"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.

Change agents in the oncology workforce: Let's be clear about community health workers and patient navigators

Despite efforts of professional organizations and government agencies to solidify the professional identities of community health workers and patient navigators in the oncology workforce, the scientific literature perpetuates wide variation in the nomenclature used to define these natural change agents, who have proven efficacy in improving access to quality cancer care for historically marginalized populations. To disseminate, sustain, and scale-up these life-saving roles in cancer care, the oncology field must come together now to adopt clear and consistent job titles and occupational identities.

A Novel Approach to Improve Health Literacy in Immigrant Communities

Background

Anchorage, Alaska, has a large immigrant and refugee population. In fact, it is one of the most ethnically diverse cities in the United States with almost 100 languages spoken by children in the public school system. The city's immigrant and refugee population speaks limited English, and most of these residents are unfamiliar with where or how to obtain health care services through the American health care system.

Brief Description of Activity

We developed a peer language navigator (PLN) program.

Implementation

The Anchorage Health Literacy Collaborative developed a community-wide program to address the health literacy needs of the city's immigrant and refugee population. Select people who attended Anchorage's adult literacy program (the Alaska Literacy Program) were chosen to learn about health and wellness topics as well as how to obtain health information from reliable online sources. These people, initially known as PLNs, were then trained to share health information resources with their respective communities.

Results

A recent evaluation of the program using ripple effects mapping showed that the program has demonstrated wide success, providing understandable health information to hundreds of new English learners throughout the area and guiding them to reliable health and wellness information they can use for themselves, their families, and their community. PLNs have become leaders in their communities and have been renamed peer leader navigators.

Lessons Learned

For similar programs to be successful, PLNs should be trained using adult learning principles, allowing them to focus on topics and issues of interest to them. The program should link with community organizations to extend the reach of the program. Care must be exercised to avoid overextending or overwhelming PLNs because after they become leaders in their communities, they will receive many requests to provide guidance and education. Finally, when possible, PLNs should be compensated so they can more fully devote their efforts to serving the community. [HLRP: Health Literacy Research and Practice. 2019;3(Suppl.):S15-S24.].

Plain Language Summary

The Anchorage Health Literacy Collaborative in Alaska developed a program in which immigrant and refugees attending the city's adult education program to learn beginning English are chosen to serve as peer language navigators (PLNs). The PLNs learn how to obtain credible and easy-to-understand health information and then share it with their respective cultural communities. Lessons learned over time are shared.

Factors associated with the implementation of community-based peer-led health promotion programs: A scoping review

Peer education is growing in popularity as a useful health promotion strategy. However, optimal conditions for implementing peer-led health promotion programs (HPPs) remain unclear. This scoping review aimed to describe factors that can influence implementation of peer-led HPPs targeting adult populations. Five databases were searched using the keywords "health promotion/prevention", "implementation", "peers", and related terms. Studies were included if they reported at least one factor associated with the implementation of community-based peer-led HPPs. Fifty-five studies were selected for the analysis. The method known as "best fit framework synthesis" was used to analyze the factors identified in the selected papers. Many factors included in existing implementation conceptual frameworks were deemed applicable to peer-led HPPs. However, other factors related to individuals, programs, and implementation context also emerged from the analysis. Based on this synthesis, an adapted theoretical framework was elaborated, grounded in a complex adaptive system perspective and specifying potential mechanisms through which factors may influence implementation of community-based peer-led HPPs. Further research is needed to test the theoretical framework against empirical data. Findings from this scoping review increase our knowledge of the optimal conditions for implementing peer-led HPPs and thereby maximizing the benefits of such programs.

Taking the Transtheoretical Model Into the Field: A Curriculum for Lay Health Advisors

The transtheoretical model (TTM) is a commonly applied theoretical perspective for understanding mammography behaviors and improving the effectiveness of one-on-one counseling. The North Carolina Breast Cancer Screening Program (NC-BCSP) developed a training curriculum to incorporate TTM into the advising practices of lay health advisors (LHAs). The TTM helped “natural helper” LHAs understand that women in their rural North Carolina communities were likely to be in different stages for mammography screening and hence required different messages. NC-BCSP staff believed that by combining an understanding of TTM with LHAs’ natural helping abilities we potentially increased the effectiveness of LHA advising. Our limited evaluation, based on LHA feedback, suggests the curriculum is a useful training tool, even for those unfamiliar with behavior change models. Our TTM curriculum serves as an example of a health behavior theory successfully operationalized outside academia for use in the field by lay people.

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.

Reflecting on the tensions faced by a community-based multicultural health navigator service

The community navigator model was developed to assist four culturally and linguistically diverse communities (Sudanese, Burmese, Pacific Islander Group, Afghani) in south-east Queensland to negotiate the Australian health system and promote health. Using participatory action research, we developed the model in partnership with community leaders and members, the local health department and two non-governmental organisations. Following implementation, we evaluated the model, with the results published elsewhere. However, our evaluation revealed that although the model was accepted by the communities and was associated with positive health outcomes, the financial, social and organisational durability of the model was problematic. Ironically, this situation was inadvertently created by critical decisions made during the development process to enhance the durability and acceptability of the model. This paper explores these critical decisions, our rationale for making those decisions and the four hidden tensions that subsequently emerged. Using a reflective case study method to guide our analysis, we provide possible resolutions to these tensions that may promote the longevity and utility of similar models in the future. What is known about the topic? The use of community navigators to assist culturally diverse communities to access health services is not new. Many benefits have been documented for communities, individuals and heath service providers following the use of such models. What is not well documented is how to maintain these models in a safe and cost-effective way within the Australian health system while respecting cultural and community practices and reducing the burden of service delivery on the navigators. What does this paper add? This paper provides a perspective on how the development of community-based service models inherently places them in a position of tension that must be resolved if they are to be long lasting. Four core tensions experienced during the development and implementation of our model in south-east Queensland are explored to develop potential resolutions. What are the implications for practice? Reducing the tensions inherent in culturally appropriate community-based service models will increase the durability of the approach. By addressing these tensions, we can create a more durable pool of community navigators that can facilitate community empowerment, self-governance of health issues and a sense of community ownership of health services.

Families of choice and noncollegiate sororities and fraternities among lesbian and bisexual African-American women in a southern community: implications for sexual and reproductive health research

Background Self-identified lesbian and bisexual African-American women living in the southern United States are a relatively hidden subpopulation within the lesbian, gay, bisexual and transgender (LGBT) community. Existing research suggests that African-American lesbian and bisexual women are at high risk for sexually transmissible infections (STIs), but the sexual and reproductive health needs of this population are just beginning to be understood.

METHODS

We conducted four focus groups and five individual interviews with 24 lesbian and bisexual African-American women living in the Jackson, Mississippi, metropolitan area, recruited through the local STI clinic and through word of mouth. We aimed to characterise the role of two types of social organisations (lesbian families and noncollegiate lesbian sororities and fraternities) among the local LGBT community, and their influence on the sexual health of their members.

RESULTS

Both types of social organisations serve positive functions for their members. Lesbian families provide support and stability; this appears beneficial for younger individuals, who may lack support from biological families. Lesbian sororities and fraternities are visible due to their emphasis on community service, and offer a strong sense of solidarity and belonging. In both organisation types, discussions about sex were common, although members acknowledged a lack of information regarding safer sex among lesbian and bisexual women.

CONCLUSIONS

Existing social organisations within the LGBT community, such as lesbian families and lesbian sororities and fraternities, should be incorporated into community-based popular opinion leader or lay heath advisor interventions in an effort to meet the sexual and reproductive health needs of marginalised populations.

Dimensions of lay health worker programmes: results of a scoping study and production of a descriptive framework

BACKGROUND

Approaches that engage and support lay health workers in the delivery of health improvement activities have been widely applied across different health issues and populations. The lack of a common terminology, inconsistency in the use of role descriptors and poor indexing of lay health worker roles are all barriers to the development of a shared evidence base for lay health worker interventions.

OBJECTIVES

The aim of the paper is to report results from a scoping study of approaches to involve lay people in public health roles and to present a framework for categorisation of the different dimensions of lay health worker programmes.

METHODS

Our scoping study comprised a systematic scoping review to map the literature on lay health worker interventions and to identify role dimensions and common models. The review, which was limited to interventions relevant to UK public health priorities, covered a total of 224 publications. The scoping study also drew on experiential evidence from UK practice.

RESULTS

Research-based and practice-based evidence confirmed the variety of role descriptors in use and the complexity of role dimensions. Five common models that define the primary role of the lay health worker were identified from the literature. A framework was later developed that grouped features of lay health worker programmes into four dimensions: intervention, role, professional support/service and the community.

DISCUSSION AND CONCLUSION

More account needs to be taken of the variations that occur between lay health worker programmes. This framework, with the mapping of key categories of difference, may enable better description of lay health worker programmes, which will in turn assist in building a shared evidence base. More research is needed to examine the transferability of the framework within different contexts.

Program planners' perspectives of promotora roles, recruitment, and selection

OBJECTIVE

Program planners work with promotoras (the Spanish term for female community health workers) to reduce health disparities among underserved populations. Based on the Role-Outcomes Linkage Evaluation Model for Community Health Workers (ROLES) conceptual model, we explored how program planners conceptualized the promotora role and the approaches and strategies they used to recruit, select, and sustain promotoras.

DESIGN

We conducted semi-structured, in-depth interviews with a purposive convenience sample of 24 program planners, program coordinators, promotora recruiters, research principal investigators, and other individuals who worked closely with promotoras on United States-based health programs for Hispanic women (ages 18 and older).

RESULTS

Planners conceptualized the promotora role based on their personal experiences and their understanding of the underlying philosophical tenets of the promotora approach. Recruitment and selection methods reflected planners' conceptualizations and experiences of promotoras as paid staff or volunteers. Participants described a variety of program planning and implementation methods. They focused on sustainability of the programs, the intended health behavior changes or activities, and the individual promotoras.

CONCLUSION

To strengthen health programs employing the promotora delivery model, job descriptions should delineate role expectations and boundaries and better guide promotora evaluations. We suggest including additional components such as information on funding sources, program type and delivery, and sustainability outcomes to enhance the ROLES conceptual model. The expanded model can be used to guide program planners in the planning, implementing, and evaluating of promotora health programs.

'Community navigators': making a difference by promoting health in culturally and linguistically diverse (CALD) communities in Logan, Queensland

A key component of the 2011 Australian National Health Reform, via the Access and Equity Policy, is to improve access to quality health services for all Australians including CALD communities. Awareness has been raised that certain CALD communities in Australia experience limited access to health care and services, resulting in poor health outcomes. To address this issue, the Community Navigator Model was developed and implemented in four CALD communities in Logan, Queensland, through a partnership between government and non-government organisations. The model draws on local natural leaders selected by community members who then act as a conduit between the community and health service providers. Nine 'navigators' were selected from communities with low service access including the Sudanese, Burmese, Afghan and Pacific Islander communities. The navigators were trained and employed at one of two local non-government organisations. The navigators' role included assessing client needs, facilitating health promotion, supporting community members to access health services, supporting general practitioners (GPs) to use interpreters and making referrals to health services. This paper explores the 'lived experience' of the navigators using a phenomenological approach. The findings revealed three common themes, namely: (1) commitment to an altruistic attitude of servility allowing limitless community access to their services; (2) becoming knowledge brokers, with a focus on the social determinants of health; and (3) 'walking the walk' to build capacity and achieving health outcomes for the community. These themes revealed the extent to which the role of CALD community navigators has the potential to make a difference to health equity in these communities, thus contributing to the Australian National Health Reform.

The effectiveness of culturally appropriate interventions to manage or prevent chronic disease in culturally and linguistically diverse communities: a systematic literature review

Culturally and linguistically diverse (CALD) communities in Australia experience both significant health disparities and a lack of access to services. Consequently, there have been calls for culturally appropriate services for people with chronic disease in CALD populations. This paper presents a systematic review of the literature on the effectiveness of culturally appropriate interventions to manage or prevent chronic disease in CALD communities. Evidence was sought from randomized controlled trials and controlled studies that examined strategies for promoting cultural competence in health service delivery to CALD communities. The outcomes examined included changes in consumer health behaviours, utilisation/satisfaction with the service, and the cultural competence of health-care providers. Of the 202 studies that were identified only 24 met the inclusion criteria. The five categories of intervention that were identified included: (1) the use of community-based bi-lingual health workers; (2) providing cultural competency training for health workers; (3) using interpreter service for CALD people; (4) using multimedia and culturally sensitive videos to promote health for CALD people and (5) establishing community point-of-care services for CALD people with chronic disease. The review supported the use of trained bi-lingual health workers, who are culturally competent, as a major consideration in the development of an appropriate health service model for CALD communities.

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.

Culturally and linguistically diverse peoples' knowledge of accessibility and utilisation of health services: exploring the need for improvement in health service delivery

With 28% of Australia’s population having a culturally and linguistically diverse (CALD) background, the health system faces an increasing challenge to provide accessible and culturally competent health care. The view that all CALD communities are homogenous and solutions can be developed for the entire nation is detrimental. Despite available health services, CALD communities are reluctant to use them due to cultural differences, perceived racism and misunderstandings leading to the existing health disparities. Therefore, gathering data from four prominent CALD communities, such as the Sudanese, Afghani, Pacific Islander and Burmese communities in Logan, Queensland, about how they perceive and use health services can provide insightful information towards development of a service model that will better suit these CALD communities. The objective of the study was to examine the extent to which four prominent CALD communities (Sudanese, Afghani, Pacific Islander and Burmese) access and use health services in Logan, Queensland. Six focus group interviews using interpreters were conducted in English with Sudanese, Afghani, Pacific Islander and Burmese people. The results indicated that even long-standing CALD communities, such as the Pacific Islander people, were unfamiliar with health services and experienced difficulties accessing appropriate health care. Most wanted doctors to use traditional healing methods alongside orthodox medicine, but did not feel respected for their beliefs. Language difficulties impeded communication with health professionals who were hindered by ineffective use of interpreters. In conclusion, a clear role for bilingual community-based navigators was identified by CALD participants to address concerns about the health system, and to improve accessibility and health service usage.

What do women gain from volunteering? The experience of lay Arab and Jewish women volunteers in the Women for Women's Health programme in Israel

Ambiguous feelings regarding women engaging in formal volunteering and concerns about their exploitation might explain the dearth of studies regarding the volunteering benefits specifically experienced by low socioeconomic status women. The current study examined benefits of volunteering among women participating in Women for Women's Health (WWH), a lay health volunteers (LHV) programme implemented in Jewish and Arab communities in Israel, and aiming at empowering such women to become active volunteers and promote health activities in their communities. Two years after the introduction of WWH in each community, all 45 Jewish and 25 Arab volunteers were contacted by phone and invited to participate in the focus group discussions. Five focus group discussions were conducted with 25/42 Jewish volunteers in 2003 and four with 20/25 Arab volunteers in 2005. The other volunteers could not attend the scheduled meetings or became inactive for personal reasons. Four benefit categories were identified in both ethnic groups: 1. Personal benefits of having increased knowledge, feeling self-satisfaction, mastering new skills and performing healthy behaviours; 2. Group-social benefits of social support and sense of cohesion; 3. Purposive benefits of achieving the WWH mission and goals; 4. Sociopolitical benefits of learning to accept the other and experiencing increased solidarity. However, the relatively less privileged Arab volunteers enumerated more benefits within the personal and purposive categories. They also identified the unique sociocultural category of improving women's status in the community by creating a legitimate space for women by public sphere involvement, traditionally solely a male domain. We conclude that volunteering in community-based health promotion programmes can be an empowering experience for lay women without being exploitative. Positive volunteering benefits will be even more discernable among underprivileged women who enjoy fewer opportunities in the personal and public domains. More studies need to explore volunteering benefits as reported by LHVs, making these benefits more visible and desirable.

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).

Overcoming barriers to cancer care through health navigation programs

OBJECTIVES

To provide an overview of theoretical concepts in community-based, culturally tailored health navigation programs that have improved access to health care for ethnic minority populations, particularly for Asian Americans and Pacific Islanders.

DATA SOURCES

Published articles, reports, book chapters, government documents, research findings.

CONCLUSION

Community-based patient navigation interventions provide promising strategies for providing culturally tailored programs that are more likely to succeed in eliminating cancer disparities in screening and early detection of cancers for diverse cultural communities.

IMPLICATIONS FOR NURSING PRACTICE

Nurses need to be more involved in developing and delivering effective, culturally competent community-based cancer screening and treatment navigation programs through education, practice, research, and policy improvement.

A cervical cancer community-based participatory research project in a Native American community

The Messengers for Health on the Apsáalooke Reservation project uses a community-based participatory research (CBPR) approach and lay health advisors (LHAs) to generate knowledge and awareness about cervical cancer prevention among community members in a culturally competent manner. Northern Plains Native Americans, of whom Apsáalooke women are a part, continue to be disproportionately affected by cervical cancer. This article examines quantitative and qualitative changes that occurred in the community since the inception of the Messengers for Health program. Paired sample t tests are used to evaluate the one-group pretest and posttest interviews of 83 Apsáalooke women in knowledge, comfort, and cancer awareness levels. Results reveal cervical cancer knowledge gains, gains in participants' comfort discussing cancer issues, and gains in awareness of cervical cancer and the Messengers program. Field notes, meeting minutes, and community perceptions are used to qualitatively evaluate the effectiveness of the Messengers program. Practice implications are discussed.

Health intervention in social context: understanding social networks and neighbourhood

Recruiting lay people from the neighbourhoods of target communities as Community Health Educators (CHEs) is an increasingly popular strategy for health interventions in the UK. CHEs are assumed to have a distinct advantage in reaching 'difficult to reach' groups by virtue of their network membership. However, results obtained from a recent intervention study [Chiu (2002). Straight talking: Communicating breast screening information in primary care. Leeds: Nuffield Institute for Health, University of Leeds] raised concerns about the much-asserted efficacy of networks and suggested that neighbourhood was a contextual factor that would potentially affect the results of health interventions. In addition, it suggested that the concept of social networks and other related concepts i.e. 'social embeddedness', 'social capital', and 'neighbourhoods' that underpin CHE interventions needed to be better understood. In order to examine these concepts in relation to CHE interventions, we conducted a pilot study involving 53 CHEs (26 White, 27 Black and Minority Ethnic) in seven health organisations across the UK. The CHEs took part in focus group interviews to explore their perceptions of social networks and neighbourhood. Quantitative information on their personal networks was also mapped using three proformas. This paper explores CHEs' networks with a specific focus on the concept of 'social embeddedness' and the effect of neighbourhood. Implications of these findings on the effectiveness of intervention are discussed.

Lessons learned from community-based cancer screening intervention research

Behaviors associated with cancer screening have been the focus of intensive research over the past 2 decades, primarily in the form of intervention trials to improve screening based in both clinical and community settings. Meta-analyses and literature reviews have synthesized and organized the resulting literature. From the accumulated work, this review distilled lessons learned from cancer screening intervention research in community settings. The authors posed the question, "What do we know about the development of effective community-based interventions (the level of good over harm achieved in real-world conditions)?" Framed around the concept of focal points (the simultaneous combination of target population, behavioral objective, and setting for an intervention), 13 lessons were derived. One lesson was cross-cutting, and the other lessons addressed the three focal-point components and the major intervention categories (access-enhancing strategies, mass media, small media, one-on-one and small-group education, and combinations of these categories). To build more systematically on existing research, recommendations are made for new directions in basic behavioral and intervention research.