BACKGROUND: People's decisions to engage in protective health behaviors, such as mask wearing during the COVID-19 pandemic, are influenced by environmental and social contexts. Previous research on mask wearing used a single question about general mask usage in public, which may not reflect actual behavior in every setting. The likelihood of wearing a mask during one activity is also related to the likelihood of wearing a mask in another or avoiding an activity entirely. This analysis compared responses between a general question and activity-specific questions and identified patterns of mask-wearing behavior across activities. METHODS: Online, opt-in, cross-sectional surveys were conducted every 2 months from November 2020 to May 2021 (n = 2508), with quota sampling and weighting to achieve a representative sample of the U.S. POPULATION: Respondents were asked how frequently they wore a mask in public and during 12 specific activities including: on public transportation, while shopping, and attending social gatherings indoors and outdoors. Spearman's rank order correlation was used to compare the frequency of mask wearing reported using a general question versus an activity specific question. Additionally, a latent class analysis was conducted to identify patterns of mask wearing behavior across activities. RESULTS: There was little to no correlation (r = .16-0.33) between respondents' general attitudes towards mask wearing and their reported frequency of mask wearing in different activities. Latent class analysis identified six distinct groups based on their mask wearing behaviors and avoidance of certain activities. The largest group (29%) avoided ten of the twelve activities and always wore a mask during activities that could not be avoided. Additional groups included those who avoided most activities but made exceptions when around friends or family (20%), part time mask wearers (18%), and never mask wearers (6%). CONCLUSIONS: The findings suggest that activity-specific questions provide more accurate and useful information than a single general question. Specific, context based, questions allow for analyses that consider the nuances of people's decision-making regarding engaging in protective health behaviors, such as mask wearing, thus enabling public health professionals to create targeted guidelines and messages.

BACKGROUND: While previous studies have identified a range of factors associated with mask wearing in the US, little is known about drivers of mask-wearing among racial and ethnic minority groups. This analysis assessed whether factors positively associated with wearing a mask early in the pandemic differed between participants grouped by race/ethnicity (Hispanic, non-Hispanic Black, non-Hispanic Asian, and non-Hispanic White). METHOD: Data were obtained from a US internet panel survey of 3217 respondents during May-November 2020 (weighted by race/ethnicity, age, gender, and education to the US national population). Within each of the four available racial/ethnic groups, crude and adjusted odds ratios (COR and AOR) were calculated using logistic regression to assess factors positively associated with wearing a mask. Adjusted models were controlled for age, gender, education, county COVID-19 case count, presence of a state-issued mask mandate, and interview month. RESULTS: The following variables were most strongly positively associated with mask wearing (p<0.05) in each racial/ethnic group: Hispanic-seeing others wearing masks (AOR: 6.7), importance of wearing a mask combined with social distancing (AOR: 3.0); non-Hispanic Black-belief that wearing a mask would protect others from coronavirus (AOR: 5.1), reporting hearing that one should wear a mask (AOR: 3.6); non-Hispanic Asian-belief that people important to them believe they should wear a mask (COR: 5.1, not statistically significant); and non-Hispanic White-seeing others wearing masks (AOR: 3.1), importance of wearing a mask (AOR: 2.3). CONCLUSION: Public health efforts to encourage mask wearing should consider the diversity of behavioral influences within different population groups.

On April 6, 2020, a confirmed COVID-19 case in a correctional facility employee (Staff A) was reported to the Vermont Department of Health (VDH). Staff A worked in the facility while symptomatic, without reporting symptoms, for 10 days. VDH and the facility conducted two facility-wide testing events, implemented symptom monitoring, and initiated contact tracing. All 197 incarcerated persons and 115 (71%) staff were tested for SARS-CoV-2; 45 (23%) incarcerated persons and 17 (10%) staff had positive results (confirmed case), of whom 37 (82%) incarcerated persons and 1 (6%) staff had asymptomatic infections. Case detection enabled isolation of incarcerated persons and staff, work exclusion of staff with COVID-19, and quarantine of staff and incarcerated persons who had close contact with persons with COVID-19. Broad-based SARS-CoV-2 testing identified more cases than symptom monitoring.

BACKGROUND: Efforts to contain the spread of Ebola in the eastern Democratic Republic of the Congo (DRC) during the 2018-2020 epidemic faced challenges in gaining community trust and participation. This affected implementation of community alerts, early isolation, contact tracing, vaccination, and safe and dignified burials. To quickly understand community perspectives and improve community engagement, collaborators from the DRC Red Cross, the International Federation of the Red Cross, and the U.S. Centers for Disease Control and Prevention explored a new method of collecting, coding, and quickly analyzing community feedback. METHODS: Over 800 DRC Red Cross local volunteers recorded unstructured, free-text questions and comments from community members during community Ebola awareness activities. Comments were coded and analyzed using a text-coding system developed by the collaborators. Coded comments were then aggregated and qualitatively grouped into major themes, and time trends were examined. RESULTS: Communities reported a lack of information about the outbreak and the response, as well as concerns about the Ebola vaccination program and health care quality. Some doubted that Ebola was real. The response used the feedback to revise some community engagement approaches. For example, 2 procedural changes that were followed by drops in negative community responses were: using transparent body bags, which allayed fears that bodies or organs were being stolen, and widening the eligibility criteria for Ebola vaccination, which addressed concerns that selectively vaccinating individuals within Ebola-affected communities was unfair. DISCUSSION: This system is unique in that unstructured feedback collected by local volunteers in the course of their work was rapidly coded, analyzed, and given to health authorities for use in making course corrections throughout the response. It provides a platform for local voices to be heard throughout an emergency response and provides a mechanism for assessing the effects of program adjustments on community sentiments.

Many US federal agencies apply principles from risk communication science across a wide variety of hazards. In so doing, they identify key research and practice gaps that, if addressed, could help better serve the nation's communities and greatly enhance practice, research, and policy development.

BACKGROUND: Investigating antecedents of behaviors, such as wearing face coverings, is critical for developing strategies to prevent SARS-CoV-2 transmission. PURPOSE: The purpose of this study was to determine associations between theory-based behavioral predictors of intention to wear a face covering and actual wearing of a face covering in public. METHODS: Data from a cross-sectional panel survey of U.S. adults conducted in May and June 2020 (N = 1,004) were used to test a theory-based behavioral path model. We (a) examined predictors of intention to wear a face covering, (b) reported use of cloth face coverings, and (c) reported use of other face masks (e.g., a surgical mask or N95 respirator) in public. RESULTS: We found that being female, perceived importance of others wanting the respondent to wear a face covering, confidence to wear a face covering, and perceived importance of personal face covering use was positively associated with intention to wear a face covering in public. Intention to wear a face covering was positively associated with self-reported wearing of a cloth face covering if other people were observed wearing cloth face coverings in public at least "rarely" (aOR = 1.43), with stronger associations if they reported "sometimes" (aOR = 1.83), "often" (aOR = 2.32), or "always" (aOR = 2.96). For other types of face masks, a positive association between intention and behavior was only present when observing others wearing face masks "often" (aOR = 1.25) or "always" (aOR = 1.48). CONCLUSIONS: Intention to wear face coverings and observing other people wearing them are important behavioral predictors of adherence to the CDC recommendation to wear face coverings in public.

On April 3, 2020, the White House Coronavirus Task Force and CDC announced a new behavioral recommendation to help slow the spread of coronavirus disease 2019 (COVID-19) by encouraging the use of a cloth face covering when out in public (1). Widespread use of cloth face coverings has not been studied among the U.S. population, and therefore, little is known about encouraging the public to adopt this behavior. Immediately following the recommendation, an Internet survey sampled 503 adults during April 7-9 to assess their use of cloth face coverings and the behavioral and sociodemographic factors that might influence adherence to this recommendation. The same survey was administered 1 month later, during May 11-13, to another sample of 502 adults to assess changes in the prevalence estimates of use of cloth face coverings from April to May. Within days of the release of the first national recommendation for use of cloth face coverings, a majority of persons who reported leaving their home in the previous week reported using a cloth face covering (61.9%). Prevalence of use increased to 76.4% 1 month later, primarily associated with increases in use among non-Hispanic white persons (54.3% to 75.1%), persons aged >/=65 years (36.6% to 79.2%), and persons residing in the Midwest (43.7% to 73.8%). High rates were observed in April and by May, increased further among non-Hispanic black persons (74.4% to 82.3%), Hispanic or Latino persons (77.3% to 76.2%), non-Hispanic persons of other race (70.8% to 77.3%), persons aged 18-29 years (70.1% to 74.9%) and 30-39 years (73.9% to 84.4%), and persons residing in the Northeast (76.9% to 87.0%). The use of a cloth face covering was associated with theory-derived constructs that indicate a favorable attitude toward them, intention to use them, ability to use them, social support for using them, and beliefs that they offered protection for self, others, and the community. Research is needed to understand possible barriers to using cloth face coverings and ways to promote their consistent and correct use among those who have yet to adopt this behavior.

During the 2014-2016 Ebola epidemic in West Africa, the US Centers for Disease Control and Prevention (CDC) developed the CARE+ program to help travelers arriving to the United States from countries with Ebola outbreaks to meet US government requirements of post-arrival monitoring. We assessed 2 outcomes: (1) factors associated with travelers' intention to monitor themselves and report to local or state public health authority (PHA) and (2) factors associated with self-reported adherence to post-arrival monitoring and reporting requirements. We conducted 1195 intercept in-person interviews with travelers arriving from countries with Ebola outbreaks at 2 airports between April and June 2015. In addition, 654 (54.7%) of these travelers participated in a telephone interview 3 to 5 days after intercept, and 319 (26.7%) participated in a second telephone interview 2 days before the end of their post-arrival monitoring. We used regression modeling to examine variance in the 2 outcomes due to 4 types of factors: (1) programmatic, (2) perceptual, (3) demographic, and (4) travel-related factors. Factors associated with the intention to adhere to requirements included clarity of the purpose of screening (B = 0.051, 95% confidence interval [CI], 0.011-0.092), perceived approval of others (B = 0.103, 95% CI, 0.058-0.148), perceived seriousness of Ebola (B = 0.054, 95% CI, 0.031-0.077), confidence in one's ability to perform behaviors (B = 0.250, 95% CI, 0.193-0.306), ease of following instructions (B = 0.053, 95% CI, 0.010-0.097), and trust in CARE Ambassador (B = 0.056, 95% CI, 0.009-0.103). Respondents' perception of the seriousness of Ebola was the single factor associated with adherence to requirements (odds ratio [OR] = 0.81, 95% CI, 0.673-0.980, for non-adherent vs adherent participants and OR = 0.86, 95% CI, 0.745-0.997, for lost to follow-up vs adherent participants). Results from this assessment can guide public health officials in future outbreaks by identifying factors that may affect adherence to public health programs designed to prevent the spread of epidemics.

We assessed how community education efforts influenced pregnant women's Zika prevention behaviors during the 2016 Centers for Disease Control and Prevention-Puerto Rico Department of Health Zika virus response. Efforts included Zika virus training, distribution of Zika prevention kits, a mass media campaign, and free home mosquito spraying. We used telephone interview data from pregnant women participating in Puerto Rico's Women, Infants, and Children Program to test associations between program participation and Zika prevention behaviors. Behavior percentages ranged from 4% (wearing long-sleeved shirt) to 90% (removing standing water). Appropriate mosquito repellent use (28%) and condom use (44%) were common. Receiving a Zika prevention kit was significantly associated with larvicide application (odds ratio [OR] 8.0) and bed net use (OR 3.1), suggesting the kit's importance for lesser-known behaviors. Offer of free residential spraying was associated with spraying home for mosquitoes (OR 13.1), indicating that women supported home spraying when barriers were removed.

Prevention of tick-borne diseases requires an understanding of when and where exposure to ticks is most likely. We used an epidemiologic approach to define these parameters for residents of a Lyme-endemic region. Two persons in each of 500 Connecticut households were asked to complete a log each night for one week during June, 2013. Participants recorded their whereabouts in 15min increments (indoors, outdoors in their yard, outdoors on others' private property, or outdoors in public spaces) and noted each day whether they found a tick on themselves. Demographic and household information was also collected. Logs were completed for 934 participants in 471 households yielding 51,895 time-place observations. Median participant age was 49 years (range 2-91 years); 52% were female. Ninety-one participants (9.8%) reported finding a tick during the week, with slightly higher rates among females and minors. Household factors positively associated with finding a tick included having indoor/outdoor pets (odds ratio (OR)=1.7; 95% confidence interval (CI): 1.1-2.9), the presence of a bird feeder in the yard (OR=1.9; CI:1.2-3.2), and presence of an outdoor dining area (OR=2.2; CI:1.1-4.3). Individual factors associated with finding a tick on a given day were bathing or showering (OR=3.7; CI:1.3-10.3) and hours spent in one's own yard (OR=1.2, CI:1.1-1.3). Nineteen participants found ticks on multiple days, more than expected assuming independence (p<0.001). Participants who found ticks on multiple days did not spend more time outdoors but were significantly more likely to be male than those finding ticks on a single day (p<0.03). Our findings suggest that most tick exposures in the study area occurred on private property controlled by the respective homeowner. Interventions that target private yards are a logical focus for prevention efforts.

As of May 2, 2017, the U.S. Virgin Islands (USVI), comprising St. Thomas, St. John, and St. Croix, had reported 1,021 probable or confirmed cases* of Zika virus disease in its population of approximately 100,000 (1); 222 symptomatic and asymptomatic pregnant women in the USVI had tested positive for Zika virus. In January 2016, USVI Department of Health (USVI DOH) initiated Zika response measures, including surveillance, vector control, and a communications program. Interventions included education and outreach, distribution of Zika prevention kitsdagger to pregnant women in the USVI, and provision of free Zika virus laboratory testing and vector control services. In November 2016, USVI DOH staff members conducted interviews with convenience samples of community members and pregnant women to gather feedback about current and proposed interventions (2). Pregnant women reported taking a median of two actions to protect themselves from Zika, with repellent use being the most commonly reported action. Community members reported taking a median of one action and were supportive of several proposed vector control approaches. Whereas multiple pregnant women and community members reported hearing messages about the cause and consequences of Zika virus infections, few recalled messages about specific actions they could take to protect themselves. Integrating evaluation into response measures permits ongoing assessment of intervention effectiveness and supports improvement to serve the population's needs.

The mass media provide an important channel for delivering crisis and emergency risk information to the public. We conducted a content analysis of 369 newspaper and television broadcast stories covering natural disaster and foodborne outbreak events and coded for seven best practices in crisis and emergency risk messaging. On average, slightly less than two (1.86) of the seven best practices were included in each story. The proportion of stories including individual best practices ranged from 4.6% for "expressing empathy" to 83.7% for "explaining what is known" about the event's impact to human health. Each of the other five best practices appeared in less than 25% of stories. These results suggest much of the risk messaging the public receives via mass media does not follow best practices for effective crisis and emergency communication, potentially compromising public understanding and actions in response to events.

This article presents the Centers for Disease Control and Prevention Clear Communication Index (the Index), a tool that emphasizes the primary audience's needs and provides a set of evidence-based criteria to develop and assess public communication products for diverse audiences. The Index consists of four open-ended introductory questions and 20 scored items that affect information clarity and audience comprehension, according to the scientific literature. A research team fielded an online survey to test the Index's validity. Respondents answered 10 questions about either an original health material or one redesigned with the Index. For 9 out of 10 questions, the materials revised using the Index were rated higher than the original materials. Regardless of education level, respondents rated the revised materials more favorably than the original ones. The results indicate that the Index performed as intended and made it more likely that audiences could correctly identify the intended main message and understand the words and numbers in the materials. The results also support the widely held view that audiences are more positive about clearly designed materials. The Index shows that an evidence-based scoring rubric can assess and improve the clarity of health materials.

To understand motivations and barriers to participation in studies that include DNA collection, focus group discussions were held with mothers who had participated in a case-control study of birth defects. Recruited mothers had completed an interview and had received a mailed kit containing cytobrushes to collect buccal cells for DNA from herself, her infant, and her infant's father. Six moderator-led focus groups were attended by a total of 38 women residing in Atlanta, Georgia. Focus groups were segmented by DNA collection status (biologics participants or nonparticipants), infant case-control status, infant birthweight, and maternal race and ethnicity. This report assesses maternal attitudes toward study materials and communication strategies. Across groups, respondents expressed concern about how their contact information was obtained. Study materials were described as clear and professional by most women, although some respondents reported confusion about disclosure of individual genetic results. Respondents generally reported that monetary incentives were not a motivation to participate, but increased perceived study legitimacy. Biologics nonparticipants expressed concerns about kit component sterility; government involvement; and DNA sample use, storage, and disposal. Respondents suggested that investigators provide feedback on whether sample collection was performed correctly and provide materials targeted to fathers to help alleviate paternal skepticism. Participation in DNA collection might be improved by strengthening study materials and communication strategies. Published 2011. This article is a U.S. Government work and is in the public domain in the USA.

BACKGROUND: Uncontrolled diabetes during pregnancy can cause adverse maternal and infant outcomes. This study explored barriers to glycemic control before, during, and after pregnancy and describes knowledge, attitudes, and behaviors among pregnant women with pregestational diabetes (PGDM) or gestational diabetes (GDM). METHODS: Focus groups were conducted in the Atlanta area among white, black, and Hispanic women who had diabetes during a recent pregnancy. Participants were a convenience sample drawn from a variety of sources. Nine focus groups were held with women who had GDM, and seven focus groups were held with women who had PGDM. RESULTS: Participants identified five main areas of barriers to management of diabetes during pregnancy: financial barriers and difficulties accessing care, barriers to maintaining a healthy diet and exercising, communication difficulties, lack of social support, and barriers related to diabetes care. Participants with GDM had general awareness of possible diabetes complications but frequently could not name specific effects of diabetes on the woman or child during and after pregnancy. Most were unaware of their risk for developing type 2 diabetes later. Participants with PGDM expressed concern about the increased risk of adverse outcomes for the baby; most knew the importance of maintaining glycemic control during pregnancy. Low rates of pregnancy planning were reported in both groups. Pregnancy planning was not identified as a strategy to ensure a healthy baby. CONCLUSIONS: The barriers to achieving glycemic control during pregnancy identified in this study could help inform future efforts to assist women in achieving optimal prepregnancy and intrapregnancy glycemic control.

BACKGROUND: Uncontrolled pregestational diabetes in pregnancy is associated with an increased risk for a major birth defect and additional adverse pregnancy outcomes. The study objective was to investigate the concerns of health care practitioners who care for women with a history of diabetes during pregnancy and their perceptions of attitudes and barriers to achieving good glycemic control. METHODS: Focus groups were conducted with physicians, midlevel practitioners, and certified diabetes educators in Atlanta, Georgia. Practitioners were eligible if they actively practiced, primarily in outpatient facilities in Atlanta, and were neither students nor interns. Six focus groups, two of each practitioner type, were conducted. RESULTS: Practitioners stated that few of their patients planned their pregnancies. Practitioners perceived that pregnant women were concerned primarily about their babies and might not be aware of complications with their personal health. Their perceptions of the greatest barriers to glycemic control for women involved lack of knowledge, lack of access, and attitude. CONCLUSION: Educating women with diabetes about the importance of using effective birth control until they have achieved good glycemic control can help reduce the risk for adverse pregnancy outcomes. Motivators and barriers for a woman with diabetes to achieve glycemic control before, during, and after pregnancy should be considered when developing approaches to improve outcomes. Helping practitioners know what and how to address the needs of childbearing women with or at risk for diabetes can be beneficial. Additional efforts to increase women's knowledge about diabetes and pregnancy and to develop effective strategies to encourage women's achievement and maintenance of glycemic control before, during, and after pregnancy are needed. (BIRTH 38:2 June 2011).

It is important to educate both men and women about preconception health (PCH), but limited research exists in this area. This paper examines men's and women's awareness of exposure to PCH information and of specific PCH behaviors, PCH planning, and PCH discussions with their partners. Data from Porter Novelli's 2007 Healthstyles survey were used. Women and men of reproductive age were included in the analysis (n = 2,736) to understand their awareness, planning, and conversations around PCH. Only 27.9% of women and men reported consistently using an effective birth control method. The majority of men (52%) and women (43%) were unaware of any exposure to PCH messages; few received information from their health care provider. Women were more aware than men of specific pre-pregnancy health behaviors. Women in the sample reported having more PCH conversations with their partners than did men. PCH education should focus on both women and men. Communication about PCH is lacking, both between couples and among men and women and their health care providers. PCH education might benefit from brand development so that consumers know what to ask for and providers know what to deliver.

Young Latina adults require targeted health messages to meet the unique needs of this life stage. Folic acid messages for the prevention of neural tube defects that are effective for other women might not be relevant to this group. The aim of this study was to identify barriers and motivators to folic acid consumption for this population and develop educational materials and messages that address their needs. This article presents 3 phases of formative research that formed the basis for the development of Spanish-language print materials and radio advertisements aimed at promoting folic acid consumption among young Latina adults.

OBJECTIVE: This article presents the results of testing draft folic acid educational materials with key gatekeepers, leading to the development of a Spanish-language print advertisement, poster, and radio public service announcement (PSA) aimed at promoting folic acid consumption among 18- to 25-year-old young Latina adults, as well as a Spanish-language print advertisement, poster, brochure, and radio PSA for 26- to 34-year-old Latina mothers. DESIGN: Individual in-person interviews yielded both qualitative and quantitative data. METHOD: In-person interviews with key gatekeepers who work closely with Spanish-speaking Latinas. SETTING: Interviews were conducted in Miami, Florida; Chicago, Illionis; Los Angeles, California; New York, New York; Denver, Colorado; and San Antonio, Texas, USA. RESULTS: Overall, the gatekeepers ratings of the materials were high. Important concerns that emerged helped guide changes that were made to the materials to ultimately enhance their reach and effectiveness. CONCLUSION: Testing draft educational materials with key gatekeepers who work closely with Spanish-speaking Latinas before final development and dissemination is a critical component of an educational outreach effort. Incorporating feedback from these professionals can help enhance the quality of the end product; such feedback can also help researchers assess whether and how the materials will be disseminated. copyright The Author(s) 2010.

BACKGROUND: The neural tube defects (NTDs) anencephaly and spina bifida, are serious birth defects of the brain and spine that affect about 3000 pregnancies per year in the United States. Research has found a strong link between periconceptional folic acid consumption and NTD prevention. METHODS: Because Hispanic women have higher rates of NTD-affected births, targeted folic acid promotion efforts were conducted in several major cities from 1999 to 2002. Efforts included paid and unpaid placements of Spanish language public service announcements (PSAs) and community-level education through the use of promotoras. Analyses focused on whether or not women's reported awareness of folic acid, regardless of promotion type, impacted their knowledge or behavior. RESULTS AND CONCLUSIONS: Women who reported awareness of folic acid had greater folic acid knowledge and use of vitamins containing folic acid than those not aware. Analyses also examined the use of vitamins containing folic acid by pregnancy intention among women who reported awareness of folic acid. The results were varied. Pregnancy wanters were most likely to use vitamins containing folic acid daily. For this group, however, awareness did not play as large a role in whether they reported consuming a vitamin containing folic acid or not, as it did for pregnancy waiters and avoiders.

To assess attitudes toward DNA collection in an epidemiological study, focus groups were assembled in September 2007 with mothers who had participated in a case-control study of birth defects. Each recruited mother previously had completed an interview and had received a mailed kit containing cytobrushes to collect buccal cells for DNA from herself, her infant, and her infant's father during the period July 2004 through July 2007. A total of 38 mothers attended six focus groups comprising: (1) non-Hispanic Black mothers of case infants who participated or (2) did not participate in DNA collection, (3) mothers of any race or ethnicity who had case infants of low birth weight who participated or (4) did not participate in DNA collection, and (5) non-Hispanic Black mothers of control infants who participated or (6) did not participate in DNA collection. Moderator-led discussions probed maternal attitudes toward providing specimens, factors that influenced decision making, and collection method preferences. Biologics participants reported that they provided DNA for altruistic reasons. Biologics nonparticipants voiced concerns about government involvement and how their DNA will be used. Information provided (or not provided) on DNA use, storage, and disposal influenced decision making. Biologics participants and nonparticipants reported that paternal skepticism was a barrier to participation. All mothers were asked to rank DNA collection methods in terms of preference (cytobrushes, saliva, mouthwash, newborn blood spots, and blood collection). Preferred methods were convenient and noninvasive. Better understanding attitudes toward DNA collection and preferred collection methods might allow more inclusive participation and benefit future studies. (c) 2009 Wiley-Liss, Inc.

OBJECTIVE: To examine the application of a social marketing approach to increase the early identification and treatment of autism and other developmental disorders. STUDY DESIGN: The intervention used formative research, behaviour change theory and traditional social marketing techniques to develop a campaign targeting parents, healthcare professionals and early educators to increase awareness of autism and other developmental delays, and to prompt action if a developmental delay was suspected. METHOD: Using social marketing principles, the Centers for Disease Control and Prevention applied baseline research with the target audiences to understand the barriers and motivators to behaviour change, which included a lack of knowledge and resources (barriers), along with a willingness to learn and do more (motivators). Focus group testing of potential campaign concepts led to one particular approach and accompanying images, which together increased perceived severity of the problem and encouraged taking action. The audience research also helped to shape the marketing mix (product, price, place and promotion). RESULTS: Three-year follow-up research in this case study indicates a significant change in parent target behaviours, particularly among parents aware of the campaign, and substantially more healthcare professionals believe that they have the resources to educate parents about monitoring their child's cognitive, social and physical development. Qualitative results from early educators and childcare professional associations have been positive about products developed for daycare settings. CONCLUSION: The application of social marketing principles, behavior change theory and audience research was an effective approach to changing behaviours in this case. Understanding what the target audiences want and need, looking beyond parents to engage healthcare professionals and early educators, and engaging many strategic partners to extend the reach of the message helped campaign planners to develop a campaign that resonated with the target audiences and, importantly, moved them towards action.