National Eye Health Education Program (NEHEP)

April 1991
Revised November 1994

• I. Introduction
• II. Background
• III. Overview of Communication Plan-A Glaucoma Public Education Program for Blacks Over Age 40 and Everyone Over Age 60
• IV. Messages, Channels, and Materials
• V. Research and Evaluation
• Sources

Three million Americans have glaucoma. Vision loss from this disease is permanent and cannot be reversed. Although glaucoma cannot be cured, it can be controlled if it is detected and treated early.¹ Early detection and treatment are hampered by a lack of symptoms in the initial stages of the disease and by low levels of public awareness and knowledge that regular, comprehensive eye examinations through dilated pupils are necessary.

Increasing public awareness and knowledge of glaucoma, its risks, and what to do about this blinding eye disease is a major goal of the National Eye Health Education Program (NEHEP).² The NEHEP is coordinated by the National Eye Institute (NEI), one of the National Institutes of Health, in partnership with other public and private organizations concerned with eye health.

This document outlines the communication plan for the glaucoma public education program formulated as a result of (1) recommendations presented at the NEHEP Planning Conference in March 1989; (2) planning documents produced by the NEHEP staff since that time; (3) deliberations of the NEHEP Planning Committee; (4) the advice of an Ad Hoc Working Group on Minority Outreach convened in July 1990, and (5) other working groups and papers. The plan describes the development of a public education program for two primary target audiences: all adults age 60 and over, and Blacks over age 40.

In developing the plan further, the NEHEP staff will identify current education efforts and the most critical gaps in public knowledge, attitudes, and practices. The staff also will seek opportunities to work in partnership with other interested organizations. To use NEHEP resources most effectively, tasks outlined in this document will be prioritized according to need, opportunities for collaboration, and potential impact.

The following section of this communication plan provides the Background of the NEHEP. Section III provides an Overview of the Communication Plan including the program need, the program overview, the theoretical tenets supporting the program, the target audiences, audience research, the program goals and objectives, the desired changes in the population, and the program strategies. Section IV, Messages, Channels, and Materials, covers communication concepts, messages, channels, and materials, the role of the NEHEP Partnership, and the response to public interest. The final section (V) discusses Research and Evaluation issues.

National Eye Institute

Eye disease, visual impairment and disability, and blindness are major public health problems. In the United States alone, more than 11 million people have some degree of visual impairment that can not be corrected with glasses.³ Of this visually impaired population, approximately 890,000 people are legally blind.⁴ In addition to the physical and emotional stresses associated with eye disease and blindness, there are significant economic burdens. Eye disorders and blindness are estimated to cost the nation more than $16 billion annually.⁵

Convinced that visual disorders constituted a national problem that could only be solved by greater emphasis on vision research, Congress authorized the establishment of the National Eye Institute (NEI) in 1968 as part of the National Institutes of Health (NIH), U.S. Department of Health and Human Services. The Institute's mission is to find new ways to prevent, diagnose, and treat diseases of the eye and visual system, thus preventing, reducing, and possibly even eliminating blindness.

National Eye Health Education Program and Goals

Since its inception, the NEI has conducted a public information program, responding to inquiries and disseminating authoritative information on eye disease and the progress of vision research. Educational materials for the public have described the causes, if known, of common eye diseases; their signs and symptoms; methods of prevention and treatment; referrals to sources of help; and current, relevant research. Blindness prevention education became more important during the last decade when the results of several clinical trials provided dramatic evidence that laser treatment could reduce the risk of vision loss from glaucoma, diabetic retinopathy, and macular edema.

Although the NEI has long been committed to communicating research results to appropriate audiences, a sustained, large-scale health education program was precluded by a scientific rationale, lack of funding, and personnel. In 1988, Congress appropriated funds that enabled the NEI to increase its commitment to the prevention of blindness through public and professional education programs and the encouragement of regular eye examinations. This was the first distinct NEI Congressional appropriation designated for eye health promotion and education.

In response, the NEI established the National Eye Health Education Program (NEHEP) to implement large-scale information, education, and applied research programs. The NEHEP program is located within the Office of Health Education and Communication (OHEC) within the Office of the Director. The goals of the NEHEP are to prevent vision loss and blindness by educating the public and health professionals about sight-threatening eye diseases. The NEHEP also seeks to ensure that the results of eye and vision research are used for the benefit of all people. The emphasis of the NEHEP is on public, patient, and professional education concerning the importance of early detection and treatment of diabetic eye disease and glaucoma. These blinding eye diseases have been selected as the Program's initial focus for three reasons:

• The high prevalence of these diseases;
  
  
• The scientific evidence demonstrating that blindness caused by these diseases can frequently be prevented by early detection and treatment; and
  
  
• The existence of important health messages that need to be conveyed to a variety of target audiences.

An essential component of the NEHEP's success is its Partnership, which consists of organizations interested in eye health education and capable of furthering the achievement of the goal of the NEHEP. This group includes professional, voluntary, and civic organizations; federal, state and local agencies; and private industry. Initial invitations to join the NEHEP Partnership were extended to the 35 organizations represented at the 1989 Planning Conference. Additional invitations to participate in the NEHEP will be extended as the program continues to grow.

In the future, other topics, such as coping with low vision, may be addressed. Additional background information on the NEHEP, including its operating principles, is contained in From Vision Research to Eye Health Education: Planning the Partnership.²

This section of the plan presents the need for the Program and an overview of it; the theoretical tenets behind it; the target audiences; audience research; Program goals; the behavioral changes desired in the population; and the strategies to be used to achieve these behavioral changes.

The Program Need

Glaucoma is the leading cause of blindness in African Americans, and the second leading cause of blindness in all Americans.^3,6,7 For adults over age 60, the prevalence of open-angle glaucoma, the most prevalent type, increases with age, from approximately 0.5% in the 6th decade to 4.4% in the 9th decade.₈ Glaucoma is at least five times more likely to occur in Blacks than Whites, and is four times more likely to cause blindness in Blacks.^9,10 The greatest difference is noted among persons ages 45 to 64, where the rate of blindness from glaucoma is 15 times higher in Blacks than in Whites.⁹ Among persons ages 45 to 64, the number of people with glaucoma per 1,000 population is 41.9 for Blacks and 9.1 for Whites.⁹ Among those 65 and older, the prevalence increases to 66.8 per 1,000 for Blacks and 46.5 per 1,000 for Whites.¹¹ Therefore, there is a compelling need to inform and educate Blacks about the need for regular, comprehensive eye examinations with dilated pupils to reduce the risk of vision loss and blindness from glaucoma. And, in general, the older the person, the greater the risk.

In addition, there is evidence of a need to inform and motivate all adults at risk. Although most adult respondents to one recent national survey believed that a healthy adult should have a routine eye examination at least every other year¹¹, another recent survey projected that 28 percent of American adults (50 million) may be having their eyes examined less often or never; 16 percent (29 million) reported having eye examinations less often than every four years, including 6 percent (11 million) who had never seen an eye doctor.¹² Most people who reported having an eye condition said that they were diagnosed as a part of a regular eye examination, not as a result of a problem or condition that led them to seek help.¹² More than 7 million adults are estimated to be "undiagnosed but at risk" for glaucoma.¹²

The large majority (75 percent) of adults are unfamiliar with glaucoma, and even more (82 percent) are unaware that Blacks are more likely to have this eye disease.¹² The survey found that only about one in five adults reported knowing something about glaucoma; those over age 50 were even less well informed.¹² The majority of the public has misconceptions—that pressure from glaucoma can be felt in the eye in early stages of the disease, that eye damage resulting from glaucoma can be corrected, and that people with hypertension are at higher than average risk for glaucoma. New programs must address gaps in public awareness and misconceptions that form powerful barriers to early diagnosis of glaucoma.

Program Overview

The Glaucoma Public Education Program includes a planning stage and three primary stages. The Planning Phase began in 1989 with the development of ideas, strategies, and methods for ensuring a successful NEHEP program. The primary purpose of Phase I is to ensure that awareness has been raised adequately within the appropriate target audiences to lay the way for changes in knowledge, attitudes, and practices (KAP) expected in Phase II. Laying ground in Phase I will consist of research, development, and dissemination activities. Phase II is intended to concentrate on activities that have shown to increase desired knowledge, attitudes, and practices, such as various types of information dissemination. Phase III will build on activities that have been implemented during the previous phases, and continue to build the capacity of local organizations and individuals to cater to the direct needs of local individuals. An initial NEHEP KAP survey was conducted in 1992 to collect baseline measures. Movement into each new phase may vary based on evaluation and new trends that may influence changes.

Theoretical Tenets

A number of models and theories have contributed to the field of health communication and that have had a direct bearing on NEHEP program development. They include the Social Learning Theory,¹³ the Stages of Change Model,¹⁴ Diffusion of Innovation,¹⁵ Social Marketing,¹⁶ and others.

Social Learning Theory, for example, is a model of behavior change in which it is assumed that relationships exist among an individual's thought processes, behavior, and environment. The emphasis of this approach is on behavior change through direct behavior change techniques, on targeting cognitive variables, and strategic alterations of the environment to stimulate, reinforce, and encourage, and maintenance of desired behavior changes.

Prochaska and DiClemente's Stages of Change Model has been vigorously applied to smoking cessation programs (as well as other addictive behaviors, acquisition, and psychological distress programs). This model states that there are various stages in the process of change. They are: precontemplation, contemplation, preparation, action, maintenance, and relapse. A person can progress from one stage to the next or they can relapse to a previous stage, either to work themselves ultimately to maintenance or relapse again. The amount of progress made is a result of the stage the person was in when beginning the program¹⁷; thus, someone in the action or maintenance stage would likely be highly successful while someone in the contemplation stage would be much less likely to be successful.¹⁸ Social support,¹⁹ which is defined as the comfort, assistance, and/or information one receives through formal or informal contacts with individuals or groups, becomes particularly important during certain stages in the Stages of Change. Other theories complement or are related to social support and also have an affect on stages of change. Social networks theory, for example, provide a great deal of information about the flow of resources. Social networks have been found to influence a number of health behaviors such as the influence of social groups on the decision to seek medical care.

Diffusion of Innovation helps to achieve broad-based changes in an individual's health status and in community structures to support and encourage such changes. The precepts described by Diffusion of Innovation provides a set of generalizations that leads to changes in organizational and community structures as well as to changes within the population. The characterization of adopters uses the criterion of innovativeness, or the degree to which an individual or other unit of adoption is predisposed to adopting new ideas or practices (Rogers, 1983). Innovativeness is conceived of as a continuous variable that is divided into various categories. An accepted group of categories that helps define this concept is: (1) innovators, (2) early adopters, (3) early majority, (4) later majority, and (5) laggards.

There is some debate about the definition and description of these categories, but the most often used characterizations have been quite precisely defined: in general, innovators are eager to try new ideas and are interested in taking risks, early adopters are willing to take calculated risks and serve as role models for others members in the social system, the early majority adopt new ideas just before the average member of a social system, the later majority adopt the ideas after the average member of a social system and are often reacting to economic or social pressures, and, finally, laggards are the last to accept an innovation.

In order to enhance the probability of an individual's adoption of a new health practice, program planners need to attend to characteristics of the adoption process such as its relative complexity, opportunities for the individual to observe others engaging in the practice, and providing situations in which the individual may try the new behavior. The relative benefits of the new behavior versus the status quo must be strongly presented. Planners must also assure that the new behavior is compatible with the individual's life style, and that the individual has opportunities to confirm the value of adopting a new behavior as opposed to reverting to the previous behavior.

Other models encompass descriptions of how to carry out interventions. The acronym of the PRECEDE model, primarily a model used for program planning, stands for Predisposing, Reinforcing, Enabling Causes in Educational, Diagnosis, and Evaluation.²⁰ The PRECEDE is a strong model that speaks to the acknowledged problem in health education—that problem being disjointed planning—and it can be applied to health education in a variety of situations. Initial attention is directed to outcomes rather than to inputs, thus forcing the planner to begin the planning process from the outcome end; it encourages asking the question "why" before asking the question "how." This directed deductive thinking helps the planner to consider the real conditions rather than to develop program ideas and choose methodologies in a subjective manner. PRECEDE has served as a successful model in a number of rigorously evaluated real world clinical trials. The Centers for Disease Control and Prevention (CDC) has used the PRECEDE framework to develop their PATCH (planned approach to community health) program, a community-intervention training program.

The above theoretical tenets are translated into effective health programs through the application of social marketing principles. Social marketing is a term that was created by a combination of marketing and social theories. It is an innovative approach to communication that uses the planning elements of marketing—product, price, promotion, and place—within the various behavioral theories such as Diffusion of Innovation and Social Learning Theory, as described above, to reach broad audiences in order to direct behavior change.

The seven steps of the social marketing approach, as defined by Kotler (1987), are: problem definition, goal setting, audience segmentation, analysis of audience approach, influencing channel analysis, strategies and tactics, and implementation and evaluation. As outlined by Lefebvre and Flora,²¹ the core components of the social marketing approach include:

• Consumer orientation in which the various consumer groups (e.g., community residents, opinion shapers, policymakers) are actively sought out and involved to understand their specific needs and concerns with respect to health issues.
  
  
• Audience segmentation and analysis in which these various consumer groups are further refined and defined into more homogenous subgroups and further characterized with respect to geographic, demographic, behavioral, and psychological attributes.
  
  
• Channel analysis in which communication channels (such as electronic and print mass media and social and interpersonal networks) are explored and evaluated with respect to the specific utilization and exposure patterns of the defined audience segments.
  
  
• Developing an exchange process between program providers and the various audiences is given a high priority to ensure that the interactions serve mutually beneficial purposes.
  
  
• Formative research is conducted to ensure that program elements are in fact responsive to the audience's needs, are delivered through appropriate channels to maximize their reach and efficiency, and can be acted upon by the audience.
  
  
• Responsive program messages/products/services are designed to meet the particular needs and characteristics of the audience group, to minimize costs to the consumer and convey anticipated benefits for responding to the offering, to be accessible to the primary audiences they are intended for, and to promote to these groups in such a way as to ensure maximum attention and participation.
  
  
• Process tracking systems are utilized by the program managers to provide assurances that the program is being implemented as planned, that the priority audiences are in fact being reached, that opponents concerns are addressed, and that this information can be used to further refine or expand the program for other audiences.
  
  
• Strong program management systems orchestrate the above elements so that the program remains attentive and responsive to the audience's needs while also achieving the health objectives set by the program planners.

The social marketing process will be used to guide the development of the procedures and materials thus far created by NEHEP, and will continue to be used to do so. For example, drawing from the research in and direction from social marketing and other theories and models for the need to develop an exchange process between program providers and the various audiences, the development of the work with various Partnership organizations will be based upon discussions and the expressed needs, desires and objectives of those organizations and NEHEP target audience needs.

One model of social marketing, known as Consumer-based Health Communication, is underlines the importance of starting from the consumer's reality to successfully market healthier lifestyles. To change behavior patterns it is important to know what motivates and reinforces the consumer's current behavior, what barriers impede the adoption of a new behavior, and what rewards the consumer perceives for making the change. CHC poses a series of strategic questions whose answers -- developed from solid consumer research and disciplined creativity -- ensure communications that are relevant and meaningful to the consumer audience. These questions focus on the target, purpose, promise, support, openings, and image of the intended message. The immediate result of the CHC process is a strategy statement -- a few pages that outline the realities of the consumer in relation to the proposed health behavior to be marketed (e.g., going for a regular eye exam). The statement then guides all aspects of program implementation, from public relations, direct marketing, media advocacy, skills-building, creating environments supportive of the health behavior, policy development or interpersonal influence. Over time, as consumers change, answers to the questions are continually reviewed and updated as necessary.

Target Audiences

Participants at the 1989 Planning Conference identified three target audiences for glaucoma education: glaucoma patients, the general public, and health care professionals.² The current general primary target groups are Blacks over age 40 and anyone over age 60. It also will be important to reach eye and other health care-related professionals to help motivate the at-risk. Educating the general public is a means to ensuring long-term success.

Primary Target Audience: People at High Risk. The major risk factors for developing glaucoma include ethnicity, age, and a family history of the disease. Participants at the 1989 Planning conference defined the key target audiences as:

• All adults age 60+
  
  
• Blacks 40 years and older
  
  
• Individuals with a family history of glaucoma
  
  
• People with diabetes.

Activities will be directed primarily to Blacks over age 40 and anyone over age 60. (These groups will be further segmented according to various characteristics and research will be conducted so that relevant and specific messages are designed. The decision to focus on these target audiences is based on the research and planning conducted since the 1989 Planning Conference, which led to these conclusions:

• Raising awareness of glaucoma among all persons in the highest risk groups is important.
  
  
• Mass media channels (television, radio, print) reach these populations.
  
  
• While mass media channels are effective in improving initial awareness of health problems, health professionals (pharmacists, general physicians, nurses, health educators) are the most credible sources of information for Blacks and anyone over age 60.²² Due to the importance put on person-to-person communication in the black community, interpersonal, community-based education also can be used effectively for health education to encourage appropriate action from Blacks.^22,23,24
  
  
• As other groups also have glaucoma, Blacks do not want to be singled out as the only risk group for glaucoma.²⁵
  
  
• Prevent Blindness America is currently conducting a glaucoma campaign targeted to Blacks. NEHEP efforts can complement this important program and the programs of other organizations.
  
  Secondary Target Audiences. Important secondary audiences are those who can influence or support the health practices of individuals at risk. These audiences include:
  • Eye and other health care-related professionals (e.g., primary care physicians, nurses, and pharmacists, health educators, social workers)
    
    
  • Family members of at-risk individuals
    
    
  • Other intermediaries (e.g., clergy).

  Activities directed at secondary target audiences focus primarily on eye and other health care-related professionals due to their very important role in motivating those at risk. Health care professionals are a very credible source of information for their patients, and provide direct access to individuals already in the medical care system. Data from the National Center for Health Statistics show that utilization of physician services increases with age. Eighty percent of all persons over 65 years of age see a physician at least once a year as compared to the general population on a whole. With Medicare benefits, the average number of contacts also appears to be increasing, particularly among older persons with lower income. Furthermore, utilizations of outpatient clinics is considerably higher as opposed to use of private physicians, especially among minority groups. The continuing growth of the older population, especially those 75 years and older, is expected to produce corresponding growth in the utilization of general health care services.

  Blacks average 4.6 physician visits each year; this frequency jumps to 6.7 for Blacks over age 65; about 25 percent of these visits occur in hospital clinics or emergency rooms.¹³ However, one study found that 19 percent of referrals to eye doctors came from health care professionals.²⁵ Therefore, strategies are designed to increase health professionals' awareness and knowledge of glaucoma risks and to encourage them to counsel patients.

  As messages and materials are developed for target audiences, the NEHEP will continue to involve health care professionals and community organizations in disseminating this information. The NEHEP staff also will continue to work with the NEHEP Partnership and others to convey information and materials to their members who will, in turn, use interpersonal channels of communication to deliver information to people at risk for glaucoma.

Audience Research

Planning for the glaucoma public education program is based on existing information related to the target audiences' awareness, and knowledge, attitudes, and practices (KAP) in relation to glaucoma. As a part of program planning, focus group discussions were conducted with members of target audiences; information was collected describing demographic, socioeconomic, cultural, and health-related characteristics of Blacks; and an extensive review of this information was completed. These activities provided the basis for this plan.

However, many questions remained about the public's understanding of and practices related to glaucoma. Therefore, concurrent with communication program planning and development, the NEHEP commissioned a national KAP survey in 1991 to gather baseline data, define information needs of target audiences, and refine communication strategies. Survey results showed the following:

• Seventy-two percent of Blacks over age 40 and 85 percent of older people did not know that glaucoma affects more Blacks than Whites.
  
  
• Fifty percent of Blacks over age 40 and 62 percent of all older people did not know that glaucoma tends to run in families.
  
  
• Thirty-six percent of Blacks over age 40 did not know that people over age 40 are more likely to develop glaucoma.
  
  
• Seventy-eight percent of Blacks over age 40 and 65 percent of all older people mistakenly believed that eye pain is an early symptom of glaucoma.
  
  
• Seventy-three percent of Blacks over age 40 and 75 percent of all older people had an eye examination by an eye care professional within the past two years.
  
  
• Of those examined within the past two years, 70 percent of Blacks over age 40 and 56 percent of all older people said their pupils had been dilated during the examination.
  
  
• When asked to choose the worst of five possible disabilities (loss of eyesight, memory, hearing, speech, or loss of an arm or leg), 50 percent of Blacks over age 40 and 42 percent of all older people cited loss of eyesight as the worst that could happen to them.
  
  
• Only 20 percent of Blacks over age 40 and 29 percent of all older people reported having seen or heard anything about eye health or disease in the past year, excluding advertisements for glasses or contact lenses.

Additional audience research has been conducted by various agencies. This information also has helped form ideas for this plan. Further research will be conducted to ensure that appropriate messages and channels and used to reach the defined target audiences.

Program Goals

The priorities for the NEHEP during Phases I and II is to increase the awareness of the primary target groups of the risk factors for glaucoma and of the need for early detection in preventing vision loss; increase their knowledge that early detection and treatment may reduce the risk of blindness; improve their attitudes with regards to obtaining early detection, screening, and treatment; increase the percentage of those in the primary target audiences having regular, comprehensive eye examinations with dilated pupils; and increase the rate of primary target group members who obtain appropriate treatment. Phase III helps sustain the advances made in Phases I and II. To ensure that the audiences are reached with proper messages, each group will be segmented by various categories (e.g., socio-economic status, geographic location). Increasing audience specificity also will help to properly monitor and evaluate program success. Specifically, the following goals have been defined for the phases of the NEHEP Glaucoma Public Education Program (objectives are specified in the Evaluation Plan):

Phase I - Raising Awareness

GOAL 1: By the end of 1998, to increase awareness of glaucoma in selected high-risk target audiences in the U.S.

GOAL 2: To increase awareness of the importance of early detection of glaucoma in high risk audiences and in preventing visual loss.

GOAL 3: To increase eye and other health care-related providers' awareness of high risk groups' need for regular (at least every two years), comprehensive eye examinations with dilated pupils.

Phase II - Increasing Knowledge, Attitudes, and Practices

GOAL 4: To increase knowledge, attitudes, and healthy behaviors concerning glaucoma and glaucoma treatment in high risk populations.

Phase III - Sustaining the Program

GOAL 5: To ensure a sustained program that addresses the needs of primary and secondary target groups for glaucoma for information, education, and communication such that they are able to gain awareness and knowledge as needed, and improve their attitudes and behavior to adequately address their glaucoma health care needs.

This section of the communication plan covers a discussion of the message concepts developed, as well as the messages, channels, and materials deemed appropriate for the target audiences. Included under messages are discussions of information gaps, barriers to acceptance, appeals, credibility, spokespersons, and language. Mass media and community channels are described. Formats, cultural sensitivity, and pretesting are covered under materials.

Message Concepts for Glaucoma Program

The communication strategy will be implemented in a way that is consistent with the social and cultural characteristics of the target audience(s). The program draws upon what it knows about these groups based on research. The program acknowledges that within any target audience people vary in where they lie on a behavioral change continuum that includes seven steps. For each step, there are general concepts and calls to action that should form the basis for crafting the specific message(s).

Unawareness to Awareness

• Present basic facts on glaucoma, including risk factors and information on eye health care screening
  
  
• Dispel myths and misinformation
  
  
• Provide data about prevalence in specific populations
  
  
• Stress the importance of early detection
  
  
• Present a call to action: For more information, write ________.

Awareness to Concern

• Provide the opportunity to assess individuals' personal risk
  
  
• Put a face and a voice to glaucoma by using credible and believable spokespersons for specific target audiences
  
  
• Show the extent to which glaucoma affects specific target audiences
  
  
• Stress that these target audiences are particularly at risk
  
  
• Tell them what can happen if glaucoma goes undetected/untreated
  
  
• Tell them how they can help protect themselves from severe consequences with early detection by having a comprehensive eye exam through dilated pupils
  
  
• Call to action: If you're in these risk groups, you should have an eye exam.

Concern to Acquire Knowledge and Skills

• Reiterate to those in need the importance of having a comprehensive eye exam through dilated pupils and why
  
  
• Tell them where they can go to get these exams
  
  
• Tell them what they can expect in terms of the exam and how much time it might take
  
  
• Call to action: You can do it.

Acquire Knowledge and Skills to Motivated

• Stress benefits of acting on what they know and are able to do: better eye sight, more involved family life, more activities in which they can participate, a fuller life overall
  
  
• Encourage them to tell others about what they have learned
  
  
• Call to action: Take action.

Motivation to Readiness

• Tell them where to find more information
  
  
• Reiterate where they go to get the exams
  
  
• Reassure them that they can help themselves and live a fuller, happier life
  
  
• Support decision-making
  
  
• Call to action: make an appointment and go see a practitioner for an eye exam.

Readiness to Trial

• Talk about what you have learned with friends, family and colleagues
  
  
• Show examples of those it has benefited
  
  
• Call to action: make sure you see practitioner

Trial to Sustained Behavior

• Reassess personal risk
  
  
• Reinforce that they are at risk
  
  
• Reinforce the need for regular eye exams
  
  
• Tell others how important it is for them to have a comprehensive eye exam through dilated pupils.

When reading through these lists of message concepts, it is important to recognize that not all concepts need to be delivered in all messages at the same time. The format of the message will impact how many concepts are covered; for example, a brief message on television will mean that only one or two concepts will be covered, while a workshop or print material may allow for the coverage of most or all of the concepts. Similarly, a curriculum intended for individuals to use over several days or weeks may cover all of the seven steps, while briefer encounters will need focus on the particular stage the target audience is in.

The design of messages should focus on having a positive and appealing tone for the target audiences. Messages that use fear appeal, when deemed appropriate, should be developed by skilled communicators who are sensitive to potential undesirable effects, such as a reminder that a person is getting old and that the effort to get an exam is not worth it. It is also important that messages be crafted to appeal to the individual's self-image, and that benefits are put in personally meaningful terms.

Messages

Most Americans are bombarded with hundreds of messages daily. In addition to this general "message clutter," glaucoma messages must compete with the many other health-related issues discussed daily in the news, in advertisements, and in individual conversations. Therefore, the most effective ways of presenting the information (e.g., suitable appeals and spokespersons) must be selected. Message pretesting is essential.

Information Gaps. Messages should address these information points:

• Glaucoma is an eye disease that can cause blindness.
  
  
• Blacks over age 40 and anyone over age 60 are at greater risk than others for developing glaucoma.
  
  
• People should find out if anyone in their family has glaucoma.
  
  
• If glaucoma is diagnosed, treatments are available.
  
  
• Early detection and treatment can usually stop further damage and prevent blindness.
  
  
• Yearly, comprehensive eye examinations with dilated pupils are necessary.
  
  
• These examinations are performed by eye care professionals.
  
  
• Inquiries for more information should be encouraged.

Barriers to Acceptance. The following barriers to message acceptance and action will be considered during message development:

• Misconceptions such as "if you can see okay, there's nothing wrong with your eyes" (cited by 30 percent of respondents—which can be projected to 55 million adults—in a 1990 survey)¹²

• Denial of susceptibility to glaucoma
  
  
• Fear of blindness
  
  
• Perceived discomfort of diagnostic tests
  
  
• Lack of familiarity with sources of eye care; lack of access to services
  
  
• Time and cost of comprehensive eye examinations
  
  
• Lack of health insurance coverage for preventive or regular eye examinations
  
  
• Concern for "more important" chronic disease conditions
  
  
• Lack of reinforcement from health care professionals.

Appeals. The message appeals used to attract attention must be relevant to the target audience and be considered credible by them. For example, ideas suggested by the target audiences might be incorporated into message development or in personal stories illustrating the key message points. Themes should reflect the values of target audiences, such as strong extended family networks and religious ties in Black families and the importance being an everyday part of society for everyone over age 60. Profile information suggested that an appeal based on fear should be used with caution and be accompanied by suggestions on how to alleviate the fear (e.g., have an eye examination).

Other identified appeals include:

• Remember to take care of your eyes as you take care of other health/lifestyle needs.
  
  
• A regular eye examination offers peace of mind and can safeguard your vision.
  
  
• Vision is important to maintaining your personal independence.
  
  
• Blindness could affect relationships with your friends and family.

Credibility. In recent NEHEP focus group discussions, Black participants were generally skeptical about statistics indicating their high risk for glaucoma. Older Black respondents were cautious about accepting as fact information provided by unidentified sources and insisted that reports of research be substantiated. The profile also suggested that Black institutions be used to increase message credibility and to overcome some Blacks' mistrust of the White medical establishment. For older adults in general, who speaks to them is of major concern.

Spokespersons. Generally, the preferences for health information spokespersons most often cited by the public are "people like me" and physicians. Older adults, like other population groups, identify with role models, especially those that have overcome an impediment or have accomplished something significant. However, use of role models to impact the elderly can have a negative impact on a campaign to reach the older population. Adults over age 60 like to be represented by just another "average person". In focus groups conducted for the NEHEP, older Blacks said that they would prefer to hear about glaucoma from "someone like themselves" who has glaucoma under control. The NEHEP Ad Hoc Working Group on Minority Outreach also recommended using Black spokespersons. Celebrities are less frequently cited as health spokespersons and may not be credible unless they have a direct relationship with the health topic.

Language. Language—as well as appeals—must be tested for appropriateness. Messages should avoid stereotypical "hip talk and slang," especially for older Blacks. Print materials also will be tested for readability.

Channels

A combination of channels will be used:

• Mass media to reach broad audiences
  
  
• Community channels.

Using several types of channels will provide repetition of the messages, an important factor in increasing awareness and knowledge.

Mass Media. The mainstream mass media will be used to reach the greatest number of Blacks over age 40 and anyone over age 60 at high risk for glaucoma. Older adults are heavier television viewers during daytime and early evening—when public service announcement (PSA) time is more likely to be available—than Blacks in other age groups.²⁶ Opportunities to convey glaucoma messages through the media go beyond public service announcements to include news, health features, talk shows, and coverage through entertainment programming.

Specific media markets and media outlets more likely to reach Blacks over age 40 and anyone over age 60 will be targeted for special attention.

Media tasks will include:

• Television PSAs for the broadest reach to generate the most public inquiry response
  
  
• Radio PSAs tailored for stations reaching the target audiences
  
  
• Print ads for selected magazines and newspapers
  
  
• Editorial coverage and public relations.

At the national level, the NEI will seek media opportunities for promoting glaucoma messages to Blacks over age 40 and anyone over age 60. The NEHEP staff will seek to place articles on glaucoma in newspapers and in magazines that target the primary target audiences, such as Ebony, Jet, Essence, Parade and Reader's Digest by networking with professional organizations such as the National Black Newspaper Publishers Association and the National Association of Black Journalists.

Community. Organizations within the community can offer direct access to the target audience, reinforce and expand upon media messages, and provide referral to services. Together with the media, community channels can form a strong support network. Each channel reinforces the glaucoma messages, encouraging those at risk to seek information and eye examinations.

Suggested community outlets for glaucoma information include barber shops, community health centers, senior centers, hospital outpatient clinics and emergency rooms, churches, civic and professional associations, supermarkets, pharmacies, eye care providers, and sororities and fraternities.

Materials

The first step was to identify existing education materials and resources on glaucoma. This task was carried out through interviews with NEHEP Partnership organizations and the establishment of an eye health education subfile of the Combined Health Information Database (CHID). CHID is a computerized bibliographic database, developed and managed by agencies of the U.S. Public Health Service.

Formats. The first priority has been to develop a set of "core" glaucoma public education materials. All print materials developed will be easy to understand, with strong graphics, large type, and colors selected to ensure visual clarity. Specific materials developed or in the development process are:

• A short, attractive glaucoma fact sheet, simple but complete; reproducible by NEHEP Partnership members;
  
  
• Materials for use by intermediaries targeting Blacks over age 40 and anyone over age 60 (including fact sheets, poster, print ads, program guide, speaker's guide—including presentation points, visuals, and questions and answers—press releases and articles, and evaluation card);
  
  
• Mass media materials, including television and radio public service announcements (PSAs) and print ads; and
  
  
• An exhibit for meetings of the NEHEP Partnership, medical and health related organizations, and other groups.

The materials development/production strategy will be:

• To produce a few simple, inexpensive materials designed to increase awareness and knowledge.
  
  
• To print large quantities of reproducible materials to be used by NEHEP Partnership organizations.

The need for cultural sensitivity. All messages and materials will be carefully tested for cultural appropriateness.

Pretesting. All materials will be tested with the target audiences and gatekeepers prior to final production to assure understanding, appeal, and personal and cultural relevancy. Materials will be revised as necessary.

Role of NEHEP Partnership

The strategy for promoting messages and materials about glaucoma will be to identify and work with the NEHEP Partnership. The first priority will be collaboration with key intermediaries who are already interested and/or involved in similar activities. Such collaboration will help strengthen existing efforts while identifying the NEHEP as an additional resource.

A range of collaborative activities between the NEHEP and Partnership members is underway, including:

• Help in developing, reviewing, and field testing materials
  
  
• Promoting and distributing materials
  
  
• Conducting presentations to patients and health care professionals
  
  
• Promoting messages through publications and newsletters
  
  
• Implementing educational programs for high-risk groups.

A parallel strategy will be to recruit additional organizations into the NEHEP Partnership from organizations with a special reach to or credibility with the target audiences. The criteria for assigning priority to collaboration will include:

• Access to the target audiences
  
  
• Credibility with the target audiences
  
  
• Interest in collaboration
  
  
• Potential effect of the proposed activity.

NEHEP staff also will seek cooperative opportunities with the business sector through trade associations, appropriate retailers, and manufacturers.

To assess whether the NEHEP reaches its defined goals and objectives, a research and evaluation (R&E) plan should be incorporated into certain program components. Various forms of R&E exist and are used for different types of programs and to answer different types of questions. The methodologies chosen must depend upon the type of program, the program's goals and objectives, and the extent to which the program's results are generalizable to the nation's population.

Although researchers may not reach consensus on the labels used to define different methodologies, there is agreement on the three most commonly used methods; 1) formative, 2) process, and 3) outcome. Formative research measures typically ask questions such as What do we want to say? Where and when do we want to say it? and How do we want to say it so that it is relevant to the target group? Responses to these questions help shape the message content, channels for delivery, and effective appeals. Formative research is used primarily for materials development and product dissemination.

Process measures help to document the extent to which a program is faithfully delivered as planned. The questions that process measures attempts to answer are: What is actually occurring at the program implementation sites? Is the program being delivered to the target audience? If so, how often? What kind of publicity, promotion and other outreach activities are being conducted? Is the rate of inquiries changing over time? Process evaluation measures often take the form of a monitoring and/or tracking system.

Outcome (or short-term) evaluation methodologies typically consist of a pre- and post-program comparison between the target audience's awareness as well as their knowledge, attitudes, and practices (KAP). Specifically, to what extent were the program objectives met? Surveys usually are used to assess this level of program effectiveness.

Phase I

Phase I goals of the NEHEP concentrate on raising the awareness of glaucoma among the high risk groups and of health-related professionals. Specific objectives are addressed in the Evaluation Plan.

Formative research has already been utilized in the design of the NEHEP materials. However, additional research (such as focus group or survey research) is needed to segment the target populations. These groups might include, for example:

• Blacks over the age of 40 with health insurance;
  
  
• Blacks over the age of 40 without health insurance;
  
  
• Blacks with low socio-economic status;
  
  
• Older people with low socio-economic status;
  
  
• Older people living alone, etc.

Appropriate evaluation measures that can be implemented to assess whether the objectives set out above are met are described below. Process measures will be used to track the use of materials. Outcome evaluation measures, primarily surveys, will be used to assess whether awareness, knowledge, attitudes, and practice increase over time. Definitive activities will be decided upon in accordance with the delineation of exact target groups.

Process measures are an important part of a total evaluation system. An appropriate strategy for reaching the high risk audiences involves working with the Partnership to increase their activities concerning the dissemination of glaucoma education messages. A process monitoring system designed to evaluate Partnership activities could be implemented. For example:

• Annual telephone interviews could be conducted to track Partnership activities, using non-NEI interviewers to reduce bias.
  
  
• A system for message dissemination and tracking technical information calls from Partners could be put in place.
  
  
• A process monitoring system could be developed. One distribution channel the NEHEP utilizes to assorted audiences, including health care professionals, pharmacists, and community health workers, involves the use of education kits. Since 1992, various educational kits have been distributed. In addition to the collection of evaluation form data, an aggressive process monitoring system could be implemented to determine kit effectiveness. Several variables with regards to the kit should be monitored including geographic location, type of caller, and source of referral. To determine which activities were stimulated by the kit, follow-up telephone calls 1 month after kit distribution should be conducted.
  
  
• Media outreach activities could be broadened. Media outreach is another intervention designed to reach the high-risk audience of Blacks over age 40. Process monitoring measures could be used to determine the placement of, the potential and/or actual number of persons reached, and the value of the electronic and print media that are placed. Professional services such as Media Link (television), North American Network (radio), and Burrelle's clipping service (newspapers) can be used to monitor message placement.
  
  
• Targeted surveys at the community level should be conducted annually to assess on-going changes (process) in awareness and KAP. Applied research grants could be offered to community based organizations to develop education programs. Annual surveys could be required of all grant recipients. Targeted surveys also could be conducted with organizations involved with the over-60 audience such as the American Association of Retired People. The NEHEP could request that KAP questions be appended to an organization's already existing survey.
  
  
• Partnership surveys could be developed. To further capitalize on existing Partnership relationships, members should assist in the development of surveys to complement the national data sources. Partnership organizations can implement annual surveys to reach more targeted audiences such as the American Association of Diabetes Educators and the National Medical Association to assess changes in awareness.
  
  
• National baseline data from secondary data sources that survey health care professionals and other audiences should be gathered. To determine program effectiveness amongst health care providers and other professionals, an approach similar to that used to measure changes in high risk populations should be applied. Examples of these sources include the Aspen Network Survey of Physicians, National Medical Care Expenditure Survey, and the Ambulatory Medical Care Expenditure Survey. This technique will monitor changes among the professional target audiences. The NEHEP may choose to work with the survey sponsors to ensure that specific glaucoma questions, necessary to measure program objectives, are appended to the already existing survey.

Phase II

The goal of Phase II is to increase knowledge, attitudes, and healthy behaviors concerning glaucoma and glaucoma treatment in high risk populations. Likely evaluation measures that can be implemented are described below:

• Primary evaluation methodologies (surveys) as proposed for Phase I also can be used to determine whether Phase II goals and objectives are reached. Surveys, both at the national and community levels, are cost effective, quantifiable, relatively fast and simple to process, and data is comparable over time. The Phase II objectives primarily focus on changes in knowledge, attitudes, and practices. As described earlier, the questions included in the Phase I surveys are capable of measuring the awareness objectives and the KAP objectives in Phase II. Distinctions, however, need to be drawn between awareness and KAP.

In relation to the NEHEP, awareness can be defined as one's cognizance of the term glaucoma and recognition that it is an eye disease. This definition is relatively superficial compared to "knowledge" of glaucoma. Questions to evaluate awareness may include: "Have you ever heard of the word 'glaucoma'?"; "Do you know what the word 'glaucoma' means?"; "If yes, what is glaucoma?" Additional questions that would determine whether target audience members recall the NEHEP messages also is an important marker for awareness.

The concept of "knowledge" follows the attainment of "awareness." A single message can attempt to communicate both awareness and knowledge such as "Blacks over age 40 and anyone over age 60 are at risk of getting the eye disease called glaucoma." The attainment of knowledge requires a greater understanding of glaucoma than awareness. Questions to ascertain whether increases in knowledge occur include: "Who is at risk for glaucoma?" "At what age should people get checked for glaucoma?" "How does one get checked for glaucoma?" "How often does one get checked for glaucoma?"

Attitudes also are formed and changed by messages. Information from formative research that was conducted as a part of the earlier KAP surveys should provide the base for this research. The information should include people's attitudes towards eye doctors. (This can be gleaned from such statements in the survey as "On a scale from 1 to 5, with 5 being strongly agree and 1 being strongly disagree, It hurts to get my eyes examined," and "My insurance pays for my eye exams.") Using effective health communication message techniques appropriate attitudes can be formed, setting the stage for adherence to healthier behaviors.

In terms of practice, the NEHEP recommends that Blacks over age 40 and anyone over age 60 get a dilated eye exam every two years. Surveys also can monitor increases in this practice by asking the target audience: "When was the last time you had a dilated eye exam?" "How many dilated eye exams have you had in the last five years?" "Did you have an eye exam that did not include a dilated exam?"

To address the focus on KAP, other evaluation methods are important to consider.

• Interviews with residents using a community-based organization for their health care can be conducted in addition to using national, targeted, and community-based surveys to assess changes in KAP. Although less cost effective than written surveys, qualitative data collected from one-on-one interviews or focus groups with high risk populations can buttress and provide additional insights that strictly quantitative measures cannot yield.
  
  
• Data abstracted from community health clinics' medical records to validate self-reported practices is another data collection method that can be used to complement surveys at the community level.

Phase III

The goal of Phase III is to ensure a sustained program that addresses the needs of primary and secondary target groups for glaucoma for information, education, and communication such that they are able to gain awareness and knowledge as needed, and enhance their attitudes and behavior to adequately address their glaucoma health care needs.

Phase III evaluation efforts should include targeted and community-based surveillance questionnaires. These data, collected over time, will help determine trends in awareness and KAP among the target audiences.

A separate analysis should be conducted for each objective separately, to accurately assess whether the objectives are met. If statistically significant increases are observed, results will support the achievements of the NEHEP. Qualitative measures, in addition to the quantitative measures, will help determine program success.

If changes either are not statistically or otherwise significant in the positive direction, operation research should be conducted to chart the program's courses. After determining which objective(s) is not being reached, various type of research, including concept, message, and materials testing, and of implementation processes, will aid in revising the program components to facilitate the NEHEP in reaching its objectives. These research processes, however, should not be applied only in Phase III. On-going targeted and community-based surveys as described above should serve to monitor program progress. If increases in awareness and KAP do not occur in Phase I, research techniques should be implemented to reassess program processes and materials during Phase II of the program.

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