Mass Media Campaigns – Healthy Eating and Active Living Fall 2016

Part 1: Needs Assessment

The American public are becoming more aware of the contribution that women have made and continue to make in the military. While the number of women joining the military is increasing, the number of women veterans are increasing as well. In 2014, there were 2,001,252 veterans, which made up 10% of the total number of veterans in the U.S. (National Center for Veterans Analysis and Statistics [NCVAS], 2015a). By 2043, the number of female veterans will reach 2,404,266 and will make up 16% of the overall veteran population (NCVAS, 2015a). Georgia has both the fifth highest percentage of women veterans (12%) and the fifth largest population of women veterans in the U.S. (90,382) (NCVAS, 2015a; NCVAS, 2016). By 2043, the number of women veterans in Georgia is expected to increase to 125,878, which will make up 19% of the total number of veterans in the state (NCVAS, 2015b).

Once attaining veteran status, one is eligible for Veteran’s Affair’s(VA) benefits and health care. Women only made up a small amount of patients in the Veteran’s Health Administration (VHA) which was 6.5% (Women’s Health Services, 2014). Compared to their male counterparts, they are more likely to have a service connected (SC) disability; in 2012, 57% of female veterans had a SC disability (Women’s Health Services, 2014). The top five conditions women veterans sought treatment for at the VHA were “musculoskeletal issues, endocrine/metabolic/nutritional issues, mental health/substance abuse issues, cardiovascular issues and reproductive health” (Women’s Health Services, 2014, p.5). All of these issues can result in decreased physical activity and contribute to additional negative health outcomes such as obesity. According to Women’s Health Services (2014), “among the youngest cohort of women (18-44 years old), nearly one in six carries a diagnosis of Overweight/Obesity, suggesting that this group is not spared from the national obesity epidemic despite having been relatively recent in military services, where fitness is a priority” (p.14).

This finding of the Women’s Health Service alludes to the “healthy soldier effect” in which a selection bias is present for those who are members of the military; having particular standards of good health was a pre-requisite for joining service (Washington et al., 2016). According to a study done about women veterans under the Women’s Health Initiative (WHI) (2016), which focused the health characteristics of postmenopausal women, the “healthy soldier effect” diminished throughout time as women veterans got older(Washington et al., 2016). This is consistent with the trend discovered in prior studies (as cited in Bross & Bross, 1987; Weitlauf et al., 2015). When comparing the health behaviors and characteristics of younger veterans(post-Vietnam) and older veterans (pre-Vietnam), younger veterans had unhealthier behaviors and characteristics such as less physical activity and higher BMI than older veterans (Washington et al., 2016).

Because the number of veterans are expected to increase not only in Georgia, but nationwide, there has been a call to provide more specialized health and support programs for women veterans. The experiences of the women veterans are distinct from male veterans and according to Murphy and Hans (2014), the support network that is set-up for the veterans once they transition from military to civilian life is designed to meet the needs of male veterans. In addition, weight management can be difficult once transitioning to civilian life; according to Almond et al (2008), “it may be unrealistic to switch easily from the military’s primarily external motivation to maintain a healthy weight to an internal motivation once the military’s expectations are removed when the member transitions to civilian life” (p. 548).

Women Health Services (2014) mentions that preventative measures should be emphasized in order to prevent the negative health outcomes that is brought on by being overweight or obese. Murphy and Hans (2014) echoes this by saying, “holistic, evidence-based programs for women’s health, mental health and rehabilitation must be expanded to address the full continuum of care needed by all veterans” (p.3). While the Department of Defense (DoD) and VA have a copious amount of resources on health promotion and women’s health care services for Post 9/11 female veterans, there is is no central source for these materials which makes them difficult to access (Murphy and Hans, 2014). Because there is not an easily obtainable source of these materials, it can be difficult for women veterans to get the assistance they need in transitioning to civilian life, obtaining a support network, or taking preventative measures in order to better their health outcomes.

REFERENCES

Almond, N., Kahwati, L., Kinsinger, L., & Porterfield, D. (2008). The Prevalence of
Overweight and Obesity among U.S. Military Veterans. Military Medicine, 173(6), 544-549.
Bross, I. D., & Bross, N.S. (1987). Do atomic Veterans have excess cancer? New results
correcting for the healthy soldier bias. American Journal of Epidemiology, 126, 1042-1050.
Murphy, F & Hans, S. Disabled American Veterans (2014). Women Veterans: The Long
Journey Home. Retrieved from https://www.dav.org/women-veterans-study/.
National Center for Veterans Analysis and Statistics (2016). Profile of Women Veterans: 2014.
Washington, DC: Retrieved from http://www.va.gov/vetdata/report.asp.
National Center for Veterans Analysis and Statistics(2015a). U.S. Department of Veterans
VetPop2014 Living Veterans by Age Group, Gender, 2013-2043 [Data file].
Retrieved from http://www.va.gov/vetdata/Veteran_Population.asp.
National Center for Veterans Analysis and Statistics (2015b). U.S. Department of Veterans
VetPop2014 Living Veterans by State, Age Group, Gender, 2013-2043 [Data
file]. Retrieved from http://www.va.gov/vetdata/Veteran_Population.asp.
Washington, D. L., Bird, C. E., LaMonte, M. J., Goldstein, K. M., Rillamas-Sun, E.,
Stefanick, M. L., & Woods, N. F. (2016). Military Generation and Its Relationship to
Mortality in Women Veterans in the Women’s Health Initiative. Gerontologist,56
(Supplement 1), S126-S137.
Weitlauf, J. C., LaCroix, A. Z., Bird, C. E., Woods, N. F., Washington,　 L., Katon, J. G.,
LaMonte, M.J., Goldstein, M.K., Bassuk S.S., Sarto G.E, & Stefanick, M. L. (2015).
Prospective analysis of health and mortality risk in Veteran and non-Veteran participants
in the Women’s Health Initiative. Women’s Health, 25, 648–656.
Women’s Health Initiative (2016). About WHI. Retrieved from
https://www.whi.org/about/SitePages/About%20WHI.aspx.
Women’s Health Services (2014). U.S. Department of Veterans Affairs. Sourcebook:
Women Veterans in the Veterans Health Administration (Vol. 3). Washington DC:
Retrieved from http://www.womenshealth.va.gov/docs/Sourcebook_Vol_3_FINAL.pdf

Stakeholder	Role in Intervention	Questions from Stakeholder	Effect on Stakeholder of a Successful Program	Effect on Stakeholder of an Unsuccessful Program
Women veterans	Recipients of health information, users of health promotion services. Possible mentor to other female veterans.	How can you implement a mass media campaign that will hit all age demographics of women veterans? What channels will you rely on for your campaign?Are you concerned about the digital divide between young and older veterans when it comes to using internet outlets to disseminate health information?	Increased access to health information. Increased knowledge of nutrition and physical activity measures to better health outcomes. Increased use of health promotion services. Better health outcomes of women veterans in terms of reducing BMI and increased physical activity.	Little to no increase in access to health information. No increase in the use of health promotion services. No increase in knowledge of nutrition and physical activity measures to better health outcomes. Increase of feelings of isolation and marginalization in the overall community of veterans.
Veteran advocacy groups(ex. Disabled American Veterans[DAV], American Women veterans, etc).	Advocate for more health promotion programs for women veterans. Providing transportation to health promotion programs (such as DAV).	How will you create a centralized mass media campaign that focuses both on VA services and the services we provide as community organizations?	Increased use of services by women veterans. Increased awareness of these organizations among women veterans.	Little to no increase in use of services by women veterans. Negative perception of such organizations among women veterans.
Veteran’s Health Administration hospitals	Providers of health promotion services and women veteran health services.	What kind of quality assurance will you implement in order to make sure you give out the correct information about VA programs for women veterans both online in and paper format?	Increased use of VA hospital health promotion programs for women veterans. Increased funding for women veteran specific wellness programs. Increased positive perception of VA hospitals among women veterans.	Little to no increase in using VA health promotion programs for women veterans. Increased negative perception of VA hospitals among women veterans.
Veteran’s Health Administration Community-based outpatient clinics (CBOC)	Local provider of health services for women veterans.	How will you increase awareness of the health promotion services that are available locally for women veterans? How will your campaign reach all age demographics of women veterans?	Increased access and use of CBOCs in local communities. Increased funding for women veteran specific health promotion programs.	Little to no increase in using the CBOC by women veterans.
Veterans of Foreign Wars(VFW) posts	Provide information about VA benefits for those who just transitioned to a civilian life, provide local community programs for women veterans.	What will you do to attract a younger demographic of women veterans to use the VFW?	Increased use of VFW posts by a younger demographic of women veterans.	Little to no increase in use by a younger demographic of women veterans.
Fitness and wellness instructors who specialize in veteran health and wellness or have an interest in veteran health and wellness.	Provide fitness and wellness sessions in a group or individual setting. Certify others to provide such services to women veterans. Make physical activity plans that can be implemented at home.	How can we be sure that our services will have equal emphasis as bigger health promotion programs such as those implemented by the Veteran’s Health Administration? (VHA) Will there be a selection bias for particular physical activities (ex. yoga programs over bootcamp style programs?) Will you be selective on which professionals you will include in this mass media campaign(ex. prefer those with experience to the newly certified professional).	Receive positive recognition of being affiliated with a successful media campaign. Increased clientele, professional opportunities, and profits.	Affiliation with an unsuccessful media campaign. Decreased clientele, professional opportunities, and profits.

Part 2: Intervention Identification

The intervention strategy that will be used for this population is a stand-alone mass media campaign to increase physical activity. According to the Community Preventative Services Task Force (2014), “stand-alone mass media campaigns are interventions that rely on mass media channels to deliver messages about physical activity to large and relatively undifferentiated audiences” (para 1). Examples of such channels are television, radio, websites, and social media. The purpose of these channels is to both increase awareness and influence behaviors regarding physical activity (Community Preventative Services Task Force, 2014). The specific mass media channels that will be used for this intervention will be websites and social media.

Mass media campaigns have been used as an intervention to promote physical activity from the local to the national level and among various populations and age groups. Out of all of the studies that the Community Preventative Task Force looked at, only three studies showed that the intervention had a significant change in self-reported physical activity. Two of the studies were about the VERB campaign (Berkhowitz, Huhman, & Nolin, 2008; Huhman et al., 2010 ) and one of the studies was about England’s ACTIVE for LIFE Campaign (Hillsdon, Cavill, Nanchahal, Diamond & White, 2001). The VERB campaign targeted tweens (9-13 years), while the ACTIVE for LIFE campaign targeted adults (Community Preventative Services Task Force, 2014). These campaigns were long-term campaigns; the VERB campaign was four years long and the ACTIVE for LIFE campaign was two years long (Community Preventative Services Task Force, 2014). Out of these two campaigns, the target audience for ACTIVE for LIFE campaign is more similar to the target audience for the proposed mass media intervention for female veterans. The ACTIVE for LIFE campaign had participants who were between 16 and 74 years old (Hillsdon, Cavill, Nanchahal, Diamond & White, 2001) and the proposed mass media intervention will be targeting a similar age demographic, which are females who are between 18 to 65 years old. The main difference between the populations of the ACTIVE for LIFE campaign and the women veteran’s mass media campaign is that the ACTIVE for LIFE campaign is an intervention that is targeted for both genders, while the women veteran’s mass media campaign will only focus on one gender. Currently, there no studies that exist regarding the use of such platforms that target female veterans in promoting healthy behaviors such as good nutrition practices and physical activity.

According to the Community Preventative Services Task Force (2014), “there is insufficient evidence to determine the effectiveness of stand-alone mass media campaigns to increase physical activity at the population level” ( para 4). They determined this based on the results of the 16 studies they looked at which produced inconsistent and moderate results. (Community Preventative Services Task Force, 2014). In terms of the platforms that the intervention wishes to use, which is the internet and social media, the Task Force did not even include studies regarding these mediums into their evaluation but did acknowledge the increasingly important role they have to play as mediums that can help increase physical activity among the broader population.

One example of a mass media campaign which was on a similar scale as the ACTIVE for LIFE and VERB campaign was the LiveLighter campaign which ran in the states of Western Australia and Victoria from June to November 2012 (Morley et al., 2016). The purpose of this intervention was to raise awareness about obesity in order to “motivate, reinforce, and enable” individuals who were at risk or currently obese to take action to reduce their body weight (Morley et al., 2016). This particular campaign was centered around a 30 second ad which included graphic display of visceral fat around a person’s organs to show the negative effects that extra fat can have on one’s health (Morley et al., 2016). There were four subsequent ads which reinforced this image and gave tips on how to change one’s behaviors to prevent this buildup of visceral fat (Morley et al., 2016).

The outcomes that were measured were based on the immediate impact the message had on the population and whether they could recall and appraise the campaign in being effective in raising their awareness about the risks of obesity (Morley et al., 2016). In addition, Morley et al. (2016) were interested in the intermediate and longer-term impacts of this campaign such as a change in beliefs and behavior. The researchers gave out a survey during both the first and second media wave of this ad campaign in order to measure such outcomes. Morley et al. (2016) concluded that there was an increased awareness of the health risks of obesity, however they stated that it was premature to say if this awareness would result in a change of behaviors. They felt that the LiveLighter campaign was still “immature” and more time was needed in order to determine whether this campaign will have any effect on intentions and behaviors in the long run (Morley et al., 2016). While the LiveLighter campaign’s main focus was on the TV ads, during the second phase, the ads were posted on a website along with supplemental information (Morley et al., 2016).

While the LiveLighter campaign used the internet as a secondary medium, the “4-day-throw-away” food safety campaign ran a mass media campaign using both traditional and social media platforms. James, Albrecht, Litchfield, and Weishaar (2013) were concerned with the effectiveness of both components of this campaign in delivering the message of throwing leftovers away after four days. In addition, James et al. (2013) were concerned with if these campaigns actually initiated a change in behaviors among the intended audience. This campaign was implemented in Nebraska and Iowa and targeted the primary food preparer in families with children ten years old or less (James et al., 2013). The traditional media campaign comprised of disseminating posters, magnets, and notepads in the locations where the target audience visited often (James et al., 2013). The magnets and notepads had the website in which they could find out more information about how to handle leftovers. The social media component was comprised of a Facebook and Twitter presence which posted or tweeted about best practices regarding leftovers (James et al., 2013).

The traditional campaign ran for around two months and at the time of the study, the social media campaign was ongoing. Both quantitative (taken from website and social media analytics) and qualitative data were collected in order to gauge the effectiveness of the campaign four months after the campaign was implemented(James, et al., 2013). Half of the respondents in communities which the campaign was implemented said that they followed the recommended practices regarding leftovers compared to 38% of the respondents that were part of the control population (James, et al., 2013). The amount of web traffic increased throughout the campaign and 40% of were introduced to the website through social media, while 60% were introduced to the website through the traditional campaign (James, et al., 2013). While James et al. (2013) mentioned that the campaign was successful in reaching the targeted audience through both mediums, they also mentioned that it is difficult to assess how social marketing can have an impact on behavior change. They recommended using mixed media methods in social marketing campaigns in reaching a broader audience (James et al., 2013).

Another campaign which utilized social media was the One Voice campaign which was conducted in Canada. The purposes of this campaign was to increase web traffic of a website, mindcheck.ca, that was created to improve mental health awareness, and to lessen the stigma of mental health conditions (Livingston, Tugwell, Korf-Uzan, Cianfone, & Coniglio, 2013). The campaign was a mixed mass media campaign which utilized TV ads and the internet in order to disseminate these messages. In addition, this campaign had a Facebook presence. The purpose of the study was to see if the campaign met these desired outcomes.

The campaign ran for about two months in 2012 and questionnaires were given out before the campaign was implemented, two months after the campaign was implemented and one year after the campaign was implemented (Livingston et al., 2013). Website analytics were also used to measure the web traffic to the website. The number of people who knew about the site increased from 6.0 to 15.6 percent and in addition, there was an 1,531% increase in web traffic (Livingston et al., 2014). However, the study concluded that after two months, there was no improvement in attitudes about mental illness. A year later, Livingston et al., shared the results of the one year effects of this study. One year later, 17.8% of the respondents still knew of the website and the web traffic on mindcheck.ca was still steady (Livingston et al., 2014). In addition, it seems that the stigma regarding mental health issues decreased which was not observed with respondents two months after the campaign was launched.

These studies reveal that the primary issue with mass media interventions, especially those that use social media and the internet, is that they are too short in duration. Because of this, it is difficult to determine if such campaigns have a significant effect on health behaviors. The results from these studies indicate that it is necessary to track these kind of campaigns for a longer period of time in order to see if the actual distal outcomes match up with the intended distal outcomes. Even though there are a lack of studies on social media and internet mass media campaigns and these campaigns are usually short-lived, these mediums have a huge potential to make an impact in affecting behaviors regarding physical activity. In order for these mediums to be more effective, it is essential for researchers to do more studies on social media and internet mass media interventions and for the Task Force to include these mediums for subsequent reports regarding mass media.

REFERENCES
Berkowitz, J.M., Hulman, M., & Nolin, M.J. (2008). Did augmenting the VERB campaign advertising in select communities have an effect on awareness, attitudes, and physical activity? American Journal of Preventative Medicine, 34(6S), S257-S266.

Community Preventative Services Task Force (2014). “Campaigns and Informational Approaches to Increase Physical Activity: Stand-Alone Mass Media Campaigns.” Retrieved from http://www.thecommunityguide.org/pa/campaigns/massmedia.html.

Hillsdon, M., Cavill, N., Nanchahal, K., Diamond, A., & White, I.R. (2001). National level promotion of physical activity: results from England’s ACTIVE for LIFE campaign. Journal of Epidemiology and Community Health, 55(10), 755-761.

Huhman, M.E., Potter, L.D., Nolin, M.J., Piesse, A., Judkins, D.R., Banspach, S.W., & Wong, F.L. (2010). The influence of the VERB campaign on children’s physical activity in 2002 to 2006. American Journal of Public Health, 100(4), 638-45.

James, K. J., Albrecht, J. A., Litchfield, R. E., & Weishaar, C. A. (2013). A summative evaluation of a food safety social marketing campaign “4-day throw-away” using traditional and social media. Journal Of Food Science Education, 12(3), 48-55.

Livingston, J.D., Tugwell, A., Korf-Uzan, K., Cianfrone, M., Coniglio, C. (2013). Evaluation of a campaign to improve awareness and attitudes of young people towards mental health issues. Social Psychiatry and Psychiatric Epidemiology, 48(6), 965-973.

Livingston, J. D., Cianfrone, M., Korf-Uzan, K., & Coniglio, C. (2014). Another time point, a different story: one year effects of a social media intervention on the attitudes of young people towards mental health issues. Social Psychiatry And Psychiatric Epidemiology, 49(6), 985-990.

Morley, B., Niven, P., Dixon, H., Swanson, M., Szybiak, M., Shilton, T., & … Wakefield, M. (2016). Population-based evaluation of the ‘LiveLighter’ healthy weight and lifestyle mass media campaign. Health Education Research, 31(2), 121-135.

Part 3: Intervention Fit

Inputs/Resources	Activities	Outputs	Short-term Outcomes	Intermediate Outcomes	Long-term Outcomes
Physical and Virtual Workspace	Conduct meetings and trainings of all volunteers and staff, provide collaborative space to work on online and mobile apps.	Conduct meetings in a physical workspace three times in six months and a mandatory training. The other meetings can be held when needed in the virtual workspace (like Citrix, Google Hangouts, Skype, etc)	Increased synergy and collaboration between different staff members. Increased enrollment in health promotion and physical activity programs by female veterans across the state.
Funding	Two of the staff will be dedicated to writing grants and do fundraising in order to finance the costs	Write 4 grant applications that total between 50,000-100,000k each within a six month period. Find sponsorships from gyms, athletic apparel lines, etc.	Increased amount of capital to maintain the web and mobile apps along with the staff. Increased enrollment in health promotion and physical activity programs by female veterans across the state.
Support Staff and Volunteers	Engage in outreach in publicizing the app amongst veteran non-profit groups, veteran organizations, the VA, fitness professionals, health practitioners, and other relevant stakeholders	Have at least six paid staff and create a volunteer network of 20-30 volunteers, Talk VA community based clinics, veteran non-profits, and one veteran health conference in the Atlanta Metropolitan Statistical Area in a six month period.	Increased collaboration between veteran non-profits, VA community based clinics, and health practitioners, and female veterans. Increased awareness of health resources among female veterans. Increased enrollment in health promotion and physical activity programs that are beneficial for female veterans. Increased clientele for health and fitness practitioners.
Computers and Servers	Necessary hardware to create mobile and online apps tailored towards the female veteran population along with hosting such apps.	Will create two apps (for iOS and Android), one online app. Servers will serve information(online maps, online pamphlets, database of health practitioners and programs) that are relevant to the needs of female veterans.	Increased of awareness regarding VA and non-VA resources to promote physical activity. Increased enrollment in VA and non-VA physical activity programs.	Increased physical activity among the female veteran population in the Atlanta MSA.	Lower risk of obesity and type II diabetes indicated by a drop in body weight and body fat. Increased participation in health promotion programs.
Research Assistants	Will conduct focus groups among female veterans to determine the services they need and to beta test the app. Will do the research of the availability of programs for female veterans or that would be suitable for female veterans in Georgia.	Populate a list of research or facilities that would be suitable for women veterans in increasing physical activity and health promotion.	Increased awareness regarding VA and non-VA programs and health practitioners that either work with female veterans or are suitable for a female veteran population. Increased enrollment not only in VA and non-VA physical activity programs, but increased enrollment of female veterans in physical activity and other health promotion programs implemented on the local level (ex. YMCA, community center, etc).
Open Source GIS Software such as QGIS and Programming Languages such as Ruby and CSS	Will be used create GIS tools embedded within online and mobile apps to show availability of physical activity facilities or health practitioners tailored for female veterans in the Atlanta Metropolitan Statistical Area	Will integrate an GIS interface within the mobile and online versions.	Increased awareness of facilities and health practitioners who work with the female veteran population within one’s particular area. Increased enrollment in VA and non-VA physical activity programs in one’s local area.
Personnel with expertise in QGIS, app development, ,database management, and management of webpages	Will develop mobile and online apps with a geospatial component to be tailored towards the female veteran population. Will create a database of health practitioners and health facilities that deal with a female veteran population or would be beneficial to such a population.	Centralized source of health facilities, health services, healthcare practitioners, and fitness professionals who can meet the needs of female veterans in both mobile and online environments.	Increased access to information regarding health promotion and physical activity among female veterans. Increased access to advertise health promotion services for health practitioners, non-profits and fitness instructors. Increased enrollment in local health promotion and physical activity programs by female veterans.
Advertisement and Promotion Materials	Will run a primarily online campaign to market the app. Will create paper materials to distribute to VFWs, VA Community Based Clinics, Local Community Centers, and other health/health promotion facilities	Disseminate materials to VFWs, VA Community Based Clinics, and veteran non-profits in the Atlanta Metropolitan Statistical Area by the end of six months.	Female veterans being more aware of the health promotion resources available to them through the app. Increased enrollment in health promotion and physical activity programs by female veterans in the Atlanta Metropolitan Statistical Area.

SMART Objectives
1.Increase physical activity by 30 minutes within six months regardless of physical activity level.
2.By the end of a six month period, have an average weight loss of 5 lbs and 5% reduction in body fat.
3. Meet recommendations for physical activity (150 minutes) within twelve months.
4. By the end of a twelve month period, have an average weight loss of 10 lbs and 8% reduction in body fat.
Why this intervention may work
This intervention might work because the app will be a centralized, easy accessible source of health promotion and physical activity for female veterans. Currently, there is no centralized source of this information which means it is difficult for female veterans to be aware of health promotion and physical activity programs and services. Having various stakeholders aware of the app will increase exposure and dissemination of information about the app in their respective channels. It is paramount for the staff to collaborate with a variety stakeholders both on the local and national level to achieve maximum dissemination and exposure of the app by female veterans. Having focus groups in which female veterans voice their needs will make the app more specialized to such needs. Merely creating and launching the app is not enough. If female veterans are not aware of the app, they will not use it. In addition, the GIS aspect of the app will give localized information to female veterans. Finally, this tool brings together a group of health promotion and fitness professionals who are dedicated to serve the needs of female veterans. Through using this app, female veterans can enroll in the services they need which could result in a decrease of weight or body fat in the short and long-term.
Limitations
One major limitation of the selected strategy is that is overly reliant on self-reported information which could result in misinformation of under reporting. For example, there could be issues in accurately measuring amount of weight-loss and body fat loss among the users of this app. This app would have an option to register and to record basic health information, however not everyone will register to use the app. Since the information is based on self-reported information, use of the app in this capacity can decrease over time. In addition, there is a cost to keeping up the servers. In addition, if it is decided to include information in other metropolitan areas in Georgia, there needs to be an increase in staff and hardware to populate the information needed for the app. Also, the VA has its own mobile app and there might be some tension between the VA and our intervention since they might want to keep the monopoly on health promotion services for female veterans.

Data, dose, reach, fidelity, and implementation
Data analytics from the mobile app and the website would be used to determine the effectiveness of the intervention strategy.Such examples of this are the number of website hits, number of downloads, and the number of people who registered for the services. By the end of a six month period, it is expected that at least 921 veterans in the Atlanta Metropolitan Statistical area (around 2.5% of female veterans in Georgia) sign up for the online service. By the end of twelve months, it is expected that number doubles to 1,842 veterans. In addition, it is expected that there will be 2,500 web hits at the end of six months and 5,000 web hits by the end of twelve months.As mentioned previously, when registering, the user will be asked to give basic health information.By looking at this registration information along with the data analytics, we can determine the reach of the program such as the age demographic of female veterans. We will also get feedback from female veterans through focus groups.Fidelity and implementation regarding achieving the SMART objectives will be measured through self-reported information by the female veterans. Every three months when the user logs into the tool, they will be asked to update their health information along with a questionnaire about the services they discovered based on using the tool. This questionnaire/update should take no more than three minutes to complete. This questionnaire will ask about the number of services discovered to fit their needs, frequency they participate in these programs, and the evaluation of the services they used. In addition, they would be able to rate the quality of the services and programs they enrolled in with the app. The review interface would be similar to Google Reviews. Looking at the reviews in the Apple and Google Play app store will be some indicators of the quality of the app. In addition, the tri-monthly questionnaire will ask a question or two regarding ease of use and points of improvement. Finally, getting feedback from focus groups comprised of users who have been using the app for six months will also determine the fidelity and implementation.Dose would be determined by the data analytics along with the tri-monthly questionnaire/information update.

The dose in terms of the number of times the online application/mobile app has been used will be shown by the data analytics(log-ins, hits, etc). Qualitative information will also be used through getting feedback from focus groups. After tabulating the metrics and analyzing the feedback given from the focus groups and online questionnaire, these results will be disseminated to the staff. This information will be used to improve the app along with improving ways to market the tool to the target population.

Part 4: Reflection

My second choice strategy for my identified behavior would be Physical Activity: Creation of or Enhanced Access to Places for Physical Activity Combined with Informational Outreach Activities. While the main goal of the previous strategy was primarily informational in nature, this strategy is both informational and place-related. The strength of this strategy is that it tackles the issue of accessibility from an environmental perspective. Examples of this is increasing access to fitness facilities through creating free or reduced cost fitness classes and combining it with classes on positive health behaviors.The way that this strategy can tackle the desired behavioral changes (increasing the amount of physical activity and meeting recommendations for physical activity) is through providing places for female veterans to engage in physical activity. As mentioned previously, the healthy soldier effect diminishes as female veterans get older. In addition, some newly separated female veterans can find difficulty in establishing and maintaining a physical activity regimen based on the change in lifestyle. Increasing accessibility in terms of decreasing costs and increasing health promotion places will increase the opportunity to engage in physical activity.The strength of this strategy is that it is a multicomponent intervention (Community Preventative Services Taskforce, 2014). The nature of this particular strategy in the context of female veterans is that it both focuses on providing female veterans increased access to places to engage in physical activity and increased knowledge on physical activity. Providing information in the form of classes, workshops, and health fairs will give female veterans essential information to integrate more physical activity in their daily lives. In addition, this strategy could incorporate the use of a buddy or support group which could prove helpful to female veterans who recently transitioned to civilian life. Another strength of this strategy is that it is a recommended strategy by the Community Preventative Services Taskforce (2014). Based on their systematic review, there were median increases in exercise, participants engaged in leisure time physical activity, and energy expenditure by 13.7%, 8.2% and 2.9% respectively (Community Preventative Services Taskforce, 2014). There were also reports of a decrease of fat or weight loss as well (Community Preventative Services Taskforce, 2014).
I am wanting to integrate the Community Guide, Nutrition Education Library and other resources in my dissertation. One strength of geography as a discipline is its interdisciplinary nature. While there are a significant number of geographers who are interested in public health issues, I believe many of them do not utilize such resources for their research. I believe that combining evidence based practices from these resources with some of the theories most commonly used in geography would create a stronger study. For the sake of my research, which is on female veterans, I could do a GIS analysis of determining the largest number of female veterans by county or census tract along with health facilities that are available for veterans in those areas. I could then use the Community Guide to create a health intervention that could be useful for various stakeholders.Another area of research I am interested in is Community or Participatory GIS, in which one works with a community partner in using GIS to investigate community issues. While there is a wide body of literature in talking about the social implications of doing work with community partners, however there is no “framework” in which GIS practitioners can look at regarding how to implement a health intervention. I believe that the Community Guide, Nutrition Education library and other resources could provide that missing framework in some contexts.The biggest thing that I liked about these resources is that it really does consolidate information in a way that one can get a general overview of a particular strategy. In addition, these resources offer the links to the studies that they refer to. This could cut down on the amount of background research one needs to do about a specific intervention. Another thing that I like is that some of the resources allows you to compare interventions. For example, the Community Guide’s new website allows you to compare two or more interventions. Also, I like that the Community Guide and the Nutrition Education Library websites have websites for mobile devices. This is beneficial because not everyone conducts their business on a computer and it is just as easily accessible on a tablet or phone.I feel like the Community Guide is the best resource compared to other resources due to the websites user-friendly functions such as the comparison tool. While the Community Guide had this feature, the Nutrition Evidence Library did not. One thing I would suggest is that more of these resources have a feature in which one could compare interventions. In addition, some of these sites do not have a feature in which one could log in. The Community Guide allows one to creates an account in which one can save the studies they are interested in. While the Nutrition Evidence Library has a copious amount of information, there is no direct way to store this information. Finally, I feel that all of the websites could integrate more types of media in the websites such as videos and podcasts.REFERENCES
Community Preventative Services Task Force (2014). “Physical Activity: Creation for Enhanced Access to Places for Physical Activity Combined with Informational Outreach Activities.” Retrieved from https://www.thecommunityguide.org/findings/physical-activity-creation-or-enhanced-access-places-physical-activity-combined .