PMCCPMCCPMCC

Search tips
Search criteria 

Advanced

 
Logo of nihpaAbout Author manuscriptsSubmit a manuscriptHHS Public Access; Author Manuscript; Accepted for publication in peer reviewed journal;
 
Health Educ Behav. Author manuscript; available in PMC 2013 June 1.
Published in final edited form as:
PMCID: PMC3358563
NIHMSID: NIHMS354835

When promotoras and technology meet: A qualitative analysis of promotoras’ use of small media to increase cancer screening among South Texas Latinos

Abstract

Computer-based multimedia technologies can be used to tailor health messages, but promotoras (Spanish-speaking community health workers) rarely use these tools. Promotoras delivered health messages about colorectal cancer screening to medically underserved Latinos in South Texas using two small media formats: a “low-tech” format (flipchart and video); and a “high-tech” format consisting of a tailored, interactive computer program delivered on a tablet computer. Using qualitative methods, we observed promotora training and intervention delivery, and conducted interviews with five promotoras to compare and contrast program implementation of both formats. We discuss the ways each format aided or challenged promotoras’ intervention delivery. Findings reveal that some aspects of both formats enhanced intervention delivery by tapping into Latino health communication preferences and facilitating interpersonal communication, while other aspects hindered intervention delivery. This study contributes to our understanding of how community health workers use low- and high-tech small media formats when delivering health messages to Latinos.

Keywords: community health workers, tailoring, cancer screening

INTRODUCTION

Community health workers provide culturally-relevant health messages to increase access to health care and improve health outcomes of underserved communities (Altpeter, Earp, Bishop, & Eng, 1999; Earp et al., 1997; Elder, Ayala, Parra-Medina, & Talavera, 2009; Perez & Martinez, 2008). Usually members of the community in which they work, community health workers can be health advocates for their priority population on local, state, and federal levels (Eng & Smith, 1995; McCloskey, 2009; Plescia, Groblewski, & Chavis, 2008). Promotoras are community health workers for Spanish-speakers who typically educate peers in a culturally appropriate manner (Elder, et al., 2009). Promotoras commonly use low-tech tools such as flipcharts, printed material, or videos in their health communication efforts. Rarely do they use high-tech communication tools such as hand-held mobile devices or tablet computers with interactive software to help them deliver health messages. This study, the Promotoras + Technology Study, sought to compare promotoras’ use of two different types of multimedia tools—low-tech and high-tech—to deliver a colorectal cancer screening intervention to medically underserved Latinos.

There is increasing evidence that two health promotion strategies—1) the use of one-on-one strategies; and, 2) small media—can effectively improve and increase cancer screening rates (Task Force on Community Preventive Services, 2008). For example, one-on-one strategies, such as programs delivered by promotoras, have been found to increase measurable health outcomes including breast and cervical cancer screening rates for many populations, including Latinos (Balcazar, Alvarado, Cantu, Pedregon, & Fulwood, 2009; Elder et al., 2005; Eng & Smith, 1995; Fernandez-Esquer, Espinoza, Torres, Ramirez, & McAlister, 2003; Fernandez et al., 2009; Ingram et al., 2007; Navarro et al., 1998; Ngoc Nguyen, Tanjasiri, Kagawa-Singer, Tran, & Foo, 2008; Yu et al., 2007). Small media materials can include video, print material, and interactive software programs that deliver tailored messages based on user input and delivered on mobile technologies such as phones or tablet computers (Task Force on Community Preventive Services, 2008). The use of small media is an effective strategy to improve health behaviors such as increasing breast, cervical, and colorectal cancer screening across a range of settings and populations (Robinson, Patrick, Eng, & Gustafson, 1998; Strecher, Greenwood, Wang, & Dumont, 1999; Task Force on Community Preventive Services, 2008).

Most small media materials developed with a particular population in mind and designed to include messages and images that are relevant, culturally acceptable, and appealing to the priority population are considered “targeted” materials. In contrast to targeting, in which messages and materials are designed to reach a specific segment of a population, tailoring is used to create messages and materials to reach one specific person based upon characteristics unique to that person, related to outcome of interest, and derived from an assessment of that individual (Kreuter, Strecher, & Glassman, 1999; Schmid, Rivers, Latimer, & Salovey, 2008).

With advanced technologies such as touch-screen computers and interactive software, small media can now be designed to tailor information in real time so that it is more salient to individuals and culturally appropriate for a particular population than targeted print or video formats (Gustafson et al., 2002). Messages in interactive health programs can include theory-based tailoring that permits streamlining information and constructing messages consistent with an individual’s responses to certain questions concerning one or more of many measured characteristics such as stage of change, interests, language, and cancer experience and worry. Furthermore, this type of delivery has the potential for making the delivered health information more consistent between clients (McTavish et al., 1995; Science Panel on Interactive Communication and Health, 1999). The characteristics of tailoring contribute to the finding that tailored small media programs are often more efficacious than material that are designed to reach a more general audience (Jibaja et al., 2000; Kreuter, Lukwago, Bucholtz, Clark, & Sanders-Thompson, 2003; Mathews, Darbisi, Sandmann, Galen, & Rubin, 2009; Suggs & McIntyre, 2009; Wilkin et al., 2007). While there is some evidence to suggest that tailored approaches using interactive communication technologies can increase cancer control behavior for one-on-one interventions, there were insufficient studies for a community guide recommendation supporting the use of tailored materials (Task Force on Community Preventive Services, 2008). It is possible that since one-on-one interactions are typically responsive to individual needs, the addition of tailored material does not necessarily represent an additional benefit. On the other hand, for promotoras, the use of tailored materials may decrease promotora burden and may increase effectiveness of their efforts (Elder et al., 2006).

Despite the promising findings concerning the use of one-on-one and small media strategies to increase cancer screening the most recent Community Guide systematic review did not result in recommendations for use of one-on-one strategies to increase colorectal cancer screening due to an insufficient number of studies (Task Force on Community Preventive Services, 2008). Similarly, there is insufficient evidence for small media for increasing colorectal cancer screening types other than the FOBT (Fecal Occult Blood Test), one of four recommended tests (Task Force on Community Preventive Services, 2008). It is also unclear exactly which small media formats (e.g. print, video, or tailored, interactive programs ) work best when delivered by community health workers. Finally, the available research lacks description of how and under what circumstances a combination of one-on-one education and varying small media formats (targeted or tailored) can effectively increase colorectal cancer screening rates among medically underserved Latinos (Lorence, Park, & Fox, 2006; Wilkin, et al., 2007).

This study, the Promotoras + Technology Study, seeks to fill gaps in knowledge about promotoras and their use of small media to increase cancer screening by describing how promotoras adapt to and use different small media formats to increase colorectal cancer screening among medically underserved Latinos. Using qualitative methods, we observed and interviewed promotoras who delivered a colorectal cancer screening intervention to this population in South Texas as a part of a CDC-funded community intervention (Vale la Pena Prevenir – Prevention: It’s Worth It!). Promotoras delivered the intervention via two different small media formats: a low-tech format (flip-chart and video) and a high-tech format (a tailored, interactive multimedia program on a tablet computer).

METHODS

Parent Study Methods

Vale la Pena was designed to increase the rates of colorectal cancer screening with any of the four types of recommended exams (FOBT, colonoscopy, sigmoidoscopy, and barium enema) among Latino men and women living in colonias (unincorporated, un-zoned, semi-rural communities often without access to public services) on the South Texas side of the Texas-Mexico border (Warner & Jahnke, 2003). The study included 24 colonias in Cameron and Hidalgo counties. Vale la Pena used a multilevel, randomized, three group design to test the effectiveness of two small media formats delivered by promotoras described elsewhere (Fernandez, Byrd, Arvey, Savas, & Vernon, 2010).

The first small media format (the low-tech fomat) included an educational flipchart and a linear telenovela (soap opera) video on DVD. The second small media format (the high-tech format) was a tailored, interactive, multimedia intervention delivered on a touch-screen computer in participants’ homes. While the educational content of both small media formats was as similar as possible, the high-tech format also included animations, live-action vignettes from the telenovela, and tailoring questions that allowed for the delivery of specific messages and images relevant to the individual participant’s level of knowledge about colorectal cancer screening, perceived risk of colorectal cancer, attitudes about screening, readiness to get screening, and specific barriers to screening.

To deliver both formats, promotoras visited participants’ homes. For the low-tech format they sat with participants to view the telenovela, and then reviewed the flipchart material. To deliver the high-tech format, promotoras sat with participants and helped them use the interactive program and answer tailoring questions by pushing computer touchscreen buttons with a stylus or finger.

Vale la Pena Promotoras

Six promotoras affiliated with two different community health organizations (Org A and Org B) located in South Texas border towns delivered either the low- or high-tech format to 316 participants (1 per household, self-identified Hispanic, ≥ 50 years of age, and had not been screened for colorectal cancer within recommended period). Promotoras were paid $10–12 per hour plus travel costs. The investigative team worked with the National Center for Farmworker Health, a non-profit organization dedicated to improving the health status of farmworker families, to develop a promotora training curriculum.

During three, 1–2 day sessions, consultants from the National Center for Farmworker Health and the investigative staff trained promotoras in cancer, colorectal cancer and screening topics, how to use the low- or high-tech small media format, and basic computer skills. Three separate trainings occurred per group. The first training session lasted four hours and mainly focused on the intervention content and familiarization with small media tools. Upon realizing the promotoras’ need for further training on basic computer skills for those delivering the high-tech intervention, we conducted a second four-hour training session a month after the first training. Initially, we assigned Org A promotoras to deliver the high-tech format and Org B to deliver the low-tech format; the organizations switched formats mid-study. At this mid-study point, we conducted a third, four-hour refresher on intervention content for Org B promotoras, and a four-hour intervention content refresher and computer training with Org A promotoras.

Parent Study Methods and Protocols

Study procedures were approved by the University of Texas Health Science Center Institutional Review Board (UTHSC IRB) and we obtained informed consent in accordance with university guidelines using a consent form developed and written in Spanish and English. The consent form described the purpose of the study, detailed the risks and benefits of participation, and included contact information for the Principal Investigator and UTHSC IRB. The interviewer read the form aloud in Spanish to the promotoras and gave them a signed copy once they consented. We kept consent forms and data from observations, interviews, surveys, and encounter logs in locked files in Principal Investigator’s office. Promotoras received $20.00 for their participation.

Promotora + Technology Study Methods

Study Design

As a process evaluation of Vale la Pena, the Promotoras + Technology Study employed qualitative methods and analysis based upon ethnography including direct observation and semi-structured interviewing of a purposive sample. The first author, a medical anthropologist, conducted multi-site direct observation during the second and third promotora trainings. The first author observed promotoras’ intervention delivery, and trained three research assistants who conducted direct observations of promotoras’ intervention delivery as well. The first author conducted in-depth, semi-structured, open-ended, interviews with the promotoras three months after the intervention implementation stage of the study (Bernard, 2002; Sobo, 2009).

Observations

As part of the process evaluation, we attended and observed two training sessions. During and after the sessions, we recorded detailed, unstructured field notes. Additionally, the first author and three research assistants observed each of the five promotoras delivering both low- and high-tech formats in 14 different sessions. Observations occurred during five separate, six-hour periods over the course of one year. All promotoras were observed at least once, and four were observed two to three times by the first author. Research assistants observed at least one promotora deliver the intervention one to two times. As part of our direct observations, we recorded detailed structured and unstructured field notes during and after intervention delivery. Structured field notes were recorded on a template used during and after observations of the intervention sessions. The template had columns in which the observer recorded: 1) the time of each noted observation during an intervention; 2) descriptions of the contextual aspects (i.e. of the site where intervention took place); 3) a verbatim description of some of the verbal and non-verbal interactions that took place; and 4) the observers’ subjective interpretation of the session and the communication between the promotora and the client. Unstructured field notes were recorded by hand after the sessions, and were typed and saved as documents using word-processing software. During the training sessions and the promotora-delivered intervention sessions, the first author spoke informally with the promotoras, asking them about their impressions of the sessions they had just had or their opinions of the intervention content and the small media formats.

Promotora Logs

Promotoras used “encounter logs” to record the time spent with each participant, topics covered, questions asked and answered, and referrals and/or recommendations given. We used MSExcel to calculate the time it took a promotora to deliver each intervention and compare average intervention times by small media format.

In-depth Interviews

The first author conducted in-depth, open-ended, semi-structured interviews in Spanish with five of the six promotoras (one was unavailable due to illness), three from Org A and two from Org B. Interviews took place in a public setting (University of Texas Brownsville private office or outside a public library) at the promotoras’ convenience. The interviewer asked promotoras to describe their work history and then to reflect upon their experiences with Vale la Pena (See interview questions, Appendix A). We digitally recorded, transcribed in Spanish, and downloaded the interviews into Atlas.ti 5.2, a qualitative software program designed to manage large bodies of qualitative data and enable systematic coding and analysis. Here, to maintain confidentiality, we have changed the names of the promotoras and identify their quotations with female pseudonyms.

Data Analysis of Interviews

The first author is fluent in Spanish, the second and third authors are native Spanish-speakers, and the fourth author is an English-only speaker. The first and second authors individually coded Spanish transcriptions for emerging themes. They later met to compare, discuss, agree upon, and add and eliminate shared codes and themes emergent in the data. The first author then refined the coding of the transcripts based upon these codes and thematic content. With the use of Atlas.ti visual displays, we examined the relationships between different codes and themes and explored interconnected sets of concepts and relationships that arose from transcripts (Green & Thorogood, 2005; Miles & Huberman, 1994; Weitzman, 1999). Finally, using the coded transcripts, the first author selected quotations illustrative of the emergent themes and integrated them into the manuscript text. Selected quotations were translated into English by first and third authors and reviewed by all four authors.

RESULTS

Promotoras + Technology Study Participant Demographics

All five promotoras who participated in this study lived in Cameron or Hidalgo County. All self-identified as Hispanic and primarily spoke Spanish in and outside of the home. Some, but not all, spoke and read English with a low-to-mid level of fluency. While one promotora had obtained a general education diploma, none had received education beyond the ninth grade. Promotoras’ ages ranged from 43 to 50 years. While all five promotoras had been born in Mexico, most had lived in the U.S. for at least 20 and up to 40 years. Although we identify the promotoras using the female form of the noun to maintain participant confidentiality, one promotor was a man.

It is likely that the promotoras had a work history similar to that of the Vale la Pena study participants. Two had worked as migrant laborers; two had worked in maquiladoras (assembly factories on the Mexico-U.S. border) and one had worked in a small family-owned retail business. At least two of the promotoras’ parents had been migrant farmworkers. Four had worked as promotoras for at least 6 and up to 25 years, and only one had worked as a promotora for less than 1 year. One promotora worked voluntarily without pay (with the exception of the Vale la Pena study), while the other four had been monetarily compensated for most of their promotora activities.

Emergent Themes

Major findings can be grouped by two descriptive themes that reveal: (1) how each small media format enhanced communication between promotora and study participant (theme: Small Media as Aid); and (2) how each small media format hindered communication between promotora and participant (theme: Small Media as Burden). Related subthemes that describe the ability of both formats to: 1) enable more than one study participant to view the intervention as it was delivered; 2) enable the promotores to deliver the session in various types of settings: and, 3) either facilitate or hinder the promotores’ ability to control the pace of the low-tech format are identified.

Small Media as Aid

Promotoras’ reports and observational data revealed that two technological aspects of both small media formats enhanced promotoras’ intervention delivery. First, both small media formats enabled “mobility” because promotoras could deliver the intervention either inside or outside the home. Second, in some cases both low- and high-tech formats provided “expanded viewing capacity” because the study participant and other household members were able to view the intervention as the promotoras delivered it. Finally, we describe our observations of and promotoras’ reported preferences for the low-tech format due to their ability to control the pace of the intervention when using it.

Mobility

Being able to power the high-tech format computer or the low-tech format portable DVD player with a battery enabled promotoras to conduct the intervention in spaces outside the home, i.e. in the yard, which in some cases, was a culturally appropriate site for intervention delivery. For example, we observed a situation in which a promotora visited a male study participant who lived by himself. In this case, the participant indicated that he wanted to receive the high-tech format intervention outside in his yard, which was open to view from the road. During the intervention cars passed the yard where we were sitting and the participant waved at the people, presumably his neighbors. Delivering the intervention outside may have enabled promotoras to avoid violating Latino cultural norms concerning the impropriety of unrelated people of the opposite sex sharing private space, particularly if one or more persons are married.

Indeed, when asked about potential problems related to promotoras visiting participants of the opposite sex, one promotora told us that she believed that when male promotoras visited the homes of married females the husbands of these women might be uncomfortable. She said, “It all depends on if the women [who is home alone] is married, you know, perhaps it would make the husband uncomfortable if a male [promotor] visits her.” Some of this caution was also related to concerns for personal safety. The same promotora mentioned that she was sometings afraid because “you could run into people out there, people who don’t think anything about their actions.” Other promotoras mentioned that the organizations they worked for did not want them entering homes to deliver interventions to men who were alone and, that they themselves were wary of doing so. In contrast, others told us that because promotoras were professionals conducting legitimate business, they thought that people should have no qualms about promotoras working inside the homes of people of the opposite sex.

Expanded Viewing Capacity

When promotoras initially began to use the DVD player to play the telenovela during the low-tech intervention format, they found that the volume on the DVD player could not be raised high enough when certain degrees of ambient noise were present. Even after speakers were ordered and distributed, promotoras often asked to use the participants’ own DVD player and television. Using the participant’s media equipment produced better audio and viewing ability and, because the telenovela was played in a communal or family setting, it enabled other household members (family, friends, and/or neighbors) who were present but not enrolled in the parent study to view the video.

In contrast, the high-tech format could not be viewed on a communal television. One promotora thought this was a disadvantage; she said that she could only deliver the high-tech format “to one person and only one person would be watching, the other person [in a couple] couldn’t.” Despite her assertion, in some instances a family member would sit beside the study participant as the high-tech format played. For example, we witnessed a female study participant’s adult daughter sit next to her mother throughout the entire session. At some points during the intervention, the mother would quietly confer with the daughter and seek approval of the selection that she was planning to make on the touchscreen.

Although we witnessed several cases in which household or family members (spouse or daughter or caretaker) sat with the study participant during the high-tech format sessions, promotoras claimed that this shared viewing situation mainly occurred with the low-tech format. They reported that study participants liked the low-tech format more because the whole family could benefit from the intervention despite the fact that only one person per household was enrolled in the study. When accompanying the promotoras, we observed cases where multiple household members of varying ages watched the telenovela together. In one home, the husband, wife, and their teenage daughter talked to each other and laughed about the content of the telenovela as it played. Promotoras mentioned this advantage of the low-tech format, saying, “there were occasions when the spouse was present…or a friend. I think that they also spread the information to…mainly to their close family members or friends who were older than 50 years” (Pamela). Another promotora said, “There is a big difference [between the two formats]….With the low-tech format, two people could watch it and if one person had questions, right, then both of them would get the information.”

Controlling the Pace of the Intervention: Benefits of Low-tech Format and Challenges of the High-tech Format

When comparing the small media formats, promotoras reported that the low- and high-tech formats produced different quality interactions and communication between themselves and participants and, for the most part, they preferred the communication style engendered in low-tech format sessions. The pace of the high-tech format was determined by the computer program and participants’ input, while with the low-tech format, promotoras described having more control over the pace and flow of information and, thus, of their communication with participants. One exchange in particular exemplifies the promotoras’ preferences for using the low-tech format and their perceptions of how it affected the pace of the intervention and of communication between themselves and participants:

Interviewer: Did you notice that participants asked you more questions in either type of intervention?

Rosa: They asked me more in the flipchart and video….

Interviewer: What does this mean to you? That they could ask more [in the low-tech format]?

Rosa: Because, with the [high-tech format]…they didn’t ask many questions because there it was all given to them, for example, if they wanted more information, they just poked the screen and out came the information. But with the video, sometimes it didn’t work that way. The video would run and they would want to know something, right, so I could press “pause” and I’d ask them, ‘Look, this is the information,’ and then with the flipchart I’d explain a little bit more.

Interviewer: So would you say that the high-tech format was almost a substitute for you?

Rosa: Sure, something like that.

Interviewer: Hmm, did you like this?

Rosa: Well, I liked the video [low-tech format] more because I could express myself more with them and give them [the participants] more, you know? With the other one, with the [high-tech format], it was something faster that just raced by. Probably if they did have a question they were left in doubt because not a lot of information came out in it.

Here, Rosa describes not only being able to control the pace of the intervention, but also her ability to disrupt the linear telenovela and use the flipchart at will in order to enhance and explain aspects of the video as it played. With the high-tech format, promotoras complained that it was difficult for participants to ask questions and for promotoras to answer question or to offer detailed explanations. For example, one promotora said, “I couldn’t interject my information like I wanted to, because it [the intervention] was between the machine and the participant….Those [participants] with the high-tech format sat there in silence because, well, they had to be attentive when the [tailoring] questions came up.”

The promotoras also reported that the low-tech format facilitated better quality interactions and stronger relationships between themselves and the participant than the high-tech format did. For example, one promotora stated, “I saw that people…were more partial to the flipchart, [because] there were more words, more playfulness, more back and forth between the promotora and the participant.” She explained further, “As they watched the telenovela, [the participants] formed questions, got familiar [with the intervention format], and they liked it, they liked it because they didn’t have to be poking screens, or waiting...” Another promotora said that she preferred the low-tech format to the high-tech format because, “I could explain things to them in more detail and I could show them bigger pictures [in the flipchart], because sometimes people can’t read and in the flipchart the pictures were bigger and I could explain things better.” Finally, a third promotora believed that the low-tech format was “easier to use and to explain, right, because they [participants] understood more…, and [in the high-tech format] they got a little lost.”

Although we only observed a sample of intervention sessions, in contrast to promotoras’ reports about the low-tech format facilitating better quality interactions between promotoras and participants than the high-tech format, the interactions we observed were fairly informational rather than interactive or “playful.” We found that promotoras often described or read the educational material with little inflection or visible engagement. Promotoras did ask study participants throughout the low-tech intervention if the participants understood the material, and they were able to explain the material in detail.

One factor that might have influenced promotoras’ perceptions is the fact that that low-tech format sessions generally lasted longer than high-tech format sessions. The average time a study participant spent receiving the intervention was approximately 20 minutes more with the low-tech format (89.5 minutes average among all) than with the high-tech format (69.7 minutes average among all) (Lairson, Fernandez, Misra, Williams, & Chan, Work in Progress).

While most promotoras favored the low-tech format, two of the promotoras mentioned that the high-tech format made their job easier and was more “entertaining” for study participants. One promotora claimed, “[The high-tech format], well, for me it was easier to use because you would just show up and connect it.” Observations of high-tech format sessions with the promotoras support this promotora’s assertion that being able to use the high-tech format to communicate complicated health messages related to colorectal cancer lessened the amount of time spent during an intervention delivery session and limited their role in various ways that will be discussed below.

Small Media as Burden

In addition to promotoras feeling less in control of the high-tech format, promotoras’ reports and our observations suggest that a combination of demands of the computer and the promotoras’ inexperience with computers hindered their delivery of the high-tech format. Promotoras reported anxiety, discomfort and lack of control related to required password protections and general computer functioning combined with nervousness about their inexperience with computers. Additionally, promotoras’ described the discomfort they felt from having to act as technological experts to help study participants overcome their own nervousness about using the tablet computer.

Technological Issues: Promotoras’ and Study Participant’s Inexperience with Computers

Initially, the requirement for computer passwords was the greatest obstacle for the promotoras’ intervention delivery. We observed that promotoras were not confident about creating or memorizing passwords that fulfilled password requirements. Powering the computers posed another technological problem. If a battery ran out in the middle of an intervention session, the promotora would have to restart and re-initialize the high-tech computer program, a process that could take up to five minutes. Furthermore, restarting the computer posed potential obstacles to the completion of a session: if the study participant did not remember the exact identifiers he or she had initially input, the program would require the promotora to abandon the unfinished session and begin a new session with new participant identifiers. Ultimately, these issues caused promotoras to be anxious about their work. One promotora explained, “I had problems with the password…one time I had to come to the office so [the project coordinator] could help me fix it. I had to suspend the session…we met at eight a.m. but I couldn’t enter the password and had to travel from here [the colonia] to [Org B to fix the problem]. But, thank God, [Org B’s manager] gave me the password, and I went back to the participant and was able to finish the encounter.” Another promotora mentioned that in order to restart the program after the battery ran out, participants would “mess up” and “try to erase their mistake [the incorrect identifiers] and that this process was “a little complicated.”

The high-tech format was delivered on computers that took a relatively long time to initialize and were slow to move from screen to screen. This slowness also made promotoras nervous. For example, one promotora believed that her computer was “breaking down” because it took so long for it to navigate [from screen to screen]. Additionally, when asked if technical problems with the high-tech format made her feel uncomfortable when she was with a study participant, another promotora revealed, “Well, yes…because if I had an appointment and this happened to me, I had to say ‘hold on a moment, wait a moment,’ I mean, you feel desperate [when this happens].”

Finally, because participant input determined the high-tech software sequence, it was possible for the study participant to mistakenly choose touchscreen options which would elicit unwanted program sections or repeated information. For example, one promotora reported that many study participants were frustrated by the high-tech format because “it was too long and sometimes the video would replay, for example, if they [participant] pushed the same button, the video would start again and they’d say ‘look at what is happening, it is going back, this is going to take up too much time, how much time will this take?’”

Technological Inexperience and Promotoras’ New Role as Technological Expert

During the promotora training, we observed that most of the promotoras did not have basic computer skills (for example, they had difficulty turning on the computer, using the keyboard, inputting passwords, using the mouse or touchpad, or choosing the correct icon to initiate the program). Further, our observations of the promotoras’ intervention delivery suggested that promotoras’ lack of experience with computers made them afraid of the computer interface, fearful that they would lose important study data being collected, and embarrassed that they would appear to be incompetent or inexperienced when delivering the intervention to study participants. This was confirmed by the promotoras’ feedback in our interviews. For example, one promotora said, “…the only thing that we lacked was a little [experience] with the computer.…Adding this to the fact that I was afraid [of the computer] because I thought ‘Ay, I’m going to erase something, some work,…’ and even though they told us this couldn’t happen…I was afraid.”

Similar to the promotoras, many study participants lacked experience with computers. To navigate the high-tech format, study participants used a touch screen and stylus to input data and to answer multiple choice questions. Direct observations in conjunction with promotoras’ reports revealed that study participants often expressed fear about using the computer and stylus and asked the promotora for help. One promotora explained, “At first they’d [i.e. participants] be afraid [and say], ‘No, I’m going to ruin it, I’ve never used this before.’ But when we would explain to them specifically what they had to do…I sat by their side to tell them how and what they had to do.” Another promotora, described participants’ reactions, “[Participants would say] ‘Ay, I can’t work a computer.’ And I’d tell them, ‘Don’t rush, whatever you cannot do I’ll tell you how to do it because really it is easy.’ I’d say this to them to give them confidence, confidence in themselves and [to help them] see that they were able to work a computer.”

Sometimes participants’ fear of the computer limited the extent of their participation and disrupted the intervention delivery. For example, in one case a participant asked the promotora to read the high-tech format prompts out loud to him and to input his responses because he did not want to use the stylus. One promotora reported that when the high-tech format prompted them to choose a touch screen option, participants would ask her, “‘Is this the right choice?’ And I’d tell them, ‘Well, you tell me what you think, if you want to know more information about this or not.’ They’d say yes, and so I’d push the button with the information that they wanted.” Another promotora agreed with this point and said, “Yes, I had to act like a mother [to get the participant through the high-tech format].”

Participants expected promotoras to act as technological experts and computer teachers during the high-tech format intervention sessions. One promotora explained, “We had to guide them bit by bit with the high-tech format so that they could familiarize themselves with the touch screen, with having to touch the screen with the stylus….This is what made them less afraid, that we could say to them, ‘No, you’re not going to have to type, you only have to use this [the stylus].’ And participants would be scared, first because they thought they would have to write or something with it, you know, and I would tell them, ‘no, no you don’t have to mess with a keyboard.’ This helped them a lot…they’d lose their fear and accept it.”

Promotoras suggested that, due to the age group of the participant population (=50), the low-tech format was a better tool with which to deliver the intervention than the high-tech format. They stated that older study participants were more inclined to be afraid of using the tablet computer. One promotora insinuated that age was the primary factor for their fear and the reason she had to help them get used to the high-tech format. Another promotorasaid, “I remember it [whether they liked the low- or high-tech format] more according to their age, you know. I think that older people, the oldest were more interested in the flipchart and telenovela ….And the younger folk also liked the high-tech format.”

DISCUSSION

While promotoras may “naturally” tailor the health information they deliver to their clients (Elder, et al., 2006), we expected that the use of a high-tech computer-based interactive program could improve the delivery of a colorectal cancer screening intervention in that it would deliver messages and content that was more relevant for participants. Since recommendations for colorectal cancer screening are relatively complex and require not only information and motivational messages to address screening barriers but also decision support to help participants choose an appropriate test, we hoped that a tailored program would help promotoras better address participant needs. Furthermore, we expected that these advanced technologies may help ease promotoras’ burden of having to learn large amounts of detailed information and tailor a health program “on the spot,” especially health programs that entail complex explanations and decision-making choices due to multiple screening options such as for colorectal cancer. Our results show that promotoras’ use of this technology created new, unanticipated challenges to their program delivery, and that promotoras in general preferred to use the low-tech small media materials.

Research indicates that promotoras’ delivery of breast cancer screening messages is often inconsistent. In one study to increase breast cancer screening, findings showed that promotoras tended to emphasize less important points, such as self-exam, and deemphasize important points, such as mammography (Fernandez, et al., 2009; Fernandez, Gonzalez, Tortolero-Luna, Partida, & Bartholomew, 2005). While Fernandez, et al. recognized that these advanced technologies may pose new problems or challenges compared to traditional, low-tech small media strategies, they proposed that a tool that could help promotoras be more consistent, repeat important information, tailor information to the client, and reduce promotora burden should be tested. The Promotoras + Technology Study explored the promotoras’ use of such a tool used to improve colorectal cancer screening among Latinos in South Texas.

Our observations and analysis of promotoras’ program training, program delivery sessions, and in-depth interviews shed light on the ways that two different small media formats (low- and high-tech) enhanced or hindered promotoras’ delivery of a colorectal cancer screening program for Latinos. Findings suggest that the more advanced technological format challenged promotoras’ intervention delivery more than the low-tech format The low-tech format did not require promotoras to memorize passwords nor were they required to learn new skills and techniques. Furthermore, promotoras reported that because they could control the pace of the low-tech format, it enabled them to establish better interpersonal communication with their clients. The high-tech format essentially created a new role for promotoras in which they had to be, or at least appear to be, technological experts in order to deliver the intervention, a role they were not comfortable playing. Findings also suggest how certain technological aspects of both small media formats, i.e. being able to be played outside and being able to be viewed simultaneously by multiple household or family members, enhanced promotoras’ communication with participants and the cultural fit of the program for Latinos in South Texas.

While promotora-delivery of both the low- and high-tech formats tapped into some of the known strengths of community health workers working in Latino communities, it appears that the low-tech format facilitated some of those strengths more so than the high-tech format. As intended, both small media formats utilized a one-on-one strategy by way of the promotoras who belonged to the same cultural group as study participants. Nevertheless, the expanded viewing capacity of the low-tech format tapped into the health communication strategy of involving multiple family or household members in public health programs. Health communication experts have stressed the importance of family involvement in strategies for Latinos (Ayala et al., 2007; Coatsworth, Pantin, & Szapocznik, 2002; Elder, et al., 2009; Tejeda, Thompson, Coronado, & Martin, 2009). Engaging more than one individual in the health education and possibly in the decision-making process concerning colorectal cancer screening was incidental to the original program intent of helping individuals make the best decision for themselves. We are not sure how intervention effectiveness was affected when more than the participant was involved.

A concern recently voiced by Pasick and colleagues is that most health promotion theory places undue importance upon the individual as a health decision maker and fails to take into account the importance and prioritization of relational culture among Latinas and other ethnic groups (Pasick et al., 2009). Relational culture is the “process of interdependence and interconnectedness among individuals and groups and the prioritization of these connections above virtually all else” (Pasick, et al., 2009). Other scholars have documented the importance of the influence of Hispanic adult daughters on their mothers’ health-related decision-making (Tejeda, et al., 2009; Washington, Burke, Joseph, Guerra, & Pasick, 2009). While we observed one instance when the high-tech format was viewed by a mother/daughter dyad, we also observed, and promotoras reported, that the low-tech format was more conducive to being played and viewed in a communal space by more than one household member. This suggests that the low-tech format may have a greater potential communicating health messages to Latinos than the advanced technology used for the high-tech format because it can easily involve multiple family members or other persons important and influential to the participant.

According to the promotoras, the low-tech format facilitated more and better quality communication between themselves and study participants than the high-tech format. In our observations, we did not notice obvious differences. However, findings reveal that on average more time (~20 minutes more) was spent delivering the low-tech format than the high-tech format. During the low-tech interventions, promotoras actively communicated with participants throughout the entire session. In contrast, during the high-tech interventions promotoras spent most of the time quietly sitting by participants’ sides. Promotoras described feeling more connected to study participants when they used the low-tech format. They claimed that during a low-tech format intervention they were able to answer participant’s questions during actual program delivery and explain concepts in more detail with flipchart pictures that they felt were superior visual aids than the high-tech format program. Additionally, some promotoras reported improvising with the low-tech format intervention, using flipchart material during the video demonstration to further illustrate certain points. Although this method was not in line with study protocol (the video was supposed to be shown first, and then the promotoras were supposed to go through the flipchart material), it may have further enhanced their intervention delivery.

Interestingly, we did not necessarily observe what we describe as superior “quality” interaction between promotora and participant during the low-tech sessions. We speculate that because promotoras spent the majority of the intervention verbally delivering the material, as well as controlled the pace of the delivery of the information when using the low-tech format as compared to the high-tech format, they perceived their activities as better quality and more playful. In essence, with the low-tech format, the promotoras were the vehicles of information transfer, whereas with the high-tech format, a computer played that role.

A crosscutting way in which both small media formats enhanced promotoras’ intervention delivery was that both formats could be viewed inside or outside the home, thus accommodating Latino cultural norms about when and where it is appropriate for unrelated people of opposite sex to share or occupy private space. Much of the literature on promotoras does not discuss this particular concern, perhaps because the majority of promotoras are women (U.S. Department of Health and Human Services, 2007) and because it is assumed that the wife/mother “bears the brunt” of instigating behavior change within the Latino family and should be the primary target of health promotion interventions for Latinos (Elder, et al., 2009). Nevertheless, as this study demonstrates, in programs delivered by promotoras to members of the opposite sex it may be important to consider Latino cultural norms such as these when thinking about possible program delivery sites.

Finally, our observations suggest that promotoras for Latino populations of low-socioeconomic status and low-education levels may lack the technological skills necessary to conduct health education programs using advanced technologies such as computers with the same ease and confidence that they report having when using the low-tech, usual practice material. Promotoras were thrust into a new role beyond that of peer educator: not only were they supposed to be knowledgeable about colorectal cancer screening, but they also had to appear to be, at the very least, at ease with the computer. While it may be that promotoras’ preference for the low-tech format could have been due to their familiarity with this “usual practice” media format, it is not clear that this would have been the case even if they were comfortable with using computers. Having to use the computer in front of study participants took a toll on the promotoras’ confidence, especially during the initial stages of intervention implementation. Many promotoras believed that the technological problems they encountered hindered their ability to conduct the intervention and induced their anxiety about their capability to effectively and correctly deliver the Vale la Pena program. It should be noted that the password requirements in place were imposed by institutional regulations and human subjects concerns that would not typically be present during program implementation outside the context of a research study.

Limitations

Some limitations to this study warrant mention here. Ideally, we would have conducted more observations of promotoras’ intervention delivery. While we were able to observe 14 sessions, more thorough saturation of observational data would have been met with a larger sample size (~25). Concerning promotoras’ preference for the low-tech format, it may be that their lack of experience biased them towards the format that was easier for them to use. Additionally, we concede that conducting in-depth interviews with the parent study participants as well as the promotoras would have shed more light on participants’ perceptions of the two intervention formats and the promotoras’ role in intervention delivery. Unfortunately, these additional observational opportunities were not built into the study design, nor were the authors able to conduct them once the study was underway.

It should be noted that tthe observers (the first author and research assistants) participated in the training of the promotoras and this relation could have acted as a constraint upon promotoras’ intervention delivery and interactions with the study participants as they were observed. Nevertheless, the first author conducted the majority of the direct observations and believes that she achieved substantial rapport with the promotoras such that they delivered the intervention while with her as they delivered it when they were not observed.

Despite these limitations, we strongly believe that the Promotoras + Technology Study provides great insight into promotoras’ use of these different small media formats and the ways the low- and high-tech formats enhance or hinder promotoras’ intervention delivery. These findings are valuable in light of the movement to develop and use new and innovative health communication strategies for medically underserved populations.

Implications

The high-tech format was clearly a challenge to promotoras, and findings suggest that we must pay attention to the ways the technology might disrupt interpersonal communication between promotoras and their clients. While the interactive format may be worth further investigation because its potential advantages of tailoring specifically to individuals, this study makes clear some of the obstacles and challenges that researchers must consider when deciding to do so. The findings of this study have important implications for health promotion researchers who wish to use a combination of two effective health communication strategies to increase cancer screening rates for medically underserved Latinos: small media and one-on-one strategies. For this population in particular, medically underserved Latinos, it is very important to design and utilize health communication tools that take advantage of cultural norms concerning gender and relational culture. And, we know that promotoras can be an effective way to deliver interventions. They also seem to “be” behavior change methods in-and-of themselves – providing role modeling and persuasion from a credible community source. What seems to be at issue here is how to create small media tools that interact with what the promotoras do normally in a way that enhances what promotoras already offer communities. Recent technological advances that offer more intuitive ways of accessing and delivering information (voice recognition technology) or delivery tools (such as with the Apple ipad or Android) may represent new opportunities to avoid some of the issues we saw in the current study while still capitalizing on the potential advantages of interactive multimedia. Clearly, however, without more research, we cannot assume that these approaches will improve promotora interactions with their clients. Perhaps two recommendations are in order: First, we need to learn more about the communication processes that occur between promotoras and their clients and to particularly discern which ones are crucial to effective interaction. Second, we need to further explore how materials (tailored or untailored, low-tech or high-tech) can be used to enhance the effective interactions, and to improve colorectal cancer screening among medically underserved Latinos.

Acknowledgments

This work was generously funded by Centers for Disease Control Prevention Research Center Special Interest Project (SIP 18- U48 DP000057-01) of which Dr. Fernandez was the Principal Investigator. Dr. Arvey conducted this research as a Postdoctoral Fellow in the University of Texas, School of Public Health Cancer Education and Career Development Program – National Cancer Institute/NIH grant R25-CA-57712. The content is solely the responsibility of the authors and does not necessarily represent the official views of the national Cancer Institute or the National Institutes of Health. This research was conducted with the approval of the Committee for the Protection of Human Subjects at the University of Texas – Houston Health Science Center, School of Public Health (HSC-SPH-04-123).

Appendix A

In-depth interview questions

  • Can you please describe the 2 types of formats you used in the Vale la Pena program?
  • Describe your process of conducting interventions:
  • Describe a typical day.
  • Describe a typical intervention session.
  • How were your sessions different from each other with the high-tech or with the low-tech format?
  • Can you tell me a story about one of your participants’ reactions to your session?
  • Which format do you think participants liked best: the low-tech or high-tech format?
  • Why?
  • Describe a time when a person really liked either the low-tech or the high-tech format. What kinds of reactions did they have?
  • Describe a time when a person did not like the low-tech or the high-tech format that you used in the session. What kinds of reactions did they have?
  • Do you think that the participants identified with the people in the video?
  • What do you think we could do to make the video better when we do it next time?
  • What would you suggest would make the flipchart better next time?
  • How do you think we can make the high-tech program better next time?
  • Do you think this program motivated people to get screened for colorectal cancer (CRC)?
  • Do you think this program increased peoples’ knowledge about cancer in general?
  • Do you think this program increased peoples’ knowledge about CRC?
  • Do you think this program helped them understand that not all cancer leads to death and that some types of cancer can be treated and cured?
  • Do you think that it might be possible that this program scared people or made them less willing to be screened because they were worried about cancer?
  • Did many people ask you to help them:
    • Make an appointment to get CRC screening?
    • Arrange transportation?
  • Do you think this program motivated people to take better care of themselves in general?
  • Did people ask you about other health problems they or they families had?
  • Were there times when participants needed or asked for help with others?
  • What kinds of questions did they ask you? What kinds of stories did they tell you?
  • What kinds of help were you willing and able to give them?
  • Were there times when people wanted or needed help with something that you could not help them with? What did you do? What did you tell them?

References

  • Altpeter M, Earp JA, Bishop C, Eng E. Lay health advisor activity levels: Definitions from the field. Health Education & Behavior. 1999;26(4):495–512. [PubMed]
  • Ayala GX, Baquero B, Arredondo EM, Campbell N, Larios S, Elder JP. Association between family variables and Mexican American children’s dietary behaviors. Journal of Nutrition Education and Behavior. 2007;39(2):62–69. [PubMed]
  • Balcazar H, Alvarado M, Cantu F, Pedregon V, Fulwood R. A promotora de salud model for addressing cardiovascular disease risk factors in the US-Mexico border region. Preventing Chronic Disease. 2009;6(1):A02. [PMC free article] [PubMed]
  • Bernard HR. Research methods in anthropology: Qualitative and quantitative methods. 3. Walnut Creek, CA: AltaMira Press; 2002.
  • Coatsworth JD, Pantin H, Szapocznik J. Familias Unidas: A family-centered ecodevelopmental intervention to reduce risk for problem behavior among Hispanic adolescents. Clinical Child and Family Psychology Review. 2002;5(2):113–132. [PubMed]
  • Earp JA, Viadro CI, Vincus AA, Altpeter M, Flax V, Mayne L, et al. Lay health advisors: A strategy for getting the word out about breast cancer. Health Education & Behavior. 1997;24(4):432–451. [PubMed]
  • Elder JP, Ayala GX, Campbell NR, Arredondo EM, Slymen DJ, Baquero B, et al. Long-term effects of a communication intervention for Spanish-dominant Latinas. American Journal of Preventive Medicine. 2006;31(2):159–166. [PubMed]
  • Elder JP, Ayala GX, Campbell NR, Slymen D, Lopez-Madurga ET, Engelberg M, et al. Interpersonal and print nutrition communication for a Spanish-dominant Latino population: Secretos de la Buena Vida. Health Psychology. 2005;24(1):49–57. [PubMed]
  • Elder JP, Ayala GX, Parra-Medina D, Talavera GA. Health communication in the Latino community:Issues and approaches. Annual Review of Public Health. 2009;30:227–251. [PubMed]
  • Eng E, Smith J. Natural helping functions of lay health advisors in breast cancer education. Breast Cancer Research and Treatment. 1995;35:23–29. [PubMed]
  • Fernandez-Esquer ME, Espinoza P, Torres I, Ramirez AG, McAlister AL. A su salud: A quasi-experimental study among Mexican American women. American Journal of Health Behavior. 2003;27(1087–3244; 5):536–545. [PubMed]
  • Fernandez ME, Byrd T, Arvey SR, Savas LS, Vernon SW. Development and evaluation of a lay health-worker delivered interactive program to increase colorectal cancer screening among Hispanics on the Texas-Mexico Border. IUHPE World Conference on Health, Equity, and Sustainable Development; Geneva, Switzerland. 2010.
  • Fernandez ME, Gonzales A, Tortolero-Luna G, Williams J, Saavedra-Embesi M, Chan W, et al. Effectiveness of Cultivando la Salud: A breast and cervical cancer screening promotion program for low-income Hispanic women. American Journal of Public Health. 2009;99(5):936–943. [PubMed]
  • Fernandez ME, Gonzalez A, Tortolero-Luna G, Partida S, Bartholomew LK. Using Intervention Mapping to develop a breast and cervical cancer screening program for Hispanic farmworkers. Health Promotion Practice. 2005;6(4):394–404. [PubMed]
  • Green J, Thorogood N. Qualitative methods for health research qualitative data analysis. Thousand Oaks, CA: Sage Publications; 2005.
  • Gustafson DH, Hawkins RP, Boberg EW, McTavish F, Owens B, Wise M, et al. CHESS: 10 years of research and development in consumer health informatics for broad populations, including the underserved. International Journal of Medical Informatics. 2002;65(3):169–177. [PubMed]
  • Ingram M, Torres E, Redondo F, Bradford G, Wang C, O’Toole ML. The impact of promotoras on social support and glycemic control among members of a farmworker community on the US-Mexico border. The Diabetes Educator. 2007;33(Suppl 6):172S–178S. [PubMed]
  • Jibaja M, Kingery P, Neff N, Smith Q, Bowman J, Holcomb J. Tailored, intereactive soap operas for breast cancer education of high-risk Hispanic women. Journal of Cancer Education. 2000;15(4):237–242. [PubMed]
  • Kreuter MW, Lukwago SN, Bucholtz RD, Clark EM, Sanders-Thompson V. Achieving cultural appropriateness in health promotion programs: Targeted and tailored approaches. Health Education & Behavior. 2003;30(2):133–146. [PubMed]
  • Kreuter MW, Strecher VJ, Glassman B. One size does not fit all: the case for tailoring print materials. Annals of Behavioral Medicine. 1999;21(4):276–283. [PubMed]
  • Lairson DR, Fernandez ME, Misra S, Williams J, Chan W. Cost effectiveness analysis of an intervention to improve colorectal cancer Screening Among Hispanics in South Texas. (Work in Progress)
  • Lorence DP, Park H, Fox S. Racial disparities in health information access: Resilience of the Digital Divide. Journal of Medical Systems. 2006;30(4):241–249. [PubMed]
  • Mathews PH, Darbisi C, Sandmann L, Galen R, Rubin D. Disseminating health information and diabetes care for Latinos via electronic information kiosks. Journal of Immigrant and Minority Health. 2009;11:520–526. [PubMed]
  • McCloskey J. Promotores as partners in a community-based diabetes intervention program targeting Hispanics. Family and Community Health. 2009;32(1):48–57. [PubMed]
  • McTavish FM, Gustafson DH, Owens BH, Hawkins RP, Pingree S, Wise M, et al. CHESS (Comprehensive Health Enhancement Support System): An interactive computer system for women with breast cancer piloted with an underserved population. Journal of Ambulatory Care Management. 1995;18(3):35–41. [PubMed]
  • Miles M, Huberman A. Quatliative Data Analysis. Thousand Oaks, CA: Sage Publications; 1994.
  • Navarro AM, Senn KL, McNicholas LJ, Kaplan RM, Roppe B, Campo MC. Por La Vida model intervention enhances use of cancer screening tests among Latinas. American Journal of Preventive Medicine. 1998;15(1):32–41. [PubMed]
  • Ngoc Nguyen TU, Tanjasiri SP, Kagawa-Singer M, Tran JH, Foo MA. Community health navigators for breast- and cervical-cancer screening among Cambodian and Laotian women: Intervention strategies and relationship-building processes. Health Promotion Practice. 2008;9(4):356–367. [PubMed]
  • Pasick RJ, Barker JC, Otero-Sabogal R, Burke NJ, Joseph G, Guerra C. Intention, subjective norms, and cancer screening in the context of relational culture. Health Education & Behavior. 2009;36(5 Suppl):91S–110S. [PMC free article] [PubMed]
  • Perez LM, Martinez J. Community health workers: social justice and policy advocates for community health and well-being. American Journal of Public Health. 2008;98(1):11–14. [PubMed]
  • Plescia M, Groblewski M, Chavis L. A lay health advisor program to promote community capacity and change among change agents. Health Promotion Practice. 2008;9(4):434–439. [PubMed]
  • Robinson TN, Patrick K, Eng TR, Gustafson D. An evidence-based approach to interactive health communication: A challenge to medicine in the information age. Science Panel on Interactive Communication and Health. Journal of the American Medical Association. 1998;280(14):1264–1269. [PubMed]
  • Schmid KL, Rivers SE, Latimer AE, Salovey P. Targeting or tailoring? Marketing Health Services. 2008;28(1):32–37. [PMC free article] [PubMed]
  • Science Panel on Interactive Communication and Health. Wired for Well-Being: The Emergence of Interactive Health Communication. Washington, D.C.: U.S. Department of Health and Human Services; 1999.
  • Sobo EJ. Culture & Meaning in Health Services Research: A Practical Field Guide. Walnut Creek, CA: Left Coast Press; 2009.
  • Strecher VJ, Greenwood T, Wang C, Dumont D. Interactive multimedia and risk communication. Journal of the National Cancer Institute. Monographs. 1999;(25):134–139. [PubMed]
  • Suggs LS, McIntyre C. Are We There Yet? An Examination of Online Tailored Health Communication. Health Education & Behavior. 2009;35(2):278–188. [PubMed]
  • Task Force on Community Preventive Services. Recommendations for Client- and Provider-based Interventions to Increase Breast, Cervical, and Colorectal Cancer Screening. American Journal of Preventive Medicine. 2008;35(1S):S21–S25. [PubMed]
  • Tejeda S, Thompson B, Coronado GD, Martin DP. Barriers and facilitators related to mammography use among lower educated Mexican women in the USA. Social Science and Medicine. 2009;68(5):832–839. [PMC free article] [PubMed]
  • U.S. Department of Health and Human Services. Community health worker national workforce study. 2007 Retrieved January 4, 2010, from http://bhpr.hrsa.gov/healthworkforce/chw/
  • Warner DC, Jahnke LR. US/Mexico Border Health Issues: The Texas Rio Grande Valley. San Antonio, TX: Regional Center for Health Workforce Studies: Center for Health Economics and Policy, The University of Texas Health Center San Antonio; 2003.
  • Washington PK, Burke NJ, Joseph G, Guerra C, Pasick RJ. Adult daughters’ influence on mothers’ health-related decision making: an expansion of the subjective norms construct. Health Education & Behavior. 2009;36(5 Suppl):129S–144S. [PMC free article] [PubMed]
  • Weitzman EA. Analyzing qualitative data with computer software. Health Services Research. 1999;34(5 Pt 2):1241–1263. [PMC free article] [PubMed]
  • Wilkin HA, Valente TW, Murphy S, Cody MJ, Huang G, Beck V. Does entertainment-education work with Latinos in the United States? Identification and the effects of a telenovela breast cancer storyline. Journal of Health Communication. 2007;12(5):455–469. [PubMed]
  • Yu MY, Song L, Seetoo A, Cai C, Smith G, Oakley D. Culturally competent training program: A key to training lay health advisors for promoting breast cancer screening. Health Education & Behavior. 2007;34(6):928–941. [PubMed]