Enabling and sustaining the activities of lay health influencers: lessons from a community-based tobacco cessation intervention study

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.

Engaging Community Networks to Improve Depression Services: A Cluster-Randomized Trial of a Community Engagement and Planning Intervention

This paper explores the effects of a group-randomized controlled trial, Community Partners in Care (CPIC), on the development of interagency networks for collaborative depression care improvement between a community engagement and planning (CEP) intervention and a resources for services (RS) intervention that provided the same content solely via technical assistance to individual programs. Both interventions consisted of a diverse set of service agencies, including health, mental health, substance abuse treatment, social services, and community-trusted organizations such as churches and parks and recreation centers. Participants in the community councils for the CEP intervention reflected a range of agency leaders, staff, and other stakeholders. Network analysis of partnerships among agencies in the CEP versus RS condition, and qualitative analysis of perspectives on interagency network changes from multiple sources, suggested that agencies in the CEP intervention exhibited greater growth in partnership capacity among themselves than did RS agencies. CEP participants also viewed the coalition development intervention both as promoting collaboration in depression services and as a meaningful community capacity building activity. These descriptive results help to identify plausible mechanisms of action for the CPIC interventions and can be used to guide development of future community engagement interventions and evaluations in under-resourced communities.

Results of a Feasibility Study of Helpers Stay Quit Training for Smoking Relapse Prevention

INTRODUCTION

Most smoking quit attempts end in relapse, and interventions focused on relapse prevention are lacking. Helpers Stay Quit (HSQ) is a novel behavioral relapse prevention intervention that teaches newly abstinent smokers to offer a "helping conversation" (HC) to help others quit tobacco.

METHODS

Pre-post intervention feasibility study with state quitline participants ≥14 days abstinent. Measures at baseline, 3 months, and 6 months included smoking status, offering HCs, and cessation self-efficacy. Primary outcomes: self-reported 7-day point prevalence abstinence; offering HCs. Cox models explored association of HCs with relapse. Preliminary effects analysis using propensity score matching compared 30-day abstinence of quitline clients with study sample at 7 months.

RESULTS

Participants (N = 104) were as follows: mean age of 53 years (SD 13.9 years), 48.1% male, mean of cigarettes smoked/day of 16.2 (SD 9.7). Compared with participants who remained abstinent (n = 82), relapsers (n = 22) had fewer HCs over 6 months (2.6 vs 7.2; 95% confidence interval [CI]: 1.4, 7.8, p = .006). Using adjusted Cox regression, the hazard ratio of relapse for each HC was 0.85 (95% CI: 0.74, 0.99, p = .03). Compared with a matched sample of quitline clients not exposed to HSQ, study participants were 49% more likely to report 30-day abstinence at 7-month quitline follow-up (95% CI: 40%, 59%, p < .0001).

CONCLUSIONS

HSQ, delivered to newly abstinent smokers who received standard quitline treatment, was associated with less self-reported relapse. These promising preliminary study results warrant further research to evaluate HSQ as a novel behavioral intervention to prevent smoking relapse.

IMPLICATIONS

To date, behavioral interventions for smoking relapse prevention that teach abstainers cessation skills to apply to themselves have not shown effectiveness. This feasibility study examines the preliminary efficacy of a conceptually novel, "help others" behavioral intervention approach for relapse prevention in newly abstinent smokers recruited from a state quitline. HSQ teaches the newly abstinent smoker communication and listening skills to encourage other smokers in their personal social network to quit. Exploratory analysis using propensity score matching suggests that participants exposed to HSQ were significantly more likely to self-report 30-day abstinence at quitline 7-month follow-up than other quitline clients.

Impact of a tobacco cessation intervention on adherence to tobacco use treatment guidelines among village health workers in Vietnam

Community health workers (in Vietnam referred to as village health workers) have the potential to play a key role in expanding access to evidence-based tobacco use treatment. We conducted a cluster randomized controlled trial in community health centers in Vietnam that compared the effect of provider advice and cessation assistance (i.e. brief counseling and patient education materials) (BC) vs. BC + three sessions of in-person counseling delivered by a village health worker (BC+R) on providers' and village health workers' adherence to tobacco use treatment guidelines. All village health workers and health care providers received training. This paper presents data on the effect of the intervention on village health workers' adherence to tobacco use treatment guidelines, including asking about tobacco use, advising smokers to quit, offering assistance and their attitude, norms, and self-efficacy related to tobacco use treatment. We examined changes in adherence to tobacco use treatment guidelines before and 12 months after the intervention among 89 village health workers working in the 13 community health centers enrolled in the BC+R study condition. Village health workers' adherence to tobacco use treatment guidelines increased significantly. Village health workers were more likely to ask about tobacco use (3.4% at baseline, 32.6% at 12 months), offer advice to quit (4.5% to 48.3%) and offer assistance (1.1% to 38.2%). Perceived barriers to treating tobacco use decreased significantly. Self-efficacy and attitudes towards treating tobacco use improved significantly. Increased adherence to tobacco use treatment guidelines was associated with positive attitudes towards their role in delivering tobacco use treatment and increasing awareness of the community health center smoke-free policy. The findings suggest that, with training and support systems, village health workers can extend their role to include smoking cessation services. This workforce could represent a sustainable resource for supporting smokers who wish to quit.

Social risk, stigma and space: key concepts for understanding HIV vulnerability among black men who have sex with men in New York City

Black men who have sex with men in the USA face disproportionate incidence rates of HIV. This paper presents findings from an ethnographic study conducted in New York City that explored the structural and socio-cultural factors shaping men's sexual relationships with the goal of furthering understandings of their HIV-related vulnerability. Methods included participant observation and in-depth interviews with 31 Black men who have sex with men (three times each) and 17 key informants. We found that HIV vulnerability is perceived as produced through structural inequalities including economic insecurity, housing instability, and stigma and discrimination. The theoretical concepts of social risk, intersectional stigma, and the social production of space are offered as lenses through which to analyse how structural inequalities shape HIV vulnerability. We found that social risk shaped HIV vulnerability by influencing men's decisions in four domains: 1) where to find sexual partners, 2) where to engage in sexual relationships, 3) what kinds of relationships to seek, and 4) whether to carry and to use condoms. Advancing conceptualisations of social risk, we show that intersectional stigma and the social production of space are key processes through which social risk generates HIV vulnerability among Black men who have sex with men.

Printed Educational Materials' Impact on Tobacco Cessation Brief Interventions in CAM Practice: Patient and Practitioner Experiences

Printed educational materials (PEMs) have long demonstrated their usefulness as economical and effective media for health communication. In this article, we evaluate the impact of targeted tobacco cessation PEMS for use along with a brief intervention training designed for three types of complementary and alternative medicine (CAM) practitioners: chiropractic, acupuncture, and massage. We describe how PEMs in CAM practitioners' offices were perceived and used by practitioners and by patients. Semistructured qualitative interviews were conducted with 53 practitioners and 38 of their patients. This analysis specifically focused on developing and distributing project-related posters and pamphlets in CAM practice. Our findings indicate that materials (1) legitimated tobacco-related expertise among CAM practitioners and tobacco-related conversations as part of routine CAM practice, (2) increased practitioners' willingness to approach the topic of tobacco with patients, (3) created an effective way to communicate tobacco-related information and broaden the reach of brief intervention initiatives, and (4) were given to patients who were not willing to engage in direct discussion of tobacco use with practitioners.

Intervention development for integration of conventional tobacco cessation interventions into routine CAM practice

Background

Practitioners of complementary and alternative medicine (CAM) therapies are an important and growing presence in health care systems worldwide. A central question is whether evidence-based behavior change interventions routinely employed in conventional health care could also be integrated into CAM practice to address public health priorities. Essential for successful integration are intervention approaches deemed acceptable and consistent with practice patterns and treatment approaches of different types of CAM practitioners – that is, they have context validity. Intervention development to ensure context validity was integral to Project CAM Reach (CAMR), a project examining the public health potential of tobacco cessation training for chiropractors, acupuncturists and massage therapists (CAM practitioners). This paper describes formative research conducted to achieve this goal.

Methods

Intervention development, undertaken in three CAM disciplines (chiropractic, acupuncture, massage therapy), consisted of six iterative steps: 1) exploratory key informant interviews; 2) local CAM practitioner community survey; 3) existing tobacco cessation curriculum demonstration with CAM practitioners; 4) adapting/tailoring of existing curriculum; 5) external review of adaptations; 6) delivery of tailored curriculum to CAM practitioners with follow-up curriculum evaluation.

Results

CAM practitioners identified barriers and facilitators to addressing tobacco use with patients/clients and saw the relevance and acceptability of the intervention content. The intervention development process was attentive to their real world intervention concerns. Extensive intervention tailoring to the context of each CAM discipline was found unnecessary. Participants and advisors from all CAM disciplines embraced training content, deeming it to have broad relevance and application across the three CAM disciplines. All findings informed the final intervention.

Conclusions

The participatory and iterative formative research process yielded an intervention with context validity in real-world CAM practices as it: 1) is patient/client-centered, emphasizing the practitioner’s role in a healing relationship; 2) is responsive to the different contexts of CAM practitioners’ work and patient/client relationships; 3) integrates relevant best practices from US Public Health Service Clinical Practice Guidelines on treating tobacco dependence; and 4) is suited to the range of healing philosophies, scopes of practice and practice patterns found in participating CAM practitioners. The full CAMR study to evaluate the impact of the CAMR intervention on CAM practitioners’ clinical behavior is underway.

Tobacco brief intervention training for chiropractic, acupuncture, and massage practitioners: protocol for the CAM reach study

BACKGROUND

Tobacco use remains the leading cause of morbidity and mortality in the US. Effective tobacco cessation aids are widely available, yet underutilized. Tobacco cessation brief interventions (BIs) increase quit rates. However, BI training has focused on conventional medical providers, overlooking other health practitioners with regular contact with tobacco users. The 2007 National Health Interview Survey found that approximately 20% of those who use provider-based complementary and alternative medicine (CAM) are tobacco users. Thus, CAM practitioners potentially represent a large, untapped community resource for promoting tobacco cessation and use of effective cessation aids. Existing BI training is not well suited for CAM practitioners' background and practice patterns, because it assumes a conventional biomedical foundation of knowledge and philosophical approaches to health, healing and the patient-practitioner relationship. There is a pressing need to develop and test the effectiveness of BI training that is both grounded in Public Health Service (PHS) Guidelines for tobacco dependence treatment and that is relevant and appropriate for CAM practitioners.

METHODS/DESIGN

The CAM Reach (CAMR) intervention is a tobacco cessation BI training and office system intervention tailored specifically for chiropractors, acupuncturists and massage therapists. The CAMR study utilizes a single group one-way crossover design to examine the CAMR intervention's impact on CAM practitioners' tobacco-related practice behaviors. Primary outcomes included CAM practitioners' self-reported conduct of tobacco use screening and BIs. Secondary outcomes include tobacco using patients' readiness to quit, quit attempts, use of guideline-based treatments, and quit rates and also non-tobacco-using patients' actions to help someone else quit.

DISCUSSION

CAM practitioners provide care to significant numbers of tobacco users. Their practice patterns and philosophical approaches to health and healing are well suited for providing BIs. The CAMR study is examining the impact of the CAMR intervention on practitioners' tobacco-related practice behaviors, CAM patient behaviors, and documenting factors important to the conduct of practice-based research in real-world CAM practices.

Works of Illness and the Challenges of Social Risk and the Specter of Pain in the Lived Experience of TMD

Temporomandibular Disorders (TMD) represent a particular form of chronic pain that, while not outwardly debilitating, profoundly impacts interactions as fundamental to human existence as smiling, laughing, speaking, eating, and intimacy. Our analysis, informed by an expanded "works of illness" assessment, draws attention to work surrounding social and physical risk. We refer to these as the work of stoicism and the work of vigilance and identify double binds created in contexts that call for both. Conflicting authorial stances in informants' narratives are shown to be essential in maintaining a positive identity in the face of illness. While earlier ethnographic studies report TMD sufferers' experience of stigma and search for diagnosis and legitimacy, we present a group of individuals who have accepted diagnosis at face value and soldier through pain as a fundamental aspect of their identity.

Activating lay health influencers to promote tobacco cessation

OBJECTIVE

To evaluate the effect of tobacco cessation brief-intervention (BI) training for lay "health influencers," on knowledge, self-efficacy and the proportion of participants reporting BI delivery post-training.

METHODS

Randomized, community-based study comparing In-person or Web-based training, with mailed materials.

RESULTS

In-person and Web-training groups had significant post-training cessation knowledge and self-efficacy gains. All groups increased the proportion of individuals reporting BIs at follow-up, with no significant between-group differences. Irrespective of participants' prior intervention experience, 80%-86% reported BIs within the past 90 days; 71%-79% reported >1 in the past 30.

CONCLUSIONS

Web and In-person training significantly increase health influencer cessation knowledge and self-efficacy. With minimal prompting and materials, even persons without BI experience can be activated to encourage tobacco cessation.

A social-media based HIV prevention intervention using peer leaders

This study seeks to investigate qualities of peer leaders in a social media-based peer-led HIV intervention. African American and Latino men who have sex with men (MSM) peer leaders were recruited through online/offline methods. They were required to have experience with health communication and social media. Over 57% of reported using social networking for seeking sex partners within 3 months. Over 53% spent over 3 hours per week online and about 53% of peer leaders had fewer than 200 Facebook friends. Results suggest that peer leaders can be recruited for social media-based health interventions. Qualities of peer leaders are discussed.

Sustainability of promotora initiatives: program planners' perspectives

The use of promotoras de salud is an increasingly widespread delivery approach for community-based health education and promotion programs targeting obesity-related lifestyle behaviors for Hispanic populations. Addressing a gap in the literature, this research examined the sustainability of promotora-led initiatives from the perspectives of those who plan, implement, and evaluate these programs. We conducted 24 in-depth interviews with program planners representing 22 promotora programs focused on Hispanic women's health in 10 states. Findings illustrated program planners' opinions regarding the components, logistics, and barriers to promotora program sustainability. Several participants challenged the notion of promotora program sustainability by reframing the issue as promoting individual promotoras' well-being and social mobility rather than maintaining their role in the program over time. Implications for community health planning, management, and policy include developing sustainability strategies during program planning stages and implementation of policies to more effectively integrate promotoras into existing health care systems at local, state, and national levels.

Feasibility of recruiting peer educators for an online social networking-based health intervention

OBJECTIVE

This study aims to determine the feasibility of recruiting peer leaders to deliver a community-based health intervention using social media.

METHOD

We recruited sixteen African American and Latino men who have sex with men (MSM) as peer leaders for either an HIV prevention or general health intervention using social media. Inclusion criteria required that peer leaders were African American or Latino MSM health communication experts experienced using social media. To receive certification, peer leaders attended 3 training sessions on using social media for public health. Questionnaires asking about health knowledge and comfort using social media to discuss health-related topics were provided at baseline and post-training to ensure that peer leaders were qualified post-training. Repeated measures ANOVA models and χ2 tests tested for differences in peer leader knowledge and comfort using social media pre- and post-training.

RESULTS

After training, peer leaders were significantly more comfortable using social media to discuss sexual positions. There were no significant differences pre- and post-training on other comfort or knowledge measures, as at baseline, almost all peer leaders were already comfortable using social media.

CONCLUSION

Results suggest that peer leaders can be recruited who are qualified to conduct health interventions without needing additional training. The discussed training plan can further ensure that any unqualified peer leaders will be prepared after training. To our knowledge, this is the first study to suggest that peer leaders can be recruited as peer health educators to communicate using social media.

Research priorities for Article 14--demand reduction measures concerning tobacco dependence and cessation

INTRODUCTION

Tobacco dependence treatment (TDT) interventions are often seen as expensive with little impact on the prevalence of tobacco use. However, activities that promote the cessation of tobacco use and support abstinence have an important role in any comprehensive tobacco control program and as such are recognized within Article 14 (A14) of the Framework Convention on Tobacco Control.

OBJECTIVES

To review current evidence for TDT and recommend research priorities that will contribute to more people being helped to stop tobacco use.

METHODS

We used the recommendations within the A14 guidelines to guide a review of current evidence and best practice for promotion of tobacco cessation and TDT, identify gaps, and propose research priorities.

RESULTS

We identified nine areas for future research (a) understanding current tobacco use and the effect of policy on behavior, (b) promoting cessation of tobacco use, (c) implementation of TDT guidelines, (d) increasing training capacity, (e) enhancing population-based TDT interventions, (f) treatment for different types of tobacco use, (g) supply of low-cost pharmaceutical devices/ products, (h) investigation use of nonpharmaceutical devices/ products, and (i) refinement of current TDTs. Specific research topics are suggested within each of these areas and recognize the differences needed between high- and low-/middle-income countries.

CONCLUSIONS

Research should be prioritized toward examining interventions that (a) promote cessation of tobacco use, (b) assist health care workers provide better help to smokers (e.g., through implementation of guidelines and training), (c) enhance population-based TDT interventions, and (d) assist people to cease the use of other tobacco products.

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

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

Lay health influencers: how they tailor brief tobacco cessation interventions

Interventions tailored to individual smoker characteristics have increasingly received attention in the tobacco control literature. The majority of tailored interventions are generated by computers and administered with printed materials or web-based programs. The purpose of this study was to examine the tailoring activities of community lay health influencers who were trained to perform face-to-face brief tobacco cessation interventions. Eighty participants of a large-scale, randomized controlled trial completed a 6-week qualitative follow-up interview. A majority of participants (86%) reported that they made adjustments in their intervention behaviors based on individual smoker characteristics, their relationship with the smoker, and/or setting. Situational contexts (i.e., location and timing) primarily played a role after targeted smokers were selected. The findings suggest that lay health influencers benefit from a training curriculum that emphasizes a motivational, person-centered approach to brief cessation interventions. Recommendations for future tobacco cessation intervention trainings are presented.

Second-hand smoke exposure and mitigation strategies among home visitation workers

OBJECTIVES

Protection of workers from second-hand smoke (SHS) in occupational settings is an important policy priority, yet little attention has been given to SHS protection for home visitation health workers, who number almost 2 million in the USA. Self-reported SHS exposure, SHS mitigation strategies and suggestions for further SHS exposure reduction approaches were obtained from home visitation health workers in Massachusetts.

METHODS

A cross-sectional survey was conducted among Massachusetts Early Intervention workers (N=316) at their state-wide conference in April 2010.

RESULTS

Eighty-three per cent of respondents reported at least 1 hour per month of SHS exposure, and 16% reported at least 11 hours per month. Nevertheless, only 22% of workers counselled clients on maintaining a smoke-free home. Fewer than 30% of workers had ever voiced concerns to their employing agency, and just 12% had raised their concerns directly with clients. Only 14% stated that their agency had rules designed to protect workers from SHS.

CONCLUSIONS

SHS exposure occurs frequently among home visitation health workers. The data point to a substantial population who are not protected from SHS exposure by formal policies.

Tobacco

Anthropologists have long studied tobacco, what is today the world's greatest cause of preventable death. Their publications have garnered modest attention, however, even as the academy is increasingly interested in global health, transnational commoditization, pharmaceuticals, and the politics of life and death. We take stock of anthropology's tobacco literature and our discipline's broader appetites. We review how colleagues have studied health issues related to tobacco and engaged with theory and policy pertaining to the production, consumption, and regulation of drugs. We assess ways scholars working at the interface of anthropology and cigarettes have analyzed gender and ethnicity, corporate predation and industry-related harm, governmental management of disease, and the semiotics of misinformation. We discuss why anthropology has not more broadly and ardently engaged the study of tobacco. And we identify areas for further research capable of illuminating more fully tobacco's analytical potential and toxic effects.

Developing a smoke free household initiative: an Indonesian case study

Little research has focused on women's exposure to secondhand smoke (SHS) in LMICs, local perceptions of SHS risk to women and children, and women's attempts to limit exposure to tobacco smoke in their households. This paper describes a community based survey in Indonesia that investigated these issues as one step in a movement to initiate community wide household smoking bans. The survey found high levels of exposure to SHS, high levels of awareness among both women and men that SHS placed women and children at risk for illness, a very low percentage of households having indoor smoking rules, great interest on the part of women to participate in a communitywide ban, and a promising level of male smoker agreement to comply with such a ban. Women expressed a low sense of self efficacy in individually getting their husbands to quit smoking in their homes, but a strong sense of collective efficacy that husbands might agree to a well-publicized and agreed-upon community household smoking ban. Men and women expressed concern about the social risk of asking guests not to smoke in their homes without a communitywide ban and visible displays communicating their participation in this movement. The smoke free initiative described requires the participation of doctors in community education programs, and is attempting to introduce household smoking bans as a way of turning tobacco control into a family health and not just a smokers' health issue.