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.

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 increased 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. 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. 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. 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.

Implementation costs of a community health worker delivered weight loss intervention in black churches serving underserved communities.

Black adults bear a disproportionate burden of the obesity epidemic but are underrepresented in weight loss research and lose less weight than their white counterparts in weight loss interventions. Comprehensive behavioral weight loss interventions cause weight loss, but their high cost have stymied their implementation in black and other underserved communities. Recent translations of evidence-based weight loss interventions for black communities have been designed to increase intervention reach. However, the costs of implementing such interventions have seldom been reported in the context of a randomized controlled trial. Thus, the costs of implementing a community-health worker delivered Diabetes Prevention Program (DPP) adaptated for rural black adults of faith (The WORD) are reported. Data from a randomized controlled effectiveness trial conducted in 31 churches (n = 440) were used to calculate implementation costs. All participants received the 16-session core weight loss intervention and weight loss data was collected at baseline and 6 months. Participants lost an average of 2.53 kg at 6 months. Total implementation costs were $340.95 per participant. Thus, the implementation cost was $138 per kg. This is one of the few comprehensive examinations of costs for a DPP translation for black adults of faith and provide initial data from which practitioners and policy makers can use to determine the engagement of churches to disseminate the DPP through churches. Future studies are needed to confirm the extent churches are a cost-effective strategy to cause weight loss in black communities.

Reducing depressive symptoms through behavioral activation in churches: A Hybrid-2 randomized effectiveness-implementation design.

Rural African Americans are disproportionately exposed to numerous stressors such as poverty that place them at risk for experiencing elevated levels of depressive symptoms. Effective treatments for decreasing depressive symptoms exist, but rural African Americans often fail to receive adequate and timely care. Churches have been used to address physical health outcomes in rural African American communities, but few have focused primarily on addressing mental health outcomes. Our partnership, consisting of faith community leaders and academic researchers, adapted an evidence-based behavioral activation intervention for use with rural African American churches. This 8-session intervention was adapted to include faith-based themes, Scripture, and other aspects of the rural African American faith culture (e.g. bible studies) This manuscript describes a Hybrid-II implementation trial that seeks to test the effectiveness of the culturally adapted evidence-based intervention (Renewed and Empowered for the Journey to Overcome in Christ: REJOICE) and gather preliminary data on the strategies necessary to support the successful implementation of this intervention in 24 rural African American churches. This study employs a randomized one-way crossover cluster design to assess effectiveness in reducing depressive symptoms and gather preliminary data regarding implementation outcomes, specifically fidelity, associated with 2 implementation strategies: training only and training+coaching calls. This project has the potential to generate knowledge that will lead to improvements in the provision of mental health interventions within the rural African American community. Further, the use of the Hybrid-II design has the potential to advance our understanding of strategies that will support the implementation of and sustainability of mental health interventions within rural African American faith communities. TRIAL REGISTRATION: NCT02860741. Registered August 5, 2016.

The 4P's Plus screen for substance use in pregnancy: clinical application and outcomes.

OBJECTIVE: Determine the prevalence of substance use among pregnant women in five diverse communities utilizing the 4P's Plus screen for alcohol, tobacco, and other drug use. STUDY DESIGN: Pregnant women enrolled in prenatal care clinics in five communities were screened for substance use with the 4P's Plus. Those women with a positive screen underwent an assessment for substance use through a follow-up structured clinical interview conducted at the same prenatal visit. RESULTS: Among 7818 women in five communities, 2555 (32.7%) had a positive screen for substance use in pregnancy. Four of the communities conducted a follow-up assessment on all women with a positive screen (n = 1548). Among these women, 717 (15% of the total population) had continued use after learning of the pregnancy. Overall, 21% of the pregnant women used alcohol prior to recognition of the pregnancy, and 11% continued use after knowledge of the pregnancy. Among the 512 women who continued to use alcohol, 2% were drinking daily, 7% were drinking 3 to 6 days per week, 27% were drinking 1 to 2 days per week, and 63% were drinking less than 1 day per week. The rates of marijuana use and other illicit drug use among the women were 7 and 2%, respectively, prior to knowledge of pregnancy and dropped to 3 and 1% after learning of the pregnancy. CONCLUSION: The 4P's Plus identifies not only those pregnant women whose drinking or drug use is at a high enough level to impair daily functioning, but provides an opportunity for early intervention for the much larger group of women whose pregnancies are at risk from relatively small amounts of substance use.

FIMR and other mortality reviews as public health tools for strengthening maternal and child health systems in communities: where do we need to go next?

This article examines FIMR in relationship to two other maternal and child health mortality reviews--child fatality review (CFR) and maternal mortality review (MMR), and explores how their approaches to reviewing deaths can complement one another. Identifying opportunities for collaboration among these case review methodologies may lead to greater efficiencies at the local and state levels and strengthen the case review approach as a public health tool for improving maternal and child health outcomes. To enable comparative analysis, a table was constructed that identifies the purpose, structure, and process features of each case review approach. This was followed by an examination of two possible ways to improve maternal and child mortality review processes in states: 1) better coordination; and 2) improving each individual process through adapting and adopting promising practices from the others. A discussion is also provided of the state Title V role in facilitating both the coordination of reviews and the process of sharing best practices. Given the similarities that exist among the three MCH mortality reviews, it is important to view each review as one component of a larger system of maternal and child health death reviews. Implementing widely the recommendations generated by these reviews may increase the likelihood of improvements in services and systems on behalf of women and children.

A process to address disparities in rates of sudden infant death syndrome.

Fetal and Infant Mortality Review (FIMR) is a continuous quality improvement program that leads to improvements in services and resources for families and, ultimately, a decrease in infant mortality. It is an action-oriented process that combines medical data with the mother's report of experiences during the life and death of her infant. The FIMR has proven to be especially important in addressing community issues associated with infant deaths related to sudden infant death syndrome.

Improving screening for alcohol use during pregnancy: the Massachusetts ASAP program.

OBJECTIVE: To motivate prenatal care staff in public and private settings to universally screen for risk of alcohol and drug use and to conduct a brief intervention with follow-up referral when appropriate during a routine office visit. METHODS: The ASAP Project methods were engagement of site staff; staff training; self-administered questionnaires embedded with a relational and broad catch screening tool; a brief intervention protocol; unique clinical decision tree/protocols for each site; identification of treatment and referral resources; and ongoing technical assistance and consultation. Sites were located in four regions of the state and included four community health centers, a network of multi-specialty private practices and a teaching hospital. RESULTS: Across 16 sites, 118 prenatal staff were trained on use of the screening tool and 175 staff on the brief intervention. The ASAP Project resulted in 95% of pregnant women being screened for alcohol use and 77% of those screening positive for at least one risk factor receiving a brief intervention during a routine office visit. CONCLUSIONS: Screening and brief interventions for alcohol use can be delivered effectively within a routine prenatal care visit by prenatal staff by utilizing and building on existing office systems with practice staff, screening for any use not only at risk use, providing training with skills building sessions and information delivered by physicians, offering easy-to-access community treatment resources, and providing ongoing technical assistance.