Eugenia Eng

Measuring Community Competence in the Mississippi Delta: The Interface between Program Evaluation and Empowerment

If political dynamics are included in the definition of community, health promotion programs have a greater potential to recognize that assisting people to empower their communities is as important as assisting them to improve their health. This paper reports on the evaluation methods employed for a health promotion program in a rural poor county of the Mississippi Delta that chose to define community in this way. The evaluation took an action research approach so that the methods would not contradict or interfere with the programs empowerment agenda. The methods required a close and collaborative working relationship among evaluators and local service providers, community leaders, and program staff who defined and operationalized eight dimensions of community com petence, determined the units of analysis, and developed the data collection protocol. Emphasis was placed on using the data to engage the program and three communities in a dialogue on how to confront a system with the difficult issues they faced. The findings revealed that after 1 year of implementation, community competence moved from social interactions internal to communities to those more externally focused on mediating with outside institutions and officials. At the same time, measures of self-other awareness and conflict containment showed a decrease or virtual nonexistence.

The power and the promise: Working with communities to analyze data, interpret findings, and get to outcomes

Although the intent of community-based participatory research (CBPR) is to include community voices in all phases of a research initiative, community partners appear less frequently engaged in data analysis and interpretation than in other research phases. Using 4 brief case studies, each with a different data collection methodology, we provide examples of how community members participated in data analysis, interpretation, or both, thereby strengthening community capacity and providing unique insight. The roles and skills of the community and academic partners were different from but complementary to each other. We suggest that including community partners in data analysis and interpretation, while lengthening project time, enriches insights and findings and consequently should be a focus of the next generation of CBPR initiatives.

Increasing Use of Mammography Among Older, Rural African American Women: Results From a Community Trial

OBJECTIVES A community trial was undertaken to evaluate the effectiveness of the North Carolina Breast Cancer Screening Program, a lay health advisor network intervention intended to increase screening among rural African American women 50 years and older. METHODS A stratified random sample of 801 African American women completed baseline (1993-1994) and follow-up (1996-1997) surveys. The primary outcome was self-reported mammography use in the previous 2 years. RESULTS The intervention was associated with an overall 6 percentage point increase (95% confidence interval [CI] = -1, 14) in community-wide mammography use. Low-income women in intervention counties showed an 11 percentage point increase (95% CI = 2, 21) in use above that exhibited by low-income women in comparison counties. Adjustment for potentially confounding characteristics did not change the results. CONCLUSIONS A lay health advisor intervention appears to be an effective public health approach to increasing use of screening mammography among low-income, rural populations.

Lay Health Advisors: A Strategy for Getting the Word out about Breast Cancer

Transforming natural helpers into lay health advisors (LHAs) is a complex undertaking. Using the North Carolina Breast Cancer Screening Program (NC-BCSP) as a case study, this article describes the steps involved in developing, implementing, and evaluating an LHA intervention, considering factors that make the LHA approach appropriate for the NC-BCSPs population, setting, and health focus. The authors review five phases of implementation (start-up, training, LHA activities, follow-up, resource mobilization) and discuss the NC-BCSPs evaluation strategies and tools in light of difficulties involved in assessing natural helping processes and impact. Program challenges related to resource needs, identification of natural helpers, and LHA monitoring and support also are considered. The authors describe ways in which one large group of older, rural, African American LHAs are helping establish countywide partnerships between health care providers, agencies, and local communities that support and sustain individual changes in health behavior.

The save our sisters project. A social network strategy for reaching rural black women

Why are older black women screened less for breast cancer? What can be done to narrow the racial gap in mammography screening? These are the questions addressed by the Save Our Sisters (SOS) Project, a pilot demonstration study funded by the National Cancer Institute in a rural county of North Carolina. The target population is 2600 black women 50–74 years of age residing in the county. To assist these women to obtain annual mammograms, SOS has recruited and trained 64 black women who are “natural helpers” to serve as lay health advisors. The lay health advisors reach older black women through their existing kin, friendship, and job networks. Responses from 14 focus group interviews found that when it is a matter of older black womens health concerns, women turn to certain women for social support. Responses revealed factors related to the individual woman and her social network that influence rural black womens seeking breast cancer screening. These results were applied to the Social Change model for designing the training and three network intervention strategies: (1) providing social support (information and referrals, emotional caring, and tangible assistance) through interpersonal counseling with women in their social networks; (2) working as a group, planning and implementing breast cancer control and prevention activities through community‐based organizations to which advisors belong (e.g., church groups, civic groups, and social groups); and (3) establishing themselves as a nonprofit, community‐based SOS Association to sustain project interventions after the funding period. The SOS Community Advisory Group and the advisors developed innovative methods of recruitment, implementation, and follow‐up. The community programs they have initiated are: (1) the Adopt‐A‐Sister Program, which assists black women who cannot afford the cost of a mammogram; (2) a committee on understanding the health care system, which assists women in negotiating regulations and using health care providers; (3) a training committee, which recruits and trains additional advisors; (4) a support group for black women with diagnoses of breast cancer; and (5) a speakers bureau, which has produced a 10‐minute video, brochure, and tee‐shirts as community education materials.

Strengthening Individual and Community Capacity to Prevent Disease and Promote Health: In Search of Relevant Theories and Principles

The dominant theoretical models used in health education today are based in social psychology. While these theories have increasingly acknowledged the role of larger social and cultural influences in health behavior, they have many limitations. Theories seek to explain the causes of health problems, whereas principles of practice, which are derived from practical experience, assist intervenors to achieve their objectives. By elucidating the relationships between theory and practice principles, it may be possible to develop more coherent and effective interventions. The key research agenda for health education is to link theories at different levels of analysis and to create theory-driven models that can be used to plan more effective interventions in the complex environments in which health educators work.

The gender ratio imbalance and its relationship to risk of HIV/AIDS among African American women at historically black colleges and universities

Abstract African American women are at increased risk of HIV transmission through heterosexual contact. HIV/AIDS is the leading cause of death among African American women between 25 to 34 years of age, and many of these women were likely infected while in college. Four focus groups were conducted with African American students attending Historically Black Colleges and Universities (HBCUs) in order to learn about the college dating environment and how it influenced womens risk of HIV infection. We used constant comparison techniques and visual display matrixes to analyse the data. Students identified the gender ratio imbalance of more women to men on campus as a key element of the campus dating environment and described how it places women at an increased risk for HIV infection. Primary consequences of this gender ratio imbalance were men having multiple female sexual partners during the same time period and women complying with mens condom use preferences. HIV preventive intervention programmes at HBCUs must address the gender ratio imbalance and its consequences to reduce womens risk of contracting the infection.

Natural helping functions of lay health advisors in breast cancer education

SummaryThe Save Our Sisters Project builds on the roles of 95 “natural helpers” to increase mammography screening among older African American women in a NC county. Natural helpers are lay people to whom others naturally turn for advice, emotional support, and tangible aid. Findings from 14 focus group interviews showed that older women seek out these individuals when they have a female-specific concern, rather than or before seeking help from professionals. The characteristics of natural helpers, revealed in the findings, were used to identify and recruit them to become trained lay health advisors in breast cancer education. Through the SOS Project, natural helpers provide a community-based system of care and social support that complements the more specialized role of health professionals; linking them to women through places and ways that no health professional could begin to acquire. The three roles of lay health advisors are: (1) to assist individuals in their social networks with needs that are difficult for professionals to address; (2) to negotiate with professionals for support from the health system; and (3) to mobilize the resources of associations in their community to sustain support from the health system.

Telling Children They Have HIV: Lessons Learned from Findings of a Qualitative Study in Sub-Saharan Africa

HIV-infected children in developing countries are living longer lives as they gain access to antiretroviral treatment programs. As they grow older, their parents/guardians are faced with the difficult decision of if, when, and how to inform their child of his/her HIV status. Both negative and positive social, psychological, and behavioral impacts of disclosure to children have been reported, including improved adherence to medication regimens. Understanding the disclosure process from the perspective of HIV positive children, therefore, is critical to developing these interventions. Through childrens experiences we can learn about what works well, what needs to be strengthened, and what is missing in current disclosure practices. We conducted in-depth interviews with eight caregiver-child dyads in Kinshasa, Democratic Republic of the Congo. The children were in a comprehensive HIV pediatric care and treatment program and had already been told their HIV diagnosis. For the analysis we placed particular emphasis on childrens reports of communication with their caregivers and health care providers about their illness. Patterns emerged of limited communication between children and their caregivers as well as their providers, before, during, and after disclosure. From the perspective of children in this study, disclosure was largely a discrete event rather than a process. Sociocultural contexts surrounding HIV/AIDS, as well as health status, variations in parent-child communication and the relationships between health providers and children under their care, should inform psychosocial interventions delivered alongside treatment programs.

Breast cancer screening in older African-American women: qualitative research findings.

Purpose. The purpose of this study was to gain a better understanding of the cultural meanings that shape the breast cancer screening behavior of older African-American women. Design. Qualitative research methods elicited social and cultural themes related to breast cancer screening. Setting. Focus group interviews were conducted in the natural settings (churches, etc.) of older African-American women. Subjects. Interviews were conducted with 132 members from 14 social networks of older African-American women. Measures. A focus group guide asked about 1) perceived risk of breast cancer, 2) behavioral intentions about breast cancer screening, 3) health seeking behavior, and 4) social support. Results. For older African-American women: other health concerns are of more concern than breast cancer; age is generally not recognized as a risk factor for breast cancer; fear of finding breast cancer and its social consequences are salient barriers to mammography; they tend to rely on breast self-exam rather than mammography to detect a breast problem; cost may be more an issue of competing priorities than cost per se; the tradition is to go to doctors for a problem, not prevention; and women in their own social networks are important sources of social support for health concerns. Conclusions. These data offer explanations for mammography screening in older African-American women and emphasize the strength of naturally existing sources of social support for designing interventions to increase breast cancer screening.