Context: In 2001, more than 60 percent of Puerto Rico’s population was overweight or obese. Also in 2001, roughly 47 percent of adults did not engage in the recommended amount of physical activity (30 minutes five times a week). With these high rates of overweight individuals and physical inactivity, Puerto Rico has seen alarming increases in chronic disease mortality. The most prominent causes of death include cardiovascular disease, arterial hypertension, diabetes, and heart disease. These illnesses are directly associated with unhealthy life styles and poor nutrition. To combat this epidemic, the Department of Health in Puerto Rico developed the program Salud te Recomienda, which means health recommends you.
DECIDE WHETHER TO CONDUCT A SOCIAL MARKETING CAMPAIGN.
The aim of this campaign was to reach as large a segment of the total population of Puerto Rico as possible. The object of this campaign was to change behavior and the outcomes of those behaviors significantly and in a way that would have lasting impacts. This project was created by the Department of Health, which felt as though the problem was so widespread that it was necessary to come up with the resources needed for the campaign, including time, personnel, and funding.
COLLECT INFORMATION FROM THOSE WHO BENEFIT FROM AND CONTRIBUTE TO THE SOCIAL MARKETING CAMPAIGN.
To gather information, the Health Department looked to the statistics they already had on file concerning obesity rates in Puerto Rico, as well as the statistics on leading causes of death. I am unaware of any other methods they used, though some commonly employed methods for this sort of initiative would include listening sessions, public forums, interviews with target groups, and focus groups. Important questions would surround topics such making the desired eating and exercise behaviors easier and understanding health and nutrition facts. The desired behavior is very important for the targets of change because it directly affects their health, well-being, and longevity. There are no extra costs or negative side effects to adopting the desired behavior. In fact, there is more likely to be a decrease in costs related to healthcare.
STATE THE GOALS AND BEHAVIORAL OBJECTIVES OF THE CAMPAING.
The broad issue that the initiative addresses is the obesity rates in Puerto Rico. The Salud te Recomienda campaign’s main goal is to promote changes in behaviors and lifestyles in the Puerto Rican population that will lead to better health. This effort will take change on the part of many different groups, including the people directly affected by the problem, as well as groups that contribute to the problem or could help to combat this issue. In order for the message to reach the largest population, it will be made available directly on food labels so that it will be visible to all buyers. An important aspect of the campaign is that it be funded and put together in such a way to ensure it will be able to reach all the classes of supermarkets and restaurants in Puerto Rico, providing the opportunity for all of the population to have access to a system that will help them to easily select healthful foods. Along with this effort, the program also incorporates other behavioral and lifestyle changes that will improve the health of the general population. Alongside the nutritional factors, the campaign promotes physical activity, stress control, and cessation efforts. The desired attributes and expected benefits include a reduced number of obese children and adults, less premature deaths due to unhealthy lifestyles, loss of weight, reduced prevalence of diabetes, and healthier people in general. The specific behavioral objective is to decrease the number of obesity cases in Puerto Rico by a significant amount in as short of time as possible.
ENGAGE POTENTIAL PARTNERS IN THE CAMPAIGN.
In order to have a successful campaign, it was necessary to start by engaging the right people. The Department of Health needed partners at all levels for Salud te Recomienda to make a difference. These partners included supermarkets; pharmaceutical companies; non-profit organizations; fast food places; the mass media; schools; cafeterias in the general public, at hospitals, and at universities; food, fruit, and vegetable distributors; and health plan and policy makers. Each of these contributors played a vital role in reaching different groups of interest.
The connectors of the campaign--that is, the people who will spread the message of the campaign through their networks--include the Department of Health as well as the mass media. The Mavens, those who know and can teach, are the non-profit organizations, including the American Heart, Cancer, and Diabetes Associations as well as health plan and policy makers. The persuaders are the healthcare providers and other people with an interest in the project, including people with political clout. The people in a position to change conditions in which the targeted behaviors occur are the supermarkets, pharmaceutical companies, fast food places, schools, cafeterias throughout the country, and food distributors.
DEFINE THE AUDIENCE OR SPECIFIC TARGET GROUPS.
In response to obesity trends, Puerto Rico Governor Anibal Acevedo Vila launched this public health campaign, Salud Te Recomienda. It was aimed at schools, supermarkets, fast food restaurants, and food distributors. The idea that is behind this approach is that if you can make desired behaviors easier for the individual and they change their lifestyle, then that change will start a cascade of improvement among their networks. The individual will help change their family, which will help change the community, then the municipality, then all of Puerto Rico. The specific targeted audience is the more than 60% of Puerto Rico’s population that is overweight or obese. This campaign is not only for this audience, as it also works though prevention, not just treatment.
Past and current behaviors that put people at higher risk include a history of tobacco use, unhealthy eating, and lack of exercise. Some personal factors may affect ability to exercise: free time for participating physical activity, availability of nutritionists or doctors, or financial trouble affording healthy foods. People who consume large amounts of calories, saturated fats, sodium, and refined sugars, and small amounts of fruits, vegetables, fiber, and water, are also at high risk for morbidity.
ANALYZE THE KEY AND ENVIRONMENTS RELATED TO THE PROBLEM OR GOAL.
The target behavior that the campaign will address is adult and child obesity and focuses specifically on the negative consequences of unhealthy eating and physical inactivity. Salud te Recomienda is part of a national social marketing campaign aimed at reducing the consequences of obesity, poor nutrition, and lack of physical activity among Puerto Ricans. The campaign’s main focus is promoting behavioral changes and healthier lifestyles choices among Puerto Ricans. This campaign provides the population with useful and practical information about proper nutritional habits and patterns. The main part of the program is a nutritional guiding system which operates through the proper labeling of products evaluated and recommended by a panel of nutritionists from the Department of Health.
IDENTIFY CORE COMPONENTS OR STRATEGIES OF THE CAMPAIGN.
The Puerto Rico Department of Health created a team of nutritionists who determined the nutritional status of foods using the guidelines from the American Heart Association, the American Diabetes Association, and the American Cancer Association, in order to ensure the campaign has credible content and sources. The food that this group recommends is then identified with a campaign logo. This logo serves as a nutritional direction system which helps the general public make healthier food choices. The products selected must fulfill the dietary recommendations from the 3 organizations. The images in the form of logos that are displayed by this campaign convey an appropriate tone. They show a heart with the campaign name and give the advice that the food found in the package is good for the buyer’s health. It is compatible with people’s lives because it does not require any extra work; they can make simple (and better) food choices without having to do any research on their own. The desired behaviors are more attractive because the campaign also works to show people how unattractive the negative behaviors are in the long run. The campaign presents information with epidemiological data explaining the public health threat posed by obesity in Puerto Rico.
TAILOR AND PRIORITIZE CAMPAIGN COMPONENTS BASED ON THEIR IMPORTANCE, FEASIBILITY, AND FIT WITH DIFFERENT TARGET GROUPS/ SUBGROUPS.
The particular information that will be most influential with the target groups is that making poor lifestyle choicse can lead to many health problems and premature deaths. The message needs to be refined so that it is not overwhelming. Salud te Recomienda needs to promotes behavior change and healthy lifestyles while still being culturally sensitive.
The Department of Health has the needed resources and personnel to provide practical and useful information about positive nutrition habits and patterns. The main component of the campaign is labeling foods according to their nutritional status. Supermarkets allow the Department to place the campaign logo on items that are considered healthy. This program has the intention to create awareness in the population of the foods that must be consumed to improve health. In addition, the program puts within reach of the Puerto Rican population the option to select low fat foods, moderate sodium intake, and increase fiber consumption, in supermarkets and fast food restaurants.
PRETEST AND REVISE THE CAMPAIGN COMPONENTS BEFORE FULL IMPLEMENTATION.
The campaign provides nutritional information that is useful and practical for implementing a balanced and healthful diet; it offers direction and education based on the present dietary recommendations for the product selection in supermarkets, fast food restaurants, cafeterias, and the foods industry. The nutritional value is displayed on a label on the food recommended by the Department of Health before it is put out to purchase in supermarkets, and on logos placed by the recommended food items on menus at restaurants. The label certifies that that product is recommended by the Department of Health of Puerto Rico and fulfills the present nutritional recommendations of the American Heart Association, the American Diabetes Association, and the American Cancer Association. A similar system was also created for the schools, which gave them the opportunity to put in place a educational program based on healthy food selection and better lifestyle choices.
IMPLEMENT SOCIAL MARKETING CAMPAING.
Within participating schools, “Salud te Recomienda” is included as an educational component in the schools’ curriculum. Supermarkets allow the health department to label products within their store, as well as advertise their participation in the campaign through television and radio. Fast food restaurants also use labeling to display their healthier food options. The participating health planners have developed educational campaigns for their providers, clients, and employees. Food distributors label their produce with nutrient information and incorporate new healthy products in supermarkets.
EVALUATE THE EFFECTS OF THE SOCIAL MARKETING CAMPAIGN.
The effects of the social marketing campaign have been very visible. Already, there are a number of organizations that have joined the effort, including local supermarkets, international fast food chains, and various food producers. At the initial evaluation, there were already short term outcomes indicators in place, which determined the efficiency and the effectiveness of this campaign. There were 364 entities participating in the campaign and the Department of Health expected that another 300 would join the campaign by the end of 2003.
CELEBRATE THE SUCCESS AND MAKE ONGOING ADJUSTMENTS.
The future strategies of Salud te Recomienda are to expand the campaign to all small retailers with support of the Department of Health and continue to offer information to the supermarkets and on the food packages. Another important adjustment is to establish new agreements between the federal and state agencies to promote healthy lifestyles that follow the social marketing campaign’s suggestions. The Department of Health would eventually like to expand the campaign’s reach to cover 90 percent of the food market on the island, as well as begin to collaborate with small businesses, other state agencies, and private partners. In addition to nutrition, they would like to include plans which add components surrounding physical fitness, promoting “Smoke Free” restaurants and public spaces, implementing a weight-loss campaign, and providing recommendations for parks and recreation facilities throughout Puerto Rico.
SUSTAIN THE EFFORT LONG ENOUGH TO MAKE A DIFFERENCE.
Salud te Recomienda was the first campaign of this type in the United States. The Undersecretary of the United States Department of Federal Agriculture was interested in understanding the results of the program pilot to promote this program as a new strategy in the reduction of the obesity epidemic in the United States. The success in Puerto Rico is the beginning of many new initiatives to come.