstores, LGBT bookstores
                Restaurants, bars or clubs with a specific clientele
                Fraternal organizations associated with the target cultural community
                Community newspapers

Step 7. Using the Pre-tested Concepts, Work in Concert with Community-based
        Experts to Develop or Select Specific Messages for Specific Media

Each communication channel may need a modified message or approach.

For example, a message that will be carried primarily on non-English radio may be quite
different from one that will be communicated primarily in print.

A message designed for word-of-mouth communication should be clear and concise
enough so that the health promotion concepts do not get lost or confused as part of the
spoken process. For example, the flu vaccine campaign in Southern California developed
the catchphrase, ―Bring a friend.‖

Step 8. Field Test the Messages and Materials with the Intended Audience

Even when the preliminary concepts have been tested and the specific messages are
designed in concert with representatives of the community, you should pre-test the actual
messages and materials before a major campaign is launched.

Borrowing from Other Programs

You don‘t need to start from scratch. Often, you can use materials from other programs
that have targeted health messages to similar audiences.

Make sure that the audiences are really similar:

                An outreach program for Asians and Pacific Islander (API) populations on
                 the West Coast may not be effective for API groups in a small midwestern
                 town
                Materials that were developed for recently arrived Mexican farm workers
                 may not be readily accepted by Mexican Americans with roots in this
                 country that go back three generations


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Developing and testing messages and materials with a sample audience will reveal
whether adaptations are needed.




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          Live Well, Live Long: Steps to Better Health—Blueprint
         Health Promotion and Disease Prevention for Older Adults

Creating Culturally Sensitive and Effective Health Promotion Materials

Common Mistakes in Developing Culturally Appropriate Messages
Program developers and providers cannot avoid making some mistakes in working with
diverse populations. Including representatives from the target audience when developing
and selecting messages and materials for campaigns reduces the likelihood of mistakes
and possible damage to relationships with the community.

The following are a few common missteps:

                 Assuming that conventional wisdom, published research studies or
                  common knowledge will hold true for minority audiences
                 Using only print materials. Audiovisual or interpersonal communication
                  may be more successful for some audiences
                 Ignoring variances and diversity within a racial or ethnic group
                 Assuming that the use of targeted media will automatically make a
                  message acceptable to the target audience
                 Trying to target a single message to an audience that is too diverse
                 Using terms or language that are offensive to the target group
                 Assuming that selecting a spokesperson from the target group, such as a
                  popular athlete or entertainer, will turn a general market message into a
                  targeted message
                 Not making revisions as necessary, based on audience reactions and
                  results
                Literally translating written materials without considering the cultural
                 interpretation
                Assuming all older people are heterosexual just because they have not
                 publicly identified themselves otherwise
                Assuming that a gay man‘s health issues revolve around sexuality,
                 sexually transmitted diseases, or HIV/AIDS
                Concluding that all LGBT people do not publicly identify their sexual
                 orientation or identity and wish to stay ―in the closet‖
                Associating a person‘s appearance with his or her gender identity (internal
                 sense of being male or female)
                Believing that all older people live in monogamous relationships, are
                 celibate, or both




Live Well, Live Long: Steps to Better Health                                            152
          Live Well, Live Long: Steps to Better Health—Blueprint
         Health Promotion and Disease Prevention for Older Adults

Creating Culturally Sensitive and Effective Health Promotion Materials

Resources
Building Linguistic and Cultural Competencies: A Tool Kit for Managed Care
Organizations and Provider Networks that Serve Foreign Born
Heartland Alliance
Contact: Sabrina Robinson—(312) 660-1342

Cultural Competence Best Practices in Health Care
Health Resource and Service Organization (HRSA)
Contact: Tamara Allen, Center for Managed Care, HRSA—(301) 443-1416

Cultural Competency: A Journey
An explanation of cultural competency, its elements and some best practices
Health Resource and Service Organization
Contact: The Bureau of Primary Care—(301) 594-4100 or http://www.bphc.hrsa.gov

Getting Started
A free checklist on cultural competency
National Center for Cultural Competency
Contact: http://www.dml.georgetown.edu/depts/pediatrics/gucdc/cultural.html

Responding to Pacific Islanders: Cultural Competence Perspectives for Substance
Abuse Prevention
Substance Abuse and Mental Health Services Administration (SAMHSA) and
Health Resource and Service Organization (HRSA).
Contact: Len Epstein, HRSA—(301) 534-4490


References
    Angel, J.L. (2000) ―Coming of Age: Minority Elders in the United States.‖ The
      Gerontologist 40:40:504.
    Friedman, S. (2000) ―Sensitivity Training for work with Lesbian, Gay, Bisexual
      and Transgender Elders.‖ Healthcare and Aging 7:4:4-5.
    Halverson, C.B. (1997) ―Caring for the Elderly: Geriatrics in Ethnic
      Communities.‖ Proceedings of a training provided by the Institute on Aging,
      Temple University, April 22, 1997. Philadelphia.
    Hill, et al. (1990) ―Culture in Clinical Medicine.‖ Southern Medical Journal.
      83:9:1071-80.
    Witten, T.M., et al. (2000) ―Transexuals, Transgenders, Cross Dressers.‖ Outword
      6:3:4-6.


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