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Feasibility of a Web-Based Training System for Peer Community Health Advisors in Cancer Early Detection Among African Americans


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We describe the feasibility of a Web-based portal for training peer community health advisors (CHAs). We conducted a community-based implementation trial in African American churches between 2012 and 2014. The Web-based portal allows CHAs to log in and view 13 training videos, preparing them to deliver 3 cancer early detection workshops in their churches. Of 8 churches, 6 completed the training, each certifying 2 CHAs. These CHAs took an average of 26 days to complete the training, requiring little technical assistance. Additional technical assistance was required to implement the workshops. The Web-based system appears to be a feasible method for training lay individuals for the CHA role and has implications for increasing the reach of evidence-based interventions. (Am J Public Health. Published online ahead of print October 16, 2014: e1-e8. doi:10.2105/AJPH.2014.302237).
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Feasibility of a Web-Based Training System for Peer Community Health
Advisors in Cancer Early Detection Among African Americans
Sherie Lou Z. Santos, MPH, Erin K. Tagai, MPH, Min Qi Wang, PhD, Mary Ann Scheirer, PhD, Jimmie L. Slade, MA, and Cheryl L. Holt, PhD
We describe the feasibility of a Web-based portal for training peer commu-
nity health advisors (CHAs). We conducted a community-based implementa-
tion trial in African American churches between 2012 and 2014. The Web-based
portal allows CHAs to log in and view 13 training videos, preparing them to
deliver 3 cancer early detection workshops in their churches. Of 8 churches, 6
completed the training, each certifying 2 CHAs. These CHAs took an average of
26 days to complete the training, requiring little technical assistance. Addi-
tional technical assistance was required to implement the workshops. The
Web-based system appears to be a feasible method for training lay individuals
for the CHA role and has implications for increasing the reach of evidence-
based interventions. (Am J Public Health. 2014;104:2282–2289. doi:10.2105/
It has been well documented that many
evidence-based health promotion interventions
fail to achieve further implementation or use in
the communities they are intended to serve.
Such interventions, without intentional effort,
do not disseminate themselves into practice.
Interest in dissemination and implementation
research is growing. Consistent with Rabin
et al.,
we use the term dissemination to refer to
the active process of spreading evidence-based
interventions to a particular audience using
planned approaches and the term implementa-
tion to refer to the processes of integrating
evidence-based interventions within a setting.
We use the phrase dissemination and imple-
mentation to refer to the broader eld in
Previous dissemination and implementation
research has mainly focused on health care
settings. More research is needed to identify
optimal ways to translate research evidence
into practice, including interventions in com-
munity settings that use community-based
participatory methods.
This includes research
on successful implementation of interventions
serving culturally and ethnically diverse pop-
Peer health educators are viewed
as a promising strategy to achieve this goal.
Volunteer laypeople, such as those used in the
community health advisor (CHA) model, have
been used worldwide to promote health.
model for community health promotion rec-
ognizes that CHAs are cultural insiders and
trusted sources of information and can help
increase access to health care while naturally
building capacity in the community for sustained
positive health outcomes.
Taking advantage of todays continuously
evolving technology landscape enhances the
capacity to close the gap between research
discovery and program delivery.
The Pew
Foundation Health Online 2013 report found
that of the 81% of US adults who use the
Internet, 59% indicated that they use it to
obtain health information.
With increased
accessibility and technological outlets paving
the way for an empowered and computer-
literate public, there has been an ever-growing
emphasis on eHealth, or the use of interactive
technologiesthe Internet, social media, per-
sonal digital assistants, cellular phones, and
computer kiosksto disseminate health informa-
tion, promote health-related behavior change,
and encourage informed decision-making.
Effective health promotion interventions in-
corporating eHealth technologies have been
reported in a variety of areas, including but
not limited to smoking cessation, weight man-
agement, anxiety and depression, substance use
disorders, diabetes self-management, HIV risk
behavior, and asthma management.
In addition, the focus on integrating eHealth
tools in peer health education interventions to
reach more diverse and broader audiences is
One such intervention is the
Centers for Disease Control and Preventions
Web-based e-learning course for promoting
the engagement of professional community
health workers.
The attraction of these
eHealth interventions stems from a number
of factors, including increasing access to tech-
nology, the potential for wide reach, reduced
delivery costs, convenience to users, en-
hanced delity, and the reduction of
geographically based, time-based, and
mobility-based barriers.
For example,
using Web-based technology increases the
potential for wider dissemination and
implementation of efcacious programs
through peer advisors in medically under-
served communities.
Currently, a number of applications have
been designed to train community health
workers (also known as lay health workers or
promotoras) via the Internet. However, these
programs appear to cater to professional com-
munity health workershealth professionals
seeking continuing education or supplemental
educationor are offered as a formalized
course with a dedicated instructor and appli-
cable tuition fees.
To our knowledge, the
current project is one of the rst applications
of a Web-based training for a volunteer CHA
curriculum that caters to individuals with little
to no health background. This approach has
the potential to be scalable to reach faith-based
institutions both nationally and globally. It
also has wider implications for use in other
lay CHA training interventions that cover
various geographic settings, health topics,
or cultural settings.
2282 |Framing Health Matters |Peer Reviewed |Santos et al. American Journal of Public Health |December 2014, Vol 104, No. 12
In this article, we describe the feasibility of
using a new Web-based portal for training
lay CHAs. The training was done in the context
of Project HEAL (Health through Early
Awareness and Learning), a community-based
implementation trial in African American
churches. The Project HEAL intervention aims
to increase early detection of breast, prostate,
and colorectal cancer using an evidence-based
Project HEAL compares 2 types
of training for lay CHAs: traditional classroom
training (TC-CHA) versus technology-based train-
ing offered through a Web-based portal (TB-
CHA). We compare implementation outcomes
from these 2 training approaches, including feasi-
bility of training completion, CHA implementation
of the HEAL intervention, and data from CHA
satisfaction and postintervention evaluation sur-
veys. We conclude with lessons learned from this
process and areas for future research.
The parent project providing the context for
this article, Project HEAL, was a community-
based implementation trial that compared 2
strategies for training CHAs to implement
evidence-based cancer communication inter-
ventions in African American churches.
research was conducted in Prince Georges
County, Maryland, which has the highest per-
centage of racial/ethnic minorities in Maryland
(65.3% African American), a wide range in
socioeconomic status, and a signicant propor-
tion of residents affected by health disparities.
Project HEAL used a cluster randomized
design in which CHAs in self-identied African
American churches were randomly assigned by
church to either the TC-CHA or the TB-CHA
training approach. Both approaches used peer
CHAs to implement a series of 3 educational
workshops on early detection of breast, prostate,
and colorectal cancer in their churches. The full
Project HEAL intervention components are
described in more detail elsewhere.
Integrated Web-Based Training
The technology-based approach to training
CHAs is accessed via a Web-based portal that
provides CHAs with a complete training
curriculum consisting of informed consent,
a memorandum of understanding, 13 content-
specic training videos (e.g., overview of can-
cer, breast cancer, leadership skills, ethical
issues) with corresponding PDFs, and CHA
certication after passing a knowledge exami-
nation (Figure 1). Project intervention materials
(e.g., cancer resource guide outlining local
health care resources) and sets of PowerPoint
slides for 3 workshops (i.e., cancer overview,
breast and prostate cancer, and colorectal
cancer) are provided in a downloadable
Combining Microsoft Visual Studio tools
(Microsoft, Redmond, WA), an SQL database,
and Web tools (i.e., HTML, CSS, JavaScript), we
developed the Web-based CHA training portal.
All document-based materials were delivered
in PDF format for ease of accessibility across
various platforms (e.g., PC, Mac, iOS). In ac-
cordance with dual-coding theory,
postulates facilitated learning and enhanced
recall with the combined use of nonverbal
and verbal stimuli, the content-specic training
modules were developed and narrated in
Microsoft PowerPoint as multimedia les and
then converted to MOV format. The MOV le
container format is capable of holding different
data types (e.g., animation, graphics, video, text)
and is a common multimedia format compati-
ble with QuickTime (Apple Inc., Cupertino,
CA), a widely available multimedia platform.
If fail
Introduction Page
Informed Consent
Knowledge Examination
CHA Evaluation
Workshop Materials
CHA Training
“retake until pass”
Note. CHA = community health advisor; HEAL = Health through Early Awareness and Learning; MOU = memorandum of
FIGURE 1—Project HEAL Web-based training flow diagram: Prince George’s County, MD,
December 2014, Vol 104, No. 12 |American Journal of Public Health Santos et al. |Peer Reviewed |Framing Health Matters |2283
To decrease download time for each training
video, we chose YouTube to host the video
contents. For evaluation purposes, program-
ming allowed the study team to track the
progress of each CHA through the training,
including (1) total number of logins and log-
outs, (2) length of time spent logged in, (3)
amount of times the knowledge examination
was taken and retaken, and (4) incorrect
certication examination answers.
The TC-CHA training delivered the same
curriculum as the TB-CHA approach; however,
the TC-CHAs received 6 hours of training in
a small-group classroom setting using a didactic
and discussion format, with content module
presentations given by Project HEAL team
members and expert speakers. HEAL project
staff members provided this training in churches
to the TC-CHAs in 2 sessions, using the same
content as for the TB-CHAs, described next.
Technology-Based Community Health
Advisor Training Process
In the Project HEAL trial phase, 15 churches
were randomly assigned to the TB-CHA
training group (n = 7) or the TC-CHA training
group (n = 8; Figure 2). The pastor at each
church identied 2 potential CHAs (1 man,
1 woman) who met the CHA eligibility re-
1. self-identied as African American,
2. older than 21 years,
3. regularly attended the enrolled church,
4. able to complete Project HEAL training,
5. had regular access to the Internet and felt
comfortable completing Web-based
training activities,
6. able to recruit 30 participants for the
3-part workshop series, and
7. able to lead the 3-part workshop series.
After TB-CHAs were identied and recruited
by their respective pastors, study staff e-mailed
each CHA a personalized username and
Figure 1 depicts the Web-based training
owchart. CHAs had to complete each stage of
the Web-based training before moving forward
to the next stage. CHAs logged into the system,
read an overview of the CHA training and
curriculum (introduction page), and then read
the informed consent and memorandum of
understanding. A waiver of written informed
consent was obtained from the institutional
review board allowing CHAs to indicate
agreement through an electronic acknowledg-
ment system (i.e., I agreeor I do NOT
agree). Only on agreement could they proceed
to the training materials. CHAs then had the
option to view each of the 13 content-specic
modules in 2 available formats to cater to
Randomized (15 churches)
Churches: n
Recruited CHAs (n
16, 2 per church)
Traditional Classroom Condition (TC-CHA)
Churches: n
Recruited CHAs (n
14, 2 per church)
Technology-Based Condition (TB-CHA)
Lost to follow-up (n
Churches replaced (n
Churches not replaced (n
Churches CHAs
Lost to follow-up (n
Withdrew with church (n
Replaced with new church
Withdrew and replaced in
same church (n
Lost to follow-up (n
Churches replaced (n
Churches not replaced (n
Churches CHAs
Lost to follow-up (n
Withdrew with church (n
Replaced with new church
Withdrew and replaced in
same church (n
Completed 3-workshop series
Completed 3-workshop series
Completed training/certication
Completed training/certication
CHA training evaluation
completed (n
CHA postworkshop evaluation
completed (n
CHA training evaluation
completed (n
CHA postworkshop evaluation
completed (n
Note. CHA = community health advisor; HEAL =Health through Early Awareness and Learning.
CHAs trained and certified, but church dropped out before first workshop date; church not replaced because of late drop out.
FIGURE 2—Flow diagram of Project HEAL church allocation and CHA recruitment: Prince George’s County, MD, 2012–2014.
2284 |Framing Health Matters |Peer Reviewed |Santos et al. American Journal of Public Health |December 2014, Vol 104, No. 12
varied learning styles or literacy levels: (1) a
video of a narrated PowerPoint in MOV format,
allowing CHAs to hear audio while reading the
content, and (2) a downloadable PDF allowing
CHAs to read and print the content.
Only when the CHAs downloaded all of the
training modules could they proceed to the
certication examination. This examination
contained cancer-specic knowledge questions
and questions related to conducting and lead-
ing the educational workshops. A score of 85%
or higher was required for passing, and CHAs
could retake the examination as many times
as needed until they passed. With a passing
score, CHAs could download their personal-
ized certicate of training completion, a CHA
training evaluation survey to be completed
and returned to study staff via e-mail, and all
materials necessary to conduct the Project
HEAL 3-part educational workshop series
(i.e., participant recruitment yers, workshop
sheets, workshop presentation slides,
digital copies of the cancer educational book-
lets). CHAs could log in and out of the system
as many times as needed until they reached
training completion, and progress was saved
at the last step completed. Contact information
for study staff was provided should the CHAs
have needed technical assistance at any point
during the training.
The CHAs in both the TB-CHA training and
TC-CHA training groups were of similar age
(mean = 51.9 years; SD = 14.5; and mean =
51.0 years; SD = 11.8, respectively; Table 1).
Most CHAs in both groups had Internet access
at home and at work. However, the TB-CHAs
had overall greater educational attainment
than the TC-CHAs (83.3% vs 37.5% with
a bachelors degree or higher, respectively).
Web-Based Training Feasibility
After the initial church randomization and
CHA recruitment, 8 of the total 36 CHAs
dropped out of Project HEAL (6 TB-CHAs and
2 TC-CHAs; Table 2 and Figure 2). Fourteen
TB-CHAs were trained and certied through
the Web-based training portal; 12 of these
TB-CHAs are still enrolled in Project HEAL
(2 TB-CHAs [1 church] were not replaced
because of late dropout; Table 2 and Figure 2).
All of the TB-CHAs who started the training
passed the certication examination, though
it is possible that they did not all pass on
the rst attempt. We have since updated the
programming to collect more detailed data
TABLE 1—CHA Demographic Profile and Evaluation of Training: Prince George’s County, MD,
CHAs (n = 12),
No. (%) or
Mean 6SD
Traditional Classroom
CHAs (n = 16),
No. (%) or
Mean 6SD
CHA demographic profile
Age, y 51.9 614.5 51 611.8
Home Internet access 11 (91.7) 16 (100.0)
Work Internet access 9 (75.0) 13 (86.7)
< bachelor’s degree 2 (16.7) 10 (62.5)
bachelor’s degree 10 (83.3) 6 (37.5)
Employment status
Retired or receiving disability 2 (18.2)
5 (38.5)
Part time 2 (18.2) 0 (0.0)
Full time 7 (63.6) 8 (61.5)
CHA posttraining satisfaction survey
CHA training “very useful” or “useful” for
Breast or prostate cancer awareness 12 (100.0) 16 (100.0)
Ease of understanding objective for breast or prostate cancer workshop 11 (91.7) 14 (87.5)
Colorectal cancer awareness 12 (100.0) 15 (93.8)
Ease of understanding objective for colorectal cancer workshop 11 (91.7) 15 (93.8)
CHA postworkshop evaluation
“Strongly agree” or “agree” CHA training materials were
Well organized 10 (83.3) 16 (100.0)
Useful in preparing for the workshops 10 (83.3) 16 (100.0)
Easy to understand 10 (83.3) 15 (93.8)
CHA is “very confident” or “confident” to
Recruit participants 8 (66.6) 12 (75.0)
Promote HEAL workshops 8 (66.7) 13 (81.3)
Present breast or prostate cancer workshops 11 (91.7) 14 (87.5)
Present colorectal cancer workshops 12 (100.0) 14 (87.5)
Respond to cancer-related questions and answers 11 (91.7) 13 (81.3)
Engage HEAL participants 12 (100.0) 13 (81.3)
“Strongly agree” or “agree” in conducting future health activities
Continue delivering Project HEAL workshops to CHA’s congregation 11 (91.7) 15 (100.0)
Lead a different health activity in CHA’s congregation 12 (100.0) 10 (76.9)
Recommend becoming a CHA to a peer 12 (100.0) 14 (100.0)
Recommend Project HEAL to men and women in CHA’s church 12 (100.0) 14 (100.0)
“Strongly agree” or “agree” the CHA certification process was fair 11 (91.7) 16 (100.0)
No. CHA certification examination attempts before passing with 85% 1.6 60.8 1.7 60.5
Note. CHA = community health advisor; HEAL = Health through Early Awareness and Learning. Results are from CHAs that
completed evaluations and excludes CHAs that dropped out.
n = 15.
n = 11.
n = 13.
n = 14.
December 2014, Vol 104, No. 12 |American Journal of Public Health Santos et al. |Peer Reviewed |Framing Health Matters |2285
(e.g., length of time logged in, total examination
attempts). We later asked for a self-report of
this information after the completion of the
workshop series. Most of the CHAs reported
passing the certication examination on the
rst attempt (n =7), and 5 CHAs each passed
on the second or third attempt (mean = 1.6;
SD = 0.8; Table 1). These results are compa-
rable to the TC-CHA training (mean =1.7;
SD =0.5). Table 2 details the CHAsWeb-
based training activity. During the training
process, the TB-CHAs logged on an average of
9.6 times (SD = 4.7; range = 3.0---21.0).
The protocol was modied after pilot testing
to allow for a technical assistance meeting if
CHAs had not logged into the training after the
initial 2 weeks post-CHA recruitment. In the
trial phase, however, none of the CHAs re-
quired such a technical assistance meeting to
be initiated to move through the system. One
church did request an in-person meeting after
certication to discuss the workshop series
format and other logistical questions. On
average, the TB-CHAs took approximately
26 days from the time that they were granted
access to the portal to the time that they
became certied (SD = 25.9; range = 0.0---89.0;
Table 2). All churches with certied TB-CHAs
completed the workshop series (n = 6).
Churches scheduled or completed their rst
workshop an average of 15 weeks after com-
pleting TB-CHA training (SD = 8.6; range =
3.4---29.3). These results are higher than
the average 7 weeks it took for TC-CHAs to
begin the workshop series (SD = 2.7; range =
Community Health Advisor Posttraining
Satisfaction Survey
After certifying as a Project HEAL CHA,
TC-CHAs (n = 16) and TB-CHAs (n = 12)
submitted a posttraining evaluation survey that
assessed their satisfaction with the training. Four
items assessed the usefulness of the CHA
training materials on a 4-point Likert-type scale
(ranging from 1 =not usefulto 4 =very
useful). Overall, CHAs in both groups were
highly satised with the training, and we found
minimal differences between groups (Table 1).
For example, all of the CHAs in both groups felt
the training was very useful or useful for creating
breast and prostate cancer awareness (n = 28).
Postworkshop Evaluation of Community
Health Advisor Training
We administered a separate CHA post-
workshop survey after the CHAs delivered the
3-part workshop series. The purpose of this
survey was to further evaluate the CHA train-
ing and assess CHA experiences in leading the
workshops. Twelve of the TB-CHAs and 16 of
the TC-CHAs completed the survey through
self-administration (Table 1). The 2 groups of
CHAs reported similar responses to 4-point
Likert-type training evaluation items (ranging
from 1 = not at all condentto 4 = very
condent) such as condence in recruiting
participants and presenting the breast and
prostate cancer workshops (Table 1). How-
ever, we found notable differences in that the
TC-CHAs were more likely than the TB-CHAs
to report that the training materials were well
organized and useful in preparing for the
workshops. In addition, the TB-CHAs were
more likely than the TC-CHAs to report con-
dence in being able to engage workshop par-
ticipants, presenting the colorectal cancer
workshops, and responding to cancer-related
questions. The TB-CHAs also had greater
interest than the TC-CHAs in leading a subse-
quent health activity in their churchin the future.
This article suggests that use of a Web-based
portal for training lay peer CHAs is feasible
and presents implementation data that
TABLE 2—Implementation Outcomes from CHAs Trained Online: Prince George’s County,
MD, 2012–2014
Church and CHA
Total Logins
Until Certified, No.
Days From E-mail
to Certification, No.
Weeks From Certification to
First Workshop, No.
Advisor 1 12 7 11.1
Advisor 2 10 8 11.0
Advisor 1 8 18 3.4
Advisor 2 9 16 3.7
Advisor 1 3 0 22.3
Advisor 2 4 4 21.7
Advisor 1 8 40 13.9
Advisor 2 8 7 18.6
Advisor 1 6 70 22.0
Advisor 2
21 15 6.0
Advisor 1 NA NA NA
Advisor 2 NA NA NA
Advisor 1 7 33 NA
Advisor 2 12 29 NA
Advisor 1 10 89 23.6
Advisor 2 16 34 29.3
Mean (SD) 9.6 (4.7) 26.4 (25.9) 15.6 (8.6)
Note. CHA = community health advisor; NA = not applicable.
CHA replaced twice; both occurrences because of medical issues.
Church dropped out before CHAs trained and certified; replaced by church 8.
CHAs trained and certified, but church dropped out before first workshop date; church not replaced because of late dropout.
2286 |Framing Health Matters |Peer Reviewed |Santos et al. American Journal of Public Health |December 2014, Vol 104, No. 12
compare reasonably well with the data from
classroom-trained CHAs. Both training methods
ultimately led to (1) the successful training and
certication of lay CHAs and (2) timely and
successful delivery of CHA-led cancer educa-
tional workshops. Across both groups of CHAs,
we saw similar responses on items assessing
the usefulness of training and condence in
recruiting participants, indicating that integrat-
ing Internet technologies in a CHA training
curriculum for lay individuals can have similar
outcomes to an evidence-based traditional
classroom training curriculum. An advantage of
a Web-based CHA training is that it enables
CHAs to complete the training at their own pace
and reduces the scheduling challenges associated
with a traditional classroom training approach.
Our TB-CHAs were able to complete the training
at their own pace and had the option to start and
stop the training modules, a fundamental princi-
ple of effective Web-based trainings.
16, 2 8
Challenges and Lessons Learned
Even though the Web-based CHA training
method was found to be feasible, it had some
drawbacks compared with the traditional
classroom training. The TB-CHAs took longer
to complete training and twice as long to
initiate the cancer educational workshops than
the TC-CHAs. Dropout was higher among the
TB-CHAs relative to the TC-CHAs. In addition,
we saw some differences in ratings of the
CHA training materials between the TC-CHAs
and the TB-CHAs. Though a majority of the
TB-CHAs responded favorably, a lower per-
centage of TB-CHAs than TC-CHAs found the
training materials to be well organized, useful
in preparing for the workshops, and easy to
understand. The content and components of
the CHA trainings were equivalent; the differ-
ence lay in the mode of delivery. Project HEAL
was a robust and dynamic project that focused
on 3 cancers, with a relatively complex in-
tervention protocol. This may be an ambitious
and complex design for a Web-based training
with minimal technical assistance, designed for
lay individuals with little to no health back-
ground. Future iterations of the Web-based
materials may need to be simplied for ease of
use with less technical assistance and greater
In the current trial, 6 TB-CHAs and 2
TC-CHAs did drop out. Of the 6 TB-CHAs,
4 dropped out because their respective
churches (n =2) chose to withdraw from the
project, and another 2 could not complete the
training for health reasons. The 2 churches that
dropped out were smaller churches that were
undergoing signicant transitions, including
a relocation process. The 2 TC-CHAs opted out
of the project because of challenges scheduling
an in-person CHA training session. They may
have continued with the project had they been
assigned to the TB-CHA group and been able
to complete the training on their own schedule.
We originally envisioned that a Web-based
training portal at which individuals would
log in, complete training, and lead the 3-part
workshop series in the relative absence of staff
support would be a more efcient way to train
CHAs and deliver an intervention than a tradi-
tional classroom training approach. However,
during the piloting process we learned that it
might be necessary to spend time building
relationships and rapport with the CHAs before
they initiated their Web-based training. It
may be unrealistic to expect people to respond
to an e-mail, log in to a Web-based system,
and complete a lengthy training even if they
are asked to do so by their church leadership.
Having the option of an individual orientation
and technical assistance meeting with the
CHAsthough not used by the 6 TB-CHA
churches during the trial phasenot only
serves to familiarize them with the Web portal,
but also gives them a human point of contact.
This may be important when working in medi-
cally underserved populations in the context of
a research study.
In addition, the need for staff support was
particularly apparent in our trial phase when
scheduling workshops on the church calendar.
Our TB-CHAs and TC-CHAs took an average
of 15 weeks and 7 weeks, respectively, to begin
their workshop series after CHA training and
certication. During this period, frequent con-
tact was made between study staff and CHAs in
both groups to assist churches and CHAs in the
progression through the project timeline. Fur-
thermore, 1 TB-CHA church requested an
in-person meeting after certication to discuss
the workshop series format and other logistical
questions. However, none of the TB-CHAs
required a technical assistance meeting to
complete the training and certication inde-
pendently, which suggests feasibility.
Limitations and Future Opportunities
The Project HEAL Web-based CHA train-
ing portal has a potentially large reach but is
currently limited in generalizability to African
American faith-based settings. This is because
we used a culturally targeted approach involv-
ing content, graphics, and spiritual material,
including religious themes and use of scripture.
The training and intervention materials could
be adapted for use with other populations using
a cultural translation process. An example of
an innovative solution to such a targeting
issue is provided in Make It Your Own, which
uses technology to provide customized small
media health communication materials en-
couraging screening.
This approach uses
a library of graphics and targeted messages in
various languages for individuals of different
demographic subgroups.
Although technology may be more efcient
and cost-effective than the traditional class-
room training approach,
reach is limited
by the need for a minimal level of technical
assistance and human contact, particularly
when initiating the training and scheduling
workshops on the church calendar. Whether
a more passive diffusion approach of this portal
would be adopted by faith-based organizations
is not known; this is another potential avenue
for future research. For example, the portal
could be modied for direct access and could
be advertised via church bulletins, social net-
works, church national organizations, or other
existing avenues of communication in African
American faith-based communities. With
regard to cost-effectiveness, considerable
start-up development and programming costs
need to be considered. Future analyses should
consider these costs in a systematic manner.
Finally, other issues such as general literacy,
computer literacy, and receptivity to using and
learning technology play a role in how easily
individuals are able to interface with the
Web-based training.
Use of the training
portal assumes computer access and a modest
level of familiarity with computers and the
Internet. This platform is not intuitive to all
types of users, which was particularly relevant
in our CHA population of African American
middle-aged adults (mean age = 51 years) and
for medically underserved populations.
The Project HEAL training portal can be
operated on a computer, smartphone, or tablet.
December 2014, Vol 104, No. 12 |American Journal of Public Health Santos et al. |Peer Reviewed |Framing Health Matters |2287
These platforms make for greater access; how-
ever, the user still needs to be comfortable with
the technology. Perhaps greater opportunities
will arise to expand this type of project as these
technologies diffuse through the younger gener-
ations of usersa population showing increased
preference for Web-based applications.
12, 4 0
Although the digital divide resulting from
race/ethnicity, age, income, and education is
closing, disparities still exist in technology
Indeed, our TB-CHAs were a small
sample of relatively educated individuals,
which may have contributed to their apparent
comfort with Web-based training. Future re-
search could examine individual characteristics
that predict who is most likely to complete
a Web-based CHA training (e.g., computer
and Internet access, age, health factors). Future
directions for the Project HEAL Web-based
CHA training portal include expansion to
other populations (e.g., Hispanic/Latino, Asian
Americans, Native Americans), faiths (e.g., Islam),
settings (e.g., CHAs trained through health
care systems), and other chronic diseases (e.g.,
diabetes, hypertension). These may be promising
ways to expand the reach and sustainability of
this potentially effective method to train lay peer
Using novel health communication strategies
in todays fast-changing technological environ-
ment can increase the capacity to close the gap
between research discovery and program de-
Even though we found the Project
HEAL Web-based CHA training method to
be feasible, it had limitations compared with
the traditional classroom training in terms of
efciency in training completion, intervention
implementation, and CHA dropout. These
limitations may be reasonable in light of the
potential for scalability and increased reach
that the Web-based training may have, partic-
ularly to prepare lay individuals to educate
underserved populations about chronic dis-
ease, thereby reducing health disparities. By
building health capacity in the community
through accessible and readily disseminated
evidence-based interventions with high poten-
tial for sustainability, the impact on community
health outcomes and positive societal change
can increase greatly. j
About the Authors
Sherie Lou Z. Santos, Erin K. Tagai, Min Qi Wang, and
Cheryl L. Holt are with the Department of Behavioral
and Community Health, School of Public Health, University
of Maryland, College Park. Mary Ann Scheirer is with
Scheirer Consulting, Princeton, NJ. Jimmie L. Slade is with
Community Ministry of Prince Georges County, Upper
Marlboro, MD.
Correspondence should be sent to Cheryl L. Holt, De-
partment of Behavioral and Community Health, School of
Public Health, University of Maryland, 2369 School of
Public Health (Building 255), College Park, MD 20742
(e-mail: Reprints can be ordered at by clicking the Reprintslink.
This article was accepted July 22, 2014.
S. L. Z. Santos led the writing and played a lead role
in the overall implementation and management of the
project. E. K. Tagai was responsible for data aggregation
and analysis and assisted with data collection and
management. M. Q. Wang contributed to the study de-
sign and evaluation plan, designed and managed the
Web-based training module, and conducted statistical
analyses. S. L. Z. Santos, E. K. Tagai, and M. Q. Wang
played a lead role in developing the Web-based com-
munity health advisor (CHA) training. M. A. Scheirer
made substantial contributions to the design of the study
as related to organizational theory, implementation, and
sustainability and provided critical reviews of the article.
J. L. Slade served as a community researcher and played
a critical role in providing guidance in study decision-
making regarding issues relating to the faith community
(e.g., recruitment, feasibility, data collection protocols).
C. L. Holt conceptualized and provided scienticand
administrative leadership and coordination of the study
and approved all edits. All authors were involved in the
interpretation and discussion of results, contributed to
the writing and review of the various drafts of the article,
and read and approved the nal article.
This work was supported by a grant from the National
Cancer Institute (R01CA147313).
We acknowledge Janice Bowie, PhD, Muhiuddin
Haider, PhD, and Tony Whitehead, PhD, for their
extensive contributions to this study and Roxanne Carter
and Rev. Alma Savoy, who conducted recruitment and
data collection activities for the study.
Human Participant Protection
This work was approved by the University of Maryland
institutional review board (no. 10-0691).
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December 2014, Vol 104, No. 12 |American Journal of Public Health Santos et al. |Peer Reviewed |Framing Health Matters |2289
... The online training, however, resulted in improvements in fruit and vegetable offerings, while the in-person training did not. Within the faith-based area, Santos et al [10]. compared the feasibility and implementation outcomes of a technology-based training (7 churches) with traditional classroom training (8 churches) designed to prepare volunteer community health advisors to promote cancer screening via church workshops. ...
... These studies [7][8][9][10], while informative, did not focus on the process and logistics of how to convert the training delivery mode from in-person to online and still retain learner engagement and interest. Further, existing models and suggested practices for developing online trainings tend to provide conceptual rather than logistical guidance and focus less on the process (e.g. ...
... Researchers have converted in-person trainings designed for organizational change agents to online trainings in clinical [8], community [7,9], and faith-based [10] settings, but these studies have not focused on the process and logistics of converting the trainings. Changing the delivery mode to online is not simply a matter of posting training slides with voice-over narration if the goal is to create an engaging training that increases user capacity and skills. ...
Full-text available
The implementation of evidence-based public health programs into practice is critical for improving health, but trainings for organizational change agents are often not scalable. To describe the process of converting a training that targets faith-based organizational capacity development from an in-person to an online format. We engaged in an iterative process to convert the training delivery mode from in-person to online that included assessing stakeholder support, consulting the literature on best practices, seeking a design team, consolidating content, designing engaging lessons, and building an online site. Feedback from end-users and other audiences was incorporated throughout. Pilot participants with characteristics like intended training users were then recruited via community and faith-based partner networks. They rated their agreement with statements about the effectiveness as well as design and functionality of each lesson and the overall training (1 = strongly disagree, 5 = strongly agree) and participated in a structured follow-up interview. Nine pilot participants (representing 9 churches in 7 states; 6 African American, 5 with health ministries) rated the online lessons favorably (all ratings ≥ 4.5). Most (90.4%) perceived the lesson duration to be “just right” and spent 52.5 ± 9.9 minutes/lesson. Participants evaluated the overall training positively (all ratings ≥ 4.7). Lesson content, resources, multimedia, and program ideas were most-liked aspects of lessons, while content, staff responsiveness, discussion board, and pace were most-liked aspects of the overall training in open-ended and interview responses. This paper shares a replicable process for converting training modalities from in-person to online with the goal of increased scalability.
... However, the online training was sometimes combined with simultaneous in-person (33,36,42) or hybrid (46) training to assess differences in implementation from delivery method. Training delivery was delivered equally between a multi-medium platform (e.g., live components and self-paced components) that enabled flexibility for training (34,35,38,42,46), and solely self-paced (31,33,36,44,45). When training was self-paced, materials included educational videos, quizzes, narrated PowerPoint slides, training manual; practice sessions with role playing; interactive discussions; and recorded webinars. ...
... Acceptability was evaluated less frequently (N = 6) than feasibility, although all studies that evaluated acceptability reported positive results (30-32, 34, 43, 44). A majority of these studies were for the same training program (31,(33)(34)(35)(36)49). ...
... Feasibility was assessed with process measures (31,34), volunteer reflections (31), volunteers' understanding of their roles and responsibilities (31), client perspectives on the volunteer program (31), and cost effectiveness (30,41,43). Acceptability was measured through volunteer perceptions of (34,44), ease of understanding (34,44), acceptability of the workload or commitment (31,34), and perceptions of effectiveness in volunteer role (30). ...
Full-text available
Background: Volunteer programs that support older persons can assist them in accessing healthcare in an efficient and effective manner. Community-based initiatives that train volunteers to support patients with advancing illness is an important advance for public health. As part of implementing an effective community-based volunteer-based program, volunteers need to be sufficiently trained. Online training could be an effective and safe way to provide education for volunteers in both initial training and/or continuing education throughout their involvement as a volunteer. Method: We conducted an integrative review that synthesized literature on online training programs for volunteers who support older adults. The review included both a search of existing research literature in six databases, and an online search of online training programs currently being delivered in Canada. The purpose of this review was to examine the feasibility and acceptability of community-based organizations adopting an online training format for their volunteers. Results: The database search identified 13,626 records, these went through abstract and full text screen resulting in a final 15 records. This was supplemented by 2 records identified from hand searching the references, for a total of 17 articles. In addition to identifying Volunteers Roles and Responsibilities; Elements of Training; and Evaluation of Feasibility and Acceptability; a thematic analysis of the 17 records identified the categories: (1) Feasibility Promoting Factors; (2) Barriers to Feasibility; (3) Acceptability Promoting Factors; and (4) Barriers to Acceptability. Six programs were also identified in the online search of online training programs. These programs informed our understanding of delivery of existing online volunteer training programs. Discussion: Findings suggested that feasibility and acceptability of online training were promoted by (a) topic relevant training for volunteers; (b) high engagement of volunteers to prevent attrition; (c) mentorship or leadership component. Challenges to online training included a high workload; time elapsed between training and its application; and client attitude toward volunteers. Future research on online volunteer training should consider how online delivery can be most effectively paced to support volunteers in completing training and the technical skills needed to complete the training and whether teaching these skills can be integrated into programs.
... The intervention platform for this secondary analysis is "Project HEAL" (Health through Early Awareness and Learning) Santos et al., 2014Santos et al., , 2017Scheirer et al., 2017). The Project HEAL intervention trains lay members of African-American churches as Community Health Advisors, who then conduct a series of three cancer educational workshops in their churches on breast, prostate, and colorectal cancer, with an emphasis on early detection. ...
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Implementation evaluations have increasingly taken into account how features of local context help determine implementation outcomes. The purpose of this study was to determine which contextual features of organizational capacity led directly to the RE-AIM Framework implementation outcomes of intervention reach and number of days taken to implement, in an implementation trial of a series of cancer education workshops conducted across 13 African-American churches in Maryland. We used a configurational approach with Coincidence Analysis to identify specific features of organizational capacity that uniquely distinguished churches with implementation success from those that were less successful. Aspects of organizational capacity (e.g., congregation size, staffing/volunteers, health ministry experience) were drawn from an existing measure of church organizational capacity for health promotion. Solution pathways leading to higher intervention reach included: having a health ministry in place for 1–4 years; or having fewer than 100 members; or mid-size churches that had conducted health promotion activities in 1–4 different topics in the past 2 years. Solution pathways to implementing the intervention in fewer number of days included: having conducted 1–2 health promotion activities in the past 2 years; having 1–5 part-time staff and a pastor without additional outside employment; or churches with a doctorally prepared pastor and a weekly attendance of 101–249 members. Study findings can inform future theory, research, and practice in implementation of evidence-based health promotion interventions delivered in faith-based and other limited-resource community settings. Findings support the important role of organizational capacity in implementation outcomes in these settings. Clinical trial registration The study was pre-registered at Identifier: NCT02076958. Registered 3/4/2014.
... The intervention platform for this research is "Project HEAL" (Health through Early Awareness and Learning) [34][35][36][37][38]. The Project HEAL intervention aims to increase awareness and screening for breast, prostate (informed decision making for screening), and colorectal cancer. ...
Lay Summary Researchers have become interested in studying how health promotion activities fit within the organizational setting where they are delivered. Health activities that are integrated into the host setting’s structures and routine operations are more likely to be fully executed, effective, and sustained. Unfortunately, we know little about how to achieve such integration. This is especially true when working outside of a healthcare system, in community organizations like churches. We report findings from a study that compared an approach to tailoring health promotion activities into their host settings, with a standard, non-tailored approach. The study was conducted in 14 African American churches randomly assigned to the tailored or standard group. The health promotion activity involved training lay people to conduct cancer educational workshops for church members. We measured the extent to which the churches integrated health promotion activities into their structures, processes, resources, and communication at the beginning and one year later. We found that while the churches had overall increases in these factors over time, those in the tailored group did not do so to a greater degree than those in the standard group. Even so, this approach to tailoring health promotion activities to the organizational setting merits future study.
... Characteristics of included studies are described in Tables 2 and 3. Of the 36 included studies, 44.4% (n=16) of studies conducted both outcome and process evaluations of the CHW intervention. The remaining 19 studies consisted of ten process evaluations (28%), eight outcome evaluations (22%), and a single formative evaluation (Santos et al., 2014). The majority of interventions employed pre-post study designs (n=19, 52.8%), followed by mixed methods (n=8, 22.2%) and randomized designs (n=8; 22.2%). ...
In recent years, community health workers (CHWs) have emerged as key stakeholders in implementing community-based public health interventions in racially diverse contexts. Yet little is known about the extent to which CHW training curriculums influence intervention effectiveness in marginalized racial and ethnic minority communities. This review summarizes evidence on the relationship between CHW training curricula and intervention outcomes conducted among African American and Latinx populations. We conducted a literature search of intervention studies that focused on CHW public health interventions in African American and Latinx populations using PubMed, PsycINFO, ERIC, CINAHL, EMBASE, and Web of Science databases. Included studies were quantitative, qualitative, and mixed methods studies employed to conduct outcome (e.g., blood pressure and HbA1c) and process evaluations (e.g., knowledge and self-efficacy) of CHW-led interventions. Out of 3,295 articles from the database search, 36 articles met our inclusion criteria. Overall, the strength of evidence linking specific CHW training curricula components to primary intervention health outcomes was weak, and no studies directly linked outcomes to specific characteristics of CHW training. Studies that described training related to didactic sessions or classified as high intensity reported higher percentages of positive outcomes compared to other CHW training features. These findings suggest that CHW training may positively influence intervention effectiveness but additional research using more robust methodological approaches is needed to clarify these relationships.
... [21] Access to a preventive cancer detection program was improved by training lay CHWs using training videos. [22] However, the CHWs have relatively less formal education and training. [7] The training of CHWs needs standardization. ...
Full-text available
CONTEXT: In India, the primary health system is inadequate to screen noncommunicable diseases (NCDs) at a population level due to sub-centers being short-staffed and underequipped. Training barefoot nurses (BFNs) to screen NCD is an important strategy of task shifting. Again, there is paucity of studies exploring the effectiveness of training program using technology for training BFNs in the screening of NCDs. AIMS: The aim of the study was to assess the effectiveness of audio-visual-based training to improve knowledge, skill, confidence, and performance (number screened and completeness of data entry) of BFNs to strengthen NCD screening. SETTINGS AND DESIGN: This study was conducted at Doddaballapura taluk of Bengaluru rural district, India. A mixed-method research design was employed to assess the effectiveness of an audio-visual module for training BFNs. SUBJECTS AND METHODS: Descriptive analysis was conducted to test the effectiveness of intervention in pre- and post-intervention period. A focus group discussion was conducted to explore the facilitators and barriers to the intervention. STATISTICAL ANALYSIS USED: Statistical analysis was performed using mean knowledge score (MKS) and two-tailed t-test. Descriptive analysis was done using simple percentages. RESULTS: The MKS of BFN improved across all the six components by 15% after the introduction of the video intervention. This improvement in MKS was statistically significant. The qualitative analysis testifies the improvement in skillsets, namely, finger pricking, swab placement, blood specimen collection, and waste disposal. In addition, the BFNs experience heightened confidence in conducting these procedures. The performance of BFNs has improved the number of screening and data entry into mobile apps. CONCLUSIONS: The findings from this study suggest that audio-visual-based training of BFNs improves their knowledge, skill, confidence, and performance during the screening of NCDs. This evidence has relevance for the Indian public health system, which is struggling due to short-staffing, and is a value addition for training BFNs.
... Javaid et al. [39] experiemented the use of animated 169:6 Deepika Yadav, Anushka Bhandari, & Pushpendra Singh videos in teaching CHWs in Pakistan and found significant knowledge gains over regular methods. Some interventions have been explored in countries where the education levels of CHWs are high or technology resources are good [33,74,84], there are not many deployments in marginalized regions. The research gap is of particular concern given that the governments, global foundations, and policymakers are looking promisingly towards ICT-based interventions. ...
Full-text available
Despite a crucial role in providing public health services, Community Health Workers (CHWs) remain disadvantaged in receiving effective skill-building opportunities. Due to the lack of health experts and appropriate infrastructure, it becomes challenging to provide training on a regular basis. Our aim is to investigate opportunities for designing technology-supported collaborative learning to compensate for the limited availability of instructors. We designed a mobile learning-based peer-led educational intervention, and conducted an eight week long between-group study with 120 CHWs across four districts of Delhi, India. We found that CHWs were able to participate and use the system on their own leading to significant knowledge gains and increased desire to learn. With little guidance, CHWs exhibited benefits of collaborative learning in terms of positive interdependence on each other and use of interpersonal skills. The informal peer learning environment encouraged CHWs to have discourses on deeper societal aspects e.g. their role in society.
Full-text available
Faith-based organizations (FBOs) can play an important role in improving health outcomes. Lay community health advisors (CHAs) are integral to these efforts. This paper assesses the sustainability of a CHA training program for congregants in African-American and Latino FBOs and subsequent implementation of educational workshops. The program is unique in that a health care chaplain in an academic medical center was central to the program’s development and implementation. Forty-eight CHAs in 11 FBOs were trained to teach workshops on cardiovascular health, mental health, diabetes, and smoking cessation. Two thousand four hundred and forty-four participants attended 70 workshops. This program has the potential to be a model to educate individuals and to address health inequities in underserved communities. Health care chaplains in other medical centers may use this as a model for enhancing community engagement and education.
Conference Paper
Accredited Social Health Activists in India play a critical role in improving the access to healthcare services of rural populations. Despite their key contribution in Millennium Development Goals, they receive inadequate training and supervision. Traditional face to face training face challenges of infrastructure, management and cost. Existing research studies have highlighted the potential of alternative approaches e.g. mHealth for capacity building, however so far they mainly focus on providing job aids only.
Globally, cancer care delivery is marked by inequalities, where some economic, demographic, and sociocultural groups have worse outcomes than others. In this review, we sought to identify patient-facing interventions designed to reduce disparities in cancer care in both high- and low-income countries. We found two broad categories of interventions that have been studied in the current literature: Patient navigation and telehealth. Navigation has the strongest evidence base for reducing disparities, primarily in cancer screening. Improved outcomes with navigation interventions have been seen in both high- and low-income countries. Telehealth interventions remain an active area of exploration, primarily in high income countries, with the best evidence being for the remote delivery of palliative care. Ongoing research is needed to identify the most efficacious, cost-effective, and scalable interventions to reduce barriers to the receipt of cancer care globally.
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Background Community-based approaches have been increasing in the effort to raise awareness and early detection for cancer and other chronic disease. However, many times, such interventions are tested in randomized trials, become evidence-based, and then fail to reach further use in the community. Project HEAL (Health through Early Awareness and Learning) is an implementation trial that aims to compare two strategies of implementing evidence-based cancer communication interventions in African American faith-based organizations. Method This article describes the community-engaged process of transforming three evidence-based cancer communication interventions into a coherent, branded strategy for training community health advisors with two delivery mechanisms. Peer community health advisors receive training through either a traditional classroom approach (with high technical assistance/support) or a web-based training portal (with low technical assistance/support). Results We describe the process, outline the intervention components, report on the pilot test, and conclude with lessons learned from each of these phases. Though the pilot phase showed feasibility, it resulted in modifications to data collection protocols and team and community member roles and expectations. Conclusions Project HEAL offers a promising strategy to implement evidence-based interventions in community settings through the use of technology. There could be wider implications for chronic disease prevention and control.
Full-text available
Clinicians and researchers are increasingly using technology-based behavioral health interventions to improve intervention effectiveness and to reach underserved populations. However, these interventions are rarely informed by evidence-based findings of how technology can be optimized to promote acquisition of key skills and information. At the same time, experts in multimedia learning generally do not apply their findings to health education or conduct research in clinical contexts. This paper presents an overview of some key aspects of multimedia learning research that may allow those developing health interventions to apply informational technology with the same rigor as behavioral science content. We synthesized empirical multimedia learning literature from 1992 to 2011. We identified key findings and suggested a framework for integrating technology with educational and behavioral science theory. A scientific, evidence-driven approach to developing technology-based interventions can yield greater effectiveness, improved fidelity, increased outcomes, and better client service.
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Background: Many U.S. adults have multiple behavioral risk factors, and effective, scalable interventions are needed to promote population-level health. In the health care setting, interventions are often provided in print, although accessible to nearly everyone, are brief (e.g., pamphlets), are not interactive, and can require some logistics around distribution. Web-based interventions offer more interactivity but may not be accessible to all. Healthy Directions 2 was a primary care-based cluster randomized controlled trial designed to improve five behavioral cancer risk factors among a diverse sample of adults (n = 2,440) in metropolitan Boston. Intervention materials were available via print or the web. Purpose. To (a) describe the Healthy Directions 2 study design and (b) identify baseline factors associated with whether participants opted for print or web-based materials. Methods: Hierarchical regression models corrected for clustering by physician were built to examine factors associated with choice of intervention modality. Results: At baseline, just 4.0% of participants met all behavioral recommendations. Nearly equivalent numbers of intervention participants opted for print and web-based materials (44.6% vs. 55.4%). Participants choosing web-based materials were younger, and reported having a better financial status, better perceived health, greater computer comfort, and more frequent Internet use (p < .05) than those opting for print. In addition, Whites were more likely to pick web-based material than Black participants. Conclusions: Interventions addressing multiple behaviors are needed in the primary care setting, but they should be available in web and print formats as nearly equal number of participants chose each option, and there are significant differences in the population groups using each modality.
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Colorectal cancer screening has clear benefits in terms of mortality reduction; however, it is still underutilized and especially among medically underserved populations, including African Americans, who also suffer a disproportionate colorectal cancer burden. This study consisted of a theory-driven (health belief model) spiritually based intervention aimed at increasing screening among African Americans through a community health advisor-led educational series in 16 churches. Using a randomized design, churches were assigned to receive either the spiritually based intervention or a nonspiritual comparison, which was the same in every way except that it did not contain spiritual/religious content and themes. Trained and certified peer community health advisors in each church led a series of two group educational sessions on colorectal cancer and screening. Study enrollees completed a baseline, 1-month, and 12-month follow-up survey at their churches. The interventions had significant pre-post impact on awareness of all four screening modalities, and self-report receipt of fecal occult blood test, flexible sigmoidoscopy, and colonoscopy. There were no significant study group differences in study outcomes, with the exception of fecal occult blood test utilization, whereas those in the nonspiritual intervention reported significantly greater pre-post change. Both of these community-engaged, theory-driven, culturally relevant approaches to increasing colorectal cancer awareness and screening appeared to have an impact on study outcomes. Although adding spiritual/religious themes to the intervention was appealing to the audience, it may not result in increased intervention efficacy.
The aim of this paper is to give a brief description of the utilization of community health workers (CHWs) in Gazankulu. The general policy framework in which these health workers function is described briefly, and the way in which these workers function evaluated. This paper is intended as a modest contribution to evaluation research in the field of community health.
For hundreds of years verbal messages - such as lectures and printed lessons - have been the primary means of explaining ideas to learners. In Multimedia Learning Richard Mayer explores ways of going beyond the purely verbal by combining words and pictures for effective teaching. Multimedia encyclopedias have become the latest addition to students' reference tools, and the world wide web is full of messages that combine words and pictures. Do these forms of presentation help learners? If so, what is the best way to design multimedia messages for optimal learning? Drawing upon 10 years of research, the author provides seven principles for the design of multimedia messages and a cognitive theory of multimedia learning. In short, this book summarizes research aimed at realizing the promise of multimedia learning - that is, the potential of using words and pictures together to promote human understanding.
As Web 2.0 and social media make the communication landscape increasingly participatory, empirical evidence is needed regarding their impact on and utility for health promotion. Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, we searched 4 medical and social science databases for literature (2004–present) on the intersection of Web 2.0 and health. A total of 514 unique publications matched our criteria. We classified references as commentaries and reviews (n = 267), descriptive studies (n = 213), and pilot intervention studies (n = 34). The scarcity of empirical evidence points to the need for more interventions with participatory and user-generated features. Innovative study designs and measurement methods are needed to understand the communication landscape and to critically assess intervention effectiveness. To address health disparities, interventions must consider accessibility for vulnerable populations.
OBJECTIVE: The objective of this study was to compare the costs associated with Internet and print-based physical activity interventions. METHOD: The costs associated with delivering tailored print and Internet-based interventions were estimated from a randomized controlled physical activity trial (n=167). The estimates were based on research assistant time sampling surveys, web development invoices, and other tracking procedures. RESULTS: Web-development costs for the Internet intervention were $109,564. Taken together with the website hosting fees and staff costs, the cost per participant per month was $122.52 The cost of the print intervention was $35.81 per participant per month. However, in a break-even analysis, the Internet intervention became more cost-efficient, relative to the print intervention, when the total number of participants exceeded 352. CONCLUSIONS: Relative to print-based interventions, Internet-based interventions may be a more cost efficient way to reach a large number of sedentary individuals.