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

Abstract

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).

Full text

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/
AJPH.2014.302237)
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.
1
Such interventions, without intentional effort,
do not disseminate themselves into practice.
2
Interest in dissemination and implementation
research is growing. Consistent with Rabin
et al.,
3
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 field in
general.
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.
4
This includes research
on successful implementation of interventions
serving culturally and ethnically diverse pop-
ulations.
2
Peer health educators are viewed
as a promising strategy to achieve this goal.
5
Volunteer laypeople, such as those used in the
community health advisor (CHA) model, have
been used worldwide to promote health.
6
This
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.
6---10
ROLE OF TECHNOLOGY IN
DISSEMINATION AND
IMPLEMENTATION
Taking advantage of today’s continuously
evolving technology landscape enhances the
capacity to close the gap between research
discovery and program delivery.
11
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.
12
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
technologies—the Internet, social media, per-
sonal digital assistants, cellular phones, and
computer kiosks—to disseminate health informa-
tion, promote health-related behavior change,
and encourage informed decision-making.
13---16
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.
14,16
In addition, the focus on integrating eHealth
tools in peer health education interventions to
reach more diverse and broader audiences is
increasing.
17---27
One such intervention is the
Centers for Disease Control and Prevention’s
Web-based e-learning course for promoting
the engagement of professional community
health workers.
25
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 fidelity, and the reduction of
geographically based, time-based, and
mobility-based barriers.
28---32
For example,
using Web-based technology increases the
potential for wider dissemination and
implementation of efficacious 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 workers—health professionals
seeking continuing education or supplemental
education—or are offered as a formalized
course with a dedicated instructor and appli-
cable tuition fees.
17---27
To our knowledge, the
current project is one of the first 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.
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PROJECT HEAL WEB-BASED
TRAINING
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
approach.
33---35
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.
Overview
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.
36
This
research was conducted in Prince George’s
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 significant propor-
tion of residents affected by health disparities.
37
Project HEAL used a cluster randomized
design in which CHAs in self-identified 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.
36
Integrated Web-Based Training
Curriculum
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-
specific training videos (e.g., overview of can-
cer, breast cancer, leadership skills, ethical
issues) with corresponding PDFs, and CHA
certification 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
format.
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,
38
which
postulates facilitated learning and enhanced
recall with the combined use of nonverbal
and verbal stimuli, the content-specific training
modules were developed and narrated in
Microsoft PowerPoint as multimedia files and
then converted to MOV format. The MOV file
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
Login
Introduction Page
Informed Consent
MOU
Knowledge Examination
CHA Evaluation
Workshop Materials
CHA Training
Videos/PDFs
“retake until pass”
Note. CHA = community health advisor; HEAL = Health through Early Awareness and Learning; MOU = memorandum of
understanding.
FIGURE 1—Project HEAL Web-based training flow diagram: Prince George’s County, MD,
2012–2014.
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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
certification 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 identified 2 potential CHAs (1 man,
1 woman) who met the CHA eligibility re-
quirements:
1. self-identified 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 identified and recruited
by their respective pastors, study staff e-mailed
each CHA a personalized username and
password.
Figure 1 depicts the Web-based training
flowchart. 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 agree”or “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-specific
modules in 2 available formats to cater to
Randomized (15 churches)
Churches: n
=
8
Recruited CHAs (n
=
16, 2 per church)
Traditional Classroom Condition (TC-CHA)
Churches: n
=
7
Recruited CHAs (n
=
14, 2 per church)
Technology-Based Condition (TB-CHA)
Lost to follow-up (n
=
0)
Churches replaced (n
=
0)
Churches not replaced (n
=
0)
Churches CHAs
Lost to follow-up (n
=
2)
Withdrew with church (n
=
0)
Replaced with new church
(n
=
0)
Withdrew and replaced in
same church (n
=
2)
Lost to follow-up (n
=
2)
Churches replaced (n
=
1)
Churches not replaced (n
=
1)
a
Churches CHAs
Lost to follow-up (n
=
6)
Withdrew with church (n
=
4)
Replaced with new church
(n
=
2)
Withdrew and replaced in
same church (n
=
2)
Completed 3-workshop series
(n
=
8)
Completed 3-workshop series
(n
=
6)
Completed training/certication
(n
=
16)
Completed training/certication
(n
=
14)
a
CHA training evaluation
completed (n
=
16)
CHA postworkshop evaluation
completed (n
=
16)
CHA training evaluation
completed (n
=
12)
CHA postworkshop evaluation
completed (n
=
12)
Note. CHA = community health advisor; HEAL =Health through Early Awareness and Learning.
a
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.
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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
certification examination. This examination
contained cancer-specific 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 certificate 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 flyers, workshop
sign-in 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.
WEB-BASED TRAINING
IMPLEMENTATION OUTCOMES
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 bachelor’s 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 certified 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 certification examination, though
it is possible that they did not all pass on
the first 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,
2012–2014
Variable
Technology-Based
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
a
Home Internet access 11 (91.7) 16 (100.0)
Work Internet access 9 (75.0) 13 (86.7)
a
Education
< 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)
b
5 (38.5)
c
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)
a
Lead a different health activity in CHA’s congregation 12 (100.0) 10 (76.9)
c
Recommend becoming a CHA to a peer 12 (100.0) 14 (100.0)
d
Recommend Project HEAL to men and women in CHA’s church 12 (100.0) 14 (100.0)
d
“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.
a
n = 15.
b
n = 11.
c
n = 13.
d
n = 14.
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(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 certification examination on the
first 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 CHAs’Web-
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 modified 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
certification 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 certified (SD = 25.9; range = 0.0---89.0;
Table 2). All churches with certified TB-CHAs
completed the workshop series (n = 6).
Churches scheduled or completed their first
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 =
3.4---12.1).
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 useful”to 4 =“very
useful”). Overall, CHAs in both groups were
highly satisfied 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 confident”to 4 = “very
confident”) such as confidence 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 confi-
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.
EVALUATION
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.
1
Advisor 1 12 7 11.1
Advisor 2 10 8 11.0
2
Advisor 1 8 18 3.4
Advisor 2 9 16 3.7
3
Advisor 1 3 0 22.3
Advisor 2 4 4 21.7
4
Advisor 1 8 40 13.9
Advisor 2 8 7 18.6
5
Advisor 1 6 70 22.0
Advisor 2
a
21 15 6.0
6
b
Advisor 1 NA NA NA
Advisor 2 NA NA NA
7
c
Advisor 1 7 33 NA
Advisor 2 12 29 NA
8
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.
a
CHA replaced twice; both occurrences because of medical issues.
b
Church dropped out before CHAs trained and certified; replaced by church 8.
c
CHAs trained and certified, but church dropped out before first workshop date; church not replaced because of late dropout.
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compare reasonably well with the data from
classroom-trained CHAs. Both training methods
ultimately led to (1) the successful training and
certification 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 confidence 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.
28
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 simplified for ease of
use with less technical assistance and greater
scalability.
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 significant 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 efficient 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
CHAs—though not used by the 6 TB-CHA
churches during the trial phase—not 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
certification. 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 certification 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 certification 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.
39
This approach uses
a library of graphics and targeted messages in
various languages for individuals of different
demographic subgroups.
Although technology may be more efficient
and cost-effective than the traditional class-
room training approach,
29---32
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 modified 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.
14,40
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.
12,40,41
The Project HEAL training portal can be
operated on a computer, smartphone, or tablet.
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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 users—a 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
access.
12
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
CHAs.
CONCLUSIONS
Using novel health communication strategies
in today’s fast-changing technological environ-
ment can increase the capacity to close the gap
between research discovery and program de-
livery.
11
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
efficiency 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 George’s 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: cholt14@umd.edu). Reprints can be ordered at
http://www.ajph.org by clicking the “Reprints”link.
This article was accepted July 22, 2014.
Contributors
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 scientificand
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 final article.
Acknowledgments
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).
References
1. Glasgow RE, Marcus AC, Bull SS, Wilson KM.
Disseminating effective cancer screening interventions.
Cancer. 2004;101(5 suppl):1239---1250.
2. National Institute of Mental Health, US Depart-
ment of Health and Human Services. The Road Ahead:
Research Partnerships to Transform Services—AReport
by the National Advisory Mental Health Council’sSer-
vices Research and Clinical Epidemiology Workgroup.
Bethesda, MD: National Institute of Mental Health;
2006.
3. Rabin BA, Brownson RC, Haire-Joshu D, Kreuter
MW, Weaver NL. A glossary for dissemination and
implementation research in health. J Public Health Manag
Pract. 2008;14(2):117---123.
4. Kerner JF, Guirguis-Blake J, Hennessey KD, et al.
Translating research into improved outcomes in com-
prehensive cancer control. Cancer Causes Control.
2005;16(suppl):27---40.
5. Ellis P, Robinson P, Ciliska D, et al. Diffusion and
Dissemination of Evidence-Based Cancer Control Interven-
tions. Rockville, MD: Agency for Healthcare Research
and Quality; 2003. AHRQ Publication No. 03---E033.
Available at: http://www.ncbi.nlm.nih.gov/books/
NBK36992/#_ncbi_dlg_citbx_NBK36992. Accessed
February 28, 2014.
6. Witmer A, Seifer SD, Finocchio L, Leslie J, O’Neil EH.
Community health workers: integral members of the
health care work force. Am J Public Health. 1995;
85(8 pt 1):1055---1058.
7. Walt G, ed. Community Health Workers in National
Programmes: Just Another Pair of Hands? Philadelphia,
PA: Open University Press; 1990.
8. Indian Health Service. Alaska Community Health Aide
Program Description. Washington, DC: Government
Printing Office; 1991.
9. Giblin PT. Effective utilization and evaluation of
indigenous health care workers. Public Health Rep.
1989;104(4):361---368.
10. Richter RW, Bengen B, Alsup PA, Bruun B, Kilcoyne
MM, Challenor BD. The community health worker: a re-
source for improved health care delivery. Am J Public
Health. 1974;64(11):1056---1061.
11. Chou W-YS, Prestin A, Lyons C, Wen K-Y. Web 2.0
for health promotion: reviewing the current evidence.
Am J Public Health. 2013;103(1):e9---e18.
12. Fox S, Duggan M. Health online 2013. Available
at: http://www.pewinternet.org/files/old-media/Files/
Reports/PIP_HealthOnline.pdf. Accessed May 31,
2013.
13. Eng TR. eHealth research and evaluation: chal-
lenges and opportunities. J Health Commun. 2002;7(4):
267---272.
14. Strecher V. Internet methods for delivering behav-
ioral and health-related interventions (eHealth). Annu
Rev Clin Psychol. 2007;3:53---76.
15. Turner-Lee N, Smedley BD, Miller JS. Minorities,
mobile broadband, and the management of chronic
diseases. Available at: http://jointcenter.org/sites/
default/files/Minorities%20Mobile%20Broadband%
20and%20the%20Management%20of%20Chronic%
20Diseases_0.pdf. Accessed July 9, 2014.
16. Aronson ID, Marsch LA, Acosta MC. Using findings
in multimedia learning to inform technology-based be-
havioral health interventions. Transl Behav Med. 2013;
3(3):234---243.
17. Livestrong Foundation. Livestrong promotores
program. Available at: http://www.livestrong.org/What-
We-Do/Our-Actions/Professional-Tools-Training/
LIVESTRONG-Promotores-Program. Accessed February
27, 2014.
18. Patient Navigator Training Collaborative. eLearning.
Available at: http://patientnavigatortraining.org/
courses/elearning-courses. Accessed February 11, 2014.
19. Texas Department of State Health Services. Com-
munity health workers: training information. Available
at: http://www.dshs.state.tx.us/mch/chw/training.aspx.
Accessed February 11, 2014.
FRAMING HEALTH MATTERS
2288 |Framing Health Matters |Peer Reviewed |Santos et al. American Journal of Public Health |December 2014, Vol 104, No. 12

20. Landon B, Loudon J, Selle M, Doucette S. Factors
influencing the retention and attrition of community
health aides/practitioners in Alaska. J Rural Health.
2004;20(3):221---230.
21. Massachusetts Department of Public Health. CHW
training program details: community health worker
online training. Available at: http://chwtraining.org/chw-
training-program-details. Accessed February 27, 2014.
22. Indian Health Service. Education: Fundamentals of
diabetes care. Available at: http://www.ihs.gov/chr/
index.cfm?module=DiabetesFundamentals. Accessed
July 9, 2014.
23. Minnesota Community Health Worker Alliance.
CHW: Education. Available at: http://mnchwalliance.
org/explore-the-field/education-2. Accessed February
24, 2014.
24. Rural Assistance Center. Community health work-
ers toolkit. Available at: http://www.raconline.org/
communityhealth/chw. Accessed February 24, 2014.
25. Brownstein JN, Mirambeau AM, Roland KB. News
from the CDC: using Web-based training to translate
evidence on the value of community health workers into
public health action. Transl Behav Med. 2013;3(3):229---
230.
26. Johns Hopkins Bloomberg School of Public Health.
Training and learning programs for volunteer community
health workers. Available at: http://www.coursera.org/
course/commhealthworkers. Accessed February 19, 2014.
27. Center for Community Health Development. Center
for Community Health Development’s Community
Health Worker Training Center. Available at: http://
www.cchd.us/pages/trainingcenter.html. Accessed
February 10, 2014.
28. Glang A, Noell J, Ary D, Swartz L. Using interactive
multimedia to teach pedestrian safety: an exploratory
study. Am J Health Behav. 2005;29(5):435---442.
29. Griffiths F, Lindenmeyer A, Powell J, Lowe P,
Thorogood M. Why are health care interventions de-
livered over the Internet? A systematic review of the
published literature. J Med Internet Res. 2006;8(2):e10.
30. Bennett GG, Glasgow RE. The delivery of public
health interventions via the Internet: actualizing their
potential. Annu Rev Public Health. 2009;30:273---292.
31. Lewis BA, Williams DM, Neighbors CJ, Jakicic JM,
Marcus BH. Cost analysis of Internet vs. print interven-
tions for physical activity promotion. Psychol Sport Exerc.
2010;11(3):246---249.
32. Marsch LA. Technology-based interventions tar-
geting substance use disorders and related issues: an
editorial. Subst Use Misuse. 2011;46(1):1---3.
33. Holt CL, Klem PR. As you go, spread the word:
spiritually based breast cancer education for African
American women. Gynecol Oncol. 2005;99(3 suppl 1):
S141---S142.
34. Holt CL, Wynn TA, Litaker MS, Southward P,
Jeames S, Schulz E. A comparison of a spiritually based
and non-spiritually based educational intervention for
informed decision making for prostate cancer screening
among church-attending African-American men. Urol
Nurs. 2009;29(4):249---258.
35. Holt CL, Litaker MS, Scarinci IC, et al. Spiritually
based intervention to increase colorectal cancer screen-
ing among African Americans: screening and theory-
based outcomes from a randomized trial. Health Educ
Behav. 2013;40(4):458---468.
36. Holt CL, Tagai EK, Scheirer MA, et al. Translating
evidence-based interventions for implementation: expe-
riences from Project HEAL in African American
churches. Implement Sci. 2014;9:66.
37. US Census Bureau. Prince George’s County quick-
facts. Available at: http://quickfacts.census.gov/qfd/
states/24/24033.html. Accessed February 25, 2014.
38. Mayer R. Multimedia Learning. New York, NY:
Cambridge University Press; 2001.
39. MIYO (Make It Your Own) [computer program].
St. Louis, MO: Washington University in St. Louis, George
Warren Brown School of Social Work, Health Commu-
nication Research Laboratory. Available at: http://
www.miyoworks.org. Accessed July 9, 2014.
40. Greaney ML, Puleo E, Bennett GG, et al. Factors
associated with choice of Web or print intervention
materials in the Healthy Directions 2 study. Health Educ
Behav. 2014;41(1):52---62.
41. Miller EA, West DM, Wasserman M. Health in-
formation Websites: characteristics of US users by race
and ethnicity. J Telemed Telecare. 2007;13(6):298---302.
FRAMING HEALTH MATTERS
December 2014, Vol 104, No. 12 |American Journal of Public Health Santos et al. |Peer Reviewed |Framing Health Matters |2289