Community health advisors as research partners: an evaluation of the training and activities

Sowing the Seeds of Health: Training of Community Health Advisors to Promote Breast and Cervical Cancer Screening among Latina Immigrants in Alabama

Latinas in the U.S. are disproportionately affected by breast and cervical cancer. This project sought to develop and evaluate a culturally relevant training for Community Health Advisors (CHA) to promote breast and cervical cancer screening among Latina immigrants in Alabama. The Empowerment Model guided training development and implementation supported by a formative evaluation and a Community Advisory Committee. The 16-hour CHA training included two intertwined components: knowledge and skills.Fifty-six (56) Latinas participated in the CHA training in six Alabama counties. The training increased the CHAs' (1) knowledge of cancer screening and other health topics and (2) their perceived confidence to communicate with women in their communities about cancer screening and to motivate them to attain cancer screenings. This work demonstrates the application of a transformative philosophical framework to promote capacity-building among CHAs toward the development and implementation of strategies to promote breast and cervical cancer screening among Latina immigrants.

Using Community Feedback to Improve Community Interventions: Results From the Deep South Network for Cancer Control Project

The Deep South Network for Cancer Control (DSNCC), initiated in 2000, is a dual-state, community-based participatory research infrastructure composed of academic and community partners committed to reducing cancer disparities among underserved African Americans in 12 designated counties of the Alabama Black Belt and the Mississippi Delta, 2 historically underserved areas of the country. Local residents trained as Community Health Advisors as Research Partners implemented a 3-tier community action plan (CAP) focused on promoting cancer screening, physical activity, and nutrition. Breast, cervical and colorectal cancer screening, healthy eating habits, and physical activity levels increased among many, but not all, African American women in the 12-county DSNCC coverage area. Seeking to improve our reach to include participants who reported they had never heard of the DSNCC or participated in the CAP, we conducted in-depth conversations with community residents about reasons for selective nonparticipation and ways to improve participation in the DSNCC community health interventions. Three patterns and their associated themes described ways to improve the penetration of CAP strategies and tailor them to effectively reach underserved African Americans in the intervention counties. We conclude with lessons learned for future interventions.

Development and evaluation of an enhanced diabetes prevention program with psychosocial support for urban American Indians and Alaska natives: A randomized controlled trial

Diabetes is highly prevalent, affecting over 25 million adults in the US, yet it can be effectively prevented through lifestyle interventions, including the well-tested Diabetes Prevention Program (DPP). American Indian/Alaska Native (AIAN) adults, the majority of whom live in urban settings, are more than twice as likely to develop diabetes as non-Hispanic whites. Additionally, prevalent mental health issues and psychosocial stressors may facilitate progression to diabetes and hinder successful implementation of lifestyle interventions for AIAN adults. This 2-phased study first engaged community stakeholders to develop culturally-tailored strategies to address mental health concerns and psychosocial stressors. Pilot testing (completed) refined those strategies that increase engagement in an enhanced DPP for urban AIAN adults. Second, the enhanced DPP will be compared to a standard DPP in a randomized controlled trial (ongoing) with a primary outcome of body mass index (BMI) and a secondary outcome of quality of life (QoL) over 12months. Obese self-identified AIAN adults residing in an urban setting with one or more components of the metabolic syndrome (excluding waist circumference) will be randomized to the enhanced or standard DPP (n=204). We hypothesize that addressing psychosocial barriers within a culturally-tailored DPP will result in clinical (BMI) and superior patient-centered (QoL) outcomes as compared to a standard DPP. Exploratory outcomes will include cardiometabolic risk factors (e.g., waist circumference, blood pressure, fasting glucose) and health behaviors (e.g., diet, physical activity). Results of this trial may be applicable to other urban AIAN or minority communities or even diabetes prevention in general.

Patient Navigation As a Model to Increase Participation of African Americans in Cancer Clinical Trials

PURPOSE

Less than 10% of patients enrolled in clinical trials are minorities. The patient navigation model has been used to improve access to medical care but has not been evaluated as a tool to increase the participation of minorities in clinical trials. The Increasing Minority Participation in Clinical Trials project used patient navigators (PNs) to enhance the recruitment of African Americans for and their retention in therapeutic cancer clinical trials in a National Cancer Institute-designated comprehensive cancer center.

METHODS

Lay individuals were hired and trained to serve as PNs for clinical trials. African American patients potentially eligible for clinical trials were identified through chart review or referrals by clinic nurses, physicians, and social workers. PNs provided two levels of services: education about clinical trials and tailored support for patients who enrolled in clinical trials.

RESULTS

Between 2007 and 2014, 424 African American patients with cancer were referred to the Increasing Minority Participation in Clinical Trials project. Of those eligible for a clinical trial (N = 378), 304 (80.4%) enrolled in a trial and 272 (72%) consented to receive patient navigation support. Of those receiving patient navigation support, 74.5% completed the trial, compared with 37.5% of those not receiving patient navigation support. The difference in retention rates between the two groups was statistically significant (P < .001). Participation of African Americans in therapeutic cancer clinical trials increased from 9% to 16%.

CONCLUSION

Patient navigation for clinical trials successfully retained African Americans in therapeutic trials compared with non-patient navigation trial participation. The model holds promise as a strategy to reduce disparities in cancer clinical trial participation. Future studies should evaluate it with racial/ethnic minorities across cancer centers.

A patient navigation intervention for drug-involved former prison inmates

BACKGROUND

Former prison inmates experience high rates of hospitalizations and death during the transition from prison to the community, particularly from drug-related causes and early after release. The authors designed a randomized controlled trial (RCT) of patient navigation to reduce barriers to health care and hospitalizations for former prison inmates.

METHODS

Forty former prison inmates with a history of drug involvement were recruited and randomized within 15 days after prison release. Participants were randomized to receive 3 months of patient navigation (PN) with facilitated enrollment into an indigent care discount program (intervention) or facilitated enrollment into an indigent care discount program alone (control). Structured interviews were conducted at baseline, 3 months, and 6 months. Outcomes were measured as a change in self-reported barriers to care and as the rate of health service use per 100 person-days.

RESULTS

The mean number of reported barriers to care was reduced at 3 and 6 months in both groups. At 6 months, the rate of emergency department/urgent care visits per 100 person-days since baseline was 1.1 among intervention participants and 0.5 among control participants (P = .04), whereas the rate of hospitalizations per 100 person-days was 0.2 in intervention participants and 0.6 in control participants (P = .04).

CONCLUSIONS

Recruitment of former inmates into an RCT of patient navigation was highly feasible, but follow-up was limited by rearrests. Results suggest a significantly lower rate of hospitalizations among navigation participants, although the rate of emergency department/urgent care visits was not improved. Patient navigation is a promising, pragmatic intervention that may be effective at reducing high-cost health care utilization in former prison inmates.

Design of a comparative effectiveness evaluation of a culturally tailored versus standard community-based smoking cessation treatment program for LGBT smokers

Background

Smoking prevalence rates among the lesbian, gay, bisexual, and transgender (LGBT) population are significantly higher than the general population. However, there is limited research on smoking cessation treatments in this group, particularly on culturally targeted interventions. Moreover, there are few interventions that address culturally specific psychosocial variables (e.g., minority stress) that may influence outcomes. This paper describes the protocol for a comparative effectiveness trial testing an evidence-based smoking cessation program, Courage to Quit, against a culturally tailored version for LGBT smokers, and examines the role of culturally specific psychosocial variables on cessation outcomes.

Methods/Design

To examine the effectiveness of a culturally targeted versus standard smoking cessation intervention, the study utilizes a 2-arm block, randomized, control trial (RCT) design. Adult LGBT participants (n = 400) are randomized to one of the two programs each consisting of a six-session group program delivered in a community center and an eight week supply of the transdermal nicotine patch. Four individualized telephone counseling sessions occur at weeks 2, 5, 7, and 9, at times of greatest risk for relapse. Study outcome measures are collected at baseline, and 1, 3, 6, and 12 months post quit date. Primary outcomes are expired air carbon monoxide verified 7-day point-prevalence quit rates at each measurement period. Secondary outcomes assess changes in cravings, withdrawal symptoms, smoking cessation self-efficacy, and treatment adherence. Additionally, study staff examines the role of culturally specific psychosocial variables on cessation outcomes using path analysis.

Discussion

Determining the efficacy of culturally specific versus standard evidence based approaches to smoking cessation is a critical issue facing the field today. This study provides a model for the development and implementation of a culturally tailored smoking cessation intervention for LGBT participants and addresses a gap in the field by examining the role of culturally psychosocial variables associated with cessation outcomes.

Trial registration

U.S. National Institutes of Health Clinical Trials NCT01633567 Registered 30 May 2012.

Adherence and retention in clinical trials: a community-based approach

BACKGROUND

The Community Health Advisor (CHA) model has been widely used to recruit rural and low-income, mostly African American women into clinical and behavioral research studies. However, little is known about its effectiveness in promoting retention and adherence of such women in clinical trials.

METHODS

The Community-Based Retention Intervention Study evaluated the effectiveness of a community-based intervention strategy using the CHA model and the empowerment theory to improve the retention and adherence of minority and low-income women in clinical trials. The research strategy included the training and use of the volunteer CHAs as research partners. The target population included women participating in the University of Alabama at Birmingham clinical site of the Atypical Squamous Cells of Undetermined Significance-Low-Grade Squamous Intraepithelial Lesion (ASCUS-LSIL) Triage Study (ALTS), a multicenter, randomized clinical trial. Two communities in Jefferson County, Alabama, that were matched according to population demographics were identified and randomly assigned to either an intervention group or a control group. Thirty community volunteers were recruited to be CHAs and to implement the intervention with the ALTS trial participants. In total, 632 ALTS participants agreed to participate in the project, including 359 in the intervention group, which received CHA care, and 273 in the control group, which received standard care.

RESULTS

Adherence rates for scheduled clinic visits were significantly higher in the intervention group (80%) compared with the control group (65%; P < .0001).

CONCLUSIONS

The results indicate that volunteer CHAs can be trained to serve as research partners and can be effective in improving the retention and adherence of minority and low-income women in clinical trials.

Acceptability of delivering and accessing health information through text messaging among community health advisors

Background

Communication technologies can play a significant role in decreasing communication inequalities and cancer disparities by promoting cancer control and enhancing population and individual health. Studies have shown that technology, such as the mobile phone short message service (SMS) or text messaging, can be an effective health communication strategy that influences individuals’ health-related decisions, behaviors, and outcomes.

Objective

The purpose of this study was to explore usage of communication technologies, assess the acceptability of mobile technology for delivery and access of health information, and identify cancer and health information needs among Deep South Network for Cancer Control trained Community Health Advisors as Research Partners (CHARPs).

Methods

A mixed-method design was used, and a triangulation protocol was followed to combine quantitative and qualitative data. Focus groups (4 focus groups; n=37) and self-administered surveys (n=77) were conducted to determine CHARPs mobile phone and text message usage. The objective was to include identification of barriers and facilitators to a mobile phone intervention.

Results

All participants were African American (37/37, 100%), 11/37 (89%) were women, and the mean age was 53.4 (SD 13.9; focus groups) and 59.9 (SD 8.7; survey). Nearly all (33/37, 89%) of focus group participants reported owning a mobile phone. Of those, 8/33 (24%) owned a smartphone, 22/33 (67%) had a text messaging plan, and 18/33 (55%) and 11/33 (33%) received and sent text messages several times a week or day, respectively. Similar responses were seen among the survey participants, with 75/77 (97%) reporting owning a mobile phone, and of those, 22/75 (30%) owned a smartphone, 39/75 (53%) had a text messaging plan, and 37/75 (50%) received and 27/75 (37%) sent text messages several times a week or day. The benefits of a text messaging system mentioned by focus group participants included alternative form of communication, quick method for disseminating information, and privacy of communication. The main barriers reported by both groups to using mobile technology to receive health information were cost and not knowing how to text message. Ways to overcome barriers were explored with focus group participants, and education was the most proposed solution. Majority of CHARPs were in favor of receiving a weekly text message that would provide cancer/health information.

Conclusions

The findings from this study indicate that CHARPs are receptive to receiving text messages focusing on cancer/health information and would be likely to engage in mobile health research. These findings represent the first step in the development of an interactive mobile health program designed to provide cancer/health information and a support network for the Deep South Network Community Health Advisors as Research Partners (DSN CHARPs).

Exploring the ideal combination of activity satisfaction and burden among health promotion volunteers: a cross-sectional study in Japan

Background

Health promotion volunteers (HPVs) who are expected to function as leaders in promoting community health in Japan feel both satisfaction and burden associated with their community engagement activities. The purposes of this study were 1) to describe the prevalence of volunteers with differing levels of activity satisfaction and burden; 2) to examine the association between satisfaction and burden with activity involvement and persistence, and life satisfaction; and 3) to explore associated factors by satisfaction/burden levels among Japanese HPVs. The research question for this study was as follows: What is the relationship between activity satisfaction and burden among HPV?

Methods

A mail-in self-administered questionnaire survey was distributed to 604 HPVs in the cities of Konan and Koka, Shiga Prefecture, central Japan, in September 2005. Questions encompassed demographic data, variables regarding HPV activity such as organizational environment, social support, and the relationship with the neighborhood association, and overall satisfaction and burden related to the activity.

Results

The analyzed sample comprised 422 HPVs. Those with high satisfaction/low burden represented the largest number of study participants (group A; 38.4%). HPVs with high satisfaction/high burden (group B), low satisfaction/low burden (group C), and low satisfaction/high burden (group D) represented 23.0%, 11.1%, and 27.5% of participants, respectively. HPVs in groups A and B reported a greater total number of activities undertaken than those in group C. However, HPVs in group A had higher life satisfaction than those in groups C and D. Multinomial logistic regression analysis used to explore group differences showed that HPVs in group B had lower initial motivation and received less social support from colleagues, and those in group C felt the head of the neighborhood association was uncooperative. Those in group D had lower initial motivation, rated their organizational climate as worse, and considered the head of the neighborhood association uncooperative compared with group A.

Conclusions

We found that feeling satisfied and lightly burdened facilitated HPVs’ active participation in community-based activities. Findings suggest the importance of improving activity environments surrounding HPVs.

Evaluating the training of Filipino American community health advisors to disseminate colorectal cancer screening

Community health advisor-led interventions are associated with improved health promotion behaviors, such as cancer screening, but the process of training community health advisors is rarely described and evaluated. We trained 91 Filipino Americans from 19 organizations to conduct small-group sessions with members of their organizations to promote colorectal cancer screening. Community health advisors completed brief pre- and post-training surveys that included knowledge of colorectal cancer screening guidelines (four items), perceived self-efficacy of performing specific tasks (15-item scale, Cronbach's alpha > 0.90) and satisfaction with the training itself (five items). Community health advisors had high levels of knowledge and self-efficacy at pre-training, but levels increased significantly immediately after the 6-h training (percent of knowledge items answered correctly: 63-94 %; self-efficacy: 8.2-8.9 on a 10 point scale, both p < 0.001). Correlates of self-efficacy at pre- and post-test were high educational attainment, health care background, high level of participation in the organization, being perceived by others as a leader, and frequent participation in research activities in the past. Consistent evaluation measuring similar constructs across studies may help to standardize the quality of the training, and may improve the implementation of community health advisor-led programs.

Developing a community action plan to eliminate cancer disparities: lessons learned

BACKGROUND

African Americans bear an unequal burden of breast, cervical, and colorectal cancer. The Deep South Network for Cancer Control (DSN) is a community-academic partnership operating in Alabama and Mississippi that was funded by the National Cancer Institute (NCI) to address cancer disparities using community-based participatory research approaches.

OBJECTIVE

In addition to reporting on the plans of this work in progress, we describe the participatory process that local residents and the DSN used to identify needs and priorities, and elaborate on lessons learned from applying a participatory approach to the development of a community action plan.

METHODS

We conducted 24 community discussion groups involving health care professionals, government officials, faith-based leaders, and other stakeholders to identify cancer health disparity needs, community resources/assets, and county priorities to eliminate cancer health disparities. To develop a community action plan, four working groups explored the themes that emerged from the discussion groups, taking into consideration evidence-based strategies and promising community practices.

RESULTS

The DSN formulated a community action plan focusing on (1) increasing physical activity by implementing a campaign for individual-level focused activity; (2) increasing the consumption of fruits and vegetables by implementing NCI's Body and Soul Program in local churches; (3) increasing cancer screening by raising awareness through individual, system, and provider agents of change; and (4) training community partners to become effective advocates.

CONCLUSIONS

A community-academic partnership must involve trust, respect, and an appreciation of partners' strengths and differences. The DSN applied these guiding principles and learned pivotal lessons.

Targeted intervention strategies to increase and maintain mammography utilization among African American women

OBJECTIVES

We assessed the impact of a theory-based, culturally relevant intervention designed to increase mammography screening among African American women in 8 underserved counties in Alabama.

METHODS

Using principles derived from the Stages of Change, Community Health Advisor, and Community Empowerment models, we developed strategies to increase mammography screening. Trained volunteers (N = 143) provided tailored messages to encourage adoption and maintenance of mammography screening. We collected baseline and follow-up data on 1513 women in the communities targeted for the intervention. Our goal was to decrease the number of women in stage 1 (never screened) while increasing the number of women in stage 2 (infrequently screened) and stage 3 (regularly screened).

RESULTS

At baseline, 14% (n = 211) of the women were in stage 1, 16% (n = 247) were in stage 2, and 70% (n = 1055) were in stage 3. After the 2-year intervention, 4% (n = 61) of the women remained in stage 1, 20% (n = 306) were in stage 2, and 76% (n = 1146) were in stage 3.

CONCLUSIONS

Tailored motivational messages and peer support can increase mammography screening rates for African American women.

Community health workers' support for cancer clinical trials: description and explanation

Ethnic differences in participation in cancer clinical trials slow advances in medical knowledge that can reduce health care disparities. Community health workers (CHWs) are an increasingly important bridge between the health care system and underserved communities and could play an important role in increasing rates of clinical trial participation. We investigated community health workers' orientations to medical research and cancer clinical trials with a mixed methods design: two focus groups, 11 intensive interviews, and a structured survey of 76 CHW training workshop participants. CHWs demonstrated high levels of commitment to improving the health of community members but considerable distrust of researchers' motives, low levels of knowledge about cancer clinical trials, and frequent perceptions of bias in the health care system. Support for research is associated with more research experience, self-assessed knowledge, and Hispanic ethnicity, but with less seniority as a CHW. Neither actual knowledge of cancer clinical trials nor perceptions of bias in the health care system were related to degree of support for medical research. Community health workers perceive bias in the health care system but recognize the importance of medical research and are interested in learning more about cancer clinical trials. Research experience increases support for medical research; education increases perceptions of health care system bias.

Recruitment, training outcomes, retention, and performance of community health advisors in two tobacco control interventions for Latinos

Community Health Advisors (CHAs) are indigenous lay health advisors who, with training, can create health awareness, disseminate health information and support behavior change in their communities. Little data are available that describe the characteristics, recruitment, training, retention, and performance of CHAs. The present study described the characteristics, recruitment process, training outcomes, retention activities, and performance of two sets of CHAs who delivered tobacco-related interventions in the local Latino community. The Tobacco Control in Latino Communities (TCLC) Center trained 35 CHAs to conduct either a smoking cessation program for Spanish-speaking adult smokers or a behavioral problem-solving intervention to reduce environmental tobacco smoke (ETS) exposure among low-income Latino children. Theoretical psychosocial constructs related to behavior change, general self-esteem, general self-efficacy, and demographics were collected from CHAs before and after training. Additional measures captured the level of professionalism exercised and effort undertaken by the CHAs, as well actual outcomes of their efforts. Of the 33 women and 2 men CHAs recruited, 86% were originally from Mexico, most had a high school education, most were married, and the average monthly household income was $1,100-$1,400. Mean participant age was 42 years, and level of acculturation was relatively low. There were changes in the desired direction pre-to-post training for both ETS and smoking cessation program CHAs for most of the psychosocial constructs. Expert ratings of CHA performance were good, and recipients of the CHAs' efforts showed positive changes in behavior. This information may aid in planning for recruitment and evaluation of CHAs for future tobacco control programs.

The Relationships Between Feelings of Satisfaction and Burden With Respect to Activity and Social Support Among Health Promotion Volunteers in Japan

Health promotion volunteers (HPVs) working to promote community health in Japan feel both satisfaction and burden with their community engagement activities. This study examined the relationship between their satisfaction and burden toward their activities and social support. A mail-in self-check questionnaire survey was distributed to 604 HPVs in Japan in September 2005. Multiple regression analysis showed that high “activity attachment” was associated with more support from family, colleagues, and public health nurses; high “personal benefit” was associated with more support from colleagues and public health nurses. It was also found that low “burden on everyday life” was associated with more support from family and colleagues and that low “psychological burden” was associated with more support from colleagues and community members. It became clear that social support from various sources was positively related to HPVs’ satisfaction and negatively related to HPVs’ burden with their activities. To encourage HPV activities, it is important to consider what kinds of social support would be most useful to increase the satisfaction and reduce the burden felt by HPVs.

An ethical framework for community health workers and related institutions

The aim of this article is to provide practical ethical guidance and to foster further critical reflection on ethical issues in the work, education, and training of community health workers. The analysis includes implications for associated institutions. We first summarize the roles of community health workers and some evaluations of their work. After next highlighting ethical elements from the literature, we then give a justification for the ethical framework that follows. The article then provides a detailed discussion of a set of basic ethical principles for the field of community health work. Among the principles, we argue that the following 3 should have a foundational role: equal and substantial respect, justice, and care. Among these, respect is most fundamental.

The Deep South Network for cancer control. Building a community infrastructure to reduce cancer health disparities

Given the recent advances in cancer treatment, cancer disparity between whites and African-Americans continues as an unacceptable health problem. African-Americans face a considerable disparity with regard to cancer incidence, survival, and mortality when compared with the majority white population. On the basis of prior research findings, the Deep South Network (DSN) chose to address cancer disparities by using the Community Health Advisor (CHA) model, the Empowerment Theory developed by Paulo Freire, and the Community Development Theory to build a community and coalition infrastructure. The CHA model and empowerment theory were used to develop a motivated volunteer, grassroots community infrastructure of Community Health Advisors as Research Partners (CHARPs), while the coalition-building model was used to build partnerships within communities and at a statewide level. With 883 volunteers trained as CHARPs spreading cancer awareness messages, both African-Americans and whites showed an increase in breast and cervical cancer screening utilization in Mississippi and Alabama. In Mississippi, taking into account the increase for the state as a whole, the proportion that might be attributable to the CHARP intervention was 23% of the increase in pap smears and 117% of the increase in mammograms. The DSN has been effective in raising cancer awareness, improving both education and outreach to its target populations, and increasing the use of cancer screening services. The National Cancer Institute has funded the Network for an additional 5 years. The goal of eliminating cancer health disparities will be pursued in the targeted rural and urban counties in Mississippi and Alabama using Community-Based Participatory Research. Cancer 2006. (c) 2006 American Cancer Society.

The community health advisor program and the deep South network for cancer control: health promotion programs for volunteer community health advisors

The Community Health Advisor program is a proven, community-driven health promotion program that identifies and trains natural helpers who then seek to improve the health of individuals and their communities. This article details the basis of the Community Health Advisor model and describes early pilot programs in the Mississippi Delta. Also described is the formation of the Community Health Advisor Network, which provides technical assistance to Community Health Advisor programs and the proliferation of Community Health Advisor programs nationally. Specifically, details are presented of the modification of the model for the Deep South Network for Cancer Control and of early findings showing a decrease in health disparities in Alabama.