Evaluation of Intervention Reach on a Citywide Health Behavior Change Campaign

Abstract

Little is known about dissemination strategies that contribute to health information recognition. This study examined (a) health campaign exposure and awareness (slogan and logo recognition); (b) perceived communication channels; (c) differences between perceptions of researcher-developed and enhancement community health information materials; and (d) differences in campaign awareness and communication channels, according to Japanese community demographic characteristics. A cross-sectional survey (N = 508) was conducted in Tokigawa, Japan, in 2013. The Small Change Campaign focused on increasing physical activity and improving dietary habits. Information dissemination was carried out using leaflets, newsletters, posters, website, local public relations magazines, health classes, events, and online newsletters. The participants completed a survey assessing their campaign awareness (i.e., slogan and logo) and exposure to the informational materials presented during the campaign. Fewer than half (45.4%) knew the slogan, and only 24.4% were aware of the logo. Public relations magazines, leaflets, and newsletters were significantly better-perceived health communication channels. Researcher-developed and enhancement community health information materials were equally recognized (p = .34, w = .08). Furthermore, women and those who were employed were significantly more aware of the slogan, logo, and communication materials. Further research should explore effective communication strategies for community-based health promotion intervention via randomized control trials.

Keywords

campaign exposure health campaigns health communication health messages information dissemination

Obesity and overweightness are worldwide health concerns (World Health Organization, 2014b) and have been reported among 29.6% and 20.5% of Japanese men and women, respectively (Japanese Ministry of Health, Labour and Welfare, 2012). An increase in physical activity and a reduction in energy intake have been included in a number of guideline lists as recommended behaviors for the prevention and treatment of obesity (Japanese Health Promotion and Fitness Foundation, 2013; Jensen et al., 2014; National Heart, Lung, and Blood Institute, 2014; Schmidt, 2012; World Health Organization, 2014a).

A substantial number of studies have found positive effects of physical activity and nutritional programs on obesity reduction. Consistent evidence has shown that the effects of interventions to promote physical activity and a healthy diet range from small to medium (Anderson et al., 2009; Eakin, Lawler, Vandelanotte, & Owen, 2007; Kroeze, Werkman, & Brug, 2006; Norman et al., 2007; van Sluijs, van Poppel, & van Mechelen, 2004). Such past interventions have included health promotion campaigns using multiple media methods (e.g., TV, radio, print media, websites, health education classes, phone calls, e-mails, and face-to-face interviews; Johns Hopkins University Center for Communication Programs, 2011). These approaches have been used with both small (e.g., office and health class) and large (community and national) populations (Arao et al., 2007; Lombard, Deeks, Ball, Jolley, & Teede, 2009; Macera, 2010; Wieland et al., 2012).

Extensive efforts have been made to document the effects of physical activity and healthy nutrition on obesity; however, little is known about the effectiveness of relevant information dissemination strategies (Ellis et al., 2003; Rabin, Glasgow, Kerner, Klump, & Brownson, 2010). Transmission of health messages through the appropriate media (i.e., messaging) contributes to behavior changes (Latimer, Brawley, & Bassett, 2010). Media exposure to health communications and messages predicts a person’s engagement with health promotion campaigns (O’Hara, Bauman, & Phongsavan, 2012) and their acquisition of preferable health behaviors (Bauman & Chau, 2009; Lorentzen, Ommundsen, Jenum, & Holme, 2007). Few studies have found that the acceptance of certain media varied according to a population’s demographic characteristics (Morris, Rooney, Wray, & Kreuter, 2009).

The identification of perceived dissemination strategies, in relation to demographic characteristics, is essential for conducting a health communication campaign. It is especially important in designing, targeting, or segmentation strategies (Kreuter & Wray, 2003). To date, few studies have evaluated the perception of communication channels in disseminating health messages. Additional research is needed to determine the most effective information dissemination strategies involving physical activity and healthy diets.

In our previous research report, a 2-year-long (April 2011 to April 2013) Small Change Campaign (SCC) focused on promoting physical activity and a healthy diet among the middle-aged to elderly population and noted a small contribution to behavioral changes among these samples. One cross-sectional survey showed that 40% of the recognized SCC population who did not engage in regular healthy behaviors reported adopting healthy behaviors later (Shimazaki, Takenaka, Kato, & Yoshizawa, 2014). However, this intervention had several limitations. Some adults may have quit such behaviors during the intervention period too; thus, the real effectiveness in changing behavior was not clear from this cross-sectional postintervention evaluation of a one-arm trial design.

The purpose of this study was to examine (a) campaign exposure and awareness (slogan and logo recognition); (b) perceived communication channels and strategies; and (c) differences in campaign awareness and communication channels in relation to gender, age, and employment characteristics within the Japanese community.

Method

Study Setting

This study was conducted in the city of Tokigawa (population 12,324; area 55.77 km²), Saitama, Japan, in which 70% of the town includes forestland and suburbs. The proportion of the population aged 60 to 64 years was higher than the proportions for other ages, and 29% of this city’s population was older than the age of 65 years. Primary prevention for the middle-aged to elderly population was the most serious health concern in the city of Tokigawa.

Data Collection

Data were collected in early April 2013 at the end of the 2-year campaign period. A total of 1,000 potential participants were recruited for this study by mail from among community residents who intended to visit Specific Health Checkups (i.e., a Japanese national health checkup focusing on ages 40-74 years; Japanese Ministry of Health, Labour and Welfare, 2009). Those agreeing to participate returned the questionnaire to the public health center. The participants who did not respond to the questions on media campaign awareness or media channels were excluded, which resulted in a total of 508 study participants.

Behavior Change Theory

Behavior change theory was decided from the results of our formative research, which defined the course of our pre-investigation and filled the gap between health messages and our target audience during the intervention process (Centers for Disease Control and Prevention, 2014). Formative research works by identifying the appropriate objectives of intervention and by offering the appropriate messages and media for the target audience (Bauman, Smith, Maibach, & Reger-Nash, 2006). The formative research on which this study was based used a combination of cross-sectional data from 182 males and 153 females aged 59 to 64 years and focus group interviews with 17 community residents who did not participate in regular physical activity. Shimazaki et al. (2012) revealed that people often did not engage in regular physical activity or follow a healthy diet because of great psychological burdens (e.g., low self-efficacy or they felt that they had no time because they were too busy working).

These findings suggest the small change strategy (SCS; Hill, Peters, & Wyatt, 2009; Lutes & Steinbaugh, 2011) is most applicable to the target audience. The SCS recommends a physical activity and dietary change program with low psychological burden and high feasibility (e.g., strength training on breaks during office hours and using lemon juice or ginger instead of high-calorie salad dressings). Several studies have reported on the efficacy of the SCS (Damschroder, Lutes, Goodrich, Gillon, & Lowery, 2010; Paxman, Hall, Harden, O’Keeffe, & Simper, 2011; Rodearmel et al., 2006; Rodearmel et al., 2007; Stroebele et al., 2009). One small intervention study reported the SCS’s long-term success for health behavioral changes and improvements (Lutes et al., 2012).

Branding

Constructing a public health brand adds value to the relationship between health products and the target audience (Evans & Hastings, 2008). A brand name, sign, symbol, and design were created to integrate multiple health communication materials (Kotler & Lee, 2008). The brand name chosen was “Health Tokigawa: Small Change” based on suggestions from researchers and local public health nurses. This was then simplified to “Small Change.” Participants’ brand support intentions were identified by the following questions: “Will you try to change your lifestyle for your health?” and “Let’s try to live a healthy life!” These were added as slogans. Publishing specialists and professional illustrators created a symbolic logo using a pea pod because of the city’s enthusiasm for agriculture. Using this vegetable as a symbol increased the campaign’s acceptability (see Figure 1). Brand acceptability was decided during discussions between the researcher, a public health nurse, and publishing specialists.

Figure 1.

Campaign logo.

Materials

Health communication guidelines emphasized community-based behavioral change using not only new researcher-created intervention materials but also community resources to promote healthy lifestyles (National Cancer Institute, 2008). The SCC focused on multiple communication media through two strategies: (a) health information materials developed by the researcher (HIMDR; e.g., posters and newsletters) and (b) enhanced community health resources (ECHR; e.g., local public relations magazines and community health classes; see Table 1). Before using the materials, the researcher conducted a presentation introducing his “aim to use” and “how to implement” these materials for the Tokigawa City health promotion board, which included the town mayor, chief and associate executives of public health centers, civil servants, and members of the commerce and industry associations. The intervention materials were modified based on discussions with the health promotion board.

Table 1.

Campaign Materials.

Strategy	Communication channel	Contents	Implementation site
HIMDR	Leaflet	Small change leaflets included: (a) ideas for small lifestyle changes (e.g., physical activity and healthy eating); (b) role model introductions; (c) small walking change recommendations; and (d) healthy behavior duration tips based on The Process of Change Theory (Burbank, Padula, & Nigg, 2000).	The leaflets were mailed to all 4,750 Tokigawa houses at the beginning of the campaign.
HIMDR	Newsletter	A newsletter suggested gender-specific small change behaviors. For example, retaining good posture while working at a desk and cutting back on eating fried foods for men and using a bicycle to go shopping and eating fruits or vegetable sticks instead of chocolates or cookies for women.	One thousand newsletters were distributed each year (twice during the campaign) during health checkups.
HIMDR	Poster	Posters introduced the concept of the SCC and made recommendations for specific small changes in physical activity and diet (e.g., small strength training in the office and using lemon juice or ginger instead of high-calorie dressing).	Two types of posters (500 copies each) were placed in local stores, eating and drinking establishments, public institutions, and hospitals each year of the campaign.
HIMDR	Website	A small change web page was established on the Tokigawa city website that (a) explained the concept of small change, (b) provided health resource information (e.g., schedules of health classes), and (c) allowed access to the PDF versions of learning materials developed by the researcher.	The website was accessible by community residents at any time.
ECHR	Local public relations magazine	We placed an ad promoting the small health behavior change campaign in a local public relations magazine that included local news, community events, and community health information.	The magazine was mailed to all 4,750 Tokigawa houses once per month.
ECHR	Health class	The concept of small change was integrated in traditional health classes (walking seminars, cooking classes, general health classes, exercise classes for young adults, explanations of health checkups, relaxation classes, and physical activity, and diet classes). Public health nurses introduced the concept of applying small changes toward an overall healthy lifestyle.	Public health nurses gave lectures in seven health classes per year.
ECHR	Events	Public health nurses directly promoted the importance of small lifestyle changes at cultural events that were unrelated to health promotion. Because the campaign was intended to encourage physical activity and healthy eating among people who did not have healthy habits, cultural events seemed to be a good way to attract people with unhealthy lifestyles.	Public health nurses gave a brief face-to-face explanation of small changes at five events per year.
ECHR	Online newsletter	Public health nurses in Tokigawa created online newsletters, including (a) general health information and (b) ideas to reduce food intake and increase physical activities to expend 100 kilocalories.	The newsletter was posted on the website twice during the campaign.

Note. HIMDR = health information material developed by the researcher; ECHR = enhanced community health resources; SCC = Small Change Campaign.

Measures

A background questionnaire collected demographic information about gender, age, and employment status. The primary outcome of this study was to increase participant exposure to the health campaign because of its expected influence on health behavior change. Campaign exposure was defined as participants’ awareness of campaign slogans, logos, and communication media, based on our previous community-wide intervention and literature review. O’Hara et al.’s (2012) Get Healthy Information and Coaching Service® tools were adopted for this study based on their reported reliability and validity. Campaign exposure measures included questions about participant awareness of slogans and logos. See Table 2 for a list of English translations of these questions and their possible answers (the original questions and answers were provided in Japanese). The participants were also asked about the channel through which they heard about the slogan or logo. See Table 2 for their responses to this question.

Table 2.

Questions.

Measurement concept	Question	Possible responses
Campaign exposure
Slogan	Do you know the term: Small Change?	I know it.
		I know it, but I do not know its meaning.
		I do not know it.
Logo	Have you seen this logo?	I have seen it.
Logo	Have you seen this logo?	I have never seen it.
Implementation channel	From which materials or opportunities did you learn about Small Change? (Multiple responses to the question were allowed)	HIMDR: Leaflet, newsletter, poster, and website
Implementation channel		ECHR: Local public relations magazines, health class, events, and online newsletter

Note. HIMDR = health information materials developed by the researcher; ECHR = enhanced community health resources.

Statistical Analysis

Age data were collapsed into two categories—younger than 65 years and older than 65 years—based on median value. In addition, employment status was divided into several different categories (see Table 3). Nonresponses were excluded from the analysis of job condition differences. Job condition was divided into either employed or unemployed. HIMDR and ECHR perceptions were said to occur if the participants responded that they perceived one or more of each communication channel that composed each strategy. They assessed perception through each strategy (rating = 1). If the participants did not perceive any communication channels for any of the strategies, they were regarded as being nonperceiving (rating = 0).

Table 3.

Participant Characteristics and Campaign Awareness.

Characteristics	n	%
Gender
Male	230	45.3
Female	278	54.7
Age (years)
40-44	14	2.8
45-49	16	3.1
50-54	26	5.1
55-59	47	9.3
60-64	135	26.6
65-69	145	28.5
70-74	125	24.6
Employment
Unemployed	148	29.1
Homemaker	104	20.5
Self-employed	53	10.4
Part-time employee	41	8.1
Company employee	36	7.1
Agriculture	31	6.1
Carrier business	5	1.0
Medical care personnel	4	0.8
Civil servant	4	0.8
No response	82	16.1
Slogan awareness
I knew	230	45.3
I knew that, but I did not know the meaning	99	19.5
I did not know	179	35.2
Logo awareness
I have seen	124	24.4
I have never seen	384	75.6

Descriptive statistics were calculated for the demographic characteristics and participants’ campaign awareness. Chi-squared or Fisher’s exact tests (Fisher, 1935; Patefield, 1981) were performed to investigate our results compared with city census data, differences in perceived communication strategies, and channels. Cohen’s standardized effect size (w) was reported for the size differences between this study sample’s participants and city census data, recognition among each communication channels, and perception differences between HIMDR and ECHR. Values of w were classified as .10 = small, .30 = medium, and .50 = large (Cohen, 1992). Awareness differences according to demographic characteristics were analyzed via logistic regression analysis. Unadjusted and adjusted odds ratios (ORs) and 95% confidence intervals (CIs) were calculated for the perception of slogans, logos, and intervention materials. Adjustments were made according to gender, age group, and job. During the logistic regression analysis, slogan recognition was divided into recognition (I know it) and nonrecognition (I know it, but I do not know its meaning; and I do not know it). For statistically significant results, the residual analysis was used to determine gender or age differences. The analyses were conducted using SPSS, Version 22.0, and R, Version 2.9.2.

Ethics Approval

The participants were assured their personal information and questionnaire responses would be kept confidential and that the information would be used for research purposes only. They all supplied written consent. This study was approved by the Human Ethics Committee of Waseda University (Ref. No. 2012-231).

Results

Sample Characteristics

Table 3 presents the characteristics of the participants who completed the questionnaire. The median value for age was 65 years, with ages ranging from 40 to 74 years, and 54.7% were female. A comparison of city census data (Town of Tokigawa, 2013) and study sample data showed that this study data slightly reflected female responses (χ² = 7.97, df = 1, p = .01, w = .03) and the responses of those who were older than age 65 (χ² = 152.43, df = 1, p = .01, w = .14).

Campaign Exposure

The participants’ campaign awareness rates were as follows: 45.3% knew the slogan and 24.4% of them were aware of the logo. As presented in Table 4, we found significant gender differences in slogan awareness (adjusted OR = 2.40). Females perceived the slogan more frequently than did males. Likewise, we found significant differences in employment regarding slogan and logo perception. The unemployed reported greater awareness of both (adjusted OR = 1.77 and 1.72, respectively).

Table 4.

Differences in Slogan and Logo Awareness According to Demographic Characteristics.

		Slogan awareness				Logo awareness
Characteristic	n (%)	Unadjusted OR	95% CI	Adjusted OR	95% CI	Unadjusted OR	95% CI	Adjusted OR	95% CI
Gender
Male	230 (45.3)	1.00		1.00		1.00		1.00
Female	278 (54.7)	2.52**	[1.75, 3.62]	2.40**	[1.59, 3.63]	1.56*	[1.03, 2.36]	1.40	[0.88, 2.25]
Age (years)
Younger than 65	237 (46.7)	1.00		1.00		1.00		1.00
Older than 65	271 (53.3)	1.04	[0.73, 1.48]	0.98	[0.66, 1.47]	0.99	[0.66, 1.49]	0.86	[0.55, 1.36]
Job
Employed	174 (40.8)	1.00		1.00		1.00		1.00
Unemployed	252 (59.2)	2.18**	[1.46, 3.25]	1.77**	[1.15, 2.71]	1.92**	[1.19, 3.08]	1.72*	[1.04, 2.82]

Note. OR = odds ratio; CI = confidence interval.

p < .05. **p < .01.

Recognized Communication Channels

Figure 2 displays participants’ responses to the different types of materials and communication channels. A local public relations magazine, leaflets, and newsletters were better recognized (χ² = 328.25, df = 7, p < .01, w = .74). Tables 5 and 6 show the demographic differences in perceptions for each of the communication channels (unadjusted ORs are provided in the Appendixes A and B). Females exhibited greater leaflet perceptions (adjusted OR = 2.04). Moreover, the unemployed reported greater awareness of the Web site (adjusted OR = 3.42), LPRM (adjusted OR = 1.56), health class (adjusted OR = 3.32), and events (adjusted OR = 2.16).

Figure 2.

Responses to questions about communication channels.

Table 5.

Differences in Perceptions of the Health Information Materials Developed by the Researcher Communication Channels According to Demographic Characteristics.

	Leaflet		Newsletter		Poster		Web site
Characteristic	Adjusted OR	95% CI	Adjusted OR	95% CI	Adjusted OR	95% CI	Adjusted OR	95% CI
Gender
Male	1.00		1.00		1.00		1.00
Female	2.04**	[1.27, 3.28]	1.82	[1.05, 3.14]	1.65	[0.86, 3.18]	0.52	[0.20, 1.32]
Age (years)
Younger than 65	1.00		1.00		1.00		1.00
Older than 65	0.99	[0.63, 1.54]	1.06	[0.64, 1.77]	1.11	[0.60, 2.05]	0.76	[0.31, 1.88]
Job
Employed	1.00		1.00		1.00		1.00
Unemployed	1.49	[0.91, 2.44]	1.27	[0.72, 2.22]	1.39	[0.71, 2.72]	3.42*	[1.06, 11.02]

Note. OR = odds ratio; CI = confidence interval.

p < .05. **p < .01.

Table 6.

Differences in Perceptions of the Enhanced Community Health Resources Communication Channels According to Demographic Characteristics.

	LPRM		HC		Events		ON
Characteristic	Adjusted OR	95% CI	Adjusted OR	95% CI	Adjusted OR	95% CI	Adjusted OR	95% CI
Gender
Male	1.00		1.00		1.00		1.00
Female	1.33	[0.88, 2.01]	1.36	[0.71, 2.58]	0.84	[0.44, 1.60]	6.61	[0.81, 54.24]
Age (years)
Younger than 65	1.00		1.00		1.00		1.00
Older than 65	1.02	[0.68, 1.52]	1.01	[0.55, 1.86]	1.05	[0.56, 1.98]	1.05	[0.28, 3.82]
Job
Employed	1.00		1.00		1.00		1.00
Unemployed	1.56*	[1.01, 2.40]	3.32*	[1.52, 7.25]	2.16*	[1.03, 4.53]	2.05	[0.40, 10.35]

Note. LPRM = local public relations magazines; HC = health class; ON = online newsletter; OR = odds ratio; CI = confidence interval.

p < .05. **p < .01.

Differences in the Perception of HIMDR and ECHR

Chi-squared analysis on the differences in response ratios for HIMDR and ECHR revealed no significant differences (66.2% vs. 72.6%; χ² = .91, df = 1, p = .34, w = .08). Positive responses were given to both the HIMDR and ECHR materials. Table 7 summarizes the gender, age, and employment differences. Our results show that females reported more perceived HIMDR than did males (adjusted OR = 1.78). In addition, the unemployed reported greater awareness of both HIMDR and ECHR (adjusted OR = 1.69, and 1.74, respectively).

Table 7.

Differences Between HIMDR and ECHR Perceptions According to Demographic Characteristics.

	HIMDR				ECHR
Characteristic	Unadjusted OR	95% CI	Adjusted OR	95% CI	Unadjusted OR	95% CI	Adjusted OR	95% CI
Gender
Male	1.00		1.00		1.00		1.00
Female	1.95**	[1.36, 2.83]	1.78**	[1.18, 2.69]	1.26	[0.89, 1.79]	1.23	[0.82, 1.84]
Age (years)
Younger than 65	1.00		1.00		1.00		1.00
Older than 65	1.02	[0.72, 1.46]	0.95	[0.63, 1.42]	1.18	[0.83, 1.68]	1.08	[0.73, 1.59]
Job
Employed	1.00		1.00		1.00		1.00
Unemployed	1.85**	[1.24, 2.76]	1.69*	[1.18, 2.69]	1.88**	[1.26, 2.79]	1.74*	[1.14, 2.64]

Note. HIMDR = health information materials developed by the researcher; ECHR = enhanced community health resources; OR = odds ratio; CI = confidence intervals.

p < .05. **p < .01.

Discussion

The present study examined the reach of various communication channels/strategies to disseminate physical activity and nutrition messages to middle-aged and elderly adults with different demographic characteristics. The study’s major findings revealed that (a) further communication strategies are needed to facilitate slogan and logo awareness, (b) gender and job seem to act as moderator variables in health information dissemination, and (c) the combination of HIMDR and ECHR strategies facilitate media exposure to messages about physical activity and dietary habits.

The slogan and logo recognition rates in this study were low (45.3% and 24.4%, respectively) compared with past studies. For example, similar population-wide physical activity and nutrition intervention studies reported that approximately 70% of the population promptly recognized other campaigns (Leavy, Rosenberg, Bull, & Bauman, 2014; O’Hara et al., 2012). Further efforts to implement health messages are needed. Several possible improvement strategies that could be implemented include using mass media communication (e.g., TV and radio) and interpersonal communication channels derived from peer supporters (e.g., word of mouth). O’Hara et al. (2012) revealed that TV and radio are great contributors to campaign awareness.

Likewise, Withall, Jago, and Fox (2012) reported that word of mouth may serve as another channel of communication for long-time intervention. Another reason why slogan and logo implementation are insufficient is the fact that using English in slogans and logos seems to be a barrier to slogan and logo recognition. Most Japanese people can understand easy English. The researcher, public health nurse, and publishing specialists discussed the term “Small Change” and considered it to have great novelty and saliency. However, the adaptation of Japanese slogans and logos promised significant campaign reach extension. Prior research suggests that the branding of the logo, sign, and symbol facilitates the development of the brand–participant relationship and communicates the benefits of engaging in health campaigns (Evans, Blitstein, Hersey, Renaud, & Yaroch, 2008). Further research is needed to assess how researchers should create acceptable, novel, and salient public health brands. In addition, before conducting intervention, more clarity is needed regarding the target audience and the process of conducting formative research specific to the target audience (Bauman et al., 2006). Likewise, pilot and feasibility trials for each intervention materials used with community residents facilitated population health intervention engagement (Thabane et al., 2010; Whitehead, Sully, & Campbell, 2014).

Our study confirmed that the combination of HIMDR and ECHR strategies facilitated health information dissemination. The basis for this study may have been the ecological model of health behavior, since the HIMDR and ECHR strategies seem to adapt well to community organizations and provide ongoing, multilevel campaign exposure (Green, Richard, & Potvin, 1996; Owen, Glanz, Sallis, & Kelder, 2006). A campaign’s ability to reach its target population should moderate the health information dissemination and, thus, the outcome of campaign exposure (Rabin, Brownson, Kerner, & Glasgow, 2006). These findings provide critical information that can contribute to improving campaign strategies.

Similarly to previous studies, we uncovered gender and employment status differences in campaign awareness, with men and the employed having less health awareness than women and the unemployed (Lorentzen et al., 2007; O’Hara et al., 2012). There might also be gender differences in the perceptions of health risks and body image. Previous research has revealed that women have a higher risk perception (Flynn, Slovic, & Mertz, 1994). Japanese men engage in more high-risk behaviors than do Japanese women (Fukuda, Nakamura, & Takano, 2005), and women are more dissatisfied with their bodies (Demarest & Allen, 2000).

Regarding employment status, those with jobs have more trouble accessing health information (due to a lack of time, lack of knowledge, and placing less priority on it; Fletcher, Behrens, & Domina, 2008). The differences in gender and employment status are associated with cultural background or confounding interactions with other variables. Gender needs to be considered during audience segmentation (Kreuter & Wray, 2003) when disseminating health messages. A communication approach tailored to the target audience would be useful in increasing the connection between media materials and the audience (Kreuter, Lukwago, Bucholtz, Clark, & Sanders-Thompson, 2003; Noar, Benac, & Harris, 2007). Further research should examine possible strategies for increasing the recruitment and engagement of men and those employed in health campaigns. Family and worksite settings seem to contribute significantly to social support in men and employed populations. Family interventions can provide ongoing support and encouragement among group members (Sallis, Owen, & Fisher, 2008). In addition, previous research has reported the effectiveness of behavior change interventions within worksites (Anderson et al., 2009).

There are several limitations to this study. First, we did not have a control condition. Second, we relied on limited materials and measures of communication channels (i.e., interpersonal channels among community residents were not included). Third, our study sample was restrictive and biased. Our participant response rate was only 50%, and all participants received a national health checkup (i.e., the selection was biased). They seemed to already have high health awareness. In addition, although effect size was small, if not nonexistent, these results accurately reflect the health awareness of females and those older than 65 years compared with city census data. Fourth, we could not acquire adequate data for statistical analysis of job type because disproportionately few participants were employed in certain areas. Finally, our investigation was only a one-point, cross-sectional study (i.e., it had a low evidence level).

A comprehensive systematic review of community-wide physical activity health promotion interventions mentioned that there were problems with these studies due to their poor quality and the fact that none of them assessed the risk of bias (Baker, Francis, Soares, Weightman, & Foster, 2011). One recent cluster-randomized control trial was conducted to assess the effectiveness of community-wide health promotion campaigns (Kamada et al., 2013) in Japan; however, more investigation into this issue is needed. Additionally, further studies are needed to design higher evidence levels (i.e., a randomized control trial), and studies that explore effective communication strategies in community-based health promotion intervention with lower bias risks should be implemented.

Conclusions

In summary, we explored the health information dissemination strategies that facilitate awareness of health information to promote healthy behavioral changes among middle-aged and elderly Japanese adults. Variations in demographic characteristics, including gender, age, and employment status and campaign exposure differences were also examined. Contrary to our expectations, we found that a combination of HIMDR and ECHR strategies seems to facilitate media exposure by gender, age, or employment. In addition, gender and job status had moderating effects on slogan, logo, and communication channel recognition. Particularly, men and those who are employed need to be further examined to obtain a more accurate picture of the middle-aged and elderly Japanese populations.

The efficacy of slogan use and both HIMDR and ECHR strategies enhanced the dissemination of information concerning healthy behavior changes. Moreover, the results suggest that gender and job are important factors to consider in the selection of the best media choice with which to communicate health messages. Despite several limitations, our study provides evidence of strategies to disseminate health information in community-based programs for physical activity and nutrition that are targeted to middle-aged and elderly Japanese adults. Further research should examine the efficacy of mass media and interpersonal communication channels by randomized control trials.

Footnotes

Appendix

Appendix B

Differences in Perceptions of the Enhanced Community Health Resources Communication Channels According to Demographic Characteristics (Unadjusted OR).

	LPRM		HC		Events		ON
Characteristic	Unadjusted OR	95% CI	Unadjusted OR	95% CI	Unadjusted OR	95% CI	Unadjusted OR	95% CI
Gender
Male	1.00		1.00		1.00		1.00
Female	1.38	[0.96, 1.99]	1.70	[0.93, 3.08]	0.89	[0.49, 1.61]	3.81	[0.82, 17.83]
Age (years)
Younger than 65	1.00		1.00		1.00		1.00
Older than 65	1.15	[0.80, 1.65]	1.26	[0.71, 2.25]	1.25	[0.69, 2.28]	1.05	[0.32, 3.49]
Job
Employed	1.00		1.00		1.00		1.00
Unemployed	1.69*	[1.12, 2.53]	3.56**	[1.68, 7.54]	2.31*	[1.14, 4.70]	2.82	[0.59, 13.44]

Note. LPRM = local public relations magazines; HC = health class; ON = online newsletter; OR = Odds ratio; CI = confidence interval.

p < .05. **p < .01.

Acknowledgements

The authors are deeply grateful to Takashi Iino (Sun Life Kikaku Publisher) who helped design the health information materials. We appreciate the cooperation of Mitsunori Kato, Mariko Yoshizawa, Takamitsu Yoshida, Harumi Okamoto (Tokigawa City Public Health Center), and Koji Tanaka (Hiroshima Bunka Gakuen University). We are grateful to Misa Iio, Kousuke Maeba, Megumi Saito, Toshiki Hosoi, Ying-Hua Lee, Kayo Konuma, Natsuko Suzuki (Applied Health Science Laboratory, Waseda University), and Masao Kikkawa (Tokai University) for their contributions to the progress of this study. Also, we thank Munehiro Matsushita (Graduates School of Sports Sciences, Waseda University) for consultation regarding the statistical analysis.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The research was supported by a research grant from the Sasakawa Sports Foundation (130B2-008).

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