Abstract
Background. The community health worker (CHW) model is utilized globally to promote health and reduce health disparities in hard-to-reach and underserved communities. The model is deemed successful due to involvement of these natural helpers who are familiar with the local customs, language, and traditions. “Research” CHWs (also known as promotores) serve as cultural mediators between their community and academic researchers and are increasingly involved in the design and implementation of research; yet few of these individuals have received formal training in research methods or ethics. This study identified requisite skills and knowledge needed by research CHWs. Method. Investigators who utilized the CHW/promotor model were recruited to complete a survey and participate in one of four focus group sessions. Participants identified (1) research roles, (2) training received, (3) research competencies, (4) training barriers and facilitators, and (5) assessment preferences. Results. Participants (n = 20) completed a survey with 19 also participating in a focus group session. All participants involved CHWs in research implementation, with nearly half involving CHWs in the study design and/or dissemination of findings phases. Critical thinking skills and application of ethical principles (e.g., demonstrating respect) were prioritized over knowledge of research infrastructure (e.g., institutional review board/ethics review process). Research ethics training designed for academic researchers was deemed inappropriate because sophisticated terminology and web-based delivery were perceived as an access barrier. Self-assessment and contextualized scenarios were recommended to assess critical thinking. Conclusions. Researchers using the CHW model should provide relevant and accessible research competency training.
Keywords
The term community health worker (CHW) is used to describe people who assist in both health care service delivery and health research studies (Kangovi et al., 2015; Witmer et al., 1995). Globally, CHWs are known by over 100 different titles 1 including promotores de salud, patient navigators, and health educators. While part of the health care landscape for decades (Rosenthal et al., 2010), CHWs are increasingly contributing to the design, implementation, and dissemination of biomedical and behavioral health research (Braun et al., 2013; Hohl et al., 2016; O’Brien et al., 2009). As research facilitators, CHWs may (1) provide cultural context during the study design phase, (2) assist with participant recruitment and informed consent during enrollment, (3) implement health interventions and collect data, and (4) communicate study results to participants and the extended community on study conclusion (Terpstra et al., 2011). For this article, we use the terms promotor (masculine), promotora (feminine), and promotores (plural) as these terms are used most frequently among public health researchers in the southern California region.
The promotor model is used primarily in underserved communities to promote health and reduce health disparities. The promotor model is deemed successful due to the involvement of natural helpers who are familiar with the customs, language, and traditions of the community; however, how they are involved in terms of responsibilities, and scope of work, as well as pay and training remains varied (Cherrington et al., 2010; Lehmann & Sanders, 2007). Biomedical research studies have used the promotor model for over 30 years to increase access to hard-to-reach communities for outreach, recruitment, and intervention delivery; however, promotores as “researchers” are clearly underrecognized with respect to their need for foundational training in the scientific method and research ethics (Nebeker et al., 2015; Terpstra et al., 2011). In addition to these community members becoming actively involved as research facilitators via the promotor model, there has been a steady increase of community-engaged and community-based participatory research initiatives (Holkup et al., 2004; Horowitz et al., 2009). While these models have gained in acceptance, professional training among those contributing has unfortunately lagged with respect to research literacy and ethics education.
In the traditional academic research model, most if not all involved in the design, implementation, and reporting of research have received extensive research training during their graduate education and postdoctoral training. Since the National Institutes of Health mandated training for key personnel involved in human research 20 years ago, several web-based programs have emerged to meet this requirement; however, these programs are intended for traditional researchers who have received extensive, formal academic research training. Moreover, the trainings available to the academic researchers are designed to meet a compliance mandate rather than to educate novice researchers. As key members of the research team, “research” promotores who contribute to the design, conduct, and dissemination phases of research are assumed to possess a foundational understanding of the scientific method and be familiar with the application of ethical principles designed to enhance human research participant protections. However, while promotores facilitate access to hard-to-reach and underserved research participants, few have received formal academic training in research methods or ethical research practices (Nebeker et al., 2015; Nebeker & Lopez-Arenas, 2016). Lacking this foundation in the scientific method, associated ethical principles and practices designed to protect research participants and communities may be missed or misunderstood resulting in protocol deviations, increased risk to participants, and potentially compromised data fidelity and interpretation of results (Alexander & Richman, 2008; Richman et al., 2012; Terpstra et al., 2011; True et al., 2011). By acquiring this specialized knowledge, promotores may better understand their role in research with respect to the importance of protocol adherence and responsibilities that enhance research integrity (Alexander & Richman, 2008; Nebeker et al., 2015; Nebeker & Lopez-Arenas, 2016; Richman et al., 2012; Terpstra et al., 2011; True et al., 2011).
Recognizing that little formal research ethics education was available to meet the needs of “research” promotores, a curriculum called “Training in Research Ethics and Standards” or TRES was developed (Nebeker et al., 2015), followed by “Building Research Integrity and Capacity” or BRIC (Nebeker & Lopez-Arenas, 2016). The BRIC training combines TRES modules with instruction to improve knowledge of basic research concepts. The BRIC objectives are to increase research literacy and improve research competencies among promotores, and other novice researchers, who have little or no formal academic research education. The BRIC content and instructional design was informed by a participatory process involving promotores, principal investigators (PIs), and project managers (PMs). The training consists of eight instructional modules including an introduction to the scientific method and research design along with principles and practices to promote research ethics and human research protections (Nebeker & Lopez-Arenas, 2016). In 2013, additional formative research was conducted to (1) examine whether key research competencies identified in 2003 remained constant and (2) determine how best to assess relevant “research” skills and knowledge in promotores. To further improve training for promotores, we asked promotor supervisors to identify requisite skills and knowledge needed to perform research tasks.
Method
A mixed-methods research design involving a web-based survey followed by focus groups sessions was used to identify (1) the role of the promotor in research, (2) training received, (3) research competencies, (4) barriers and facilitators to professional development, and (5) assessment preferences. This formative research was reviewed by the University of California, San Diego institutional review board and verified as exempt (45 CFR 46.101).
Recruitment
Participants were recruited in November 2013. Eligible individuals were those who had supervised or were involved with training promotores to assist with research. Prospective participants were identified through an informal network composed of local community organizations and universities and were sent a recruitment message via email explaining the study purpose and aims. Once eligibility was confirmed, individuals were sent an informed consent statement appended to a web-based survey. Recipients were asked to review the consent form and, if consenting to participate, to complete the survey prior to participating in a focus group interview.
Data Collection: Pre–Focus Group Survey
Participants completed a web-based survey prior to attending a focus group session. The survey, developed by the research team, included demographic items, experience and practices with engaging research promotores, and a 68-item Research Competency Rating Form (RCRF). The RCRF items were informed by the review of learning objectives associated with the BRIC curriculum (Nebeker et al., 2015).
Focus Group Protocol
The focus group semistructured interview guide was designed to assess participant perceptions of promotores’ involvement in health research, their needs specific to developing research competencies, and related training provided by PIs/PMs. Prompts were included to explore the appropriateness of current research ethics training and evaluation practices for training promotores.
Focus Group Process
Four focus groups were conducted between December 2, 2013, and December 18, 2013, at one of three locations in the greater San Diego area including two universities and one community health center. A research coordinator facilitated each focus group session assisted by a graduate student who managed logistics and recorded notes. Focus groups involved three to six participants per 90-minute session and were audio recorded.
Focus Group Content
Discussion prompts focused on (1) promotores’ roles in research projects, (2) current practices for training, (3) evaluation of research skills, and (4) knowledge and recommendations for improvement. Participants also identified knowledge and skills considered essential to carry out research responsibilities. During the latter part of the focus group, participants were presented with select questions from the RCRF survey in which there was variability in responses to address potential misconceptions of the survey items. Focus group participants received a $25 gift card as a token of appreciation for their contributions.
Analysis
Quantitative Data
Analyses of participant demographic and descriptive data were conducted using Microsoft Excel. Participants rated the importance of each RCRF item using a 5-point scale where 1 = definitely not important and 5 = definitely important. A mean score was calculated for each item and then grouped as reflecting a high, medium, or low priority. Distribution of competency ratings were also organized based on investigator involvement of promotores across the continuum of research engagement (e.g., planning, implementation, and reporting).
In addition to classifying items across research phases, each item was assigned to one of three ethical principles: “Respect for Persons,” “Beneficence,” or “Justice” (The National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research, 1979). These three principles of biomedical ethics are a backbone of research ethics and considered an important aspect of ethics education. The principle of “Respect for Persons” is demonstrated through the informed consent process, which occurs during the study implementation phase. Therefore, an item that mapped to the informed consent process was classified as “implementation” with respect to research phase and “respect” in relation to the ethical principle. Similarly, the principle of “Beneficence” was coded for items that influenced study risks and benefits and assigned to the appropriate phase. For example, items that addressed data management would be classified under the “Beneficence” principle and either assigned to “Planning” or “Implementation.” The principle of “Justice” was used to identify items focusing on participant characteristics and suitability for answering the research questions and, similar to “Beneficence,” was assigned to the appropriate phase depending on the context of the item. If items did not pertain to a research phase but, instead, focused on the role of the research team (e.g., PI responsibilities) or were definitions (e.g., the definition of research), they were not categorized as a phase or as an ethical principle. Confirmation of this coding process was carried out by two research team members (CN, MK) who independently coded each item and then discussed any disagreement until a resolution was achieved.
Qualitative Data
Digital audio recordings of each focus group session were professionally transcribed and reviewed by staff to ensure accuracy of the transcription. Two research team members (RG, BP) experienced in qualitative methods independently coded a transcript to construct the initial codebook. The coders then met on two separate occasions to compare thematic and subthematic codes and refine coherent patterns to reach intercoder agreement. Minor differences in interpretation were resolved by discussion and conceptual categories, and themes were established. Intercoder agreement between the two coders was 92% during the first meeting. After discussion during the second meeting agreement was 100%.
Results
Thirty-six individuals who supervised promotores in research studies were invited to participate in this formative research. Of the 36, 22 agreed to participate in a focus group. Of the 22 individuals who agreed to participate, 20 completed the demographic and RCRF survey prior to attending a focus group and 19 participated in one of the four scheduled sessions. Reasons for not participating were attributed to scheduling conflicts.
Pre–Focus Group Descriptive Data
Participants
Survey participants (n = 20) were identified as being directly involved in supervising research promotores. Participants, the majority of whom were female (89%), reported an average of 10.5 years of research experience with 9.5 years involving promotores in behavioral and biomedical research. Participants ranged in age from 29 to 53 years (M = 39 years), with 86% reporting a bachelor’s degree and 63% a graduate degree. Participants included project coordinators (18%), PMs (23%), PIs (36%), and “other” (23%). The “other” included, for example, evaluation coordinator or data manager. The majority of participants led research in the local Latino community, but participants also included those working with African American, Somali, East African, and Native Hawaiian/Pacific Islander communities.
Role in Research: Involvement of Promotores
Participants reported that promotores were involved in epidemiological, cross-sectional, randomized control trials and mixed-methods studies. Likewise, they reported that responsibilities assigned to promotores included participant recruitment, obtaining informed consent, data collection, intervention delivery, and data entry. When mapping responsibilities to phases in the research process, participants involved promotores across all aspects of research including design/planning (50%); research implementation/conduct (e.g., recruitment, intervention delivery, and data collection; 100%), and data analysis and/or dissemination of results (42%). In contrast to our 2003 data where promotores were reported to be exclusively involved in planning and implementation, participants in 2013 reported that promotores were involved in all phases of research including reporting and dissemination of results. See Figure 1.
Percentage of Principal Investigators/Project Managers Who Involve Promotores Across Three Phases of Research (n = 20)
Research Competencies
Not surprisingly, participants reported that the majority of knowledge and skill items were “important” or “definitely important” for research staff to know or be able to do when engaged in health research. The emphasis of these competencies paralleled the scope of work held by promotores in their work setting. Table 1 depicts top-ranked areas of knowledge and skills that PI/PMs identified as most important (see supplemental material for the complete list). Included is the research phase (i.e., planning, implementation and dissemination) and relevant ethical principle (i.e., respect for persons, beneficence, and justice). Similar to what we learned in 2003, priority was placed on the competencies associated with the implementation phase (Terpstra et al., 2011); however, there was an increase in attention to the planning phase. And while participants indicated that promotores were increasingly involved in dissemination of results, training focused on this phase was considered to be lower in priority.
Mean Scores of Top 25 Competency Items, Research Phase, and Ethical Principles
The competency items were also organized by knowledge and ability categories (see Table 2). Of the 68 items, 44 (65%) were labeled as “Knowledge,” which was something the promotor needed to know, or as “Abilities” (n = 24 or 35% of total), which was defined as something the promotor needed to be able to do. Each participant was asked to indicate the importance of the item using a 5-point Likert-type scale where 1 = definitely not important, 2 = not important, 3 = neither important nor unimportant, 4 = important, and 5 = definitely important. The mean score was computed for each item. Items labeled “High Priority” were those receiving a mean score of 4.5 or higher, “Moderate Priority” received a mean score of 4.0 or higher but less than 4.5, and “Low Priority” were those with a mean score less than 4.0. Needless to say, participants thought that almost everything was important. The lowest mean score of 3.4 was at worst a neutral score, which is important to keep in mind when reviewing results. Overall, participants marginally identified Abilities (24%, 16 items) over Knowledge (16%, 11 items). Given that 67% (16 out of 24 items) of the Ability items but only 25% (11 out of 44) of the Knowledge items were scored in the highest priority category suggests that the ability to perform in a manner that supports the overall research activity was seen as of utmost value.
Priority Rank of Knowledge and Abilities
Note. Values presented as n (%).
Data were also analyzed for how item priority mapped to research phase and ethical principles (Supplemental Table S1). Of the 68 items, 14 (20%) were categorized as “Basic Research Knowledge” and were assigned a moderate to low priority. Nine items (13%) were categorized as Knowledge of “Research Team Role,” with all but one classified as moderate to low priority. Neither “Research Knowledge” nor “Team Roles” was categorized under a research phase or assigned to an ethical principle.
Research Phase
Eight items identified as “Planning” research (12%) were split across Knowledge and Ability categories, with 62% (n = 5) rating as high priority and 38% (n = 3) as moderate or low priority. The “Implementation” category consisted of 17 Knowledge and 16 Ability items (47% of total), with 22 (67%) being rated as high priority and 10 (30%) as moderate priority. The “Dissemination” category consisted of two Knowledge and one Ability item (4% of total), with the Knowledge items considered moderate priority and Ability rated as low priority.
Ethical Principles
The Principle of “Respect for Persons,” generally associated with individual agency and the informed consent process, was assigned as the key ethical principle for six Knowledge and seven Ability items. Of the Knowledge items, 100% received a moderate (n = 7) or a high-priority (n = 6) rating. Likewise, 12 of 13 Ability items were rated as moderate (n = 5) or high priority (n = 7; see Table 3). The principle of “Beneficence” focuses on the balance of risks to benefits and the likelihood that the study will contribute valuable new knowledge to society and those represented by the research participants. A total of 15 items classified as being aligned with the principle of “Beneficence” were split between Knowledge (n = 6) and Ability (n = 9). All Knowledge items were rated as high (n = 4) or moderate priority (n = 2), with the majority of the Ability items (n = 8) rated as high priority. The principle of “Justice” is considered by the research team when designing the study and determining who should be included. It is important that those included in research reflect the characteristics of those most likely to benefit from knowledge gained from the study. As the study inclusion criteria are typically determined prior to a promotores’ involvement, there were only three items grouped under the “Justice” domain, which were split between Knowledge (n = 2) and Ability (n = 1). The two Knowledge items were split between moderate and low priority, with the Ability item rated as high priority.
Priority Rank of Research Phase and Ethical Principles
Focus Group Results
Focus group participants were asked to describe their experience with promotores/CHWs, requisite skills and knowledge, involvement in research projects, useful training strategies, training barriers/challenges, assessment preferences, use of web-based trainings, and lessons learned. The results are organized by the following themes: (1) Value of Promotores, (2) Research Competencies, (3) Promotor/CHW Involvement in Research, (4) Training Strategies, (5) Barriers and Challenges, and (6) Assessment.
Value of Promotores
Participants were asked to describe the characteristics and qualities of a promotor that contribute to their value on the research team. Overwhelmingly, participants indicated that the promotores’ value came from being part of the community, understanding of the language and customs, and their commitment to making a difference within the community. Participants also acknowledged the promotores’ value in making important community connections. The following quotes depict promotor value as a research liaison: Community member interested and motivated to improve the community in all areas behavioral health, environmental, just overall A representative from the community that serves as a liaison between the research team and their respective community
Research Competencies
Participants acknowledged that the promotores they worked with have varied research experience and rarely have formal training in research design and methods. When asked about what research competencies were needed, participants reported that critical thinking skills and ability to respond appropriately in the field were essential. When characterizing “research competency,” participants described it as a metric for assessing one’s knowledge and skills in the planning, implementation, and impact of research, for example: Competency and understanding of what research is, how research is conducted, and the purpose of research and one’s role in the research process. Knowledge of research. For example, informed consent, confidentiality, randomization among those working on a research study. Just understanding the basic research concepts of “How do you design a study?” and “Why do you do experimental designs?” But also “What’s the time frame?” and “What are the outcomes for that?” and “What does that mean for the community?”
Adding to this description, participants indicated that essential competencies include the value of having good communication skills to work with members at various levels of the research team, critical thinking skills, the ability to carry out the scope of work specific to each project, and knowledge of research participant protection (e.g., ethical conduct).
Promotor/CHW Involvement in Research
Participants reported promotores’ involvement across research planning, intervention delivery, data management, and dissemination of study results. Promotores were involved primarily in the implementation phase of research studies (e.g., health education delivery, data collection, participant recruitment, etc.) or, in clinical settings, as patient navigators. Some participants stated that it was important to have a promotor involved in research studies from the beginning design phase (i.e., protocol development) since they can contribute an accurate perspective that is culturally sensitive to the community’s needs.
We want them to contribute to the design to make sure that it’s feasible and relevant to the community that we’re targeting. [Promotoras] are in constant communication with families, trouble-shooting barriers, finding additional resources. We have promotoras involved in every aspect from recruitment to outreach to intervention; a little bit of evaluation. They might be the ones giving the pre- and post-tests or those kind of things.
Training Strategies
Training content sources and process
Participants indicated that current methods used to prepare a promotor to undertake research responsibilities include web-based tutorials such as the university institutional review board (IRB) tutorial and the “Collaborative Institutional Training Initiative” (CITI), along with TRES (Nebeker et al., 2015). Project supervisors also created project-specific training manuals that included shadowing of research promotores to make observations and provide specific and timely feedback. Participants expressed that these methods increased staff confidence and empowerment and helped build the skills necessary to carry out their responsibilities. Role-play and shadowing were seen as essential to empower promotores and to assess their skills and knowledge.
We do a lot of group trainings and then work slowly down to role-playing and they have to really feel comfortable explaining [the material] to us before we’ll send them out [to the community].
When utilizing training designed for academic researchers (e.g., CITI), participants indicated that they reviewed the content with the trainee to explain how the information applied to their role on a project. Participants acknowledged that this process was very time-consuming and did not appear to enhance understanding of the concepts presented. Training that was tailored to promotores (i.e., TRES) was viewed as a valuable resource by all participants. Participants frequently reported “ongoing,” and “as needed,” refresher or booster types of training. Additionally, the TRES curriculum (or the use of selected segments from this curriculum) and other multisource, free trainings were also used by focus group participants.
We’re training all of our data collectors on how to do the initial recruitment and study eligibility and then the consent process. So, they go through a very extensive training on how to not engage in coercion. It’s all usually delivered in group settings with a lot of role-plays, going through scripts, insuring that they’re meeting some sort of criteria at the end through some sort of observational assessment and/or a written test to make sure that they get it . . .
Training time allotted
Although the trainings offered to promotores were extensive (i.e., 40–60 hours), participants stated that the majority of training focused on the relevant health condition and project-specific intervention delivery, with only a small portion of training addressing research ethics (e.g., confidentiality).
[The training is] a combination of the disease, the science, and then their role in terms of training them with the data collectors it’s more about rigorous data collection and maintaining confidentiality.
Barriers and Challenges
Reported challenges in carrying out research ethics training largely focused on educational, language, and literacy barriers. Participants described lack of understanding among promotores regarding the purpose of research and reasons behind certain procedures (e.g., evaluation data, maintaining confidentiality), as well as a lack of interest in formal research training. Language and literacy barriers in IRB tutorials and study materials often require staff to assist promotores (e.g., simplify or reword information) and translate material. Participants also identified several challenges in training research competencies. These challenges mainly pertained to language and educational barriers, the length of the trainings, and the amount of work that the promotor was involved with (i.e., community service at local health clinics). A misunderstanding of the purpose and importance of research studies was also identified as a challenge among supervisors responsible for training promotores/CHWs.
There might not be an understanding of the importance of [the different components of research], so when people think “research” . . . they just want to collect data; but it’s also a form of evaluating a program . . . I think that happens with some of the student . . . They don’t realize the importance of why they’re collecting certain data. What I’ve observed is that a lot of the promotores . . . don’t see a need for formal training, they don’t feel that they’re part of that and so a lot of the times . . . I’ve heard [statements such as] “Why do they give us these types of trainings?” or it’s more of a waste of time for them . . . because they have things they have to get done on the study, on the project, and so they’re more concerned about getting what . . . needs to be . . . done with the families . . . So, a formal training for them is not something that they look forward to.
Assessment
To evaluate promotores, skill-based assessments were identified as most important for determining whether the promotor was able to implement specific tasks for a health research study. Reflective self-assessments, question banks, third-party assessment of competencies, and written assessments were described as the most utilized to measure research competencies. These were most often administered informally and conducted periodically or routinely depending on the type of research study. Knowledge assessment techniques included tutorial-based evaluations (e.g., from the IRB); individual, one-on-one, evaluation with senior staff; reflective self-assessments; internally developed question banks; routine/staggered assessments; and group-level assessments (meetings). Skills assessment reported techniques were largely observational: role-playing, observational assessments, and shadowing. Participants identified self-assessment as being a potentially useful method of gauging a promotores’ research skills and knowledge.
I think if there was a self-evaluation tool that we could do with them in the beginning but use really general terms like explaining like this is what consent is, how comfortable do you feel with consent forms, but we need to play with the language around it.
Participants emphasized the importance of using lay terminology—simple terminology—when training the promotores about research and shared that it can be challenging to address language barriers due to low literacy. Specific to promotores, supervisors recommended that knowledge and skills should be evaluated separately with a focus on context and accessible terminology.
Again, the words for me, I mean . . . of course it’s important to let them know about the study . . . but just the words “scientific method” . . . I won’t say it like that; for me that’s “puffed” up. (When asked about how they would improve promotor knowledge of the scientific method)
Accessible terminology and contextualized examples that map to real-life situations can help address language and educational barriers in the delivery of research ethics education. Another priority identified was the importance of conveying the potential benefits of research to the community of interest.
Written materials, videos, scenarios, group discussions, and interactive approaches were described as appropriate formats to assess research knowledge and skills among research staff. Additionally, an understanding of protocol adherence, IRB components, the difference between service delivery and research, understanding of study design (i.e., randomization), and basic research concepts were classified as essential concepts to include in any assessment of research competencies of promotores.
Discussion
This is the first study, that we know of, that has identified and prioritized promotor/CHW research competencies based on supervisor input. By identifying the skills and knowledge necessary to be successful as a research promotor, we can tailor training and educational initiatives to increase relevant core competencies.
Using a mixed-methods approach, this study revealed research knowledge and abilities that supervisors believe essential when involving promotores/CHWs in health research. It is noteworthy, yet not surprising, that the ranking of competencies in Table 2 aligned with the learning objectives found in the BRIC research ethics training, which was designed for these learners (Nebeker & Lopez-Arenas, 2016).
Importantly, accessible terminology and contextualized examples that align with real-life situations were identified as key to addressing language and educational barriers in the delivery of research ethics education. Another priority identified by the participants was the importance of conveying the potential benefits of research to the community of interest. Written assessments, group discussions, observation, and interactive approaches were described as appropriate formats to assess research knowledge and skills in lay research staff. Additionally, an understanding of protocol adherence, the difference between health service delivery and research, understanding of study design (i.e., randomization), and basic research concepts was classified as the most essential elements to include in research capacity development targeting promotores.
As noted, one goal was to see how roles of promotores have changed over the decade since we had conducted the formative research to develop precursors to the BRIC curriculum. Interestingly, in 2003, promotores were involved only in the implementation phase of research (Nebeker et al., 2015), whereas in 2013, the PI/PMs reported involvement of promotores in the study design and dissemination phases of research, in addition to contributing to study implementation. This shift to include promotores across all research phases may be indicative of more authentic involvement of community members in community-engaged and community-based participatory research as well as researchers recognizing the value added by consulting with community members at the study onset when developing the research questions and design. That being said, instruction focused on the dissemination phase of research may be needed to prepare promotores who are responsible for sharing research findings with participants and the extended community.
There is a clear need for research ethics education designed specifically for people who have limited or no formal academic research training—especially when these individuals play a key role on the research team and related research outcomes. This study to identify the training needs for promotores/CHWs is both novel and timely because it comes during a period of increasing awareness of the need for formal training and engages research team members directly responsible for that training (Rosenthal et al., 2016). That being said, there is a lack of research ethics curricula designed specifically for promotores. Over the past few years, trainings have become available for community partners, some of whom may be CHWs or promotores (Anderson et al., 2012; Solomon & Piechowski-Whitney, 2012; Yonas et al., 2016). In some cases, the CITI program has been adapted for use in training novice research staff (Galna et al., 2014). Given the complexities of teaching nonscientists about the scientific method and associated ethical dimension of conducting research, it is critical that instruction be designed with the intended learners so that the concepts and language are appropriate. In formative research, to develop ethics education for promotores, both research supervisors and promotores should be involved in the process (Nebeker et al., 2015). The study reported here was carried out to develop an appropriate assessment tool that could be used to gauge promotor research knowledge and skills.
Limitations
While this study addresses a gap in research ethics education, there are limitations. Participants in this study worked primarily, yet not exclusively, with promotores in Latino-focused community-based research studies. As such, the core competencies identified may not translate to all CHWs or promotores involved in behavioral and biomedical research.
Implications for Practice
The involvement of CHWs/promotores in the planning, implementation, and reporting of community health research is increasing, and rightly so. This opportunity to develop and contribute to important health research comes with responsibilities that are shared by all on the research team. A critical responsibility is providing appropriate and accessible training to not only develop research literacy but also ensure that the research is conducted with integrity. Policies and mandates for compliance training fall short of developing the research competencies needed—especially by those who do not have formal academic training in research methods. Our article provides the rationale for educating promotores to enhance their research competencies and understanding of human research ethics.
Conclusions
The traditional research environment is changing. Community members are increasingly expected to be more actively involved in the research enterprise through, for example, community advisory boards, which are often required by funders. With the launch of the Precision Medicine Initiative’s All of Us Research Program, there is an explicit requirement for participants to be partners in the research process (Sabatello & Appelbaum, 2017). Over the past decade, the citizen science movement has increased as well (Bonney et al., 2014; Wiggins & Wilbanks, 2019), presenting opportunities for nonscientists to be involved in a variety of research activities. However, without adequate research literacy, it is nearly impossible for people to know how to contribute in a meaningful way. Research ethics education that is intentionally developed for those with little to no formal academic research training is necessary for capacity building, which can then support authentic engagement in the research process. This study fills an important gap in research ethics education by identifying necessary competencies to inform research ethics education.
Supplemental Material
HPP913548_suppl_mat – Supplemental material for Prioritizing Competencies for “Research” Promotores and Community Health Workers
Supplemental material, HPP913548_suppl_mat for Prioritizing Competencies for “Research” Promotores and Community Health Workers by Camille Nebeker, Rebeca Espinoza Giacinto, Blanca Azucena Pacheco, Araceli López-Arenas and Michael Kalichman in Health Promotion Practice
Footnotes
Authors’ Note:
We thank the participants and community organizations contributing time and insights to advancing this formative research. The Building Research Integrity and Capacity educational modules may be accessed through 
. The project described was supported by Grant No. 1ORIIR130005 from the Office of Research Integrity (PI: Nebeker, 2013-2016). Contents are solely the responsibility of the authors and do not necessarily represent the official views of the Department of Health and Human Services or the Office of Research Integrity.
Notes
References
Supplementary Material
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