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

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Translational Behavioral Medicine

Abstract

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.

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References

  1. Neta, G., Sanchez, M. A., Chambers, D. A., et al. (2015). Implementation science in cancer prevention and control: a decade of grant funding by the National Cancer Institute and future directions. Implementation Science, 10(1), 4.

    Article  PubMed  PubMed Central  Google Scholar 

  2. Glasgow, R. E., Vinson, C., Chambers, D., Khoury, M. J., Kaplan, R. M., & Hunter, C. (2012). National Institutes of Health approaches to dissemination and implementation science: current and future directions. American Journal of Public Health., 102(7), 1274–1281.

    Article  PubMed  PubMed Central  Google Scholar 

  3. America IoMCoQoHCi 2001. Crossing the quality chasm: a new health system for the 21st century. National Academy Press.

  4. Brownson RC, Colditz GA, Proctor EK. (2012). Dissemination and implementation research in health: translating science to practice. Oxford University Press.

  5. Proctor, E., Luke, D., Calhoun, A., et al. (2015). Sustainability of evidence-based healthcare: research agenda, methodological advances, and infrastructure support. Implementation Science, 10, 88.

    Article  PubMed  PubMed Central  Google Scholar 

  6. Scheirer, M. A., & Dearing, J. W. (2011). An agenda for research on the sustainability of public health programs. American Journal of Public Health., 101(11), 2059.

    Article  PubMed  PubMed Central  Google Scholar 

  7. Scheirer, M. A. (2005). Is sustainability possible? A review and commentary on empirical studies of program sustainability. American Journal of Evaluation., 26(3), 320–347.

    Article  Google Scholar 

  8. Whelan, J., Love, P., Pettman, T., et al. (2014). Cochrane update: predicting sustainability of intervention effects in public health evidence: identifying key elements to provide guidance. Journal of Public Health., 36(2), 347–351.

    Article  PubMed  Google Scholar 

  9. Bovbjerg, R. R., Eyster, L., Ormond, B. A., Anderson, T., & Richardson, E. (2013). The evolution, expansion, and effectiveness of community health workers. Washington, DC: The Urban Institute.

    Google Scholar 

  10. Goodwin K, Tobler L. (2008). Community Health Workers: Expanding the Scope of the Health Care Delivery System. National Conference of State Legislatures. Available from: http://www.ncsl.org/print/health/chwbrief.pdf. 1:2.

  11. Shediac-Rizkallah, M. C., & Bone, L. R. (1998). Planning for the sustainability of community-based health programs: conceptual frameworks and future directions for research, practice and policy. Health education research., 13(1), 87–108.

    Article  CAS  PubMed  Google Scholar 

  12. Tibbits, M. K., Bumbarger, B. K., Kyler, S. J., & Perkins, D. F. (2010). Sustaining evidence-based interventions under real-world conditions: results from a large-scale diffusion project. Prevention Science, 11(3), 252–262.

    Article  PubMed  PubMed Central  Google Scholar 

  13. Fagen MC, Flay BR. (2006). Sustaining a school-based prevention program: Results from the Aban Aya sustainability project. Health Education & Behavior.

  14. Cooper, B. R., Bumbarger, B. K., & Moore, J. E. (2013). Sustaining evidence-based prevention programs: correlates in a large-scale dissemination initiative. Prevention Science, 16(1), 145–157.

    Article  Google Scholar 

  15. Palinkas, L. A., Chavarin, C. V., Rafful, C. M., et al. (2015). Sustainability of evidence-based practices for HIV prevention among female sex workers in Mexico. PloS One, 10(10), e0141508.

    Article  PubMed  PubMed Central  Google Scholar 

  16. Paine-Andrews, A., Fisher, J. L., Campuzano, M. K., Fawcett, S. B., & Berkley-Patton, J. (2000). Promoting sustainability of community health initiatives: an empirical case study. Health Promotion Practice, 1(3), 248–258.

    Article  Google Scholar 

  17. Johnson, K., Hays, C., Center, H., & Daley, C. (2004). Building capacity and sustainable prevention innovations: a sustainability planning model. Evaluation and Program Planning., 27(2), 135–149.

    Article  CAS  Google Scholar 

  18. Tabak RG, Duggan K, Smith C, Aisaka K, Moreland-Russell S, Brownson RC. (2015). Assessing capacity for sustainability of effective programs and policies in local health departments. Journal of public health management and practice: JPHMP.

  19. Aarons, G. A., Green, A. E., Willging, C. E., et al. (2014). Mixed-method study of a conceptual model of evidence-based intervention sustainment across multiple public-sector service settings. Implementation Science, 9(1), 183.

    Article  PubMed  PubMed Central  Google Scholar 

  20. Hunter, S. B., Han, B., Slaughter, M. E., Godley, S. H., & Garner, B. R. (2015). Associations between implementation characteristics and evidence-based practice sustainment: a study of the adolescent community reinforcement approach. Implementation Science, 10(1), 173.

    Article  PubMed  PubMed Central  Google Scholar 

  21. Peterson, A. E., Bond, G. R., Drake, R. E., McHugo, G. J., Jones, A. M., & Williams, J. R. (2014). Predicting the long-term sustainability of evidence-based practices in mental health care: an 8-year longitudinal analysis. The journal of behavioral health services & research., 41(3), 337–346.

    Article  Google Scholar 

  22. Fisher, E. B., Coufal, M. M., Parada, H., et al. Peer support in health care and prevention. Cultural, organizational, and dissemination issues, 352014, 363–383.

  23. Earp, J. A. L., Viadro, C. I., Vincus, A. A., et al. (1997). Lay health advisors: a strategy for getting the word out about breast cancer. Health Education & Behavior., 24(4), 432–451.

    Article  CAS  Google Scholar 

  24. Eng, E., & Parker, E. (2002). Natural helper models to enhance a community’s health and competence. In R. J. Diclemente, R. A. Crosby, & M. C. Kegler (Eds.), Emerging theories in health promotion practice and research: strategies for improving public health (pp. 126–156). San Francisco: Jossey-Bass.

    Google Scholar 

  25. Eng, E., Parker, E., & Harlan, C. (1997). Lay health advisor intervention strategies: a continuum from natural helping. Health Education & Behavior., 24(4), 413–417.

    Article  CAS  Google Scholar 

  26. Viswanathan M, Kraschnewski J, Nishikawa B, et al. (2009). Outcomes of community health worker interventions. Rockville, MD: Agency for Healthcare Research and Quality. Evidence Report/Technology Assessment No. 181.

  27. Earp, J. A., Eng, E., O'Malley, M. S., et al. (2002). Increasing use of mammography among older, rural African American women: results from a community trial. American Journal of Public Health., 92(4), 646–654.

    Article  PubMed  PubMed Central  Google Scholar 

  28. Russell, K. M., Champion, V. L., Monahan, P. O., et al. (2010). Randomized trial of a lay health advisor and computer intervention to increase mammography screening in African American women. Cancer Epidemiology Biomarkers & Prevention., 19(1), 201–210.

    Article  Google Scholar 

  29. Paskett, E., Tatum, C., Rushing, J., et al. (2006). Randomized trial of an intervention to improve mammography utilization among a triracial rural population of women. Journal of the National Cancer Institute., 98(17), 1226–1237.

    Article  PubMed  PubMed Central  Google Scholar 

  30. Margolis, K. L., Lurie, N., McGovern, P. G., Tyrrell, M., & Slater, J. S. (1998). Increasing breast and cervical cancer screening in low-income women. Journal of General Internal Medicine., 13(8), 515–521.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  31. Legler, J., Meissner, H. I., Coyne, C., Breen, N., Chollette, V., & Rimer, B. K. (2002). The effectiveness of interventions to promote mammography among women with historically lower rates of screening. Cancer Epidemiology Biomarkers & Prevention., 11(1), 59–71.

    Google Scholar 

  32. Wells KJ, Luque JS, Miladinovic B, et al. (2011). Do community health worker interventions improve rates of screening mammography in the United States? A systematic review. Cancer Epidemiology Biomarkers & Prevention. cebp. 0276.2011.

  33. Kiger, H. (2003). Outreach to multiethnic, multicultural, and multilingual women for breast cancer and cervical cancer education and screening: a model using professional and volunteer staffing. Family & community health., 26(4), 307–318.

    Article  Google Scholar 

  34. Twombly, E. C., Holtz, K. D., & Stringer, K. (2012). Using promotores programs to improve Latino health outcomes: implementation challenges for community-based nonprofit organizations. Journal of social service research., 38(3), 305–312.

    Article  PubMed  PubMed Central  Google Scholar 

  35. Koskan, A., Friedman, D. B., Messias, D. K. H., Brandt, H. M., & Walsemann, K. (2013). Sustainability of promotora initiatives: program planners’ perspectives. Journal of public health management and practice., 19(5), E1–E9.

    Article  PubMed  PubMed Central  Google Scholar 

  36. Shelton, R., Dunston, S. K., Leoce, N., et al. (2016). Predictors of activity level and retention among African American lay health advisors from the National Witness Project: implications for the implementation and sustainability of community-based programs from a longitudinal study. Implementation Science., 11(41), 1.

    Google Scholar 

  37. Kkmoe, M. (2013). Kalofonos I. Becoming and remaining community health workers: perspectives from Ethiopia and Mozambique. Social Science & Medicine., 87, 52–59.

    Article  Google Scholar 

  38. Alam, K., Tasneem, S., & Oliveras, E. (2012). Retention of female volunteer community health workers in Dhaka urban slums: a case-control study. Health policy and planning., 27, 477–486.

    Article  PubMed  Google Scholar 

  39. Erwin, D. O., Spatz, T. S., & Turturro, C. L. (1992). Development of an African-American role model intervention to increase breast self-examination and mammography. Journal of Cancer Education., 7(4), 311–319.

    Article  CAS  PubMed  Google Scholar 

  40. Thompson, H. S., Valdimarsdottir, H. B., Winkel, G., Jandorf, L., & Redd, W. (2004). The group-based medical mistrust scale: psychometric properties and association with breast cancer screening. Preventive Medicine, 38(2), 209–218.

    Article  PubMed  Google Scholar 

  41. Division of Cancer Control and Population Sciences, National Cancer Institute. The Witness Project: Products. Research-tested Intervention Programs (RTIPs) 2012; http://rtips.cancer.gov/rtips/productDownloads.do?programId=270521. Accessed February 13, 2015.

  42. Erwin, D. O. (2009). The Witness Project: narratives that shape the cancer experience for African American women. In J. McMullin & D. Weiner (Eds.), In confronting cancer: Metaphors, advocacy, and anthropology (pp. 125–146). Sante Fe, CA: School for Advanced Research Seminar Series.

    Google Scholar 

  43. Erwin, D. O., Spatz, T. S., Stotts, R. C., & Hollenberg, J. A. (1999). Increasing mammography practice by African American women. Cancer practice., 7(2), 78–85.

    Article  CAS  PubMed  Google Scholar 

  44. Kreuter, M. W., Green, M. C., Cappella, J. N., et al. (2007). Narrative communication in cancer prevention and control: a framework to guide research and application. Annals of Behavioral Medicine., 33(3), 221–235.

    Article  PubMed  Google Scholar 

  45. Erwin, D. O. (2002). Cancer education takes on a spiritual focus for the African American faith community. Journal of Cancer Education., 17(1), 46–49.

    PubMed  Google Scholar 

  46. Hurd, T. C., Muti, P., Erwin, D. O., & Womack, S. (2003). An evaluation of the integration of non-traditional learning tools into a community based breast and cervical cancer education program: the Witness Project of Buffalo. BMC Cancer, 3(1), 18.

    Article  PubMed  PubMed Central  Google Scholar 

  47. Bailey, E. J., Erwin, D. O., & Belin, P. (2000). Using cultural beliefs and patterns to improve mammography utilization among African-American women: the Witness Project. Journal of the National Medical Association., 92(3), 136.

    CAS  PubMed  PubMed Central  Google Scholar 

  48. Arvey, S. R., & Fernandez, M. E. (2012). Identifying the core elements of effective community health worker programs: a research agenda. American journal of public health., 102(9), 1633–1637.

    Article  PubMed  PubMed Central  Google Scholar 

  49. Erwin, D. O., Ivory, J., Stayton, C., et al. (2003). Replication and dissemination of a cancer education model for African American women. Cancer Control, 10(5; SUPP), 13–21.

    Article  PubMed  Google Scholar 

  50. Shelton, R. C., Dunston, S. K., Leoce, N., Jandorf, L., Thompson, H. S., & Erwin, D. O. (2017). Advancing understanding of the characteristics and capacity of African American women who serve as lay health advisors in community-based settings. Health Education & Behavior., 44(1), 153–164.

    Article  Google Scholar 

  51. Creswell JW, Clark VLP. Designing and conducting mixed methods research. 2007.

  52. Borkan, J. (1999). Immersion/crystallization. Doing qualitative research., 2, 179–194.

    Google Scholar 

  53. Stirman, S. W., Kimberly, J., Cook, N., Calloway, A., Castro, F., & Charns, M. (2012). The sustainability of new programs and innovations: a review of the empirical literature and recommendations for future research. Implementation Science, 7(17), 1–19.

    Google Scholar 

  54. Luke, D. A. (2014). The program sustainability assessment tool: a new instrument for public health programs. Preventing Chronic Disease, 11.

  55. Aarons, G. A., Hurlburt, M., & Horwitz, S. M. (2011). Advancing a conceptual model of evidence-based practice implementation in public service sectors. Administration and Policy in Mental Health and Mental Health Services Research., 38(1), 4–23.

    Article  PubMed  Google Scholar 

  56. Scheirer, M. A. (2013). Linking sustainability research to intervention types. American journal of public health., 103(4), e73–e80.

    Article  PubMed  PubMed Central  Google Scholar 

  57. Damschroder, L. J., Aron, D. C., Keith, R. E., Kirsh, S. R., Alexander, J. A., & Lowery, J. C. (2009). Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science. Implementation Science, 4(1), 1.

    Article  Google Scholar 

  58. Fixsen DL, Naoom SF, Blase KA, Friedman RM. Implementation research: a synthesis of the literature. 2005.

    Google Scholar 

  59. Strachan, D. L., Källander, K., ten Asbroek, A. H., et al. (2012). Interventions to improve motivation and retention of community health workers delivering integrated community case management (iCCM): stakeholder perceptions and priorities. The American journal of tropical medicine and hygiene., 87(5 Suppl), 111–119.

    Article  PubMed  PubMed Central  Google Scholar 

  60. Chambers, D. A., Glasgow, R. E., & Stange, K. C. (2013). The dynamic sustainability framework: addressing the paradox of sustainment amid ongoing change. Implementation Science, 8(1), 117.

    Article  PubMed  PubMed Central  Google Scholar 

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Acknowledgements

We are grateful to the NWP National Steering Committee, project directors, coordinators, LHAs, and role models from the National Witness Project who contributed their time to this study. In particular, we would like to thank and acknowledge Detric “Dee” Johnson and Mattye Willis for all of their efforts and support. This research was funded by a grant from the National Cancer Institute (5R03CA150543-03, “Serving as a Lay Health Advisor: The Impact on Self and Community”). Thank you to Danielle Crookes for her editorial assistance with this article.

Author information

Author notes

  1. Sheba King Dunston EdD, MPH

    Present address: Office of Research and Methodology, Question Design Research Laboratory, National Centers for Health Statistics, Centers for Disease Control and Prevention, 3311 Toledo Road, Hyattsville, MD, 20782, USA

Authors and Affiliations

  1. Mailman School of Public Health, Department of Sociomedical Sciences, Columbia University, 722 168th Street, Room 941, New York, NY, 10032, USA

    Rachel C. Shelton ScD, MPH, Thana-Ashley Charles MPH & Sheba King Dunston EdD, MPH

  2. Department of Oncological Sciences, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Place, Box 1130, New York, NY, 10029, USA

    Lina Jandorf MA

  3. Office of Cancer Health Disparities Research, Cancer Prevention and Population Sciences, Roswell Park Cancer Institute, Elm & Carlton Streets, Buffalo, NY, 14263, USA

    Deborah O. Erwin PhD

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  1. Rachel C. Shelton ScD, MPH
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Corresponding author

Correspondence to Rachel C. Shelton ScD, MPH.

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Funding

This research was funded by a grant from the National Cancer Institute (5R03CA150543-03, “Serving as a Lay Health Advisor: The Impact on Self and Community”). The Lerner Center for Public Health Promotion at Columbia School of Public Health provided support for Thana-Ashley Charles to assist on the project as a Lerner Center Fellow.

Statement of human rights/Helsinki statement

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1975 Helsinki Declaration and its later amendments or comparable ethical standards.

IRB approval

Institutional Review Board approval was awarded through Columbia University.

Animals

This article does not contain any studies with animals performed by any of the authors.

Informed consent

Informed consent was obtained from all individual participants included in the study.

Conflict of interest

All authors declare that they have no conflicts of interest.

Additional information

Implications

Practice:

Multiple factors are likely to facilitate the sustainability of community-engaged LHA programs including key partnerships with academic/medical centers and community organizations to build capacity and facilitate access to resources and funding, committed leadership and program champions, initial and ongoing training, and passionate LHAs who gain personal and professional benefits through their participation.

Policy:

National, state-level, and local policies and funding sources are critical to the long-term sustainability of LHA programs in community settings; furthermore, policymakers should consider the broader impact of LHA programs to build leadership and capacity in underserved communities.

Research:

Future studies should empirically test which theoretically informed factors predict long-term sustainability of LHA programs in community settings and explicitly develop and test strategies to promote and plan for program sustainability.

This research has not been previously published and the present manuscript is not simultaneously being submitted elsewhere. There has been no previous reporting of the data. The authors have full control of the primary data and agree to allow the journal to review the data if requested.

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Shelton, R.C., Charles, TA., Dunston, S.K. et al. Advancing understanding of the sustainability of lay health advisor (LHA) programs for African-American women in community settings. Behav. Med. Pract. Policy Res. 7, 415–426 (2017). https://doi.org/10.1007/s13142-017-0491-3

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