title: Predictors of activity level and retention among African American lay health advisors (LHAs) from The National Witness Project: Implications for the implementation and sustainability of community-based LHA programs from a longitudinal study.
abstract: BACKGROUND
  Lay health advisor (LHA) programs are increasingly being implemented in the USA and globally in the context of health promotion and disease prevention. LHAs are effective in addressing health disparities when used to reach medically underserved populations, with strong evidence among African American and Hispanic women. Despite their success and the evidence supporting implementation of LHA programs in community settings, there are tremendous barriers to sustaining LHA programs and little is understood about their implementation and sustainability in "real-world" settings. The purpose of this study was to (1) propose a conceptual framework to investigate factors at individual, social, and organizational levels that impact LHA activity and retention; and (2) use prospective data to investigate the individual, social, and organizational factors that predict activity level and retention among a community-based sample of African American LHAs participating in an effective, evidence-based LHA program (National Witness Project; NWP).
  
  
  METHODS
  Seventy-six LHAs were recruited from eight NWP sites across the USA. Baseline predictor data was collected from LHAs during a telephone questionnaire administered between 2010 and 2011. Outcome data on LHA participation and program activity levels were collected in the fall of 2012 from NWP program directors. Chi-square and ANOVA tests were used to identify differences between retained and completely inactive LHAs, and LHAs with high/moderate vs. low/no activity levels. Multivariable logistic regression models were conducted to identify variables that predicted LHA retention and activity levels.
  
  
  RESULTS
  In multivariable models, LHAs based at sites with academic partnerships had increased odds of retention and high/moderate activity levels, even after adjusting for baseline LHA activity level. Higher religiosity among LHAs was associated with decreased odds of being highly/moderately active. LHA role clarity and self-efficacy were associated with retention and high/moderate activity in multivariable models unadjusted for baseline LHA activity level.
  
  
  CONCLUSIONS
  Organizational and role-related factors are critical in influencing the retention and activity levels of LHAs. Developing and fostering partnerships with academic institutions will be important strategies to promote successful implementation and sustainability of LHA programs. Clarifying role expectations and building self-efficacy during LHA recruitment and training should be further explored to promote LHA retention and participation.
authors.affiliation: Department of Sociomedical Sciences, Mailman School of Public Health, Columbia University, 722 168th Street, Room 941, New York, NY, 10032, USA. rs3108@cumc.columbia.edu.
authors.forename: Rachel C
authors.initials: RC
authors.lastname: Shelton
authors.affiliation: Department of Sociomedical Sciences, Mailman School of Public Health, Columbia University, 722 168th Street, Room 941, New York, NY, 10032, USA.|Present Address: Office of Research and Methodology, Question Design Research Laboratory National Centers for Health Statistics, Centers for Disease Control and Prevention, 3311 Toledo Road, Hyattsville, MD, 20782, USA.
authors.forename: Sheba King
authors.initials: SK
authors.lastname: Dunston
authors.affiliation: Department of Biostatistics, Mailman School of Public Health, Columbia University, 722 168th Street, New York, NY, 10032, USA.
authors.forename: Nicole
authors.initials: N
authors.lastname: Leoce
authors.affiliation: Department of Oncological Sciences, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Place, Box 1130, New York, NY, 10029, USA.
authors.forename: Lina
authors.initials: L
authors.lastname: Jandorf
authors.affiliation: Department of Oncology, Karmanos Cancer Institute, Population Studies and Disparities Research Program, Wayne State University School of Medicine, 4100 John R-MM03CB, Detroit, MI, 48201, USA.
authors.forename: Hayley S
authors.initials: HS
authors.lastname: Thompson
authors.affiliation: Department of Epidemiology, Mailman School of Public Health, Columbia University, 722 168th Street, New York, NY, 10032, USA.
authors.forename: Danielle M
authors.initials: DM
authors.lastname: Crookes
authors.affiliation: Roswell Park Cancer Institute, Office of Cancer Health Disparities Research, Cancer Prevention & Population Sciences, Elm & Carlton Streets, Buffalo, NY, 14263, USA.
authors.forename: Deborah O
authors.initials: DO
authors.lastname: Erwin
mesh_terms: D001741:Black or African American; D003150:Community Health Workers / Q000458:organization & administration; D003210:Concept Formation; D055317:Evidence-Based Practice; D005260:Female; D006801:Humans; D010558:Personnel Loyalty; D015397:Program Evaluation; D011446:Prospective Studies; D011795:Surveys and Questionnaires; D014481:United States
keywords: African Americans; Cancer screening; Evidence-based programs; Implementation; Lay health advisors; Sustainability