Abstract
Training lay community members to implement health promotion interventions is an effective method to educate medically underserved populations. Some trainings are designed for individuals who already have a health-related background; however, others are developed for those with no previous health promotion experience. It is unknown whether those with backgrounds in health promotion are more effective in this role than those without. This study assessed the relationship between health promotion experience among trained community health advisors (CHAs) and their self-efficacy to implement an evidence-based cancer control intervention, as well as cancer knowledge and screening behavior outcomes among intervention participants. Data were collected from 66 trained CHAs and 269 participants in CHA-led cancer awareness and early detection workshops. CHAs reported high self-efficacy to implement the intervention independent of their health promotion experience. CHA health promotion experience was neither indicative of differences in participant colorectal or breast cancer knowledge at 12 months, nor of changes in participant-reported cancer screening. However, participant prostate cancer knowledge at 12 months was greater when taught by CHAs with previous health promotion experience (P < 0.01). Prior health promotion experience of trained health advisors may not be pivotal across all contexts, but they may affect specific knowledge outcomes.
Background
While the health of the US population has generally improved over the past 2 decades, health disparities continue to persist [1]. Training lay community members is an effective method to combat health disparities by reaching medically underserved populations [2] and improving intervention outcomes [3–6]. This approach has been referred to using various terms, including but not limited to training peer (health) educators, community health workers (CHWs), community health advocates or advisors, promotores de salud and lay health educators or workers [7]. In the context of this study, we utilize the term community health advisor (CHA) to describe lay community members trained to promote health. There is considerable variation in the CHA training process represented within this body of research [8]. CHA trainings have ranged from on-the-job training to standardized and state-mandated certificate programs [9]. For example, a lay health advisor training developed by Galiatsatos and Hale [10] consisted of 2-hour training sessions per week for 12 weeks covering 13 health topics from diabetes to accidental injury. In another study, CHAs were given a binder of training materials and trained in-person on breast and cervical cancer knowledge over the course of 8 h in 2 days, receiving a certificate of completion after the training [11]. In this training, cancer survivors were also trained in narrative communication to share the stories of their cancer journeys. In yet another example of lay training, individuals received 80 h of instruction to act as patient navigators for geriatric cancer patients [12].
Some possible reasons for the effectiveness of CHA interventions include facilitating a culturally appropriate learning environment [6], reducing learner anxiety [13], providing a source of peer support in addition to peer influence [14] and peers being viewed as credible sources of information by intervention participants [15]. There is research to suggest peer-led education can be more effective in public health contexts for promoting knowledge gains than traditional, non-peer instructor formats [16, 17]. While training lay community members as health educators may be effective for improving intervention outcomes, to further refine the public health workforce, it is critical to understand what characteristics of lay community members, if any, lend themselves to successful performance in this role.
It is well established that the characteristics of a CHA can affect intervention outcomes. For example, a learner’s positive opinion of their CHA has been related to improvements in knowledge and attitude outcomes in a study promoting AIDS awareness [18]. Others report that people learning about an illness may learn best from peers who have or have had that particular illness [7]. Common considerations for selecting CHAs include that they be members of the priority community, be viewed as leaders within it and be chosen by other individuals of that community [8]. CHAs must also be ready to learn, dependable, confident and able to communicate effectively with the intended audience [7]. It stands to reason that prior health promotion experience could relate to some of these qualities, such as confidence and ability to communicate health information. However, little research has examined the implications of CHA’s previous health promotion experience on intervention outcomes [19].
Purpose
The purpose of this study was to investigate the relationship between CHA’s prior health promotion experience and intervention outcomes in an evidence-based cancer education intervention. The current analysis compares CHAs with and without prior health promotion experience (e.g. work-related health experience, health ministry experience) in their self-efficacy to implement the intervention and in the primary intervention outcomes—intervention participant cancer knowledge and change in cancer screening behaviors from baseline to 12 months post-intervention. Findings have implications for health promotion and education. If differences are present, particularly in the primary outcomes of participant cancer knowledge and screening, this may indicate the importance of identifying prospective CHAs with previous health experience to maximize intervention effectiveness. If no differences in the aforementioned outcomes are detected, this would suggest that health experience need not be a prerequisite for prospective CHAs, provided that the training itself is accessible and appropriate. As the training for this intervention was designed for community members regardless of previous health experience, we hypothesized that prior CHA health promotion experiences would not either affect CHA self-efficacy to implement the intervention or participant cancer knowledge or change in cancer screening behaviors.
Methods
Intervention platform
This study was approved by the University of Maryland Institutional Review Board (#10-0691 and #894923-18). Project HEAL (Health through Early Awareness and Learning) is an evidence-based cancer education and early detection intervention implemented in African American churches [20]. In the Project HEAL trials, at least one man and one woman were identified by the leader in each church to train as a Project HEAL CHA. Eligible Project HEAL CHAs were at least 21 years old, self-identified African American members of the host church, had regular access to the Internet, and expressed the ability to complete web-based training activities. CHAs completed a 13-module training (e.g. colorectal cancer, breast cancer, prostate cancer, how to conduct a workshop) and earned a score of 85% or greater on a certification exam covering topics presented in the training. This training method has been used by the senior author in seven previous cancer education intervention trials to train over 150 CHAs [21–27]. Project HEAL CHA training has been delivered in both online and in-person formats with comparable outcomes [26]. The CHAs trained for Project HEAL represent nearly 30 African American churches in the state of Maryland.
Trained and certified CHAs led a series of three group educational workshops on cancer early detection (overview, breast/prostate and colorectal) for their fellow community members. The cancer overview workshop was led in tandem by the male and female CHAs in each church. The second workshop was split, with female CHAs leading a breast cancer session for participating women and male CHAs leading a prostate cancer session for participating men. The CHAs and workshop participants come together once more as a full group for the third workshop on colorectal cancer.
Measurement
All data for this analysis were collected via self-report questionnaires from trained Project HEAL CHAs and participants in the CHA-led cancer education workshops. Questionnaires were most frequently administered as pen and paper surveys, however, an online option was made available via the Qualtrics Survey Software [28] for CHAs, which 32 CHAs (48%) took advantage of.
CHA health promotion experience and education
Three dichotomous items measured prior CHA health promotion experience at baseline. CHAs indicated if they had any kind of prior health promotion experience, work-related health promotion experience and health ministry (church-related health promotion) experience. CHA education was dichotomized into those CHAs with a 4-year college degree or greater and those without a 4-year degree to mirror the health promotion experience items.
CHA self-efficacy
CHAs’ perceived self-efficacy to implement the intervention was measured following the CHA training process using seven items developed by the investigative team, each on either 4- or 5-point scales (e.g. confidence in presenting cancer information, confidence recruiting participants for the workshops) with higher scores indicating greater confidence. CHA self-efficacy to implement the intervention is summarized using a mean score of the seven items (α = 0.66 in the current sample).
Participant cancer knowledge
Workshop participants’ cancer knowledge was measured at baseline and again at 12 months post-intervention using established instruments for each cancer type (colorectal, breast and prostate). Colorectal cancer knowledge was measured using seven items (e.g. ‘Colorectal cancer screening is not necessary if there are no symptoms’) in an agree/disagree/don’t know format [29]. This measure demonstrated acceptable internal reliability in the current sample (α = 0.74). Knowledge surrounding breast cancer in three areas was assessed using yes/no/not sure response scales. Six items measured general breast cancer knowledge (e.g. ‘Are older women more likely to get breast cancer than younger women?’; α = 0.49 in the current sample), five items on mammography knowledge (e.g. ‘Do mammograms find all breast cancers?’; α = 0.30 in the current sample) and three items on breast cancer treatment knowledge (e.g. ‘Can breast cancer be treated without removing the breast?’; α = 0.46 in the current sample) [30, 31]. General prostate cancer knowledge was measured using five yes/no/not sure format items (e.g. ‘More African American men are diagnosed with prostate cancer than Whites’; α = 0.56 in the current sample) [32] and knowledge surrounding prostate cancer screening controversy was assessed with a four-item yes/no/not sure scale (e.g. ‘Prostate screening may lead to unneeded biopsies and treatment.’; α = 0.49 in the current sample) [21]. The number of correct responses for each knowledge subscale was summed to generate a separate score for each subscale, with higher scores indicating greater cancer knowledge.
Participant cancer screening behavior
Self-reported cancer screening behaviors, also assessed at baseline and 12-month follow-up, were measured by asking the participant about a specific cancer screening, if they had ever had it (yes, no, not sure) and the last time they had received that screening method [21, 26, 30, 33]. A participant was considered to have been screened for: colorectal cancer if they indicated that they had received a fecal occult blood test (FOBT), sigmoidoscopy or colonoscopy; breast cancer if they indicated that they had received a mammography; and prostate cancer if they indicated that they had received a prostate specific antigen test (PSA) or a digital rectal exam (DRE).
Analysis
This analysis includes data provided by 66 Project HEAL CHAs from 27 African American churches across two trials evaluating the implementation of the Project HEAL intervention [26, 27] and 269 workshop participants from the first Project HEAL trial [26]. Data from workshop participants in the second trial was insufficient for analysis due in part to disruption from the COVID-19 pandemic. Comparisons between individual CHAs with and without previous health promotion experience on their self-efficacy to implement the intervention were assessed using independent two-sample t-tests for the seven self-efficacy items and the self-efficacy summary score.
A one-way analysis of covariance (ANCOVA) was used to determine if there was a difference in participant 12-month cancer knowledge outcomes based on the number of CHAs with any prior health promotion experience leading the cancer education workshops at their church, controlling for baseline participant cancer knowledge. A subsequent sex-specific ANCOVA tested the difference in female participant breast cancer knowledge outcomes for those taught by female CHAs with health promotion experience as compared to those without health promotion experience, and male participant prostate cancer knowledge outcomes for those taught by male CHAs with as compared to without health promotion experience. Sex-specific analyses were performed for these two cancers due to the sex specificity of their respective CHA-led workshops.
Finally, the relationship between CHA health promotion experience and change in workshop participant cancer screening behavior was assessed using logistic mixed-effects models, controlling for workshop participant age and education level at baseline. A random effect term was included to adjust for the within-subject association between repeated measures at baseline and 12 months. The number of CHAs in the church with any health promotion experience was used as the independent variable in the colorectal cancer model, however, due again to the sex specificity of the breast and prostate cancer workshops, the presence or absence of female or male CHA health promotion experience was again used for breast and prostate cancer analyses respectively. Cancer screening was analyzed as whether or not the participant had ever been screened in the cases of colorectal and prostate cancer because participants often struggle to accurately report the time frame for their screenings [34]. However, due to the high frequency of women reporting ever having had a mammogram at baseline, mammogram currency (whether or not the woman had completed a mammogram in the past year) was analyzed in lieu of ever having had a mammogram.
Results
Sample description
Over half of the 66 participating CHAs were female (56.1%), most were either employed full-time (42.4%) or were retired (33.3%), and most were not cancer survivors (77.3%). Over half of the CHAs (56.1%) had completed at least a 4-year college degree. Most CHAs reported some type of previous health promotion experience (68.2%). Many had done health promotion previously through their employment (42.4%) and some (25.8%) had participated in their church’s health ministry. The workshop participants were 269 African American men and women between the ages of 40 and 75 years with no history of colorectal, breast or prostate cancer. The mean age of workshop participants was 55.7 years (SD = 9.05), 68% were female and 71.4% did not have a 4-year college degree or greater (see Table I).
Table I.
CHA and workshop participant demographics
| CHAs (n = 66) | Frequency (%) |
| African American | 66 (100%) |
| Female | 37 (56.1%) |
| 4-year college degree or higher | 37 (56.1%) |
| Any prior health promotion experience | 45 (68.2%) |
| Employed full-time | 28 (42.4%) |
| Employed part time | 6 (9.1%) |
| Retired | 22 (33.3%) |
| Cancer survivor | 15 (22.7%) |
| Workshop participants (n = 269) | |
| African American | 269 (100%) |
| Female | 183 (68.0%) |
| Mean age (SD) | 55.7 (9.05) |
| 4-year college degree or higher | 77 (28.6%) |
CHAs (Community Health Advisors) are lay community members trained by staff to lead cancer education workshops for the study participants.
CHA self-efficacy for implementing the intervention
CHAs generally reported high self-efficacy to implement the intervention (see Table II). CHAs with work-related health experience rated their confidence to present cancer information at an average of 4.79 on a 5-point scale; this was significantly higher than the 4.38 average reported by those without work-related health experience (P = 0.02). However, there were no other differences in CHA self-efficacy to implement the intervention by prior CHA health promotion experience. CHA education demonstrated several significant associations with reported self-efficacy. CHAs with a 4-year college degree or greater reported higher confidence recruiting participants for the cancer workshops (4.35 versus 3.93; P = 0.04), presenting cancer information (4.73 versus 4.28; P < 0.01), and wished less that their skills as CHAs were stronger (1.95 versus 2.88; P < 0.01) than CHAs without a 4-year degree. No other significant differences between CHA health promotion experience and self-efficacy or between CHA education and self-efficacy were detected.
Table II.
Means and t-tests of CHA personal health promotion/educational experience and intervention self-efficacy
| Any prior health promotion experience? | Prior work-related health experience? | Prior health ministry experience? | 4 year degree or higher? | |||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| No M (SD) [n = 21] | Yes M (SD) [n = 45] | t-value | No M (SD) [n = 38] | Yes M (SD) [n = 28] | t-value | No M (SD) [n = 49] | Yes M (SD) [n = 17] | t-value | No M (SD) [n = 29] | Yes M (SD) [n = 37] | t-value | |
| Felt well trained to fulfill CHA role /4 | 3.82 (0.405) | 3.83 (0.461) | −0.10 | 3.76 (0.436) | 3.90 (0.447) | −1.00 | 3.80 (0.484) | 3.91 (0.302) | −0.70 | 3.74 (0.452) | 3.91 (0.426) | −1.25 |
| Wish my skills as a CHA were stronger /4 | 2.40 (1.265) | 2.36 (1.062) | 0.10 | 2.61 (1.037) | 2.15 (1.137) | 1.30 | 2.52 (1.087) | 2.00 (1.095) | 1.33 | 2.88 (0.928) | 1.95 (1.071) | 2.82** |
| Confidence recruiting workshop participants /5 | 4.10 (0.831) | 4.20 (0.842) | −0.47 | 4.05 (0.880) | 4.36 (0.731) | −1.48 | 4.10 (0.881) | 4.41 (0.618) | −1.33 | 3.93 (0.961) | 4.35 (0.676) | −2.09* |
| Confidence promoting Project HEAL in the church /5 | 4.38 (0.805) | 4.24 (1.004) | 0.55 | 4.19 (1.023) | 4.46 (0.793) | −1.18 | 4.31 (0.879) | 4.29 (1.105) | 0.07 | 4.17 (1.071) | 4.38 (0.828) | −0.88 |
| Confidence presenting cancer information during workshops /5 | 4.38 (0.865) | 4.60 (0.618) | −1.18 | 4.38 (0.794) | 4.79 (0.418) | −2.67* | 4.52 (0.714) | 4.65 (0.606) | −0.65 | 4.28 (0.882) | 4.73 (0.450) | −2.71** |
| Confidence responding to questions about cancer /5 | 4.14 (0.793) | 4.22 (1.064) | −0.30 | 4.19 (0.845) | 4.29 (1.084) | −0.40 | 4.19 (0.960) | 4.35 (0.931) | −0.62 | 4.07 (0.961) | 4.30 (0.996) | −0.94 |
| Confidence engaging workshop participants in group discussion /5 | 4.14 (0.910) | 4.47 (0.588) | −1.74 | 4.24 (0.796) | 4.57 (0.504) | −1.91 | 4.29 (0.743) | 4.65 (0.493) | −1.83 | 4.31 (0.850) | 4.41 (0.599) | −0.53 |
| Mean score of self-efficacy items | 4.11 (0.635) | 4.11 (0.552) | 0.01 | 4.06 (0.649) | 4.17 (0.458) | −0.77 | 4.08 (0.603) | 4.19 (0.491) | −0.67 | 4.02 (0.698) | 4.17 (0.454) | −1.07 |
CHAs (Community Health Advisors) are lay community members trained by staff to implement the Project HEAL cancer education intervention.
Difference is significant at P < 0.05.
Difference is significant at P < 0.01.
Workshop participant cancer knowledge
Results demonstrated relatively high cancer knowledge among participants at 12 months post-intervention, with the exception of prostate cancer knowledge (mean = 2.96 on a 5-point scale) and especially prostate cancer screening controversy knowledge (mean = 1.03 on a 4-point scale). No statistically significant relationship was detected between the number of CHAs with health promotion experience and colorectal cancer knowledge among workshop participants (F = 1.57, P = 0.21) (see Table III). However, the number of CHAs with previous health promotion experience was significantly associated with improved breast and prostate cancer knowledge among their workshop participants (F = 5.44, P < 0.01; F = 6.21, P < 0.01, respectively). Subsequent sex-specific analyses demonstrated no relationship between previous health promotion experience of female CHAs and breast cancer knowledge among female workshop participants (F = 0.11, P = 0.74). However, male CHA prior health promotion experience was positively associated with male workshop participants’ prostate cancer knowledge (F = 7.98, P < 0.01) and knowledge about the prostate cancer screening controversy (F = 5.52, P = 0.02). Similar analyses showed no significant associations between CHA education level and participant knowledge outcomes.
Table III.
ANCOVA comparisons of the number of CHAs in the church with any prior health promotion experience and workshop participant cancer knowledge
| 12-month knowledge scores | |||||
|---|---|---|---|---|---|
| Number of CHAs in the church with any prior health promotion experience | 0 CHAs with any prior health promotion experience | 1 CHA with any prior health promotion experience | 2 CHAs with any prior health promotion experience | Total | F-value (n) |
| M (SD) | M (SD) | M (SD) | M (SD) | ||
| Colorectal cancer knowledge /7 | 6.22 (1.27) | 6.31 (1.03) | 6.54 (0.75) | 6.36 (1.00) | 1.57 (240) |
| a Breast cancer knowledge /6 | 4.14 (1.13) | 4.17 (1.24) | – | 4.13 (1.24) | 0.11 (173) |
| a Mammogram knowledge /5 | 4.23 (0.85) | 4.13 (0.88) | – | 4.08 (0.93) | 0.48 (181) |
| a Breast cancer treatment knowledge /3 | 2.08 (0.82) | 2.13 (0.78) | – | 2.11 (0.80) | 0.22 (164) |
| b Prostate cancer knowledge /5 | 2.59 (1.38) | 3.43 (1.46) | – | 2.96 (1.45) | 7.98 (86)** |
| b Prostate cancer controversy knowledge /4 | 0.88 (0.94) | 1.31 (0.83) | – | 1.03 (0.91) | 5.52 (86)* |
Results are controlled for workshop participant baseline cancer knowledge.
CHAs (Community Health Advisors) are lay community members trained by staff to implement the Project HEAL cancer education intervention.
Analysis performed based solely on female CHA experience.
Analysis performed based solely on male CHA experience.
Difference is significant at P < 0.05.
Difference is significant at P < 0.01.
Workshop participant cancer screening behavior
CHA health promotion experience was not significantly associated with the change in log odds of ever being screened for colorectal cancer (P = 0.08) (see Table IV), neither being up to date on breast cancer screening (P = 0.28) nor ever being screened for prostate cancer (P = 0.77) (data not shown). Subsequent sex-specific analyses demonstrated no association between previous health experience of female CHAs and the change in log odds of a female participant being up to date on breast cancer screening (P = 0.39) and no association between previous health experience of male CHAs and change in the log odds of a male participant ever being screened for prostate cancer (P = 0.35) (see Table IV).
Table IV.
Estimates of the fixed effects for number of CHAs in the church with any prior health promotion experience and change in participant cancer screening behavior
| Parameter | β | SE | P-value |
|---|---|---|---|
| a Model 1: Ever had a screening for colorectal cancer | |||
| Intercept | −10.008 | 3.060 | 0.001** |
| Number of CHAs in the church with any prior health promotion experience | 1.288 | 0.855 | 0.132 |
| Time | 3.395 | 1.239 | 0.006** |
| Age | 0.584 | 0.180 | 0.001** |
| Education | 1.940 | 1.102 | 0.078 |
| Number of CHAs in the church with any prior health promotion experience × Time | −1.502 | 0.860 | 0.081 |
| b Model 2: Ever had a screening for prostate cancer | |||
| Intercept | −2.242 | 1.287 | 0.081 |
| Male CHA in the church with any prior health promotion experience | 0.868 | 1.130 | 0.442 |
| Time | 0.618 | 0.735 | 0.400 |
| Age | 0.204 | 0.075 | 0.006** |
| Education | 1.409 | 1.004 | 0.160 |
| Male CHA in the church with any prior health promotion experience × Time | 1.160 | 1.237 | 0.348 |
| c Model 3: Current on mammography screening for breast cancer | |||
| Intercept | −1.275 | 0.563 | 0.023* |
| Female CHA in the church with any prior health promotion experience | 0.316 | 0.442 | 0.475 |
| Time | −0.086 | 0.429 | 0.841 |
| Age | 0.084 | 0.018 | <0.001** |
| Education | 0.134 | 0.311 | 0.667 |
| Female CHA in the church with any prior health promotion experience × Time | 0.450 | 0.518 | 0.385 |
CHAs (Community Health Advisors) are lay community members trained by staff to implement the Project HEAL cancer education intervention.
Includes independent variable representing participants taught by male and female CHAs with/without prior health promotion experience as colorectal cancer workshops were delivered by male and female CHAs in tandem.
Includes independent variable representing participants taught by a male CHA with/without prior health promotion experience as prostate cancer workshops were delivered by male CHAs; the time effect presented is for the reference group only (i.e. participants taught by a male CHA with no prior health promotion experience).
Includes independent variable representing participants taught by a female CHA with/without prior health promotion experience as breast cancer workshops were delivered by female CHAs; the time effect presented is for the reference group only (i.e. participants taught by a female CHA with no prior health promotion experience).
Effect is significant at P < 0.05.
Effect is significant at P < 0.01.
Discussion
The current study aimed to investigate CHAs with and without previous health promotion experience and differences in intervention outcomes in the context of the Project HEAL cancer education and early detection intervention. While training lay community members, even those with no previous health background, to provide cancer education in community settings can be an effective and efficient way to reach priority groups [3–6], some research suggests that CHA prior health promotion experience may be related to intervention outcomes [19, 35, 36]. Even still prior health promotion experience is seldom a point of emphasis of CHA interventions.
Project HEAL developed a CHA training for trusted lay individuals to promote cancer knowledge and screening in their churches. CHA perceived self-efficacy to implement the intervention across all indicators was generally high for both those with and without prior health experience in this analysis. This may be due in part to the CHA training itself, but may also be attributable to the influence of self-report and social desirability bias in self-efficacy measurement [37]. Previous CHA health promotion experience largely did not affect their self-efficacy to implement the intervention, and where self-efficacy did differ significantly, the differences may not be large enough to be considered significant in practice (e.g. 4.79 as compared to 4.38 on a 5-point scale).
Although CHAs with less education reported lower self-efficacy to implement the intervention on some indicators, the mean score on the scale assessing self-efficacy to implement the intervention did not differ by education. Differences by education on some of the self-efficacy items also did not appear to inhibit CHA ability to affect change in participant intervention outcomes (i.e. cancer knowledge and screening behaviors), as these outcomes did not differ by CHA education level. Prior research suggests that individuals with lower education generally have lower self-efficacy [38]. As such, the difference in CHA self-efficacy by education may be attributable to these overarching differences in self-efficacy by education.
CHA health promotion experience did not appear to affect participant colorectal cancer knowledge, breast cancer knowledge outcomes or participant screening outcomes for colorectal, breast or prostate cancer. Although this finding does not support existing work that suggests prior health promotion experience among CHAs can influence intervention outcomes [19, 35, 36], this may be due, at least in part, to the Project HEAL training, which was designed with the intent to be effective in preparing CHAs to teach participants about colorectal, breast cancers and prostate cancers, regardless of their health promotion history. These results support our hypothesis that CHA prior health promotion history would not affect intervention outcomes at the participant-level since the CHA training was designed for lay individuals regardless of their previous health promotion experience. However, contrary to our hypothesis, and in support of prior research [19, 35, 36], male CHA health promotion experience was positively associated with participant prostate cancer knowledge outcomes. As CHA health promotion experience affected prostate cancer knowledge outcomes, but not screening outcomes, it would seem that male CHAs were equally effective at conveying an overall message of prostate cancer screening urgency, but varied in their ability to effectively communicate more nuanced prostate cancer information. However, the variation in communicating nuanced information about prostate cancer screening may again not be significant in practice, as prostate cancer screening controversy knowledge was low across both groups.
The relationship between male CHA previous health promotion experience and prostate cancer knowledge outcomes for male workshop participants suggests unique challenges in prostate cancer education. A primary challenge, as identified in previous research, is the generally low baseline knowledge of prostate cancer among men [39–41], especially African American men [39, 40]. This includes a lack of knowledge about prostate cancer risk factors and screening options. Our research supports these findings as we found low prostate cancer knowledge and prostate cancer screening controversy knowledge in the current sample. The inclusion of information addressing the controversy about the use of, and guidelines for, prostate cancer screening in the health sector is a crucial feature distinguishing the prostate cancer curriculum and workshops from the colorectal and breast cancer counterparts. To encourage men to learn and make informed decisions about screening, the Project HEAL CHA training and workshop materials reflected both sides of the prostate cancer screening argument, presenting the side of health professionals in favor of and those in opposition to screening. The complexity of prostate cancer education and the current curriculum is evidenced by low prostate cancer knowledge in previous research [39–41], as well as within the current sample. It is highly feasible that previous experience in health promotion becomes more pertinent to intervention outcomes depending on the complexity of the health information being presented and the initial level of knowledge among intervention participants. This could explain the differences in knowledge outcomes detected for prostate cancer but not for colorectal or breast cancer. Alternatively, some sex-specific differences in knowledge communication and/or reception could be at play since prostate cancer workshops were presented to men, by men. It is feasible that men with a health promotion background may be perceived as more credible by a male audience than those without health experience, or may otherwise be able to convey information more effectively due to their background. While it is unclear whether this difference in prostate cancer knowledge outcomes by CHA health promotion experience is attributable to information complexity, a unique sex effect, or some combination of the two, these findings suggest that presenter health promotion background has the potential to affect key intervention outcomes.
Strengths and limitations
This study presents several strengths. Examining participant breast and prostate cancer knowledge and screening behavior outcomes considering only the CHA (male or female) who actually taught those workshops provides a more relevant indicator of the relationship between CHA health promotion experience and intervention outcomes than analyzing these outcomes by aggregated male and female CHA health promotion experience. Additionally, this analysis presents a harmonization of data from two intervention trials. The inclusion of data from each of these trials yields a larger sample size and greater statistical power than could have been achieved otherwise.
However, when interpreting the findings of this study, it is important to consider the limitations of the study. First reliability among some of the measures was modest in the current study (e.g. alpha reliability for the mammography knowledge measure). Indicators specific to CHA prior ‘cancer’ health promotion experience, and quantification (e.g. years) of health promotion experience were not collected as part of this study. One might expect greater outcomes in prostate cancer knowledge for participants taught by CHAs with more years of cancer-specific health promotion experience than those with less experience, based on this analysis. Of note, the range in values of the independent variables (number of CHAs with previous health promotion experience: 0, 1 or 2) is particularly limited in the portion of the analysis focused on participant outcomes. While the current study largely demonstrated null findings for an association between the number of CHAs with previous health promotion experience and participant cancer knowledge and behavior outcomes, the data depict a trend in which participant outcomes are frequently greater (although negligibly so) for those taught by more CHAs with previous health promotion experience. It is feasible that with greater variability in the number of CHAs with previous health promotion experience (e.g. 0–10) a statistically significant difference in participant outcomes could be detected. This study also accounts for a specific set of CHA characteristics (i.e. health promotion experience and education) without analyzing further characteristics of the CHA such as CHA reputation, charisma or status within the church setting. It may be that the charisma of a CHA, for instance, could interact with their health promotion experience to drive intervention outcomes. Additionally, while the CHA-level analyses span two projects, we were, unfortunately, unable to include workshop participants from the second trial due in large part to COVID-19-related research disruption.
Implications for practice
The current findings have implications for intervention scale-up, public health workforce development and specifically, future peer health education interventions. Health promotion experience of a lay health advisor may not be pivotal across all contexts, but findings from this study suggest that the health background of health information presenters has the potential to affect intervention knowledge outcomes. Further study is warranted to determine if differences in prostate cancer knowledge outcomes were due to the presenter and/or audience being comprised of men, or the complexity of the information presented. While trained lay community members may be particularly effective at engaging medically underserved populations, these individuals may require more training if they have less health promotion experience, particularly when presenting complex health information. It is recommended that intervention developers consider the previous health promotion experience of prospective CHAs in context of their intervention as they seek to apply a health advisor approach to health education interventions moving forward.
Acknowledgements
The team would like to acknowledge the work of Jimmie Slade, Ralph Williams and B.J. Robinson-Shaneman, for their community engagement efforts throughout the Project.
Contributor Information
Nathaniel Woodard, Department of Behavioral and Community Health, School of Public Health, University of Maryland, SPH Building, 4200 Valley Drive, Rm 1234, College Park, MD 20742-2611, USA.
Chang Chen, Department of Epidemiology and Biostatistics, University of Maryland, SPH Building, 4200 Valley Drive, Rm 2234, College Park, MD 20742-2611, USA.
Maisha R Huq, Department of Behavioral and Community Health, School of Public Health, University of Maryland, SPH Building, 4200 Valley Drive, Rm 1234, College Park, MD 20742-2611, USA.
Xin He, Department of Epidemiology and Biostatistics, University of Maryland, SPH Building, 4200 Valley Drive, Rm 2234, College Park, MD 20742-2611, USA.
Cheryl L Knott, Department of Behavioral and Community Health, School of Public Health, University of Maryland, SPH Building, 4200 Valley Drive, Rm 1234, College Park, MD 20742-2611, USA.
Funding
American Cancer Society (RSG1602201CPPB), the Maryland Department of Health’s Cigarette Restitution Fund Program and National Cancer Institute (R01CA147313, P30CA134274).
Conflict of interest statement
The authors have no relevant financial or non-financial interests to disclose.
Compliance and ethical standards
All human participants were treated in accord with Declaration of Helsinki and the study was approved by the University of Maryland Institutional Review Board (#10-0691 and #894923-18).
Consent
All participants provided their informed consent prior to participation in this study.
Author contributions
All authors have made scientific contributions to this manuscript. Mr. Woodard led the development of the research question, data analysis and interpretation, as well as the development of the manuscript. Mr. Chen and Dr. He provided considerable support in the data analysis and interpretation, led the analysis and interpretation for the third leg of the analysis (i.e. the logistic mixed effect models) and contributed to corresponding manuscript sections. Ms. Huq provided support in the refinement of the research question, execution of the literature review and development of the manuscript. Dr. Knott provided critical support in the development of the research question, data analysis and interpretation and development of the manuscript.
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