Assessing the feasibility of an online training designed to enable community health workers to deliver a comprehensive, evidence-based weight loss intervention for rural African Americans of faith

Abstract

Background:

Obesity is a critical modifiable risk factor in cancer prevention, control, and survivorship. Comprehensive weight loss interventions (e.g. Diabetes Prevention Program (DPP)) have been recommended by governmental agencies to treat obesity. However, their high implementation costs limit their reach, especially in underserved African American (AA) communities. Community health workers (CHWs) or trusted community members can help increase access to obesity interventions in underserved regions facing provider shortages. CHW-led interventions have been shown to increase weight loss. However, in-person CHW training can be costly to deliver and often requires extensive travel to implement. Web-based trainings have become common to increase reach at reduced cost. However, the feasibility of an online CHW training to deliver the DPP in AAs is unknown.

Methods:

The feasibility of an online CHW training to deliver the DPP adapted for AAs was assessed. The online training was compared to an in-person DPP training with established effectiveness. CHW effectiveness and satisfaction were assessed at baseline and 6-weeks.

Results:

Nineteen participants (in-person n=10; online n=9) were recruited. At post-training, all scored higher than the 80% on a knowledge test required to deliver the intervention. All participants reported high levels of training satisfaction (88.9% of online participants and 90% of in-person participants rated the training as at least 6 on a 1–7 scale) and comfort to complete intervention tasks (78% of online participants and 60% of in-person participants scored at least 6 on a 1–7 scale). There were no significant differences in outcomes by arm.

Discussion:

An online CHW training to deliver the DPP adapted for AAs faith communities produced comparable effectiveness and satisfaction to an evidence-based in-person CHW training. Further research is needed to assess the cost-effectiveness of different CHW training modalities to reduce obesity.

BACKGROUND

Excess body weight is a critical modifiable risk factor for numerous cancers^1–3 and one of the top public health problems in the country.^4–6 Adiposity is associated with increased cancer incidence, cancer mortality, and poorer prognosis at diagnosis^1–3. Underserved groups, such as African American (AA) and rural residents bear a disproportionate burden^6–8. A myriad of social factors, including racism, poverty, and lack of educational and economic opportunities^9,10 have contributed to the disproportionate burden of obesity in rural AAs.

Behavioral weight loss interventions (e.g. Diabetes Prevention Program (DPP)) have been recommended by several governmental agencies^11,12 to treat obesity and improve cancer risk, control, and survivorship.³. These intensive 6–12 month interventions have caused an average weight loss of 2.9 kg in AA adults¹³, reduce the risk of chronic diseases associated with obesity¹⁴, and have maintained weight loss for 48 months¹⁴. Despite the ability of the DPP and similar interventions to produce and sustain weight loss in AAs, health care provider shortages in underserved areas have resulted in access gaps. The high cost of implementing comprehensive behavioral weight loss interventions (e.g. delivery by health professionals, in-person intervention delivery) limits their reach, adoption, and sustainability¹⁵. This high cost is particularly prohibitive for DPP implementation among underserved communities¹⁵.

Strategies to reduce cost and maximize spread of the DPP have included training community health workers (CHWs). CHWs are community members who are not health professionals but have been trained to some extent to serve as a bridge between communities and health care services¹⁶. CHWs’ effectiveness in disease prevention and health promotion—including behaviors associated with weight loss and cancer^17,18—has led to the World Health Organization’s promotion of integrating CHWs in health systems¹⁹. CHWs have been used to scale-up health interventions in underserved areas^16,19,20, and several DPP-adapted interventions delivered by CHWs have reported significant weight loss among samples including AA^13,21.

In-person training strategies of CHWs have been the norm¹⁹, but web-based trainings have become increasingly common to increase training reach—particularly in low-resource areas where face-to-face training is limited due to the considerable distance between training sites and CHWs, fewer number of trainers, and lower internet access^19,20,22. One randomized controlled trial that tested a web-based training for CHWs to deliver a tobacco cessation intervention reported no differences in CHW outcomes (knowledge, self-efficacy, intervention delivery frequency) by training modality (in-person vs. web-based)²³. In other studies, CHWs reported that learning computer skills was a training barrier and that web-based trainings did not facilitate the same level of interaction between CHWs and the project compared to in-person trainings^19,24.

Purpose

Prior studies have not tested the feasibility of an online training to equip CHWs to deliver the DPP adapted for rural AAs. Thus the study tested the feasibility of an online training designed to enable CHWs to deliver the DPP for those who bear a disproportionate obesity burden—rural AA adults. The feasibility of the online CHW training was compared to an in-person CHW DPP weight loss training with established effectiveness²⁵. The study’s central hypothesis was that compared to an in-person training, an online training of CHWs would result in equivalent effectiveness (user’s accurate and comprehensive completion of tasks) and satisfaction (user’s comfort and acceptance). The online training was also hypothesized to be attractive (e.g. capture users attention) to users.

METHODS

Setting and Partnerships

The study took place in the Arkansas Delta, a predominately rural region bordering the Mississippi River in eight states²⁶. An estimated 16–22% of households in the Delta have incomes below the federal poverty level²⁷. It is well established that rates of chronic disease are higher in the Delta than the rest of the nation, with Delta counties having higher rates of obesity compared to non-Delta counties²⁸.

The study built on a 14-year collaboration between Dr. Yeary and a Community Advisory Board known as the Faith Task Force, which has received federal funding for behavioral change interventions for over a decade^21,25. One of the projects the Faith Task Force led was The WORD (Wholeness, Oneness, Righteousness, Deliverance), a 5-year cluster-randomized effectiveness trial of the DPP translated for rural AA adults of faith. The WORD’s effectiveness was tested among 440 AA participants nested in 31 black churches. Trained CHWs (n=61) delivered the group-based intervention, which consisted of 16 core lessons and 12 maintenance lessons. The WORD produced significant weight loss from baseline to 6-month follow-up in participants [−2.47% (−3.13%, −1.80%); 21.8% losing at least 5% (clinically significant weight loss)] that is comparable to the weight loss produced in AAs by other DPP adaptations¹³. The in-person training of CHWs for The WORD was used in the current study as the comparison to the online CHW training. CHWs for The WORD’s effectiveness trial reported high levels of training satisfaction (6.68 (range of 1=low, 7=high)) and self-efficacy (6.35 (range of 1=low, 7=high)) to deliver program components, in addition to program fidelity (average composite fidelity scores was 25 (range of 6=low, 30=high).

Recruitment

The team’s preexisting networks throughout the Arkansas Delta region were engaged to recruit 20 participants. Eligibility criteria included: 1) aged 18 and older; 2) AA; and 3) no previous CHW training. The team recruited participants using personal contacts, flyers, and announcements to community organizations. Computer-based, rolling randomization was used to assign participants to the in-person or on-line training.

Training

Participants in both arms were trained within a 6-week timeframe. Each participant who completed the training received a total of $200. All participants were assessed at baseline and 6-weeks (post-training) and received compensation (baseline=$10, follow-up=$20).

In-person Training

Participants randomized to the in-person training received the training from The WORD (Table 1). The WORD’s training of CHWs is entirely in-person and consists of 7 sessions (15–18 hours total) delivered over 4–6 weeks²⁵.

Table 1.

Trainee demographic characteristics (n=19)

	Percentage (n)
Female	89% (17)
Age (years) (mean, SD)	57.2 (9.2)
African American	100% (19)
Hispanic or Latino (yes)	0% (0)
Marital status
Married or member of an unmarried couple	84.2% (16)
Other	15.8% (3)
Education
Less than high school	36.8% (7)
High school or more	63.2% (12)
Income
Less than $25,000	47.4% (9)
$25,000-or more	52.6% (10)
Insurance
Private	47.4% (9)
Other	52.6% (10)
Employment
Employed	63.2% (12)
Other	36.8 (7)
Household size (mean, SD)	2.1 (0.85)

The training was delivered by a Master Trainer certified by the Centers of Disease Control (CDC) to train others to deliver the DPP. The Master Trainer used a training-of-trainers model that incorporated didactic education, experiential learning, trainee practice, and written and verbal feedback to train CHWs to facilitate the intervention. The training builds knowledge about obesity and health, obesity-related health behaviors, and behavioral strategies through experiential learning. The training also includes a description of the CHW and social support and network models, in addition to skills in group facilitation, leadership, communication, and behavior change promotion. Mastering of training content is confirmed through CHWs scoring 80% or higher on quizzes and demonstrating appropriate lesson delivery to the Master Trainer.

Online CHW DPP Training

Previous work in the use of technology in weight change from the literature²⁹ and the team’s expertise in behavior change using e-learning tools²⁹ was used to adapt The WORD’s in-person training to an online training. The online training consists of 9 training sessions, with the first and last training session delivered by The Master Trainer in person. The first in-person training session consists of an overview of the online training platform, any needed instruction in basic computer skills to access and complete the training (e.g. uploading files), and a summary of trainings topics. After receiving the in-person introduction to the training, CHWs receive a weblink via email to the interactive online training delivered through Coursesites. To mirror the in-person training content, the online training consists of 7 sessions. Each session includes animated slide presentations³⁰, videos by investigators to explain concepts (total duration of all videos: 2 hours and 23-minutes total), assignments, and quizzes to verify mastery of module concepts. The CHWs were directed to complete the sessions in sequential order and were required to score at least an 80% on quizzes to advance to subsequent modules. CHWs were asked to complete the online training in 4 weeks. The final in-person training session was then delivered by the Master Trainer at least 2 weeks within online training completion, whereby CHWs practiced delivering intervention lessons. The final in-person training session was delivered either in group or individual formats.

Assessment

In addition to participant characteristics, the following attributes of usability were assessed: effectiveness (user’s accurate and comprehensive completion of tasks), satisfaction (user’s comfort and acceptance), and attractiveness of online platform only (attracting the user’s attention)³¹. The Master Trainer administered all assessments. To minimize any pressure participants may have felt to assess the training positively, the Master Trainer left the room when participants completed the anonymous assessments and placed assessments in an envelope. All measurements were assessed at baseline and 6-weeks follow-up unless otherwise stated.

Participant characteristics

Demographics of gender, age, race/ethnicity, education, marital status, employment, income, household size, and health insurance were assessed through self-report at baseline only. Computer self-efficacy was assessed by a 14-item scale³². Respondents selected the level of confidence they felt completing computer-related tasks (e.g. copying a file, using a printer). Likert responses ranged from 1=Very little confidence, to 5=Quite a lot of confidence. The 14 items were summed to create a total computer confidence score for each respondent, ranging from 14 (low) to 70 (high).

Effectiveness

Content knowledge needed for CHWs to deliver the intervention was assessed using a 21-item quiz previously used in The WORD studies^21,25. The multiple choice quiz assesses knowledge regarding the intervention’s goals (i.e. weight loss, healthy eating, physical activity), rationale of the goals, leading groups, self-monitoring, and safety. Participants were required to score at least an 80% on the quiz to complete the training.

Satisfaction

Multiple domains of training satisfaction were assessed. Participants in both arms were asked about their comfort in delivering intervention components through indicating their level of comfort in completing 11 intervention delivery tasks (e.g. delivering the lessons, giving feedback to track books, checking in and weighing group members, etc.). Likert responses ranged from 1=Not at all comfortable, to 7=Very comfortable. Participants were also asked how comfortable they felt overall with their role as a CHW.

Participants were also asked about their overall opinion of the training through a single item, with Likert responses ranging from 1=Not very well at all, to 7=Very well. Training length was assessed by asking participants whether they thought the training should have been longer, shorter, or the same. Time spent in training was also captured by the Master Trainer (in-person arm) or computer platform (on-line arm). All trainees rank ordered training aspects. Those in the in-person arm rank ordered their training aspects (i.e. presentations, keeping track, delivering program lesson, demonstrations, interactions with trainer, interacting with other trainees) from 1=6, with 1=Liked that part of the training the best, to 6=Liked that part of the training the least. Participants in the online training arm were asked to rank order aspects of their training (i.e. videos, tests, in-person training) from 1 to 3, with 1=Liking it the least, and 3=Liking it the best.

In the in-person arm, participants were asked the degree they were satisfied with materials received at training and with their Master Trainer, with Likert responses ranging from 1=Not at all satisfied, to 4=Very Satisfied. In the online arm, participants were also asked their degree of satisfaction with specific online training components, including the training videos, tests, in-person sessions, and the online training platform. Likert responses ranged from 1=Not at all satisfied, to 4=Very satisfied.

In the online arm only, ease of moving through the online training was assessed by a single item that asked participants how difficult it was to move through the training, with Likert responses ranging from 1=Not difficult at all to 4=Very difficult.

Attractiveness

Visual appeal of the online training was assessed in online arm participants only and included four questions assessing the degree to which different training components (i.e. videos, tests, in-person session, overall training platform) captured the user’s attention³³. Likert responses ranged from 1=Did not capture my attention at all to 4=Captured my attention a lot.

RESULTS

Participant Characteristics

Demographics are reported in Table 1. All participants were AA and majority female (89%), with an average age of 57.2 (SD=9.2) years. Most trainees were married (84.2%); more than half were employed (63.2%), had at least a high school education (63.2%), and an income greater than $25,000 (52.6%).

On average, CHWs in the in-person training reported an average total computer efficacy score of 42.6 (SD=18.3) out of 70 at baseline and an average score of 54.5 (SD=18.1) during follow-up (i.e., average change score of 11.9). The online trainees reported an average total computer efficacy score of 56.2 (SD=13.1) at baseline and an average score of 59.0 (SD=8.2) during follow-up. This produced an average change score of 2.8 among the online trainees. There were no statistical differences in the average change scores of computer efficacy by treatment arm (p =0.249).

Effectiveness

Regarding content knowledge, CHWs at baseline who completed the in-person training (n=10) scored an average of 12.0 (SD=2.3) questions correctly (out of 21) on The WORD’s CHW training quiz (57%; not meeting the passable score of at least 80%). At follow-up, CHWs in the in-person training arm scored an average of 18.9 (SD=1.9) questions correctly (90%), a significant within arm increase (p=0.002).

CHWs in the online training arm (n=9) scored an average of 11.0 (SD=2.1) questions correctly out of 21 at baseline (52%); at follow-up CHWs scored an average of 17.0 (SD=3.2) questions (81%). The within-arm change from baseline to follow-up was statistically significant (p=0.004). There were no statistical differences between arms in content knowledge at baseline or follow-up.

Satisfaction

Comfort completing intervention tasks is reported in Table 2. A total of 60% of CHWs in the in-person arm reported a high level of comfort (6 or 7) overall in delivering the DPP and its specific components. Nearly all reported high levels of comfort (6 or 7) checking in intervention participants (WORD group members), identifying moderate physical activity, and in graphing body weight. About one third reported moderate levels comfort (4 or 5) recruiting participants, providing self-monitoring feedback, leading physical activity, completing records, and helping discouraged participants.

Table 2.

Trainee comfort in completing intervention delivery components by training modality (1=not at all comfortable, 7=very comfortable) (n=19)

	In-person (n=10) % (N)	Online (n=9) % (N)
Comfort Overall
3 or less	10% (1)	0
4 or 5	30% (3)	22.2% (2)
6 or more	60% (6)	77.8% (7)
Recruiting participants
3 or less	10% (1)	0
4 or 5	30% (3)	33.3% (3)
6 or more	60% (6)	66.6% (6)
Delivering The WORD program lessons
3 or less	10% (1)	0
4 or 5	20% (2)	44.4% (4)
6 or more	70% (7)	55.5% (5)
Giving feedback on group members’ WORD Track Books
3 or less	10% (1)	0
4 or 5	30% (3)	55.5% (5)
6 or more	60% (6)	44.4% (4)
Checking in your WORD group members
3 or less	10% (1)	0
4 or 5	0	22.2% (2)
6 or more	90% (9)	77.7% (7)
Figuring out what counts as moderate physical activity
3 or less	0	0
4 or 5	20% (2)	11.1% (1)
6 or more	80% (8)	88.8% (8)
Helping group members graph weight
3 or less	10% (1)	0
4 or 5	10% (1)	33.3% (3)
6 or more	80% (8)	66.6% (6)
Encouraging discussion between your WORD group members
3 or less	10% (1)	0
4 or 5	20% (2)	22.2% (2)
6 or more	70% (7)	77.7% (7)
Leading physical movement
3 or less	0	0
4 or 5	30% (3)	33.3% (3)
6 or more	70% (7)	66.6% (6)
Completing records on a regular basis (WORD Leader Logs)
3 or less	0	0
4 or 5	40% (4)	33.3% (3)
6 or more	60% (6)	66.6% (6)
Helping discouraged WORD group members stick with the program
3 or less	10% (1)	0
4 or 5	30% (3)	11.1% (1)
6 or more	60% (6)	88.9% (8)

The majority of CHWs in the online arm reported high levels of comfort (6 or 7) overall and in all intervention delivery components except delivery of lessons and providing self-monitoring feedback, where about half of CHWs reported high comfort levels. Nearly all CHWs reported high levels of comfort (6 or 7) ascertaining moderate physical activity and the ability to encourage discouraged group members to stick with the program. About a third reported moderate levels of comfort (4 or 5) recruiting participants, helping group members graph weight, leading physical activity, and completing CHW logs. There were no statistical differences by overall and task-specific comfort by arm.

Nine out of ten participants in the in-person training arm rated the overall training the maximum score of 7. One rated the training a 5. In the online training arm, a total of six out of nine rated the overall training the maximum score of 7. Two trainees rated the training a 6, with one trainee rating the training a 5. There were no statistical differences in overall training satisfaction by arm.

On average, in-person CHWs spent 10 hours to complete the training (time spent). A total of six participants thought the training length should remain the same. A total of three trainees reported that the training length should be longer. On average, CHWs in the online training arm completed the entire course in 6.5 hours (SD=3.3), opened the course 168 times (SD=74), opened the resources folder 1.3 times (SD=1.9), and took the tests an average 2.1 times (SD=2.7) for each module before moving to the next section. The majority (n=7) reported that the training length should remain the same.

In rank ordering training aspects, in-person arm trainees gave the highest ranking to interactions with their trainer (n=4), followed by interaction with other CHWs (n=3), presentations (n=3), practice keeping track (n=2), practice delivering lessons (n=1), and demonstrations (n=1). In the online arm, four trainees ranked the in-person sessions as the aspect of the training they liked the most, followed by the tests (n=3) and videos (n=1).

The majority of trainees (9 out of 10) in the in-person arm reported a high degree of satisfaction with both the trainer and the materials: A total of 9 out of 10 were very satisfied with their trainer, and 8 out of 10 were very satisfied with the materials. The degree of satisfaction with various online training components is reported in Table 4, in addition to trainee’s perceived ease of movement through the online training. The majority of CHWs in the online arm reported being either somewhat satisfied (n=4) or very satisfied (n=4) with the videos, tests, in-person sessions, and training platform. Regarding the ease of movement through the online training, the majority (n=6) reported the training was a little difficult to move through. Three reported it was not at all difficult.

Attractiveness

Visual appeal of various online training components is reported in Table 3. More than half (n=5) of the CHWs in the online arm reported that the videos captured their attention a lot while the remainder (n=4) reported they captured their attention somewhat. Six out of nine trainees reported that the tests captured their attention a lot and the other three trainees reported that the tests captured their attention somewhat. Five online trainees reported that the in-person sessions captured their attention somewhat while the other four reported that the in-persons sessions captured their attention a lot. Overall online CHWs reported that the online platform captured their attention, with the majority (n=7) reporting the platform captured their attention a lot, and the others (n=3) reporting it captured their attention somewhat.

Table 3.

Trainee satisfaction, appeal, and ease of the online training (n=9)

Satisfaction with training videos	% (N)
Not at all satisfied	0
A little satisfied	111 (1)
Somewhat satisfied	44.4 (4)
Very Satisfied	44.4 (4)
Satisfaction with training tests
Not at all satisfied	0
A little satisfied	11.11 (1)
Somewhat satisfied	44.4 (4)
Very Satisfied	44.4 (4)
Satisfaction with training in-person sessions
Not at all satisfied	0
A little satisfied	111 (1)
Somewhat satisfied	44.4 (4)
Very Satisfied	44.4 (4)
Satisfaction with online platform
Not at all satisfied	0
A little satisfied	111 (1)
Somewhat satisfied	44.4 (4)
Very Satisfied	44.4 (4)
To what extent did the training videos capture your attention
Did not capture my attention at all	0
Captured my attention a little	0
Captured my attention somewhat	44.4 (4)
Captured my attention a lot	55.6 (5)
To what extent did the tests capture your attention
Did not capture my attention at all	0
Captured my attention a little	0
Captured my attention somewhat	33.3 (3)
Captured my attention a lot	66.7 (6)
To what extent did the in-person sessions capture your attention
Did not capture my attention at all	0
Captured my attention a little	0
Captured my attention somewhat	55.6 (5)
Captured my attention a lot	44.4 (4)
To what extent did the overall training platform capture your attention
Did not capture my attention at all	0
Captured my attention a little	0
Captured my attention somewhat	33.3 (2)
Captured my attention a lot	77.8 (7)
How difficult was it to move through the online training
Not at all difficult	33.3 (3)
A little difficult	66.7 (6)
Somewhat difficult	0
Very difficult	0

DISCUSSION

The effectiveness and satisfaction of an online-training for CHWs to deliver an evidence-based adaptation of the DPP for rural AAs of faith was compared to an in-person CHW training with established effectiveness. There were no statistical differences in content knowledge, comfort completing intervention tasks, and training satisfaction by training arm. CHWs in the online training arm also reported high levels of attractiveness of the training platform. An online-version of a CHW training to deliver the DPP adapted for rural, underserved communities may be a feasible and more scalable alternative to traditional in-person CHW training approaches.

In a recent review of CHW-led DPP interventions, Hill et al.³⁴ report that online CHW trainings do not presently exist, and conclude that more specific information regarding what CHW trainings need to entail to maximize outcomes is needed. Several online CHW trainings targeting behaviors other than the DPP have reported user feasibility and satisfaction in the areas of cancer prevention³⁵, mental health³⁶, cardiovascular disease management²⁴, and smoking²³. To the authors’ knowledge, comparing an online vs. in-person CHW training with subsequent intervention delivery to compare behavioral outcomes has not been done. This study adds to the current literature of CHW training by providing evidence for the feasibility of an online CHW training to deliver a comprehensive evidence-based weight loss intervention.

Limitations

Limitations of the study include the study’s small sample size, which may have precluded the power to detect significant differences. Future, larger scale studies would be needed to test the online training’s effectiveness in causing weight loss and related outcomes in the context of DPP delivery. Comparing the cost-effectiveness of both training methods (online vs. in-person) would also advance the literature.

Implications for practice and research

Currently, dissemination of the DPP is a national priority as the U.S. Centers of Medicare and Medicaid Services (CMS) provides reimbursement to participants enrolled in Centers for Disease Control (CDC) certified sites to deliver the DPP³⁷. Currently, nearly 1700 sites across the U.S. offer the DPP, including state departments of health³⁸. Typically sites partner with or include healthcare systems and providers in CDC-certified hospitals and clinics; however, some sites³⁹ have expressed concern that these healthcare-based programs are not reaching groups at highest risk for obesity (e.g. rural AAs). Integrating CHWs to reach those who do not have ready access to the healthcare system has the potential to facilitate broader scale-up of the DPP, particularly in areas with limited resources. CHWs have already successfully filled gaps between evidence and practice in numerous areas and have the potential to sustain interventions in underserved communities^17,18. Already successfully proven to cause weight loss at the participant level⁴⁰, online approaches to train CHWs have the potential to increase reach, adoption, and sustainability of weight loss interventions like the DPP¹⁵, and mitigate evidence-based interventions’ high cost to promote health among those who need it the most.