Introduction
Community health workers and promotoras (CHW/Ps) engage in direct service provision, health education, advocacy, and community capacity building as well as help individuals navigate the healthcare system [Reference Messias, Parra-Medina, Sharpe, Treviño, Koskan and Morales-Campos1,Reference Scott, Beckham and Gross2]. Moreover, their role in health-related research has been increasing as they are often perceived as trusted liaisons in underserved communities by amplifying the voices of the community’s needs, concerns, and perspectives about health research as well as highlighting pressing disparities that need attention [Reference Scott, Beckham and Gross2–Reference Krok-Schoen, Weier, Hohl, Thompson and Paskett5]. While CHWs provide these services in the community, generally, promotoras are committed to providing culturally and linguistically relevant services to Spanish-speaking communities [6]. By engaging meaningfully with research teams, CHW/Ps can help bridge the significant gap between researchers and communities. For example, because the CHW/Ps often come from historically marginalized communities, researchers have increasingly integrated CHW/Ps in the research team to meaningfully engage these populations to augment representation and overcome limitations in understanding the unique socioeconomic and cultural factors affecting those populations [Reference Andrews, Felton, Wewers and Heath7,Reference Cottler, Striley, O’Leary, Ruktanonchai, Wilhelm, S.Karger, Alving, Dai and Chan8]. Despite this critical role, the benefits of including CHW/Ps in research, and attempts to establish a set of core competencies [Reference Covert, Sherman, Miner and Lichtveld9], CHW/Ps often receive no standardized research training. While some state-level requirements for training and competencies exist, national competencies are not followed or do not [Reference Nebeker, Giacinto, Pacheco, López-Arenas and Kalichman10–Reference Mason, Rush and Sugarman12]. As such, some CHW/Ps can be involved in research tasks beyond their acquired skillset, resulting in potential issues with scientific rigor, such as the inability to describe or reluctance to apply randomization principles and inadequate maintenance of participant confidentiality in community settings [Reference Terpstra, Coleman, Simon and Nebeker13].
In response, our diverse team of researchers, CHW/Ps, and healthcare providers co-developed a culturally and linguistically tailored research best practices training for CHW/Ps in English and Spanish [Reference Varma, Samuels and Piatt14–Reference Murphy, Harper and Jay16]. The training, which aimed to provide foundational education in role-specific best practices for research, consists of five modules (Figure 1) and can be accessed in several different formats. One way CHW/Ps can participate in the training is via a self-directed, asynchronous online format, which we previously found feasible and effective at increasing CHW/P learners’ perceptions of their knowledge and skills in participating in community-engaged research [Reference Murphy, Jay and Samuels15]. Alternatively, CHW/Ps can also participate in a synchronous peer-led “Champion” facilitated version of the training conducted virtually or in-person. A recent quantitative evaluation of the peer-led training found this format satisfactory and effective for increasing CHW/Ps’ perceived knowledge and skills; no meaningful differences were found in CHW/Ps’ ratings of perceived knowledge or skills based on site or modality (i.e., virtual or in-person) [Reference Murphy, Harper and Jay16]. Given that no quantitative differences were found in modalities, the purpose of this qualitative study was to further explore the nuance in our findings and to identify opportunities to enhance the research best practices training for CHW/Ps.
Figure 1. Five module research best practices training for community health workers and promotoras (CHW/Ps).
Materials and methods
We used a combination of criterion sampling and maximum variation sampling to identify CHW/P participants for this study [Reference Creswell and Guetterman17]. We took this multi-pronged approach to sampling to conduct a representative qualitative evaluation of the training, seeking to capture perspectives from (a) CHW/Ps across sites who rated the training better or worse than the average of their peers at the site and (b) a diverse group of CHW/P learners. Using criterion-based sampling, we invited participants to the qualitative interviews based on site-level averages of training experience ratings. Specifically, we recruited equal proportions of CHW/P participants who scored above or below the average training experience for each site (California = 4.83 out of 5, Florida = 4.83 out of 5, Michigan = 4.66 out of 5, overall 4.77 out of 5). We also used maximum variation sampling to identify potential participants across four characteristics: gender, training language, past research experience, and training mode (e.g., virtual or in-person). Of the 394 CHW/Ps who completed the Champion facilitated training, 39 were invited to participate in an interview; 26 agreed and 17 participated, of whom 10 were English-speaking and 7 were Spanish-speaking. Nine invited individuals did not participate because they were unresponsive to repeated attempts at scheduling. This study was considered exempt by the University of Michigan Institutional Review Board, and all participants completed verbal informed consent with the interviewer.
Interviews were conducted with members of the research team in the preferred language of the CHW/P (i.e., English or Spanish). Interview protocols and guides were developed in both English and Spanish (see Supplemental Materials). The interview guide asked CHW/Ps’ role in the community, gauged their feedback about the training (e.g., likes, dislikes, suggestions for improvement, and modality of training) as well as strategies for disseminating the training to other CHW/Ps. All interviews were video- and audio-recorded via Zoom with participant consent. Interviews lasted approximately 30 minutes, ranging from 15 minutes for the shortest and 56 minutes for the longest. The team at University of California, Davis included Spanish-speaking individuals who facilitated the interviews in Spanish. Once the interviews were completed, they used a qualified bilingual translation editor for the initial transcription and translation then had bilingual team members review the translated transcripts for content and contextual accuracy to ensure that no nuance was lost. Analysis was conducted in English, but we cross-referenced anything that was unclear against the original Spanish transcript as needed to verify consistency and appropriateness. To begin data analysis, the two first authors used the rigorous and accelerated data reduction (RADaR) technique for the purposes of data reduction and to develop a codebook. The RADaR technique is a five-step qualitative data analysis method that encourages researchers to use word-processing software to organize, reduce, code, and analyze qualitative data [Reference Watkins18]. Two authors (AP, AH) first organized and reduced the data that were not relevant to the research aims using Microsoft Excel. This included ensuring that the data transcripts across all participant interviews were formatted in the same way (step 1), reviewing the transcripts and noting similarities and differences across participant responses (step 2), and graying out redundant information that did not align with the research aims (steps 3 and 4). These steps were completed individually, then discussed between the two coders until consensus was achieved. After the data were reduced, the coders developed a codebook, and all transcripts were coded by the two coders and reviewed to mitigate coding discrepancies.
A Champion CHW/P (MM) also participated in the coding process to further enhance the community-engaged participatory research practices and help us to better understand and amplify the insider (i.e., CHW/P’s) perspectives. “Champions” are the individuals who facilitated the research best practices training and are CHW/Ps or otherwise work or volunteer in community-based organizations. The Champion CHW/P independently coded nine transcripts (53% of interviews) and met with the coders to discuss additions or discrepancies during the coding process. At the final stage, MAXQDA 2024 (Verbi, Germany) was used to facilitate the analysis process. We used thematic text analysis to generate categories and grouped similar categories into overarching themes [Reference Kuckartz19]. The goal of thematic text analysis was to categorize the data to establish thematic categories or overarching themes that enable a deeper understanding of the data by identifying patterns or relationships. As such, we used an inductive, data-driven approach to generate the themes from the initial codes and categories [Reference Kuckartz19,Reference Kuckartz, Kaiser and Presmeg20].
Results
As seen in Table 1, of the 17 interview participants, six attended a Spanish training led in California, one attended a Spanish training led in Florida, and 10 attended an English training in Florida, Michigan, or California; 12 attended the training virtually via Zoom. The average age of participants was 43.7 years ± 14.5, most were female (59%), and approximately half (48%) had prior experience as a member of a research team conducting community-engaged research.
We identified three overarching themes from the qualitative analysis that each consisted of subthemes. The overarching themes identified were: 1) CHW/Ps’ Perceptions of the Training; 2) Factors Influencing Receipt of the Training; and 3) CHW/Ps’ Recommendations for Future Trainings (see Figure 2).
Table 1. Sample characteristics of participants (N = 17)
Note: * = nonmutually exclusive category can exceed 100%; CHW/P = community health worker/promotora; GED = general educational development (diploma).
Figure 2. Themes and subthemes.
CHW/Ps’ Perceptions of the Training
Participants discussed their varying perceptions of the training as learners, including two subthemes – well-received training content and materials and improved understanding of research role. Within the improved understanding of research role subtheme, a secondary subtheme arose relating to the meaningful certificate of completion. Brief descriptions and representative quotes for each subtheme are presented in Table 2.
Table 2. CHW/P learners’ perceptions of the training
Well-received training content and materials
CHW/P learners reported various broad reactions to the training; most reactions were positive and noted that the training content and materials were well received. Participants appreciated the opportunity to meet and interact with other CHW/Ps, enjoyed the video scenarios and knowledge checks embedded within the training, and thought the training was completed in an appropriate length of time (i.e., not too short or too long). Further, participants reported that the presentation of the content was inclusive, demonstrating diversity in pictures, videos, and scenarios, as well as representative of their work as CHW/Ps. Although two participants identified some content that felt repetitive to prior trainings (e.g., how to communicate with community members), everyone reported the training covered content and skills essential for CHW/Ps.
Improved understanding of research role
Along with reactions to the training, CHW/P learners discussed its effects on them as it related to their work. This subtheme refers to CHW/Ps’ perspectives on how the training made participants feel about their roles and ability to do their jobs. All participants reported some positive effects of the training. Specifically, the training clarified their role in research and helped CHW/Ps feel empowered and more confident, better prepared to engage in research-related activities, and valued as members of the community-engaged research workforce. Some participants reported that having access to this training demonstrated that those in academia valued their work and their role.
Meaningful certificate
Aside from the effects of the training, receipt of a certificate of completion emerged as a particularly important component for 14 of the 17 participants. The certificate demonstrates CHW/Ps’ competence and dedication to continued learning to their community and academic partners, can be an incentive to attend the training, and, pragmatically, helps track the trainings they have attended. Further, receiving the certificate was a source of pride. The remaining three participants had neutral perceptions of the certificate, noting that it was not necessary for them to obtain one, nor did it incentivize their attendance.
Factors Influencing Receipt of the Training
Participants were keen to note factors influencing the receipt of the training from their perspective, resulting in two subthemes – the CHW/P learners valued peer Champion facilitators and training modality was not one size fits all (i.e., virtual vs. in-person). Brief descriptions and representative quotes for each subtheme are presented in Table 3.
Table 3. Factors influencing receipt of the training
CHW/P learners valued peer Champion facilitators
All participants reported neutral-to-positive feedback about the Champions facilitating the training and commented about the value of having peer facilitators. Participants noted key traits of effective Champions, such as being personable and communicating in a warm and engaging tone, as well as demonstrating active listening, patience, and professionalism (e.g., punctual, articulate in the language of learners). They also identified actions that Champions took to effectively facilitate the training, such as managing time (e.g., pacing of information, offering breaks), providing clarifying answers to questions, allowing space for participants to share experiences and engage with each other, and communicating scientific information in plain, easy-to-understand language.
Training modality was not one size fits all
Aside from gleaning information about whether it was important to have the facilitator be a peer, we also gathered substantial insights from participants about the environments in which they learned. Specifically, participants had mixed opinions about the training modality – virtual or in-person. Some participants preferred and noted the benefits of virtual training, including convenience and decreased burden to attend (e.g., fuel costs, travel time). Other participants preferred and noted the benefits of in-person training, such as the ease of interacting with other participants and it is how they are accustomed to learning.
CHW/Ps’ Recommendations for Future Trainings
CHW/Ps offered several recommendations on ways to further enhance the current research best practices training for CHW/Ps. These recommendations are divided into three subthemes: minor refinements to improve learning, minor refinements to improve access, and the power of advertising to CHW/Ps (Table 4). Minor refinements to improve learning refer to ways the training could be refined by enhancing either the training content or material or increasing dedicated time for interactions. The subtheme minor refinements to improve access refers to potential logistical modifications to improve the training. The final subtheme, the power of advertising to CHW/Ps, refers to the increased need to advertise this training across different groups and use various suggested strategies by CWH/Ps.
Table 4. CHW/Ps’ recommendations for trainings
Minor refinements to improve learning
Participants discussed making potential modifications to the training content. For example, participants mentioned that the module on COVID was not as relevant as it was a few years ago. Some participants also suggested adding a section on statistics within a public health or community health context, such as learning about chronic conditions within a specific state or city and having more conversations around implicit bias and the health needs of particular groups (e.g., African Americans). Participants also vocalized the importance of obtaining access to the PowerPoint slides used in the training. One participant noted that although they wrote notes during the training, they were often unable to write all the information presented to them. Another participant shared the idea of offering a workbook that would allow them to take notes on paper and have relevant training information. Therefore, having a set of slides would ensure they have more complete information. Participants also recommended that a glossary of concepts be included as part of the training, especially if words are not familiar to participants (e.g., randomization), and the language for the training videos and subtitles be consistent. Participants also suggested increasing opportunities throughout the training for peer interaction in groups to learn from each other and their experiences in the field.
Minor refinements to improve access
Participants offered several considerations regarding the training to improve their ability to access and attend the training. These included suggestions for modifications to logistical and structural components of the training. Participants discussed offering multiple in-person options that are centrally located in the community. Given that a virtual option was offered, participants acknowledged that while this is convenient for many, everyone has differing knowledge of and access to various types of technology. Thus, they suggested including a survey question when registering for the training to determine people’s level of comfort with technology and including a video to demonstrate how the online platform would look for participants taking the training. Participants also suggested giving the option of a flexible schedule and offering the training multiple times, such as early morning, late evening, or on weekends. Regarding the training structure, one recommendation offered was to embrace a “train the trainer” model that enables CHW/P attendees to become trainers to lead this training in the future. Overall, participants shared the benefits of an in-person option with increased face-to-face interaction and acknowledged the convenience of online training, especially when weather could present challenges.
The power of advertising to CHW/Ps
Participants discussed three different avenues for advertising the research training for CHW/Ps. These were categorized into 1) among CHW/Ps themselves, 2) the communities in which CHW/Ps live, and 3) across media outlets. Participants expressed sharing information about the training among themselves across organizations where they work, such as local, state-based, or national CHW organizations, organizational websites specific to CHW/Ps (e.g., The National Association of Community Health Workers – https://www.nachw.org), and nonprofit organizations. They also recommended partnering with CHW/P-specific accounts on LinkedIn and social media. Several community spaces where CHW/Ps live were also discussed as potential areas to disseminate information about the training to reach other CHW/Ps. These locations include a religious assembly hall or church, barbershops, beauty salons, public health centers, clinics, schools, housing commissions, legal clinics, and mental health organizations. Participants also discussed the widespread use of social media and suggested sharing information about the training across social media, including Facebook, Instagram, and TikTok to “reach a broader network” (13) more efficiently. Overall, participants acknowledged the importance of disseminating information about the training with CHW/Ps and using multiple modalities across different avenues.
Discussion
As a strategy to enhance CHW/Ps’ ability to be effective members of community-engaged research teams and to address a gap in this vital workforce’s knowledge and skills, we developed a research best practices training for CHW/Ps. Regardless of whether participants completed the English or Spanish training in-person or virtually, CHW/Ps reported positive feedback about the training. Existing literature provides mixed findings on the benefits and drawbacks of in-person and virtual training [Reference Adams, Richmond and Watson21–Reference Holt, Tagai and Santos24]. Our results indicate that the choice of training modality varies and depends on the preferences and priorities of the staff and CHW/P learners at each site. Offering the choice of training modality appears important for meeting learners’ needs and building capacity for CHW/Ps to engage in research. Our qualitative evaluation builds on the positive results from our quantitative evaluation [Reference Murphy, Harper and Jay16], specifically revealing that CHW/Ps appreciated the training content, the flexibility to attend the training based on their preferences, and the academic community is recognizing the importance of CHW/Ps in conducting community-engaged research. Nonetheless, they reported opportunities for refining the training content and promoting its dissemination. These recommendations were practical and implementable to refine this already well-received training.
A few CHW/P learners reported that some content felt repetitive to other foundational trainings they had previously attended. Indeed, this likely reflects the variation in years of experience among our sample of CHW/Ps. However, this repetition seemed necessary as our training puts the information within the context of a research study. This shift in mindset required CHW/Ps to think about engaging community members to support health and well-being to think about engaging community members as research participants, thus requiring a different type of interaction and increased levels of scrutiny and protection. Data protection is critical when involving underserved and underrepresented communities in research given historical mistrust [Reference Kue, Szalacha, Happ, Crisp and Menon25]. There is also value in repeatedly exposing learners to critical information to facilitate retention [Reference Musfeld, Souza and Oberauer26–Reference Brinkmann, Laros, Fuhr and Taylor28]. Further, our peer-led training offers the opportunity to interact with other CHW/Ps, which can be a beneficial strategy for promoting a deeper understanding among CHW/Ps and the communities they serve.
Our key takeaways for future iterations of the training include ensuring language congruence (i.e., all videos, subtitles, and handouts match the language of the training); maintaining cultural and linguistic representativeness in videos, images, and scenarios; and adding deliverables to support learning, such as a glossary of terms, workbook, and handouts of the slides. Further, learners perceived neither modality to be superior to the other, so we will continue to support sites by offering both in-person and virtual training based on the needs of their communities. Taken together, the results from our quantitative and qualitative evaluations demonstrate that the training is promising but needs minor refinements before undertaking scaling efforts.
As noted previously, there is limited and variable training in research best practices for CHW/Ps; some research teams provide study-specific training, but no standardized training exists that is accessible to all CHW/Ps. As such, our development and evaluation of a standardized research best practices training contributes to the limited research on role-specific training programs for CHW/Ps engaged in conducting research with communities. Given the challenges in recruiting and retaining participants of ethnic and racial minority groups across health-related studies, CHW/Ps can also help to bridge historically marginalized groups into research through the skills fostered by the research best practices training [Reference Sheffet, Howard and Sam29,Reference Rochon, Mashari and Cohen30]. The research best practices training equips CHW/Ps with the necessary skills to recruit and inform potential participants about the research process, which can ultimately help to increase the inclusion of racial and ethnic minorities in research. It is important to note several differences pertaining to state requirements for CHW/Ps. Certification is recommended, though not required in Florida, is under development in California, and in Michigan, CHW/Ps require training, but no certification is necessary [31]. As a result, our sample represented varying scenarios as it pertained to state-regulated requirements. Importantly, regardless of state-specific regulatory requirements, CHW/Ps in each state found the training provided a critical foundation for understanding their role as it pertains to research. A future study could explore differences in training uptake across CHW/Ps living in states with different requirements to examine their receptivity to research best practices training. Ultimately, teaching CHW/Ps fundamental research skills can help them promote health equity and improve patient engagement and health outcomes [Reference Lloyd, Moses and Davis32].
Limitations
One limitation was that most Spanish-speaking participants were from the California site, as the Florida and Michigan sites had less success recruiting Spanish-speaking participants for the original quantitative evaluation [Reference Murphy, Harper and Jay16]. Further, we did not record the organizations where participants are currently employed as it was beyond the scope of this study. As a result, this could limit our understanding of the populations they serve and standard practices in their organizations. Nevertheless, our sample was diverse, and participants were well-represented across ethnicity, race, gender, education, and professional status. Another limitation is that the Champion CHW/P was able to code only half of the transcripts (53%). We decided to not have them code 100% of transcripts intentionally to preserve the community-academic relationship, acknowledging their own commitments and responsibilities as a highly involved member of the community. In this way, we attempted to balance gaining insights into the data with the time burden. CHW/P participants expressed their desire to have access to the PowerPoint slides used in the training. Due to ongoing development, we decided not to share the slides during the evaluation study; however, we plan to share the materials with CHW/Ps participants now that they are finalized. Lastly, we followed translation procedures recommended by the World Health Organization [Reference Harkness, Pennell, Villar, Gebler, Aguilar-Gaxiola and Bilgen33] and believe the steps our team of bilingual analysts took to ensure contextual accuracy, such as multiple reviews of the Spanish-to-English translation and cross-referencing the original Spanish transcripts for further clarity, prevented the loss of critical meaning or nuance during translation. It is possible that not conducting the analysis in Spanish resulted in some loss of nuance. However, we embraced a community-engaged approach to qualitative data analysis, requiring us to have the transcripts in English to engage our community partner, which we consider a strength of our methods [Reference Perez, Harper and Mitchell34]. Teams conducting qualitative analyses in languages other than English may consider different approaches.
Future directions
We have finalized refinements and updates to the training based on feedback from our collaborators and CHW/P learners from this evaluation, such as providing handouts and ensuring language consistency. In this process, we leveraged the expertise of an instructional designer to maximize the accessibility and utility of the training and supporting materials. We are currently piloting the implementation of the refined training with four new sites with community-academic partnerships engaging CHW/Ps in their community-engaged research. This implementation will be focused on understanding the feasibility of and barriers and facilitators to scaling this training in preparation for a larger multisite hybrid effectiveness-implementation trial, a design well-suited to translating and scaling trainings into real-world settings [Reference Curran, Bauer, Mittman, Pyne and Stetler35].
Conclusion
CHW/Ps expressed appreciation that the importance of their work was recognized and that they were more prepared to engage community members in the research process after attending the research best practices training for CHW/Ps, regardless of whether they were participating in the English or Spanish version of the training. Our team members, who were from diverse cultural and professional backgrounds, created this training to enhance the capacity of the community-engaged research workforce by providing standardized training for CHW/Ps. The refined English and Spanish training and materials are now publicly available at https://www.chwresearchtraining.org/.
Supplementary material
The supplementary material for this article can be found at https://doi.org/10.1017/cts.2025.10094.
Acknowledgements
We are grateful to the CHW/P learners who participated in the training and follow-up interviews, our community partners, and the team involved in translation efforts.
Author contributions
Alexandra Harper: Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Project administration, Resources, Visualization, Writing-original draft, Writing-review and editing; Analay Perez: Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Visualization, Writing-original draft, Writing-review and editing; M. Miaisha Mitchell: Conceptualization, Formal analysis, Investigation, Validation, Visualization, Writing-original draft, Writing-review and editing; Daphne Watkins: Conceptualization, Formal analysis, Funding acquisition, Investigation, Methodology, Resources, Validation, Writing-original draft, Writing-review and editing; Gina Jay: Conceptualization, Data curation, Formal analysis, Funding acquisition, Investigation, Project administration, Writing-original draft, Writing-review and editing; Vanessa Trujillo: Conceptualization, Data curation, Formal analysis, Investigation, Project administration, Validation, Writing-original draft, Writing-review and editing; Kristen Weeks-Norton: Conceptualization, Data curation, Formal analysis, Investigation, Project administration, Validation, Writing-original draft, Writing-review and editing; Shannen McIntosh: Conceptualization, Data curation, Formal analysis, Investigation, Project administration, Writing-original draft, Writing-review and editing; Brenda Eakin: Conceptualization, Formal analysis, Funding acquisition, Investigation, Writing-original draft, Writing-review and editing; Elias Samuels: Conceptualization, Data curation, Formal analysis, Funding acquisition, Investigation, Writing-original draft, Writing-review and editing; Gretchen Piatt: Conceptualization, Formal analysis, Funding acquisition, Supervision, Writing-original draft, Writing-review and editing; Catherine Striley: Conceptualization, Formal analysis, Funding acquisition, Investigation, Project administration, Supervision, Writing-original draft, Writing-review and editing; Linda Cottler: Conceptualization, Data curation, Formal analysis, Funding acquisition, Investigation, Methodology, Project administration, Supervision, Validation, Writing-original draft, Writing-review and editing; Sergio Aguilar-Gaxiola: Conceptualization, Data curation, Formal analysis, Funding acquisition, Investigation, Methodology, Project administration, Supervision, Validation, Writing-original draft, Writing-review and editing; Susan Murphy: Conceptualization, Data curation, Formal analysis, Funding acquisition, Investigation, Methodology, Project administration, Supervision, Validation, Writing-original draft, Writing-review and editing.
Funding statement
This project was supported by a grant from the National Center of Advancing Translational Sciences, National Institutes of Health (U01TR003409; MPIs Murphy, Aguilar-Gaxiola, Cottler) and supported by Clinical Translational Science Awards from the Michigan Institute of Clinical and Health Research (MICHR) (UL1TR002240; UM1TR004404), the University of California, Davis Clinical and Translational Science Center (UL1TR001860-06), and the University of Florida Clinical and Translational Science Institute (UL1TR001427).
Disclosure
The authors have no conflicts of interest.
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