Lay health advisors: a strategy for getting the word out about breast cancer

"They should've talked to us more": lay health advisors' experiences with community-engaged hypertension research

BACKGROUND

Lay health advisors (LHAs) are increasingly being used to increase patient and public involvement in research, disseminate health information, and work toward preventing health disparities within communities at risk. This research explored LHAs' experiences with training and recruiting for a hypertension research project which ended due to minimal enrollment.

METHODS

The methodological design was qualitative description. One face-to-face semi-structured focus group was held with eight African American LHAs in Cleveland, Ohio, in the fall of 2019. The focus group was digitally recorded and transcribed by a professional transcriptionist and thematically analyzed.

RESULTS

Trainees reflected on how much they learned from the training and described feeling passionate and excited about their community work for the project. We identified three key themes from the data: (1) Systemic and Institutional Factors Affected LHAs' Experiences (subthemes: Unnecessarily Burdensome Requirements and Exploitation of Community Members for Research Gain; (2) Feeling Used Yet Unseen: Exclusion from Decision-Making Processes; (3) Worrying that Project Termination Damaged their Reputation; and (4) Disengaging from Research. We share lessons learned, including the need for LHAs' expertise to be integrated into research studies, and for projects to establish clear communication and expectations regarding research rigor and requirements.

CONCLUSION

Our results have implications for future studies attempting to build equitable and strong academic-community relationships to yield rigorous and useful research to reduce health disparities.

Addressing Tobacco Use in Underserved Communities Outside of Primary Care: The Need to Tailor Tobacco Cessation Training for Community Health Workers

Individuals from communities with a low socioeconomic status have the highest rates of tobacco use but are less likely to receive assistance with quitting. Community health workers (CHWs) are well-positioned to engage these communities; however, CHWs face barriers in receiving relevant tobacco cessation training. The objective of this study was to conduct a mixed methods needs assessment to describe tobacco practices and the desire for training among CHWs. After incorporating CHW feedback, we developed a needs assessment survey to understand knowledge, practices, and attitudes about tobacco cessation in Chicago, IL. CHWs (N = 23) recruited from local community-based organizations completed the survey online or in-person. We then conducted a focus group with CHWs (N = 6) to expand upon the survey and used the Framework Method to analyze the qualitative data. CHWs reported that their clients had low incomes, low literacy levels, and high smoking rates (e.g., "99%" of patients). About 73.3% reported discussing tobacco use during visits, but fewer reported that they had provided cessation advice (43%) or intervened directly (9%). CHWs described high variability in their work environments (e.g., location, duration, content of visits, etc.) and greater continuity of care. CHWs discussed that existing training on how to conduct tobacco interventions is ineffective, because of its stand-alone design. Our findings illustrate how CHWs adapt to their clients' needs, and that the currently available "gold-standard" cessation curricula are incompatible with the training needs and flexible care delivery model of CHWs. A curriculum tailored to the CHW experience is needed to maximize the strengths of the CHW care model by training CHWs to adaptively intervene regarding tobacco use in their highly burdened patients.

Promotoras de Salud in a Father-Focused Nutrition and Physical Activity Program for Border Communities: Approaches and Lessons Learned from Collaboration

Promotoras de salud (promotoras) have been a valuable part of community research for Latino families, such as in the recruitment or delivery of health promotion programs. However, there has been limited discussion of how to integrate a promotora model into a father-focused program to support nutrition and physical activity within Latino families. This manuscript's purpose is to describe how to engage and collaborate with promotoras in a father-focused, family-centered program for Latino families living in colonias near the U.S.-Mexico border. As part of a longstanding community-academic partnership, the authors outline approaches and lessons learned from collaboration with promotoras during the design (including formative work and training), implementation, and evaluation of a behavioral program-¡Haz Espacio para Papi! (HEPP, Make Room for Daddy!). Promotoras' contributions supported the entire program, from design through evaluation. The team of all-female promotoras created a balance between the needs and preferences of the community and the goals and requirements of the research. While there is considerable time and human capital required for collaboration, the mutual benefits can make this work meaningful to all involved.

Highlighting Contributions of Behavioral and Social Sciences in Advancing Public Health: Where We've Come, Where We're Headed

CONTEXT

Social and behavioral sciences, a cross-disciplinary field that examines the interaction among behavioral, biological, environmental, and social factors, has contributed immensely to some public health achievements over the last century. Through collaboration with community organizations and partners, social and behavioral scientists have conducted numerous program interventions involving community engagement and advocacy efforts at the local, state, federal, and international levels.

CONTRIBUTIONS OF SOCIAL AND BEHAVIORAL SCIENCES

This article traces select historical underpinnings of the applications of social and behavioral sciences theories and evidence to public health and highlights 4 areas in which health education specialists have distinctly contributed to public health achievements by building on theory and evidence. Applied social and behavioral sciences have formed the basis of various health education interventions. These 4 areas include the following: (1) Theory, Model Development, and the Professionalization of Health Education; (2) Participation and Community Engagement; (3) Health Communication; and (4) Advocacy and Policy.

DISCUSSION

We present contemporary challenges and recommendations for strengthening the theory, research, and practice of health education within the context of social and behavioral sciences in addressing emerging public health issues.

Assessing the Effectiveness of Cancer Screening Interventions Targeting Appalachian Populations: A Systematic Review

PURPOSE

Appalachian residents have higher cancer prevalence and invasive cancer incidence in almost all cancer types relative to non-Appalachian residents. Public health interventions have been carried out to increase preventive cancer screening participation. However, no studies have evaluated the effectiveness of existing interventions targeting cancer screening uptake in this high-risk population. The main objective of this study is to assess the effectiveness of interventions aimed at increasing uptake and/or continuing participation in screened cancers (breast, cervical, colorectal, lung, and prostate) in Appalachia.

METHODS

We conducted a systematic review of electronic databases and gray literature using a combination of MeSH and free-text search terms related to breast, cervical, colorectal, lung, and prostate cancer; mass screening; health promotion; and Appalachia. We identified 3,014 articles of which 15 articles were included. We assessed methodological quality using validated tools and analyzed findings using narrative synthesis.

FINDINGS

Fifteen studies reported uptake and/or continued participation in screening interventions; these focused on cervical (n = 7), colorectal (n = 5), breast (n = 2), and lung (n = 1) cancers in Appalachia. Interventions included diverse components: mass media campaigns, community outreach events, community health workers, interpersonal counseling, and educational materials. We found that multi-strategy interventions had higher screening uptake relative to interventions employing 1 intervention strategy. Studies that targeted noncompliant populations and leveraged existing community-based organization partnerships had a substantial increase in screening participation versus others.

CONCLUSIONS

There is an urgent need for further research and implementation of effective cancer prevention and screening interventions to reduce disparities in cancer morbidity and mortality in Appalachian populations.

Trust and Mistrust in Shaping Adaptation and De-Implementation in the Context of Changing Screening Guidelines

Objective

To understand barriers and facilitators to the adaptation of programs reflecting changing scientific guidelines for breast/cervical cancer screening, including factors influencing the de-implementation of messaging, program components, or screening practices no longer recommended due to new scientific evidence.

Setting

National sample of NWP sites from across the United States.

Design and Methods

We conducted a convergent mixed-methods design in partnership with The National Witness Project (NWP), a nationally implemented evidence-based lay health advisor (LHA) program for breast/cervical cancer screening among African American (AA) women. Surveys were conducted among 201 project directors (PDs) and LHAs representing 14 NWP sites; in-depth interviews were conducted among 14 PDs to provide context to findings. Survey data and qualitative interviews were collected concurrently from January 2019-January 2020.

Results

Trust and mistrust were important themes that arose in quantitative and qualitative data. Common concerns about adapting to new guidelines included: 1) perceptions that new guidelines misalign with the personal values and beliefs of AA women; 2) mistrust of guidelines, providers, medical organizations; 3) confusion about inconsistent guidelines and concern they are based on studies that don't reflect the experience of AA women (who experience more aggressive tumors at younger ages); and 4) belief that breast self-exam (BSE) is an empowerment tool for AA women and should be included to promote awareness, given many women discovered lumps/cancer through BSE.

Conclusion

Findings highlight that trust and mistrust are important but understudied social determinants of health among AAs that should be considered in implementation science as they: 1) have critical implications for shaping health inequities; and 2) help explain and contextualize why new screening guidelines may not be fully embraced in the AA community.

Community Empowerment Partners (CEPs): A Breast Health Education Program for African-American Women

Peer educators have been shown to provide effective interventions in breast cancer screening. Few studies have compared the effects of peer education on breast cancer knowledge among peer educators and the community members who are subsequently reached through the peer education. Further, little is known as to whether those who received the education then go on to educate others in the community. The purpose of this study is to address those gaps. Using a pre- and post-test study design, we trained peer educators, provided the educators with resources to train community members, and assessed changes in knowledge. We sought to train ten educators and recommended each train ten community members in breast cancer knowledge and screening strategies. A total of 14 peer educators were trained, who subsequently trained a total of 121 community members, of whom 94 were African American women. Peer educators and community members, showed comparable increases in knowledge. Community members who were educated also increased intention to discuss breast cancer and breast cancer screening with their family, friends, and acquaintances. Our study suggests that it is feasible to train peer educators to increase knowledge among community members to the same level that they themselves experience when trained. Further, community members are interested in sharing information learned related to how much they learn from peer educators.

Culture, identity, strength and spirituality: A qualitative study to understand experiences of African American women breast cancer survivors and recommendations for intervention development

OBJECTIVE

Despite advancements in cancer treatment, racial disparities in breast cancer survival persist, with African American women experiencing lower survival rates and poorer quality of life than non-Hispanic White women. Using a social cognitive model of restorative well-being as a framework, this qualitative study sought: (a) to examine strength- and culture-related factors associated with African American female breast cancer survivors' cancer coping and post-treatment experiences and (b) to make recommendations for culturally sensitive intervention.

METHODS

Eight focus groups occurred with a total of 40 local African American breast cancer survivors. Focus groups were audiotaped and transcribed verbatim. Framework analyses were used to identify themes. NVivo qualitative analysis software-managed data.

RESULTS

Two major themes emerged from the focus group discussions: (a) God enables breast cancer survivorship and works every day in our lives and (b) the healthiest thing about us is that we are strong African American women. Recommendations for intervention planning and implementation were made towards intervention structure, content development and language framing in a local context.

CONCLUSION

Findings suggest a need for community-based participatory survivorship interventions that are culturally and spiritually consonant and peer-based. Such interventions may respond to the cancer-related and personal needs of the target population.

Active Ottumwa: Adapting Evidence-Based Recommendations to Promote Physical Activity in a Micropolitan New Destination Community

Background: Evidence-based interventions have been developed and tested to promote physical activity, but fewer studies have focused on identifying effective intervention strategies for mid-size rural communities, especially new immigrant destinations. We report here on the design and implementation of Active Ottumwa, a community-wide intervention using a lay health advisor approach to increase physical activity in a micropolitan new destination community in the rural state of Iowa. Methods: The Active Ottumwa study is part of a community-academic partnership in Ottumwa, IA. Evidence-based strategies recommended by the Community Guide for Preventive Services guided study implementation and included behavioral and social, campaign and informational, and environmental and policy approaches. Evaluation methods for this study are multi-faceted and include a cross-sectional community survey, longitudinal cohort assessment, observational data, key informant interviews, and project records. Results: We are currently in our second year of intervention implementation, with 45 lay health advisors (termed physical activity leaders here) trained to carry out behavioral and social intervention approaches, including walking groups, tai chi, and yoga. We have completed a communication and informational campaign utilizing five channels. Our longitudinal cohort has been recruited, with baseline and 12-month data collection completed. Conclusions: This study will assess the effectiveness and impact of a community-wide intervention to support physical activity.

Community-Clinical Linkages With Community Health Workers in the United States: A Scoping Review

Despite the proliferation of community-clinical linkage (CCL) interventions with community health workers (CHWs), little is known about the components of these programs or how linkages are realized. In this scoping review, we synthesize evidence concerning the role of CHWs in creating and sustaining CCLs aimed at improving individual health outcomes. Our inclusion criteria included peer-reviewed articles that described a CHW intervention in the United States that used a CCL model. A total of 2,776 titles and/or abstracts were screened and 47 articles underwent full text review. Two independent reviewers rated the screened articles based on additional criteria including the CHW connection to community and evidence of linkage follow up rather than simple referral. For the 11 peer-reviewed articles included in the final review, we describe the CHW's relationship to the community, training, and role within the intervention, linkage, and outcomes. We used a standardized framework to determine commonalities in CHW roles across the interventions. CCLs with CHWs positively affect the delivery of both clinical care and community resources across a range of disease areas in a variety of contexts. To identify effective CCL models, additional information on CHW training, CCL follow-up methods, and the CHW role in CCLs is recommended.

Advancing understanding of the sustainability of lay health advisor (LHA) programs for African-American women in community settings

Lay health advisor (LHA) programs have made strong contributions towards the elimination of health disparities and are increasingly being implemented to promote health and prevent disease. Developed in collaboration with African-American survivors, the National Witness Project (NWP) is an evidence-based, community-led LHA program that improves cancer screening among African-American women. NWP has been successfully disseminated, replicated, and implemented nationally in over 40 sites in 22 states in diverse community settings, reaching over 15,000 women annually. We sought to advance understanding of barriers and facilitators to the long-term implementation and sustainability of LHA programs in community settings from the viewpoint of the LHAs, as well as the broader impact of the program on African-American communities and LHAs. In the context of a mixed-methods study, in-depth telephone interviews were conducted among 76 African-American LHAs at eight NWP sites at baseline and 12-18 months later, between 2010 and 2013. Qualitative data provides insight into inner and outer contextual factors (e.g., community partnerships, site leadership, funding), implementation processes (e.g., training), as well as characteristics of the intervention (e.g., perceived need and fit in African-American community) and LHAs (e.g., motivations, burnout) that are perceived to impact the continued implementation and sustainability of NWP. Factors at the contextual levels and related to motivations of LHAs are critical to the sustainability of LHA programs. We discuss how findings are used to inform (1) the development of the LHA Sustainability Framework and (2) strategies to support the continued implementation and sustainability of evidence-based LHA interventions in community settings.

Does Racial/Ethnic Identity Influence the Effectiveness of a Community Health Worker Intervention for African American and Latino Adults With Type 2 Diabetes?

Background. Community health worker (CHW) interventions are known to be an effective strategy to improve health behaviors and outcomes in relation to diabetes, particularly for racial/ethnic communities. Although understanding the function of identity with same race/ethnicity among clients of CHW interventions could contribute to more effective program design, few studies have explored whether levels of racial/ethnic identity among participants can influence the effectiveness of CHW interventions. Aims. We tested the relationship between level of racial/ethnic identity and changes in hemoglobin A1c and diabetes self-efficacy among low-income African American and Latino adults with type 2 diabetes who participated in a CHW intervention. Methods. Data came from a randomized controlled trial of the CHW intervention with a 6-month delayed control group design for 164 African American and Latino adults in Detroit, Michigan. Racial/ethnic identity was created from two items and classified into high, moderate, and low. We combined the two arms (immediate and delayed) into one because there was no significant difference in baseline characteristics, other than age and postintervention self-efficacy, and multivariable linear regression models were applied in the analysis. Results. Possession of high racial/ethnic identity was associated with greater improvement both in hemoglobin A1c and diabetes self-efficacy at 6 months. Moreover, among those with high hemoglobin A1c at preintervention, higher racial/ethnic identity had a greater impact on hemoglobin A1c improvement, compared with those with lower identity. Conclusions. This study suggests the importance of considering racial/ethnic identity of the participants in designing and operating the CHW intervention for racial/ethnic minority population.

Promotora Diabetes Intervention for Mexican Americans

PURPOSE

The purpose of this randomized controlled trial is to determine the effectiveness of an intervention led by promotoras (community lay workers) on the glycemic control, diabetes knowledge, and diabetes health beliefs of Mexican Americans with type 2 diabetes living in a major city on the Texas-Mexico border.

METHODS

One hundred fifty Mexican American participants were recruited at a Catholic faith-based clinic and randomized into 2 groups. Personal characteristics, acculturation, baseline A1C level, diabetes knowledge, and diabetes health beliefs were measured. The intervention was culturally specific and consisted of participative group education, telephone contact, and follow-up using inspirational faith-based health behavior change postcards. The A1C levels, diabetes knowledge, and diabetes health beliefs were measured 3 and 6 months postbaseline, and the mean change between the groups was analyzed.

RESULTS

The 80% female sample, with a mean age of 58 years, demonstrated low acculturation, income, education, health insurance coverage, and strong Catholicism. No significant changes were noted at the 3-month assessment, but the mean change of the A1C levels, F(1, 148) = 10.28, P < .001, and the diabetes knowledge scores, F(1, 148) = 9.0, P < .002, of the intervention group improved significantly at 6 months, adjusting for health insurance coverage. The health belief scores decreased in both groups.

CONCLUSIONS

The intervention resulted in decreased A1C levels and increased diabetes knowledge, suggesting that using promotoras as part of an interdisciplinary team can result in positive outcomes for Mexican Americans who have type 2 diabetes. Clinical implications and recommendations for future research are suggested.

Assessing Lay Health Advisor Activity in an Intervention to Prevent Lead Poisoning in Native American Children

The purpose of this study is to assess patterns of lay health advisor (LHA) activity in an intervention to reduce lead exposure in Native American children exposed to mine waste. A total of 39 LHAs were recruited and trained to become LHAs from eight tribes in northeastern Oklahoma. LHAs completed activity tracking forms over a 2-year intervention period to document contacts made with community groups and individuals in their social networks. They engaged in an average of 5.4 activities per month, reaching an average of 39 persons. Close members of their social networks were reached in 40.4% of the contacts; persons outside of their networks were reached in 24% of the contacts. This study suggests that 1 to 3 contacts per week may be a reasonable expectation for LHA activity. Findings also suggest that LHA interventions are a promising approach for engaging Native American communities in addressing an environmental health problem.

Implementing a Natural Helper Lay Health Advisor Program: Lessons Learned from Unplanned Events

Programs that train natural helpers, or members of the community to whom others naturally turn for help, to be lay health advisors (LHAs) have proliferated throughout the United States; evaluations of these programs, however, are uncommon. The goal of this exploratory study was to understand how the natural helper LHA approach, as operationalized by the North Carolina Breast Cancer Screening Program (NC-BCSP), was translated from idea into practice. Data from document review and in-depth interviews with 24 LHAs and four of their coordinators were used to compare theory-based program plans with actual practice. Results suggest that although in large part the natural helper model was followed, program implementation departed from program plans in several unanticipated ways in the areas of (a) recruitment, (b) program direction, and (c) LHA activities. Differences illustrate the tensions between theory and practice and between community and program planners that may be inherent in a natural helper program, and highlight the need to include community members and program participants in all aspects of planning.

Predictors of activity level and retention among African American lay health advisors (LHAs) from The National Witness Project: Implications for the implementation and sustainability of community-based LHA programs from a longitudinal study

BACKGROUND

Lay health advisor (LHA) programs are increasingly being implemented in the USA and globally in the context of health promotion and disease prevention. LHAs are effective in addressing health disparities when used to reach medically underserved populations, with strong evidence among African American and Hispanic women. Despite their success and the evidence supporting implementation of LHA programs in community settings, there are tremendous barriers to sustaining LHA programs and little is understood about their implementation and sustainability in "real-world" settings. The purpose of this study was to (1) propose a conceptual framework to investigate factors at individual, social, and organizational levels that impact LHA activity and retention; and (2) use prospective data to investigate the individual, social, and organizational factors that predict activity level and retention among a community-based sample of African American LHAs participating in an effective, evidence-based LHA program (National Witness Project; NWP).

METHODS

Seventy-six LHAs were recruited from eight NWP sites across the USA. Baseline predictor data was collected from LHAs during a telephone questionnaire administered between 2010 and 2011. Outcome data on LHA participation and program activity levels were collected in the fall of 2012 from NWP program directors. Chi-square and ANOVA tests were used to identify differences between retained and completely inactive LHAs, and LHAs with high/moderate vs. low/no activity levels. Multivariable logistic regression models were conducted to identify variables that predicted LHA retention and activity levels.

RESULTS

In multivariable models, LHAs based at sites with academic partnerships had increased odds of retention and high/moderate activity levels, even after adjusting for baseline LHA activity level. Higher religiosity among LHAs was associated with decreased odds of being highly/moderately active. LHA role clarity and self-efficacy were associated with retention and high/moderate activity in multivariable models unadjusted for baseline LHA activity level.

CONCLUSIONS

Organizational and role-related factors are critical in influencing the retention and activity levels of LHAs. Developing and fostering partnerships with academic institutions will be important strategies to promote successful implementation and sustainability of LHA programs. Clarifying role expectations and building self-efficacy during LHA recruitment and training should be further explored to promote LHA retention and participation.

A Male Promotores Network for Latinos: Process Evaluation From a Community-Based Participatory Project

Background Lay health advisor (LHA) interventions with Latino men are rare, especially in emerging Latino communities. We present a process evaluation of a male LHA network aiming at connecting Latino men to various kinds of services and to the Latino community. It assesses the feasibility of (1) maintaining a steering coalition; (2) hiring, training, and retaining male LHA; and (3) recruiting and assisting underserved participants. Methods Project management data and LHA debriefings were analyzed qualitatively and compared to a logic model and evaluation table prepared before the project started. Results The community coalition steered the project during its implementation. Eleven men attended the initial LHA training. Two thirds of them reflected the community in educational level. One third did not and required extra mentoring from the other LHA to recruit participants. LHA requested topics for monthly trainings according to their needs in the field, including housing, sexual health, and immigration. LHA enrolled 182 participants. Participants' needs went beyond health issues. Therefore, LHA needed to forge new collaborations with local social service organizations. Conclusions Recruiting male LHA is feasible. LHA and the community coalition can suggest adaptations to fit the local context.

Selection and performance of village health teams (VHTs) in Uganda: lessons from the natural helper model of health promotion

BACKGROUND

Community health worker (CHW) programmes have received much attention since the 1978 Declaration of Alma-Ata, with many initiatives established in developing countries. However, CHW programmes often suffer high attrition once the initial enthusiasm of volunteers wanes. In 2002, Uganda began implementing a national CHW programme called the village health teams (VHTs), but their performance has been poor in many communities. It is argued that poor community involvement in the selection of the CHWs affects their embeddedness in communities and success. The question of how selection can be implemented creatively to sustain CHW programmes has not been sufficiently explored. In this paper, our aim was to examine the process of the introduction of the VHT strategy in one rural community, including the selection of VHT members and how these processes may have influenced their work in relation to the ideals of the natural helper model of health promotion.

METHODS

As part of a broader research project, an ethnographic study was carried out in Luwero district. Data collection involved participant observation, 12 focus group discussions (FGDs), 14 in-depth interviews with community members and members of the VHTs and four key informant interviews. Interviews and FGD were recorded, transcribed and coded in NVivo. Emerging themes were further explored and developed using text query searches. Interpretations were confirmed by comparison with findings of other team members.

RESULTS

The VHT selection process created distrust, damaging the programme's legitimacy. While the Luwero community initially had high expectations of the programme, local leaders selected VHTs in a way that sidelined the majority of the community's members. Community members questioned the credentials of those who were selected, not seeing the VHTs as those to whom they would go to for help and support. Resentment grew, and as a result, the ways in which the VHTs operated alienated them further from the community. Without the support of the community, the VHTs soon lost morale and stopped their work.

CONCLUSION

As the natural helper model recommends, in order for CHW programmes to gain and maintain community support, it is necessary to utilize naturally existing informal helping networks by drawing on volunteers already trusted by the people being served. That way, the community will be more inclined to trust the advice of volunteers and offer them support in return, increasing the likelihood of the sustainability of their service in the community.

Who's Missing? Predictors of Attrition Following Participation in Culturally Targeted Educational Breast and Cervical Cancer Outreach Programs for Latinas

Rates of breast and cervical cancer screening among Latinas are suboptimal. The Esperanza y Vida program was developed to increase awareness of screening methods among Latinas. Lay health advisor cancer survivors are trained to deliver the program and use a narrative communication approach to promote breast and cervical cancer awareness and screening. This study aimed to identify characteristics of participants, within the larger study, who were lost, due to attrition, for follow-up assistance. Participants (N = 908) completed questionnaires that assessed knowledge, perceptions, and beliefs about breast and cervical cancer and were contacted after the program to assess screening and offer assistance in obtaining screening exams. Latinas who were younger than 40 years of age and who felt that the survivor's story would prompt them to make an appointment for screening were more likely to be lost to follow-up at 2 months. These findings have implications for future breast and cervical cancer outreach programs and interventions.

Promotoras as facilitators of change: Latinas' perspectives after participating in a lifestyle behaviour intervention program

AIM

To describe immigrant Latinas' perspectives of a lifestyle behaviour intervention, focusing on their interactions with and perceptions of the promotoras who delivered the program in the USA.

BACKGROUND

Immigrant Latinas in the USA have high obesity rates, which contribute to increased risk for cardiovascular disease and other long-term diseases. Interventions using the promotora model appear to be effective in reducing cardiovascular disease risk by improving dietary habits, physical activity and selected clinical variables among Latinas. However, there has been very limited enquiry into what it is about these interventions and promotoras that facilitates behaviour change, from the perspective of participants.

DESIGN

Grounded theory methodology guided the data collection and analysis.

METHODS

This qualitative study was completed in 2012 in California, after the end of a lifestyle behaviour intervention. Four focus groups and seven one-on-one interviews were conducted with a total of 18 immigrant Latina intervention participants.

RESULTS

Women described promotoras as helping them change by motivating them through three interconnected elements: tools, support and knowledge. Latinas viewed their ability to make lifestyle changes as connected with their emotional and psychological health and saw promotoras as counsellors who gave emotional and social support. In this respect, the intervention was emotionally therapeutic for this sample of Latinas, although this was not the original intention of the program.

CONCLUSION

Promotoras gave the backbone of the intervention and were crucial in motivating Latinas to implement lifestyle changes. Future lifestyle behaviour interventions should include a strong component of mental and emotional well-being.

Acceptance of a community-based navigator program for cancer control among urban African Americans

Patient navigation is now a standard component of cancer care in many oncology facilities, but a fundamental question for navigator programs, especially in medically underserved populations, is whether or not individuals will use this service. In this study, we evaluated acceptance of a community-based navigator program for cancer control and identified factors having significant independent associations with navigation acceptance in an urban sample of African Americans. Participants were African American men and women ages 50-75 who were residents in an urban metropolitan city who were referred for navigation. Of 240 participants, 76% completed navigation. Age and perceived risk of developing cancer had a significant independent association with navigation acceptance. Participants who believed that they were at high risk for developing cancer had a lower likelihood of completing navigation compared with those who believed that they had a low risk for developing this disease. The likelihood of completing navigation increased with increases in age. None of the socioeconomic factors or health care variables had a significant association with navigation acceptance. There are few barriers to using community-based navigation for cancer control among urban African Americans. Continued efforts are needed to develop and implement community-based programs for cancer control that are easy to use and address the needs of medically underserved populations.

Community engagement to reduce inequalities in health: a systematic review, meta-analysis and economic analysis

Background

Community engagement has been advanced as a promising way of improving health and reducing health inequalities; however, the approach is not yet supported by a strong evidence base.

Objectives

To undertake a multimethod systematic review which builds on the evidence that underpins the current UK guidance on community engagement; to identify theoretical models underpinning community engagement; to explore mechanisms and contexts through which communities are engaged; to identify community engagement approaches that are effective in reducing health inequalities, under what circumstances and for whom; and to determine the processes and costs associated with their implementation.

Data sources

Databases including the Cochrane Database of Systematic Reviews (CDSR), The Campbell Library, the Database of Abstracts of Reviews of Effects (DARE), the Health Technology Assessment (HTA) database, the NHS Economic Evaluation Database (NHS EED) and EPPI-Centre’s Trials Register of Promoting Health Interventions (TRoPHI) and Database of Promoting Health Effectiveness Reviews (DoPHER) were searched from 1990 to August 2011 for systematic reviews and primary studies. Trials evaluating community engagement interventions reporting health outcomes were included.

Review methods

Study eligibility criteria: published after 1990; outcome, economic, or process evaluation; intervention relevant to community engagement; written in English; measured and reported health or community outcomes, or presents cost, resource, or implementation data characterises study populations or reports differential impacts in terms of social determinants of health; conducted in an Organisation for Economic Co-operation and Development (OECD) country. Study appraisal: risk of bias for outcome evaluations; assessment of validity and relevance for process evaluations; comparison against an economic evaluation checklist for economic evaluations. Synthesis methods: four synthesis approaches were adopted for the different evidence types: theoretical, quantitative, process, and economic evidence.

Results

The theoretical synthesis identified key models of community engagement that are underpinned by different theories of changes. Results from 131 studies included in a meta-analysis indicate that there is solid evidence that community engagement interventions have a positive impact on health behaviours, health consequences, self-efficacy and perceived social support outcomes, across various conditions. There is insufficient evidence – particularly for long-term outcomes and indirect beneficiaries – to determine whether one particular model of community engagement is likely to be more effective than any other. There are also insufficient data to test the effects on health inequalities, although there is some evidence to suggest that interventions that improve social inequalities (as measured by social support) also improve health behaviours. There is weak evidence from the effectiveness and process evaluations that certain implementation factors may affect intervention success. From the economic analysis, there is weak but inconsistent evidence that community engagement interventions are cost-effective. By combining findings across the syntheses, we produced a new conceptual framework.

Limitations

Differences in the populations, intervention approaches and health outcomes made it difficult to pinpoint specific strategies for intervention effectiveness. The syntheses of process and economic evidence were limited by the small (generally not rigorous) evidence base.

Conclusions

Community engagement interventions are effective across a wide range of contexts and using a variety of mechanisms. Public health initiatives should incorporate community engagement into intervention design. Evaluations should place greater emphasis on long-term outcomes, outcomes for indirect beneficiaries, process evaluation, and reporting costs and resources data. The theories of change identified and the newly developed conceptual framework are useful tools for researchers and practitioners. We identified trends in the evidence that could provide useful directions for future intervention design and evaluation.

Funding

The National Institute for Health Research Public Health Research programme.

The role of a lack of social integration in never having undergone breast cancer screening: results from a population-based, representative survey in the Paris metropolitan area in 2010

OBJECTIVES

This study aims to investigate the association between social contact and social support and women's breast cancer screening (BCS) practices, taking their socioeconomic status (SES) into account.

METHODS

The SIRS survey was conducted in 2010 in the Paris metropolitan area among a representative sample of 3000 French-speaking adults. For the 784 women aged 50years or older with no history of breast cancer, multivariate logistic regressions and bootstrap methods were used to analyze the factors associated with never having undergone BCS.

RESULTS

6.5% of these women had never undergone BCS. In multivariate analysis, being older, having a low education level, having poor-quality health insurance, and having one or less than one social contact per 3-day period were significantly associated with never having undergone BCS during their lifetime, but the level of social support was not. The strength of the association with a low frequency of social contact tended to increase with age.

CONCLUSION

This study analyzed the role of social contact in social inequalities in BCS practices in the Paris metropolitan area. Like SES, social integration and social isolation should be taken into consideration by public health professionals and practitioners when planning BCS programs and incentives.

Culturally targeted patient navigation for increasing african americans' adherence to screening colonoscopy: a randomized clinical trial

BACKGROUND

Patient navigation has been an effective intervention to increase cancer screening rates. This study focuses on predicting outcomes of screening colonoscopy for colorectal cancer among African Americans using different patient navigation formats.

METHODS

In a randomized clinical trial, patients more than 50 years of age without significant comorbidities were randomized into three navigation groups: peer-patient navigation (n = 181), pro-patient navigation (n = 123), and standard (n = 46). Pro-patient navigations were health care professionals who conducted culturally targeted navigation, whereas peer-patient navigations were community members trained in patient navigation who also discussed their personal experiences with screening colonoscopy. Two assessments gathered sociodemographic, medical, and intrapersonal information.

RESULTS

Screening colonoscopy completion rate was 75.7% across all groups with no significant differences in completion between the three study arms. Annual income more than $10,000 was an independent predictor of screening colonoscopy adherence. Unexpectedly, low social influence also predicted screening colonoscopy completion.

CONCLUSIONS

In an urban African American population, patient navigation was effective in increasing screening colonoscopy rates to 15% above the national average, regardless of patient navigation type or content.

IMPACT

Because patient navigation successfully increases colonoscopy adherence, cultural targeting may not be necessary in some populations.

Culturally targeted patient navigation for increasing african americans' adherence to screening colonoscopy: a randomized clinical trial

BACKGROUND

Patient navigation has been an effective intervention to increase cancer screening rates. This study focuses on predicting outcomes of screening colonoscopy for colorectal cancer among African Americans using different patient navigation formats.

METHODS

In a randomized clinical trial, patients more than 50 years of age without significant comorbidities were randomized into three navigation groups: peer-patient navigation (n = 181), pro-patient navigation (n = 123), and standard (n = 46). Pro-patient navigations were health care professionals who conducted culturally targeted navigation, whereas peer-patient navigations were community members trained in patient navigation who also discussed their personal experiences with screening colonoscopy. Two assessments gathered sociodemographic, medical, and intrapersonal information.

RESULTS

Screening colonoscopy completion rate was 75.7% across all groups with no significant differences in completion between the three study arms. Annual income more than $10,000 was an independent predictor of screening colonoscopy adherence. Unexpectedly, low social influence also predicted screening colonoscopy completion.

CONCLUSIONS

In an urban African American population, patient navigation was effective in increasing screening colonoscopy rates to 15% above the national average, regardless of patient navigation type or content.

IMPACT

Because patient navigation successfully increases colonoscopy adherence, cultural targeting may not be necessary in some populations.

Using the interactive systems framework to support a quality improvement approach to dissemination of evidence-based strategies to promote early detection of breast cancer: planning a comprehensive dynamic trial

Dissemination efforts must optimize interventions for new settings and populations. As such, dissemination research should incorporate principles of quality improvement. Comprehensive Dynamic Trial (CDT) designs examine how information gained during dissemination may be used to modify interventions and improve performance. Although CDT may offer distinct advantages over static designs, organizing the many necessary roles and activities is a significant challenge. In this article, we discuss use of the Interactive Systems Framework for Dissemination and Implementation to systematically implement a CDT. Specifically, we describe "Bronx ACCESS", a program designed to disseminate evidence-based strategies to promote adherence to mammography guidelines. In Bronx ACCESS, the Intervention Delivery System will elicit information needed to adapt strategies to specific settings and circumstances. The Intervention Synthesis and Translation System will use this information to test changes to strategies through "embedded experiments". The Intervention Support System will build local capacities found to be necessary for intervention institutionalization. Simulation modeling will be used to integrate findings across systems. Results will inform on-going policy debate about interventions needed to promote population-level screening. More generally, this project is intended to advance understanding of research paradigms necessary to study dissemination.

Explaining and improving breast cancer information acquisition among African American women in the Deep South

OBJECTIVES

A major challenge facing contemporary cancer educators is how to optimize the dissemination of breast cancer prevention and control information to African American women in the Deep South who are believed to be cancer free. The purpose of this research was to provide insight into the breast cancer information-acquisition experiences of African American women in Alabama and Mississippi and to make recommendations on ways to better reach members of this high-risk, underserved population.

METHODS

Focus group methodology was used in a repeated, cross-sectional research design with 64 African American women, 35 years old or older who lived in one of four urban or rural counties in Alabama and Mississippi.

RESULTS

Axial-coded themes emerged around sources of cancer information, patterns of information acquisition, characteristics of preferred sources, and characteristics of least-preferred sources.

CONCLUSIONS

It is important to invest in lay health educators to optimize the dissemination of breast cancer information to African American women who are believed to be cancer free in the Deep South.

Effectiveness of community health workers in providing outreach and education for colorectal cancer screening in Appalachian Kentucky

The purpose of this study was to examine the effectiveness of a community health worker (CHW)-delivered cancer education program designed to increase knowledge and awareness of colorectal cancer screening options. The study population was an extremely vulnerable and medically underserved geographic region in Appalachian Kentucky. CHWs enrolled participants in face-to-face visits, obtained informed consent, and administered a baseline assessment of knowledge of colorectal cancer risks and the benefits of screening and screening history. An educational intervention was then provided and participants were re-contacted 6 months later when a posttest was administered. The mean score of the 637 participants increased from 4.27 at baseline to 4.57 at follow-up (p < .001). Participants who reported asking their health care provider about colorectal cancer screening increased from 27.6% at baseline to 34.1% at follow-up (p = .013). Results suggest that CHWs were very effective at maintaining the study population; no loss to follow-up occurred. The results also showed increased knowledge and awareness about colorectal cancer screening education. Implications for social work practice, policy and research are discussed.

When promotoras and technology meet: a qualitative analysis of promotoras' use of small media to increase cancer screening among South Texas Latinos

Computer-based multimedia technologies can be used to tailor health messages, but promotoras (Spanish-speaking community health workers) rarely use these tools. Promotoras delivered health messages about colorectal cancer screening to medically underserved Latinos in South Texas using two small media formats: a "low-tech" format (flipchart and video) and a "high-tech" format consisting of a tailored, interactive computer program delivered on a tablet computer. Using qualitative methods, the authors observed promotora training and intervention delivery and conducted interviews with five promotoras to compare and contrast program implementation of both formats. The authors discuss the ways each format aided or challenged promotoras' intervention delivery. Findings reveal that some aspects of both formats enhanced intervention delivery by tapping into Latino health communication preferences and facilitating interpersonal communication, whereas other aspects hindered intervention delivery. This study contributes to our understanding of how community health workers use low- and high-tech small media formats when delivering health messages to Latinos.

'Think differently and be prepared to demonstrate trust': findings from public hearings, England, on supporting lay people in public health roles

Professional support processes are critical for the establishment and maintenance of community health worker programmes. This paper reports on three public hearings held in England, UK, that were conducted as part of a national study into approaches to develop and support lay people in public health roles. Individuals with relevant theoretical or practical expertise, including lay activists, presented evidence in public as expert witnesses. Formal presentations, questions and plenary discussions were recorded and later analysed as qualitative data. This paper presents the results and critically examines emergent issues relating to the sustainability of lay health worker programmes. Consideration is given to the diversity of contemporary practice in England. Barriers seen to affect sustainability included organizational culture and onerous bureaucratic processes. Major themes emerging from the expert evidence included recruitment and training strategies, financial support and the need for a robust infrastructure. The expert hearings, in creating a public space for deliberation, opened up discussion on the levels and type of programme support required to foster lay health worker programmes. The paper concludes that professional support needs to be accompanied by a reorientation of public services to support lay engagement in programme delivery.

Engaging with marginalized communities: the experiences of London health trainers

AIMS

Health trainers represent a new occupational role within the NHS which has been developing since 2006, when the first 'early adopter' sites were funded by the Department of Health. Health trainers are 'lay' people recruited to engage 'harder-to-reach' people from their communities, offering one-to-one support to enable them to make the healthy lifestyle changes of their choice. The aim of this study was to explore the experiences and approaches adopted by health trainers in engaging with marginalized communities.

METHODS

This paper describes an exploratory study using in-depth semi-structured interviews with 10 currently employed health trainers with diverse backgrounds, forms of employment and interpretation of role, drawn from seven London primary care trusts (PCTs) or boroughs.

RESULTS

The study found tensions between the lay identity of health trainers and their adoption of a formalized role. Health trainers emphasized their similarities but underestimated their often significant differences to their communities. Health trainers based in community or voluntary groups found engagement easier than those based in PCTs, and saw engagement as an end in itself, through its creation of opportunities for health.

CONCLUSIONS

There remains a lack of clarity about the role of the health trainer. Lay workers are not necessarily part of the marginalized communities they are expected to engage, while their ability to do so is compromised by the professional culture of the NHS and its approach to community engagement. Health trainers based in the community or voluntary sector appear to offer greater potential for engaging communities and providing those communities with practical opportunities for health gain.

Comparison of online and face-to-face dissemination of a theory-based after school nutrition and physical activity training and curriculum

This study was conducted to compare two different online delivery methods to train after school program leaders (ASPLs) to implement a nutrition and physical activity curriculum for children to each other and to a face-to-face (FTF) training model. A three-group design was used in which ASPLs from 12 states were randomized to either standard (n = 34) or an enhanced interaction (n = 31) online training, while a FTF group (n = 24) served as comparison. All ASPLs completed training and implemented curriculum lessons over 16 weeks from March to June 2007. Weekly evaluations and pre and post-intervention questionnaires compared number of lessons implemented, subjective ratings of lesson success, and pre and post leader nutrition and physical activity knowledge. Multivariate linear regression analyses were used for among-group comparisons, paired Ttests for within-group knowledge change. Knowledge scores increased significantly (p < .001) within each group. All ASPLs fulfilled the goal of conducting at least 9 lessons, and they rated 64% of lessons successful. After adjustment, knowledge change and success scores did not differ among groups. Implementation was significantly higher for FTF (+2.23 lessons, p = .013) than for enhanced interaction, but not for standard. Online training for ASPLs, such as the standard condition, are viable means of nutrition and physical activity education and program dissemination.

Outcome effectiveness of the lay health advisor model among Latinos in the United States: an examination by role

The objective of this study was to examine lay health advisor (LHA) programs designed to promote health among US Latinos and the extent to which educator-only versus educator-plus-bridge programs differed in designs and outcomes achieved. Two independent coders reviewed 128 published articles on LHAs yielding information at two levels: (i) study design and participant and LHA characteristics from 61 studies that broadly compared educator-only versus educator-plus-bridge programs and (ii) implementation features and outcomes from 17 randomized controlled trials or quasi-experimental studies with outcome data. LHA programs have been widely used with Latinos in certain US regions; our findings indicate that LHAs are effective intervention agents. We identified differences between educator-only and educator-plus-bridge LHA programs, although the small number of educator-plus-bridge programs with outcome data limited comparisons. Major gaps remain in research targeting Latino subgroups other than Mexican immigrants/Mexican Americans. Sufficient research has evaluated LHA programs among Latinos on their ability to achieve health behavior and/or health status changes. In the future, more of a focus on organizational and policy changes is warranted. Questions remain about diversity in LHAs' characteristics and roles, which influence not only outcomes but also program sustainability and dissemination.

Development and feasibility of an HIV and IPV prevention intervention among low-income mothers receiving services in a Missouri Day Care Center

This article outlines the development and feasibility of an HIV and IPV prevention intervention. Researchers formed a partnership with a group of women representative of the population that the intervention was intended to reach using methods derived from participatory action research. The use of health protective behaviors changed from pre- to postintervention in the clinically desirable direction. Results indicated that intervention delivery was feasible in the novel setting of a large urban day care center. This intervention has promise as a strategy to reduce HIV among low-income women; however, a controlled study is indicated to further examine intervention efficacy.

Applying the social cognitive perspective to volunteer intention in China: the mediating roles of self-efficacy and motivation

When predicting volunteer intention, much attention is paid to the volunteer organization environment (VOE). Given that self-efficacy and motivation have emerged as important predictors of volunteer intention, we adopted a combination of ideas of Bandura's social cognitive theory and Ajzen's theory of planned behavior integrating VOE, self-efficacy and motivation to examine their effects on volunteer intention and to determine whether self-efficacy and motivation mediate the relationship between VOE and volunteer intention. The subjects of this study consisted of 198 community health volunteers in Shanghai city, China. Exploratory factor analysis was performed to identify the factor structure using standard principal component analysis. Six new factors were revealed, including two VOE factors, relation with organization and support from government; two motivation factors, personal attitude and social recognition; self-efficacy and volunteer intention. The results of a hierarchical regression analysis indicated that relation with organization accounted for 14.8% of the variance in volunteer intention, and support from government failed to add significantly to variance in volunteer intention; self-efficacy and personal attitude motivation partially mediated the effects of relation with organization on volunteer intention; social recognition motivation did not mediate the relationship between relation with organization and volunteer intention; and relation with organization, self-efficacy and personal attitude motivation accounted for 33.7% of the variance in volunteer intention. These results provide support for self-efficacy and personal attitude motivation as mediators and provide preliminary insight into the potential mechanisms for predicting volunteer intention and improving volunteering by integrating VOE, self-efficacy and motivation factors.

Community health workers speak out about the Kin KeeperSM model

Community health workers (CHWs) informed students and researcher alike on the Kin Keeper(SM) Cancer Prevention Intervention. Students interested in medicine, guided by faculty, conducted a focus group session with 13 CHWs to find out if the intervention was effective for delivering breast and cervical cancer education. Strengths reported were (1) cultural appropriateness, (2) home visits, (3) CHW resource kits, and (4) increased awareness. The barriers were privacy perceptions and scheduling home visits. Overall, the CHWs indicated that the intervention was effective and flexible enough to accommodate the African American, Latina, and Arab groups of women.

Social support among Latina immigrant women: bridge persons as mediators of cervical cancer screening

New Latina immigrants face numerous linguistic, cultural, logistical, and material barriers to cervical cancer screenings. Promotoras (lay health advisors) are a proven strategy to promote utilization of care. Since the mid-1990s, interventions in North Carolina have aimed to connect Latina immigrants to a broader range of bridge persons. This study assessed the effect of bridge persons on utilization of cervical cancer screening by Latina immigrants in North Carolina. Women were recruited in Spanish-language churches in four counties (N = 223). Logistic regression results show that persons known through advocacy organizations appeared to increase probability of recent Pap screening by an average of 10.4 percentage points (p < 0.05). Promotoras remain more effective, increasing probability of screening by 12.9 percentage points (p < 0.05) but few women (14%) knew one. No association was found with other bridge person profiles. Interventions are needed to better engage all bridge persons in linking immigrants to preventive health services.

Secretos de la Buena Vida: processes of dietary change via a tailored nutrition communication intervention for Latinas

Secretos de la Buena Vida was a successful tailored nutrition communication intervention delivered to Latinas living along the US-Mexico border in California. The intervention was delivered over a 14-week period and consisted of three intervention conditions: weekly home visits with promotoras + weekly tailored mailed newsletters in the first condition, weekly tailored mailed newsletters in the second condition and targeted materials in the attention control condition. The current study examined what elements of the promotora + tailored newsletter and tailored newsletter-only conditions were most effective for behavioral adoption and maintenance in a sample of 238 Latina women. Process evaluation measures assessed the implementation, fidelity and dose of these two intervention conditions. Results indicate that there was high fidelity to program implementation and delivery. Perceived effort, perceived support and intervention length predicted adoption of a lower fat diet at the 15-month follow-up. In the promotora + tailored newsletter condition, married women were four times more likely to be adopters of dietary fat changes than single women. These findings highlight the importance of process evaluation measures and help us understand the mechanism by which tailored print materials and interpersonal health communication via promotoras can facilitate health behavior change.

The role of culture in the context of school-based BMI screening

The high prevalence of overweight and obesity is a significant public health concern in the United States. Minority populations are disproportionately affected, and the impact of obesity on minority children is especially alarming. In this article we discuss school-based BMI reporting, which is intended to increase parental awareness of their children's weight status. This information could potentially lead parents of overweight and obese children to carefully examine and possibly change their children's diet and activity patterns. However, any program related to child weight status must consider culturally defined aspects of body size and shape. In other words, the cultural context in which information on child BMI is presented to and received by parents must be considered. In this article we review parental perceptions of child weight. Multiple studies have shown that parents of overweight or obese children often fail to correctly perceive their children as overweight. Possible reasons for, and implications of, this misperception of child weight status among minority parents are then explored within a cultural framework. The PEN-3 model is used to examine influences on health behaviors and could help inform the development of a culturally sensitive BMI-notification program for minority parents. Reporting materials congruent with the social and cultural values and practices of the target audience are likely to maximize program effectiveness. A culturally based BMI-notification program should be conceptualized as a small step in a comprehensive plan to reduce childhood obesity and improve the current and future health of minority children.

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.

A Community Health Advisor Program to reduce cardiovascular risk among rural African-American women

The Uniontown, Alabama Community Health Project trained and facilitated Community Health Advisors (CHAs) in conducting a theory-based intervention designed to reduce the risk for cardiovascular disease (CVD) among rural African-American women. The multiphased project included formative evaluation and community organization, CHA recruitment and training, community intervention and maintenance. Formative data collected to develop the training, intervention and evaluation methods and materials indicated the need for programs to increase knowledge, skills and resources for changing behaviors that increase the risk of CVD. CHAs worked in partnership with staff to develop, implement, evaluate and maintain strategies to reduce risk for CVD in women and to influence city officials, business owners and community coalitions to facilitate project activities. Process data documented sustained increases in social capital and community capacity to address health-related issues, as well as improvements in the community's physical infrastructure. This project is unique in that it documents that a comprehensive CHA-based intervention for CVD can facilitate wide-reaching changes in capacity to address health issues in a rural community that include improvements in community infrastructure and are sustained beyond the scope of the originally funded intervention.

Theorising interventions as events in systems

Conventional thinking about preventive interventions focuses over simplistically on the "package" of activities and/or their educational messages. An alternative is to focus on the dynamic properties of the context into which the intervention is introduced. Schools, communities and worksites can be thought of as complex ecological systems. They can be theorised on three dimensions: (1) their constituent activity settings (e.g., clubs, festivals, assemblies, classrooms); (2) the social networks that connect the people and the settings; and (3) time. An intervention may then be seen as a critical event in the history of a system, leading to the evolution of new structures of interaction and new shared meanings. Interventions impact on evolving networks of person-time-place interaction, changing relationships, displacing existing activities and redistributing and transforming resources. This alternative view has significant implications for how interventions should be evaluated and how they could be made more effective. We explore this idea, drawing on social network analysis and complex systems theory.

Moving from theory to practice: implementing the Kin Keeper Cancer Prevention Model

This paper presents the rationale and findings of a feasibility and process study of the Kin Keeper(SM) Cancer Prevention Intervention. An observational cohort study design was implemented with African-American women in synergistic female family relationships. Community health workers (CHWs) from two Michigan public health programs recruited women to serve as 'kin keepers' who in turn recruited their female family members. In total, 161 kin keepers and female family members were sampled. Trained CHWs led kin keepers and family members in learning about breast cancer. Data methods included baseline and post-training administration of a breast cancer literacy assessment, post-training focus groups and review of personal action plans. To validate the feasibility of the process, a linear mixed-effects regression with 97% power was identified and differences in pre-post scores were detected at 5% significance level. Adjusting for family random effects, breast cancer literacy scores increased for all participants recruited (P-value = 0.0004) suggesting that the process was feasible. Analysis of focus groups and action plans indicated that participants valued the instruction and planned to act upon it. This experience with kin keepers and their families offers encouragement that the theoretical model and its community-based delivery can continue to enhance scholarship dedicated to ameliorating health care disparities.

The experiences of leaders of self-management courses in Queensland: exploring Health Professional and Peer Leaders' perceptions of working together

This paper describes the experiences of volunteers who have been trained to deliver the Stanford Chronic Disease Self-Management Program course. In Queensland, Australia, Leaders usually work in pairs (a Health Professional Leader (HPL) and a Peer Leader (PL)). Qualitative data were collected to explore volunteers' experiences as Leaders and their opinions about working together to deliver self-management courses. The data were collected from September 2005 to December 2005. In-depth, semistructured telephone interviews were conducted with a purposive sample of 34 Leaders (17 PL, 17 HPLs). Thematic analysis revealed two core themes that described Leaders' perceptions and experiences of working relationships between HPLs and PLs: (i) The Value of Working Together and (2) Relationship Tensions. Both HPLs and PLs believed that working together represented 'the best of both worlds' and that the combination of peers and health professionals enhanced the sustainability of the approach. However, a number of tensions were revealed that undermined the development and sustainability of these working relationships. From HPLs' perspective, the benefits of working with volunteer PLs did not always justify the 'burden'. Finding the 'right person' for the PL role was difficult and a higher value was often placed on the contribution of professionals. The tensions that were most prominent for PLs were grounded in the disparity between their status and that of HPLs, their lack of ownership over courses coupled with lack of a strong voice in the co-Leader relationship, and the absence of connection and engagement among Leaders. Working relationships between HPLs and PLs have potential to deliver positive outcomes for people with chronic disease, but the current study has highlighted the necessity of developing a culture of mutual respect and a system that values both forms of knowledge and expertise (i.e. experiential and professional).