Lay health worker as interventionist training: reflective writing in US family health promotion practice.

Lay health worker-led health promotion interventions are well received within racial and ethnic minority communities. Increasing numbers of trained lay health workers will be needed to meet global health goals. The purpose of this process evaluation was to gain insights about how lay health worker as interventionists used theory-based approaches within a nutrition and physical activity health behavior change intervention in a clinical trial enrolling immigrant and refugee families. Data were comprised of ongoing reflective writing statements from four health workers about their implementation of the intervention. Using content analysis three themes emerged: (i) encouraging setting of small, family focused and relevant goals, (ii) being flexible in content delivery and (iii) being personally transformed (i.e. gained a sense of meaning from their experience). Lay health worker interventionist reflections on practice revealed they delivered the intervention within the primacy of the family partnering relationship by attending to unique family needs, and adjusting educational content and goal setting accordingly. Our results provide guidance for training and process evaluation of lay health worker intervention delivery in ethnically and racially diverse populations. Incorporating real-time reflection upon what was learned about skills of facilitating family motivation and family confidence enhanced affective learning and may be useful in future research studies and health promotion practice. The processes identified including setting small goals, flexibility and personal transformation could be considered in future lay health worker-delivered health promotion interventions.

Health programs taught by lay health workers from within racial and ethnic communities are often more successful than those not taught by persons from these communities. Lay health workers are specifically trained in these programs. It is hard to know how lay health workers use this training. We asked lay health workers about how they used a specific approach of teaching and goal setting to help families change nutrition and physical activity behaviors. Four different lay health workers wrote notes after each time they met with families. We read these notes to see what we could learn about how they used their training. Lay health workers wrote that they followed their training by listening to each family so they could encourage families to set small goals that made sense to the family. They also followed their training by being flexible while doing the teaching and goal setting because there were many other things going on in the family. Lay health workers were personally changed and got better at teaching because of the relationships they had with each family. Writing these notes helped lay health workers focus on the skills and emotions needed to put their training into place.

Sustainability of a Tuberculosis Screening Program at an Adult Education Center Through Community-Based Participatory Research.

The majority of active tuberculosis (TB) cases in the United States occur through reactivation of latent TB infection among foreign-born individuals. While screening of at-risk individuals through community partnerships is recommended, it is not commonly accomplished. A community-academic partnership developed a TB-screening intervention at an adult education center serving a large foreign-born population in Rochester, Minnesota. The intervention was cocreated with grant support by diverse stakeholders through a community-based participatory research partnership. The intervention was sustained beyond the grant interval through adaptation of staffing inputs, a robust partnership with sustained dialogue around TB and operational issues, and adaptation of governance through coownership of the intervention by the adult education center and the public health department. Eight years of data demonstrate that adult education centers may be effective venues for sustaining partnerships to address TB prevention among at-risk communities.

A focus group study of healthy eating knowledge, practices, and barriers among adult and adolescent immigrants and refugees in the United States.

BACKGROUND: Immigrants and refugees to the United States exhibit lower dietary quality than the general population, but reasons for this disparity are poorly understood. In this study, we describe the meanings of food, health and wellbeing through the reported dietary preferences, beliefs, and practices of adults and adolescents from four immigrant and refugee communities in the Midwestern United States. METHODS: Using a community based participatory research approach, we conducted a qualitative research study with 16 audio-recorded focus groups with adults and adolescents who self-identified as Mexican, Somali, Cambodian, and Sudanese. Focus group topics were eating patterns, perceptions of healthy eating in the country of origin and in the U.S., how food decisions are made and who in the family is involved in food preparation and decisions, barriers and facilitators to healthy eating, and gender and generational differences in eating practices. A team of investigators and community research partners analyzed all transcripts in full before reducing data to codes through consensus. Broader themes were created to encompass multiple codes. RESULTS: Results show that participants have similar perspectives about the barriers (personal, environmental, structural) and benefits of healthy eating (e.g., 'junk food is bad'). We identified four themes consistent across all four communities: Ways of Knowing about Healthy Eating ('Meanings;' 'Motivations;' 'Knowledge Sources'), Eating Practices ('Family Practices;' 'Americanized Eating Practices' 'Eating What's Easy'), Barriers ('Taste and Cravings;' 'Easy Access to Junk Food;' 'Role of Family;' Cultural Foods and Traditions;' 'Time;' 'Finances'), and Preferences for Intervention ('Family Counseling;' Community Education;' and 'Healthier Traditional Meals.'). Some generational (adult vs. adolescents) and gender differences were observed. CONCLUSIONS: Our study demonstrates how personal, structural, and societal/cultural factors influence meanings of food and dietary practices across immigrant and refugee populations. We conclude that cultural factors are not fixed variables that occur independently from the contexts in which they are embedded.

Evaluation of a tuberculosis education video among immigrants and refugees at an adult education center: a community-based participatory approach.

Tuberculosis disproportionately affects immigrants and refugees to the United States. Upon arrival to the United States, many of these individuals attend adult education centers, but little is known about how to deliver tuberculosis health information at these venues. Therefore, the authors used a participatory approach to design and evaluate a tuberculosis education video in this setting. The authors used focus group data to inform the content of the video that was produced and delivered by adult learners and their teachers. The video was evaluated by learners for acceptability through 3 items with a 3-point Likert scale. Knowledge (4 items) and self-efficacy (2 items) about tuberculosis were evaluated before and after viewing the video. A total of 159 learners (94%) rated the video as highly acceptable. Knowledge about tuberculosis improved after viewing the video (56% correct vs. 82% correct; p <.001), as did tuberculosis-related self-efficacy (77% vs. 90%; p <.001). Adult education centers that serve large immigrant and refugee populations may be excellent venues for health education, and a video may be an effective tool to educate these populations. Furthermore, a participatory approach in designing health education materials may enhance the efficacy of these tools.

Rochester Healthy Community Partnership: Then and now.

Community-engaged research partnerships promote health equity through incorporation of regional contexts to inform partnership dynamics that shape research and interventions that reflect community voice and priorities. Long-term partnerships build trusted relationships and promote capacity building among community and academic partners, but there are many structural barriers to sustaining long-term partnerships. Here we describe lessons learned from sustaining Rochester Healthy Community Partnership (RHCP), an 18-year community-based participatory research (CBPR) partnership in Southeast Minnesota. RHCP collaborates with immigrant and refugee populations to co-create interventions that promote health equity for community health priorities. Challenges to sustainability include a tension between project-based funding and the needs of long-term community-based research infrastructure. These challenges can be met with a focus on shared CBPR principles, operating norms, partnership dynamics, and governance. RHCP began in 2004 through identification of a community health priority, defining the community, and establishment of CBPR principles. It grew through identification of broader community health priorities, capacity building for community and academic partners, and integration of diverse learners. We describe the capacity for RHCP to respond to new societal contexts, the importance of partnership dynamics as a barometer for partnership health, and lessons learned about sustainability of the CBPR partnership.

Screening for tuberculosis at an adult education center: results of a community-based participatory process.

OBJECTIVES: We used a community-based participatory research (CBPR) approach to plan and implement free TB skin testing at an adult education center to determine the efficacy of CBPR with voluntary tuberculosis (TB) screening and the prevalence of TB infection among immigrant and refugee populations. METHODS: We formed a CBPR partnership to address TB screening at an adult education center that serves a large immigrant and refugee population in Rochester, Minnesota. We conducted focus groups involving educators, health providers, and students of the education center, and used this input to implement TB education and TB skin testing among the center's students. RESULTS: A total of 259 adult learners volunteered to be skin-tested in April 2009; 48 (18.5%) had positive TB skin tests. CONCLUSIONS: Our results imply that TB skin testing at adult education centers that serve large foreign-born populations may be effective. Our findings also show that a participatory process may enhance the willingness of foreign-born persons to participate in TB skin-testing efforts.

Outcomes of a Community-Based Participatory Research Partnership Self-Evaluation: The Rochester Healthy Community Partnership Experience.

BACKGROUND: Community-based participatory research (CBPR) can effectively address health disparities among groups that are historically difficult to reach, disadvantaged, of a minority status, or are otherwise underrepresented in research. Recent research has focused on the science of CBPR partnership constructs and on developing and testing tools for self-evaluation. Because CBPR requires substantial investment in human and material resources, specific factors that support successful and sustainable research partnerships must be identified. We sought to describe the evolution, implementation, and results of a self-evaluation of a CBPR partnership. METHODS: Academic and community members of the Rochester Healthy Community Partnership (RHCP) and researchers from the University of New Mexico-Center for Participatory Research collaborated to evaluate RHCP with qualitative and quantitative research methods and group analysis. RESULTS: The self-evaluation was used to provide an overall picture of the "health" of the partnership, in terms of sustainability and ability to effectively collaborate around community priorities. RHCP members revisited the partnership's mission and values; identified associations between partnership practices, dynamics, and outcomes; and elicited insight from community and academic partners to help guide decisions about future directions and the sustainability of the partnership. Positive partnership dynamics were associated with perceived improvements in health and equity outcomes. CONCLUSIONS: Although engaging in a comprehensive self-evaluation requires substantial investment from stakeholders, such assessments have significant value because they enable partners to reflect on the mission and values of the partnership, explore the history and context for its existence, identify factors that have contributed to outcomes, and plan strategically for the future.

The Development of a Collaborative Self-Evaluation Process for Community-Based Participatory Research Partnerships Using the Community-Based Participatory Research Conceptual Model and Other Adaptable Tools.

BACKGROUND: Established community-based participatory research (CBPR) partnerships need tools to assist with self-evaluation of the effectiveness and engagement with CBPR principles and to inform ongoing work. A growing part of the CBPR field is focused on the evaluation of partnering processes and outcomes. OBJECTIVES: The Rochester Healthy Community Partnership (RHCP), a partnership with more than a decade of engagement in health promotion research, performed a self-evaluation in collaboration with the University of New Mexico Center for Participatory Research (UNM-CPR). METHODS: We collaboratively developed and implemented a facilitated self-evaluation using adaptations of existing tools and the CBPR conceptual model. Partners contributed through surveys and qualitative interviews. Initially, data were analyzed collaboratively by members of RHCP and UNM-CPR, but RHCP partners further processed and consolidated findings, leading to the development of key questions that guided a full partnership discussion of action steps. RESULTS: Our process confirmed the adaptability of existing tools and the CBPR conceptual model for the purpose of partnership reflection and self-evaluation. We offer the key findings of our assessment of partnering practices and directions for the future, and share our approach to collaborative analysis and dissemination. Our discussion includes lessons learned, with applicability to other established partnerships. CONCLUSIONS: Our experience indicates that collective reflection is empowering for members of established partnerships, which can be facilitated by engagement in self-evaluation through the use of adapted, available tools. The incorporation of participatory processes adds complexity, but leads to a level of resonance and usefulness that would not have been obtained from a traditional evaluation.

Healthy Immigrant Families: Randomized Controlled Trial of a Family-Based Nutrition and Physical Activity Intervention.

PURPOSE: To evaluate a healthy eating and physical activity intervention for immigrant families, derived through community-based participatory research. DESIGN: The Healthy Immigrant Families study was a randomized controlled trial with delayed intervention control group, with families as the randomization unit. SETTING: US Midwest city. PARTICIPANTS: Participants were recruited by community partners from Hispanic, Somali, and Sudanese immigrant communities. INTERVENTION: Family health promoters from participating communities delivered 6 healthy eating modules, 4 physical activity modules, and 2 modules synthesizing information in 12 home visits (60-90 minutes) within the first 6 months. Up to 12 follow-up phone calls to each participant occurred within the second 6 months. MEASURES: Primary measures were dietary quality measured with weekday 24-hour recall and reported as Healthy Eating Index score (0-100) and physical activity measured with accelerometers (14 wear days) at baseline, 6, 12, and 24 months. RESULTS: In total, 151 persons (81 adolescents and 70 adults; 44 families) were randomly assigned. At 12 months, significant improvement occurred in Healthy Eating Index scores for adults in the intervention group compared with controls (change, +8.6 vs -4.4; P < .01) and persisted at 24 months (+7.4 from baseline; P < .01). No differences were observed for adolescents and no significant differences occurred between groups for physical activity. CONCLUSION: This intervention produced sustained dietary quality improvement among adults but not among adolescents. Program outcomes are relevant to communities working to decrease cardiovascular risk among immigrant populations.

Treatment Fidelity Among Family Health Promoters Delivering a Physical Activity and Nutrition Intervention to Immigrant and Refugee Families.

Lack of treatment fidelity can be an important source of variation affecting the credibility and utility of outcomes from behavioral intervention research. Development and implementation of a well-designed treatment fidelity plan, especially with research involving underserved populations, requires careful conceptualization of study needs in conjunction with what is feasible in the population. The purpose of this article is to review a fidelity-monitoring plan consistent with the National Institutes of Health Behavior Change Consortium guidelines (e.g., design, training, delivery, receipt, and enactment) for an intervention trial designed to improve physical activity and nutrition among immigrant and refugee families. Description of the fidelity monitoring plan is provided and challenges related to monitoring treatment fidelity in a community-based participatory intervention for immigrant and refugee families are discussed.

Relationship Between Negative Mood and Health Behaviors in an Immigrant and Refugee Population.

Immigrants experience an escalation of negative health behaviors after arrival to the United States. Negative mood is associated with poorer health behaviors in the general population; however, this relationship is understudied in immigrant populations. Adolescent (n = 81) and adult (n = 70) participants completed a health behavior survey for immigrant families using a community-based participatory research approach. Data was collected for mood, nutrition, and physical activity. Adolescents with positive mood drank less regular soda, and demonstrated more minutes, higher levels, and greater social support for physical activity (all ps < .05). Adults with positive mood reported more snacking on fruits/vegetables, greater self-efficacy for physical activity, and better physical well-being (all ps < .05). Negative mood was associated with low physical activity level and poor nutritional habits in adolescent and adult immigrants. Designing community-based programs offering strategies for mood management and healthy lifestyle change may be efficacious for immigrant populations.

Lessons Learned from Community-Led Recruitment of Immigrants and Refugee Participants for a Randomized, Community-Based Participatory Research Study.

Ethnic minorities remain underrepresented in clinical trials despite efforts to increase their enrollment. Although community-based participatory research (CBPR) approaches have been effective for conducting research studies in minority and socially disadvantaged populations, protocols for CBPR recruitment design and implementation among immigrants and refugees have not been well described. We used a community-led and community-implemented CBPR strategy for recruiting 45 Hispanic, Somali, and Sudanese families (160 individuals) to participate in a large, randomized, community-based trial aimed at evaluating a physical activity and nutrition intervention. We achieved 97.7 % of our recruitment goal for families and 94.4 % for individuals. Use of a CBPR approach is an effective strategy for recruiting immigrant and refugee participants for clinical trials. We believe the lessons we learned during the process of participatory recruitment design and implementation will be helpful for others working with these populations.

Erratum to: Lessons Learned from Community-Led Recruitment of Immigrants and Refugee Participants for a Randomized, Community-Based Participatory Research Study.

The original version of this article unfortunately contained an error in the author affiliation. The affiliations for the Authors Marcelo M. Hanza, Miriam Goodson, Ahmed Osman, Maria D. Porraz Capetillo, Abdullah Hared, Julie A. Nigon, Mark L. Wieland, and Irene G. Sia were published incorrectly. The correct affiliations are given in this erratum.

Diabetes Knowledge, Attitudes and Behaviors Among Somali and Latino Immigrants.

Persons from Somalia constitute the largest group of immigrants and refugees from Africa among whom diabetes-related health disparities are well documented. As one of the first steps toward developing a behavioral intervention to address diabetes among Somali immigrants and refugees, we administered a face to face interview-based survey to Somali and Latino adults with diabetes in a single community to assess diabetes knowledge, attitudes and behaviors. Respondents (N = 78) reported several barriers to optimal diabetes management for physical activity and glucose self-monitoring, as well as a high burden of disease and negative perceptions of diabetes. High participant engagement in disease management, self-efficacy, and social support were important assets. Similarities suggest that the shared experiences of immigration and related systemic socioeconomic and linguistic factors play a significant role in the understanding and self-management of diabetes in these populations. Together with previously collected qualitative work, the survey findings will inform development of a behavioral intervention to improve outcomes and reduce diabetes-related health disparities among immigrant and refugee groups to the U.S.

Healthy immigrant families: Participatory development and baseline characteristics of a community-based physical activity and nutrition intervention.

BACKGROUND: US immigrants often have escalating cardiovascular risk. Barriers to optimal physical activity and diet have a significant role in this risk accumulation. METHODS: We developed a physical activity and nutrition intervention with immigrant and refugee families through a community-based participatory research approach. Work groups of community members and health scientists developed an intervention manual with 12 content modules that were based on social-learning theory. Family health promoters from the participating communities (Hispanic, Somali, Sudanese) were trained to deliver the intervention through 12 home visits during the first 6 months and up to 12 phone calls during the second 6 months. The intervention was tested through a randomized community-based trial with a delayed-intervention control group, with measurements at baseline, 6, 12, and 24 months. Primary measurements included accelerometer-based assessment of physical activity and 24-hour dietary recall. Secondary measures included biometrics and theory-based instruments. RESULTS: One hundred fifty-one individuals (81 adolescents, 70 adults; 44 families) were randomized. At baseline, mean (SD) time spent in moderate-to-vigorous physical activity was 64.7 (30.2) minutes/day for adolescents and 43.1 (35.4) minutes/day for adults. Moderate dietary quality was observed in both age groups. Biometric measures showed that 45.7% of adolescents and 80.0% of adults were overweight or obese. Moderate levels of self-efficacy and social support were reported for physical activity and nutrition. DISCUSSION: Processes and products from this program are relevant to other communities aiming to reduce cardiovascular risk and negative health behaviors among immigrants and refugees. TRIAL REGISTRATION: This trial was registered at Clinicaltrials.gov (NCT01952808).

Perspectives on physical activity among immigrants and refugees to a small urban community in Minnesota.

Immigrants and refugees to the United States exhibit relatively low levels of physical activity, but reasons for this disparity are poorly understood. 16 gender and age-stratified focus groups were conducted among 127 participants from heterogenous immigrant and refugee groups (Cambodian, Mexican, Somali, Sudanese) in a small Minnesota urban community. We found many similarities in perceived barriers and facilitators to physical activity between heterogeneous immigrant and refugee groups. While the benefits of physical activity were widely acknowledged, lack of familiarity and comfort with taking the first steps towards being physically active were the most significant barriers to physical activity. Participants described being motivated by social support from family, friends, and communities to be physically active. Our findings suggest that shared experiences of immigration and associated social, economic, and linguistic factors influence how physical activity is understood, conceptualized and practiced.

Perceptions of tuberculosis among immigrants and refugees at an adult education center: a community-based participatory research approach.

English as a Second Language programs serve large foreign-born populations in the US with elevated risks of tuberculosis (TB), yet little is known about TB perceptions in these settings. Using a community-based participatory research approach, we elicited perceptions about TB among immigrant and refugee learners and staff at a diverse adult education center. Community partners were trained in focus groups moderation. Ten focus groups were conducted with 83 learners and staff. Multi-level, team-based qualitative analysis was conducted to develop themes that informed a model of TB perceptions among participants. Multiple challenges with TB control and prevention were identified. There were a variety of misperceptions about transmission of TB, and a lack of knowledge about latent TB. Feelings and perceptions related to TB included secrecy, shame, fear, and isolation. Barriers to TB testing include low awareness, lack of knowledge about latent TB, and the practical considerations of transportation, cost, and work schedule conflicts. Barriers to medication use include suspicion of generic medications and perceived side effects. We posit adult education centers with large immigrant and refugee populations as excellent venues for TB prevention, and propose several recommendations for conducting these programs. Content should dispel the most compelling misperceptions about TB transmission while clarifying the difference between active and latent disease. Learners should be educated about TB in the US and that it is curable. Finally, TB programs that include learners and staff in their design and implementation provide greater opportunity for overcoming previously unrecognized barriers.