Use of lay health educators for smoking cessation in a hard-to-reach urban community

Cost-Effectiveness of Community-Based Tobacco Dependence Treatment Interventions: Initial Findings of a Systematic Review

Introduction

Scientific literature evaluating the cost-effectiveness of tobacco dependence treatment programs delivered in community-based settings is scant, which limits evidence-based tobacco control decisions. The aim of this review was to systematically assess the cost-effectiveness and quality of the economic evaluations of community-based tobacco dependence treatment interventions conducted as randomized controlled trials in the United States.

Methods

We searched 8 electronic databases and gray literature from their beginning to February 2018. Inclusion criteria were economic evaluations of community-based tobacco dependence treatments conducted as randomized controlled trials in the United States. Two independent researchers extracted data on study design and outcomes. Study quality was assessed by using Drummond and Jefferson’s economic evaluations checklist. Nine of 3,840 publications were eligible for inclusion. Heterogeneity precluded formal meta-analyses. We synthesized a qualitative narrative of outcomes.

Results

All 9 studies used cost-effectiveness analysis and a payer/provider/program perspective, but several study components, such as abstinence measures, were heterogeneous. Study participants were predominantly English speaking, middle aged, white, motivated to quit, and highly nicotine dependent. Overall, the economic evaluations met most of Drummond and Jefferson’s recommendations; however, some studies provided limited details. All studies had a cost per quit at or below $2,040 or an incremental cost-effectiveness ratio (ICER) at or below $3,781. When we considered biochemical verification, sensitivity analysis, and subgroups, the costs per quit were less than $2,050 or the ICERs were less than $6,800.

Conclusion

All community-based interventions included in this review were cost-effective. When economic evaluation results are extrapolated to future savings, the low cost per quit or ICER indicates that the cost-effectiveness of community-based tobacco dependence treatments is similar to the cost-effectiveness of clinic-based programs and that community-based interventions are a valuable approach to tobacco control. Additional research that more fully characterizes the cost-effectiveness of community-based tobacco dependence treatments is needed to inform future decisions in tobacco control policy.

Barriers and Facilitators to the Adoption and Sustained Use of Cleaner Fuels in Southwest Cameroon: Situating 'Lay' Knowledge within Evidence-Based Policy and Practice

Approximately four million people die each year in low- and middle-income countries from household air pollution (HAP) due to inefficient cooking with solid fuels. Liquid Petroleum Gas (LPG) offers a clean energy option in the transition towards renewable energy. This qualitative study explored lay knowledge of barriers and facilitators to scaling up clean fuels in Cameroon, informed by Quinn et al.'s Logic Model. The model has five domains and we focused on the user and community needs domain, reporting the findings of 28 semi-structured interviews (SSIs) and four focus group discussions (FGDs) that explored the reasons behind fuel use choices. The findings suggest that affordability, safety, convenience, and awareness of health issues are all important influences on decision making to the adoption and sustained use of LPG, with affordability being the most critical issue. We also found the ability of clean fuels to meet cooking needs to be central to decision-making, rather than an aspect of convenience, as the logic model suggests. Local communities provide important insights into the barriers and facilitators to using clean fuels. We adapt Quinn et al.'s logic model accordingly, giving more weight to lay knowledge so that it is better positioned to inform policy development.

Effectiveness of Two Community Health Worker Models of Tobacco Dependence Treatment Among Community Residents of Ohio Appalachia

INTRODUCTION

Community health workers (CHW) may be effective in the delivery of tobacco dependence treatment with underserved groups. This study evaluated two evidence-based CHW models of treatment. It was hypothesized that smokers assigned to a CHW face-to-face condition would have higher abstinence at 12-month posttreatment than smokers enrolled in CHW referral to a state-sponsored quitline condition. Intrapersonal and treatment-related factors associated with abstinence at 12 months were determined.

METHODS

A group-randomized trial was conducted with residents of 12 Ohio Appalachian counties with counties (n = 6) randomized to either a CHW face-to-face (F2F) or CHW quitline (QL) condition. Both conditions included behavioral counseling and free nicotine replacement therapy for 8 weeks. Follow-up data were collected at 3-, 6-, and 12-month posttreatment. Biochemically validated abstinence at 12 months served as the primary outcome.

RESULTS

Seven hundred and seven participants were enrolled (n = 353 CHWF2F; n = 354 CHWQL). Baseline sample characteristics did not differ by condition. Using an intent-to-treat analysis (85.4% retention at 12 months), 13.3% of CHWF2F participants were abstinent at 12 months, compared to 10.7% of CHWQL members (OR = 1.28; 95% confidence interval [CI] = 0.810, 2.014; p = .292). No differences in abstinence were noted at 3 or 6 months by condition. Age, marital status, and baseline levels of cigarette consumption, depressive symptoms, and self-efficacy for quitting in positive settings were associated with abstinence, as was counseling dose during treatment.

CONCLUSIONS

This research adds to the body of science evaluating the effectiveness of CHW models of tobacco dependence treatment. Both approaches may offer promise in low-resource settings and underserved regions.

IMPLICATIONS

This 12-county community-based group-randomized trial in Ohio Appalachia adds to the body of science evaluating the effectiveness of CHW models of tobacco dependence treatment. Both CHW approaches may offer promise in low-resource settings and underserved regions. These findings are useful to national, state, and local tobacco control agencies, as they expand delivery of preventive health care services postadoption of the Affordable Care Act in the United States.

A Community-Based "Street Team" Tobacco Cessation Intervention by and for Youth and Young Adults

Most tobacco users initiate use as youth or young adults. To promote tobacco cessation for this group and encourage non-users' engagement in tobacco control efforts, a community-based organization developed a "Street Team" brief outreach intervention that enlisted youth and young adults to encourage their peers to stop tobacco use through a brief intervention. Street Team members provided education, a Quit Kit, and referrals to cessation resources at a total of 27 community events over a four-year period. Tobacco users (n = 279) completed assessments of tobacco use, quit intention, and quit self-efficacy at baseline. Self-reports of cessation outcomes including past week abstinence were assessed 1-, 3-, and 6-months post-intervention. Perceptions of the intervention were gathered from Street Team members (n = 28) and intervention participants post-intervention. T-tests and χ²-tests were used to compare those who completed at least one follow-up assessment to those lost to follow-up. Time effects were analyzed using fixed effect models. Missing = using analyses indicate 16.1, 18.6, and 12.5% 7-day quit rate at 1-, 3-, and 6-months follow-up. Feedback from intervention participants indicate the intervention was acceptable and that discussions with Street Team members and provision of quit kits motivated tobacco users to consider quitting. All Street Team members responded positively to their participation in the intervention. This Street Team approach for youth and young adults is promising as an effective approach to the promotion of tobacco cessation among users and engagement and empowerment in tobacco control efforts among non-users.

Tobacco cessation in Vietnam: Exploring the role of village health workers

The purpose of this study was to explore current tobacco use treatment (TUT) practice patterns, and attitudes and beliefs among Village Health Workers (VHWs) about expanding their role to include delivering smoking cessation interventions and the perceived barriers. We conducted a survey of 449 VHWs from 26 communes in Thai Nguyen province, Vietnam. We assessed TUT practice patterns including asking about tobacco use, advising smokers to quit, offering assistance (3As) and attitudes, self-efficacy, and norms related to TUT. Seventy two per cent of VHWs reported asking patients if they use tobacco, 78.6% offered advice to quit, and 41.4% offered cessation assistance to few or more patients in the past month. Self-efficacy was low, with 53.2% agreeing that they did not have the skills to counsel patients about smoking cessation. The most commonly reported barriers to offering TUT were a lack of training and perceived lack of patient interest. Greater awareness of their commune health centre's smoke-free policy and higher levels of self-efficacy were associated with screening and offering cessation assistance. VHWs support an expanded role in tobacco cessation, but require additional resources and training to increase their self-efficacy and skills to provide effective treatment.

Recruiting Pregnant Indigenous Women Who Smoke into a High Contact Incentivized Cessation Trial: A Feasibility Study

INTRODUCTION

Smoking prevalence among pregnant indigenous women is disproportionately higher than for nonindigenous pregnant women. Incentives have been shown to increase retention in and the effectiveness of smoking cessation programs. To trial if this could work for indigenous women, we aimed to recruit and observe retention of Māori (New Zealand indigenous people) pregnant women that smoke into a cessation program using incentives.

METHODS

A parallel group, randomized controlled feasibility trial was undertaken in New Zealand. Pregnant Māori women who smoked were recruited through health practitioners, social media, and general media advertising. Outcomes included ease of recruitment, enrollment rate, retention, cost, and time and distance traveled to visit participants.

RESULTS

Seventy-four women were referred for the trial over 7 months. The highest enrollment rate was among self-referrals from media (6 of 10), then women referred from cessation providers (47%, 8 of 17). About three-quarters of women referred from health professionals did not enroll. Only 32% (24) were randomized. Nine women completed the intervention, three withdrew, and 12 were lost to follow-up. On average, it took less time to contact abstinent participants (29 vs. 43 minutes for nonabstinent women). No deception was noted.

CONCLUSIONS

Recruitment was difficult and varied by source of first contact. Once enrolled, it was feasible to maintain intensive contact with participants who stayed engaged. The number lost to follow-up was high. We concluded that the tenor of trial promotion could have influenced recruitment and retention rates. Further research with indigenous women is needed to identify better recruitment and retention methods.

IMPLICATION

With the rising cost of research and the increased competition for funds, it is important to have evidence that intervention studies with minority group pregnant women who smoke are feasible. Maintaining contact with participants seemed feasible, but the tenor of trial promotion and type of recruitment strategy could influence enrollment and retention of sufficient numbers of participants. Nonjudgmental supportive advertising and invitations direct to women may work better than relying on health professionals as recruiters.

Adherence to Tobacco Dependence Treatment Among HIV-Infected Smokers

High prevalence of tobacco use and low success in quitting remain significant problems for reducing disease burden among HIV-infected persons. This study's purpose was to examine participant responsiveness and tobacco dependence treatment adherence and their influences on tobacco abstinence among HIV-infected patients. This non-randomized study included HIV-infected smokers 18 years of age or older, who smoked at least 5 cigarettes per day, and had an interest in quitting smoking in the next 30 days. HIV-infected smokers (n = 247) received a 12-week tobacco dependence treatment intervention that included pharmacotherapy and telephone counseling. Younger age and non-White race were associated with lower adherence to pharmacotherapy. Younger age, non-White race, and increased monthly binge drinking were associated with lower adherence to telephone counseling. High participant responsiveness was associated with adherence to pharmacotherapy, counseling, and abstinence. Development and testing of interventions to improve adherence to evidence-based tobacco dependence treatment is warranted.

Reaching the hard-to-reach: a systematic review of strategies for improving health and medical research with socially disadvantaged groups

Background

This study aims to review the literature regarding the barriers to sampling, recruitment, participation, and retention of members of socioeconomically disadvantaged groups in health research and strategies for increasing the amount of health research conducted with socially disadvantaged groups.

Methods

A systematic review with narrative synthesis was conducted. Searches of electronic databases Medline, PsychInfo, EMBASE, Social Science Index via Web of Knowledge and CINHAL were conducted for English language articles published up to May 2013. Qualitative and quantitative studies as well as literature reviews were included. Articles were included if they reported attempts to increase disadvantaged group participation in research, or the barriers to research with disadvantaged groups. Groups of interest were those described as socially, culturally or financially disadvantaged compared to the majority of society. Eligible articles were categorised according to five phases of research: 1) sampling, 2) recruitment and gaining consent, 3) data collection and measurement, 4) intervention delivery and uptake, and 5) retention and attrition.

Results

In total, 116 papers from 115 studies met inclusion criteria and 31 previous literature reviews were included. A comprehensive summation of the major barriers to working with various disadvantaged groups is provided, along with proposed strategies for addressing each of the identified types of barriers. Most studies of strategies to address the barriers were of a descriptive nature and only nine studies reported the results of randomised trials.

Conclusions

To tackle the challenges of research with socially disadvantaged groups, and increase their representation in health and medical research, researchers and research institutions need to acknowledge extended timeframes, plan for higher resourcing costs and operate via community partnerships.

Behavior change interventions to improve the health of racial and ethnic minority populations: a tool kit of adaptation approaches

CONTEXT

Adapting behavior change interventions to meet the needs of racial and ethnic minority populations has the potential to enhance their effectiveness in the target populations. But because there is little guidance on how best to undertake these adaptations, work in this field has proceeded without any firm foundations. In this article, we present our Tool Kit of Adaptation Approaches as a framework for policymakers, practitioners, and researchers interested in delivering behavior change interventions to ethnically diverse, underserved populations in the United Kingdom.

METHODS

We undertook a mixed-method program of research on interventions for smoking cessation, increasing physical activity, and promoting healthy eating that had been adapted to improve salience and acceptability for African-, Chinese-, and South Asian-origin minority populations. This program included a systematic review (reported using PRISMA criteria), qualitative interviews, and a realist synthesis of data.

FINDINGS

We compiled a richly informative data set of 161 publications and twenty-six interviews detailing the adaptation of behavior change interventions and the contexts in which they were undertaken. On the basis of these data, we developed our Tool Kit of Adaptation Approaches, which contains (1) a forty-six-item Typology of Adaptation Approaches; (2) a Pathway to Adaptation, which shows how to use the Typology to create a generic behavior change intervention; and (3) RESET, a decision tool that provides practical guidance on which adaptations to use in different contexts.

CONCLUSIONS

Our Tool Kit of Adaptation Approaches provides the first evidence-derived suite of materials to support the development, design, implementation, and reporting of health behavior change interventions for minority groups. The Tool Kit now needs prospective, empirical evaluation in a range of intervention and population settings.

Smoking cessation interventions for ethnic minority groups--a systematic review of adapted interventions

OBJECTIVE

Existing smoking cessation interventions tend to be under utilized by ethnic minority groups. We sought to identify smoking cessation interventions that have been adapted to meet the needs of African-, Chinese- and South Asian-origin populations, to increase understanding of the approaches used to promote behavior change, to assess their acceptability to the target populations, and to evaluate their effectiveness.

METHODS

Two reviewers independently searched for, identified, critically appraised and extracted data from studies identified from 11 databases (January 1950-April 2013). Study quality was assessed using validated instruments (EPHPP and STROBE). Adaptations were independently coded using an established typology, and findings descriptively summarized and thematically synthesized.

RESULTS

23 studies described interventions adapted for African-Americans, and five for Chinese-origin populations. No intervention adapted for South-Asian populations was identified. Six studies directly compared a culturally adapted versus a non-adapted intervention. Adapted interventions were more acceptable to ethnic minority groups, but this did not translate into improvements in smoking cessation outcomes.

CONCLUSIONS

Given the evidence of greater acceptability of adapted interventions, it may be ethically preferable to use these. There is, however, no clear evidence of the effectiveness of adapted interventions in promoting smoking cessation in ethnic minority groups.

Treatment adherence in a lay health adviser intervention to treat tobacco dependence

Lay health advisers (LHAs) are increasingly used to deliver tobacco dependence treatment, especially with low-socioeconomic status (SES) populations. More information is needed about treatment adherence to help interpret mixed evidence of LHA intervention effectiveness. This study examined adherence to behavioral counseling and nicotine patches in an LHA intervention with 147 Ohio Appalachian female daily smokers. Participants were randomly selected from clinics and randomized to the intervention condition of a randomized controlled trial. Overall, 75.5% of participants received all seven planned LHA visits, 29.3% used patches for >7 weeks and approximately half received high average ratings on participant responsiveness. Depressive symptoms and low nicotine dependence were associated with lower patch adherence while high poverty-to-income ratio was associated with high responsiveness. Compared with those with fewer visits, participants who received all visits were more likely to be abstinent (22.5 versus 2.8%, P=0.026) or have attempted quitting (85.0 versus 47.4%, P=0.009) at 3 months. High participant responsiveness was associated with 12-month abstinence. LHA interventions should focus on improving adherence to nicotine patches and managing depression because it is an independent risk factor for low adherence.

Community health workers and medicaid managed care in New Mexico

We describe the impact of community health workers (CHWs) providing community-based support services to enrollees who are high consumers of health resources in a Medicaid managed care system. We conducted a retrospective study on a sample of 448 enrollees who were assigned to field-based CHWs in 11 of New Mexico's 33 counties. The CHWs provided patients education, advocacy and social support for a period up to 6 months. Data was collected on services provided, and community resources accessed. Utilization and payments in the emergency department, inpatient service, non-narcotic and narcotic prescriptions as well as outpatient primary care and specialty care were collected on each patient for a 6 month period before, for 6 months during and for 6 months after the intervention. For comparison, data was collected on another group of 448 enrollees who were also high consumers of health resources but who did not receive CHW intervention. For all measures, there was a significant reduction in both numbers of claims and payments after the community health worker intervention. Costs also declined in the non-CHW group on all measures, but to a more modest degree, with a greater reduction than in the CHW group in use of ambulatory services. The incorporation of field-based, community health workers as part of Medicaid managed care to provide supportive services to high resource-consuming enrollees can improve access to preventive and social services and may reduce resource utilization and cost.

Effectiveness of a nurse-managed, lay-led tobacco cessation intervention among ohio appalachian women

OBJECTIVES

The purpose of this study was to evaluate a nurse-managed, lay-led tobacco cessation intervention delivered to adult women in Ohio Appalachia.

METHODS

A randomized controlled experimental design included intervention participants (n = 147) enrolled in a nurse-managed, lay-led protocol that incorporated nicotine replacement and behavioral counseling. Control participants (n = 155) received a personalized letter from their clinic physician, who advised them to quit smoking and requested they schedule a clinic appointment to discuss cessation.

RESULTS

Self-reported and cotinine-validated quit rates were significantly higher among intervention group participants compared with control group participants at 3-and 6-month follow-up (P < 0.02). At 12 months, self-reported abstinence was 19.1% (intervention group) and 9.0% (control group), with cotinine-validated rates of 12.2% and 7.1%, respectively (P = 0.13). Prolonged abstinence rates were significantly different between groups at 3, 6, and 12 months (P < 0.02). Logistic regression analyses indicated adjusted odds of cotinine-validated quitting was associated with cigarette consumption per day (odds ratio, 0.94; 95% confidence interval, 0.89-0.99) and Center for Epidemiologic Studies Depression Scale score > or = 16 (odds ratio, 0.39; 95% confidence interval, 0.17-0.90).

CONCLUSIONS

A lay-led approach that is managed by a nurse may serve as an effective cessation strategy among this high-risk population. Additional efforts are needed to sustain long-term abstinence, even after intensive intervention.

The role of lay health advisors in cardiovascular risk reduction: a review

Interventions are needed to reduce the negative impact of cardiovascular disease. The combination of health risks for disease, disability, and mortality, particularly among underserved populations, might be best addressed with programs designed to enhance awareness and development of resources within a context of community support. The objectives of this review were to: (1) provide a comprehensive review and evaluation of the roles, evaluation, and effectiveness of LHA in community-based programs with an emphasis on cardiovascular risk reduction; and (2) provide recommendations for future research involving LHA in such programs. Computer and manual searches were conducted of articles in the English-language literature from 1980 to 2007. Twenty articles were evaluated, which emphasized the role of the LHA in cardiovascular risk reduction. A review of research literature provides a starting point for determining salient approaches for intervention and evaluation, issues related to program implementation and sustainability, and strengths and limitations of existing approaches.

Clinical trials and tribulations: lessons learned from recruiting pregnant ex-smokers for relapse prevention

The development of smoking cessation and relapse prevention interventions for pregnant and postpartum women is a public health priority. However, researchers have consistently reported substantial difficulty in recruiting this population into clinical trials. The problem is particularly acute for relapse prevention studies, which must recruit women who have already quit smoking because of their pregnancy. Although these individuals are an important target for tobacco control efforts, they represent an extremely small subgroup of the general population. This paper describes multiple recruitment strategies used for a clinical trial of a self-help relapse prevention program for pregnant women. The effectiveness of the strategies and the direct expense per participant recruited are provided. A proactive recruitment strategy (telephoning women whose phone numbers were purchased from a marketing firm) was ultimately much more successful than a variety of reactive strategies (advertisements, press releases, direct mail, Web placement, health care provider outreach). We found few differences between proactively and reactively recruited participants on baseline variables. The primary difference was that the former had smoked fewer cigarettes per day and reported lower nicotine dependence prior to quitting. Strengths and limitations of the recruitment strategies are discussed.

Correlates of Participation in a Family-Based HIV Prevention Program: Exploring African-American Women's Motivations and Understanding of the Program

This study examines the relationship between contextual factors and attendance in a family-based HIV prevention program for low-income, urban, African-American women and their children. Participants' motivations to become involved, their concerns about discussing sex-related issues with their children, recruiters' perceptions of respondents' understanding of the program, and environmental stressors were examined. Participants' level of motivation and recruiters' success in improving respondents' understanding of the program were significant correlates of attendance. Stressors experienced by the family and concerns around talking with children about sex were not significantly associated with participation. Recommendations to enhance involvement in family-based HIV prevention programs are made.

Strategies to recruit and retain older Filipino-American immigrants for a cancer screening study

Recruitment and retention of subjects in cancer prevention, screening, and treatment trials is challenging, especially if subjects are low-income, from minority groups or immigrants with limited English fluency. This article describes our experiences in recruiting 530 female Filipino-American immigrants at community based organizations and churches for a randomized trial that assessed the effect of a small group educational session on breast and cervical cancer screening. We found that a personal invitation from either a female project liaison, a friend, or the Filipino project director were all successful strategies that resulted in over 80% attendance at an educational session that was offered as part of the study. Although non-attendees did not differ from attendees in demographic characteristics, they expressed significantly more barriers to participating in a health study. Attendance at the group session was a significant predictor of retention in the study. We were able to conduct telephone follow-up surveys among 88% of enrollees at 12 month follow-up and 76% at 24 month follow-up. Results and implications are discussed in the hope that they may facilitate future participation of Filipinos and other Asian immigrants in research.

Use of community health workers in research with ethnic minority women

PURPOSE

To explore roles and effectiveness of community health workers in research with ethnic minority women in the United States (US).

METHODS

Medline (1966-2002) and CINAHL (Cumulative Index to Nursing and Allied Health Literature; 1982-2002) databases were used to locate published research studies on the use of community health workers with ethnic minority women in the US. Key words for searches were community health workers, community health aides, health promoters, and community workers.

RESULTS

An integrative analysis of 24 studies showed that, despite varying roles and functions, evidence indicates that community health workers are effective in increasing access to health services, increasing knowledge, and promoting behavior change among ethnic minority women. Other advantages of using community health workers are to provide social support and culturally competent, cost-effective care. Recommendations for future directions of research with community health workers and ethnic minority women include improved conceptualization of the community health worker role, theoretical frameworks for research designs, enhanced methods for evaluating effectiveness, and increased community involvement.

Results of a randomized trial to increase breast and cervical cancer screening among Filipino American women

BACKGROUND

This paper reports the first evaluation of an intervention to increase breast and cervical cancer screening among Filipino American women.

METHODS

Filipino women over 40 years of age were recruited through nine community-based organizations and six churches in Los Angeles County. After completion of a short baseline interview, all women were invited to attend a group session with some of their peers and a female Filipino health educator. Women within each organization were randomized to receive a cancer screening module (intervention) or a physical activity module (control). Telephone follow-up interviews 12 months after the group session assessed the impact of the intervention.

RESULTS

Of the 530 women invited, 444 (84%) attended a session. At baseline and follow-up, screening rates for breast and cervical cancer did not differ between study groups. Moderate increases in screening rates (9 to 12 percentage points) were observed in both arms of the study. Among relatively recent immigrants who had spent less than 10 years in the United States, mammography screening increased substantially more in the intervention arm than under the control condition (a 27 vs 6 percentage point increase, P<0.05).

CONCLUSION

Our intervention was only effective in increasing cancer screening among relatively recent immigrants who had very low baseline screening rates.

Outcome effectiveness of community health workers: an integrative literature review

Community health workers (CHWs) are promoted as a mechanism to increase community involvement in health promotion efforts, despite little consensus about the role and its effectiveness. This article reviews the databased literature on CHW effectiveness, which indicates preliminary support for CHWs in increasing access to care, particularly in underserved populations. There are a smaller number of studies documenting outcomes in the areas of increased health knowledge, improved health status outcomes, and behavioral changes, with inconclusive results. Although CHWs show some promise as an intervention, the role can be doomed by overly high expectations, lack of a clear focus, and lack of documentation. Further research is required with an emphasis on stronger study design, documentation of CHW activities, and carefully defined target populations.

Peer coaching: an intervention for individuals struggling with diabetes

PURPOSE

The purpose of this study was to determine the value of peer coaching and its influence on behavior change.

METHODS

Coaches who were known to be successfully managing their diabetes were paired with individuals who were struggling with behavior change associated with managing diabetes. The pairs were matched according to age, sex, and physical appearance. Coaches met initially with participants in a face-to-face meeting for 1 hour and talked with them once a week for 10 to 15 minutes for the next 8 weeks. The initial interview and subsequent phone conversations focused on the person's problems and efforts at behavior change.

RESULTS

At the end of the study, the pairs participated in a videotaped focus group to discuss their views on coaching and its influence on behavior change. Participants reported that coaching was personal, useful in disease management, and helpful in their quest to establish and adhere to routines of care. Participants also reported making progress toward changing their behavior related to diet, exercise, and blood glucose monitoring. Sustained behavior change was not measured.

CONCLUSIONS

Peer coaching appears to have merit as a viable, low-cost intervention with the potential of helping individuals with diabetes who need to change their behavior.

Training lay health educators to conduct a church-based weight-loss program for African American women

PURPOSE

Community-based lay health educators have been utilized in a range of settings and with a variety of health issues. However, little has been published about the specifics of training lay health educators to effectively deliver community-based programs. This paper describes the training used to prepare volunteer, church-based lay health educators to conduct a community-based weight-loss program, and the evaluation of that training.

METHODS

After recruitment through their respective churches, volunteer lay health educators were given structured training in how to conduct the PATHWAYS weight-loss program. Program sessions were observed to monitor program delivery, and participation rates and weight loss were evaluated.

RESULTS

The lay health educators were highly consistent in their delivery of the program content. Participant attendance was high and virtually all of the participants completed the program. Participant weight loss averaged 8.3 pounds, which correlated with session attendance.

CONCLUSIONS

Given training appropriate to the structure of the program and specific to the targeted health behavior, lay health educators can reliably and effectively administer even rather complex programs.

A community diabetes educator course for the unemployed in South Auckland, New Zealand

PURPOSE

This paper describes an education program that targeted long-term unemployed people from the community and trained them to work as diabetes educators in their own communities in an attempt to address issues of cultural appropriateness.

METHODS

Government funding was obtained to conduct two 22-week training courses for people who had been selected by their communities. These courses built on participants' existing cultural skills and provided appropriate diabetes training.

RESULTS

The results indicate that the courses were successful both in creating a cadre of culturally acceptable diabetes educators and providing employment for course participants.

CONCLUSIONS

Previously unemployed lay people are able to provide diabetes education in the primary prevention and group settings. Such individuals are able to incorporate extensive cultural skills in their work.

Impact of community health workers on access, use of services, and patient knowledge and behavior

Community health workers have been used in health centers for several decades. Known by various names (e.g., community health advisors, outreach workers, promotoras), they are trusted community members providing informal community-based health-related services and establishing vital links between health providers and the community. They perform many functions, including outreach and case finding, health education, translation, patient transportation, and case management (under the supervision of a nurse or social worker). This article, based on a study of community health worker programs at seven sites, is intended to share the lessons learned that could be helpful to other program managers and to examine the outcomes of such programs.

Using peer volunteers to promote mammography education in senior citizens' housing facilities

A peer volunteer intervention to encourage attendance at mammography education programs was developed and evaluated as part of a multi-intervention study to improve mammography by women 65 years and older. Approximately five to seven women from each of 20 racially and socioeconomically diverse senior citizens' housing facilities were recruited. After completing a training session, they distributed invitations and spoke personally with fellow residents about attending the upcoming program. Attendance rates for facilities with the peer volunteer program were compared with those in facilities without the volunteers. Results of a logistic regression analysis found the volunteer program, in addition to facility size, to have had a statistically significant effect on attendance at the mammography education presentations.

Solution-focused approaches to tobacco reduction with disadvantaged prenatal clients

Despite high rates of smoking among socioeconomically disadvantaged pregnant women, few tobacco cessation programs have been geared for this client group. This article describes newly developed strategies for addressing tobacco reduction with disadvantaged, high-risk prenatal clients enrolled in a community-based Pregnancy Outreach Program in a northern Canadian city. The new tobacco reduction strategies were based on "solution-focused" approaches to interviewing and counseling. Process evaluations conducted with program staff revealed that solution-focused approaches provided effective, client-centered, respectful ways of discussing tobacco reduction with disadvantaged clients. Solution-focused approaches also positively impacted clients' sense of self-efficacy regarding tobacco reduction. The benefits of using solution-focused approaches as an alternative approach to tobacco reduction with disadvantaged prenatal clients are discussed.

Recruitment and training issues from selected lay health advisor programs among African Americans: a 20-year perspective

The use of lay health advisors (LHAs) to address the health disparity among African Americans is well documented and considered a culturally appropriate model of community health promotion. The recruitment and training of LHAs are important components of the model but have not been fully explored in the LHA literature. Recruitment and training of LHAs should reflect both the existing roles they have in their respective communities and those proposed by the programs to which they are recruited. This article reviews and describes the components of recruitment and training as implemented in selected LHA programs among African Americans. The article will address the role and purpose of LHAs in health promotion among African Americans, a historical perspective of recruitment and training, recruitment and training methods in selected LHAs programs for African Americans, and recommendations for the recruitment and training of LHAs for health promotion among African Americans.

Community health workers: integral members of the health care work force

As the US health care system strives to function efficiently, encourage preventive and primary care, improve quality, and overcome nonfinancial barriers to care, the potential exists for community health workers to further these goals. Community health workers can increase access to care and facilitate appropriate use of health resources by providing outreach and cultural linkages between communities and delivery systems; reduce costs by providing health education, screening, detection, and basic emergency care; and improve quality by contributing to patient-provider communication, continuity of care, and consumer protection. Information sharing, program support, program evaluation, and continuing education are needed to expand the use of community health workers and better integrate them into the health care delivery system.

Behavioral and psychosocial cancer research in the underserved. An agenda for the future

BACKGROUND

This research was undertaken to review the status of behavioral and psychosocial cancer research in the underserved.

METHODS

The author extensively reviewed the literature related to behavioral and psychosocial cancer research in the underserved for this article. The author's experience as the Principal Investigator for the only National Institutes of Health smoking cessation study targeting Asian-Americans also was used in analyzing the literature and developing an agenda for the future.

RESULTS

Two questions and accompanying agenda items were addressed. The underserved were defined, and the effect of being underserved was illustrated through their disproportionate and earlier (younger) presence in morbidity and mortality statistics. Initiating behavioral and psychosocial cancer research in the underserved begins with a proper attitude and making accommodations to culture. The agenda for research should be practical and assessed on the basis of prevalence and preventability of cancer related behaviors. Examples from underserved Asian-American populations were cited.

CONCLUSIONS

Behavioral and psychosocial cancer research needs to be done.

Cancer prevention and early detection strategies for reaching underserved urban, low-income black women. Barriers and objectives

To achieve national health goals set for reduction of cancer by the year 2000, populations with higher cancer mortality and lower survival must be reached with proven advances for use in cancer prevention and early detection. This article focuses on one segment of those populations that continues to have a poor cancer experience: urban, low-income black women. Barriers for them to cancer prevention and early detection are identified and discussed from studies conducted in Chicago. Specifically tailored interventions that have been used to bring services to this population are described, and implications from the outcomes of this work are discussed.

Factors associated with nicotine dependence among African American women cigarette smokers

Cigarette smoking contributes to disproportionate morbidity and mortality among African Americans. Purposes of the study were to describe smoking behavior and test a model of nicotine dependence among African American women. Participants (n = 187) smoked a low rate of high nicotine mentholated cigarettes and had a mean salivary cotinine of 402 ng/mL. The proposed model predicted 48% of variance in nicotine dependence with smoking to cope, number of cigarettes/day, positive outcome expectancies about smoking, and interest in quitting, as significant contributors. Suggested interventions include developing alternative coping skills, cognitive restructuring, and techniques focused on the precontemplation stage of smoking cessation.