The GOTCHA project aimed to address health disparities in rural Mississippi through a community-based participatory research (CBPR) approach using community health advisors (CHAs). An interdisciplinary team developed an innovative CHA training curriculum in response to identified needs from community discussions. The training included a 35-hour core skills component to equip CHAs with comprehensive outreach skills, followed by disease-specific modules. The training employed popular education techniques grounded in adult learning theory to raise consciousness and empower community members for social change. The goal was to transform community health through grassroots efforts led by indigenous CHAs.

1. F e a t u r e
Getting on Target with Community
Health Advisors (GOTCHA): an
innovative stroke prevention project
Lachel Story, Susan Mayfield-Johnson, Laura H Downey,
Charkarra Anderson-Lewis, Rebekah Young
and Pearlean Day
The University of Southern Mississippi, Hattiesburg, MS, USA
Accepted for publication 18 September 2010
STORY L, MAYFIELD-JOHNSON S, DOWNEY LH,
ANDERSON-LEWIS C, YOUNG R and DAY P. Nursing Inquiry
2010; 17:
373–384
Getting on Target with Community Health Advisors
(GOTCHA): an innovative stroke prevention project
Health disparities along with insufficient numbers of healthcare
providers and resources have created a need for effective and
efficient grassroots approaches to improve community health.
Community-based participatory research (CBPR), more specifi-
cally the utilization of community health advisors (CHAs), is

2. one such strategy. The Getting on Target with Community
Health
Advisors (GOTCHA) project convened an interdisciplinary team
to answer the call from 10 counties in the rural Mississippi
Delta area of ‘The Stroke Belt’ to meet the region’s identified
health needs, and to impact the health of a disparaged state.
This
article explores this CBPR project including the community
involvement strategies, innovative CHA training curriculum,
evalua-
tion plan, and implications to healthcare professionals,
particularly nurses.
Key words: cardiovascular health, community, education, health
promotion, lay health workers, minority.
Health disparities along with insufficient numbers of health-
care providers and resources have created a need for grass-
roots approaches that effectively and efficiently address
community health needs. Community-based participatory
research (CBPR) is one such strategy and is defined as a ‘col-
laborative approach to research that equitably involves all
partners in the research process and recognizes the unique
strengths that each bring’ (Minkler and Wallerstein 2003, 4).

3. CBPR is a long-term cyclical process that requires commit-
ment to meet three goals: research, action, and education.
In this participatory process, information is exchanged freely
and all partners share problem-solving to accomplish knowl-
edge attainment. The community is a unit of identity with
existing strengths and resources upon which to build this
process. Additionally, the resources and expertise of research
partners are employed to benefit all stakeholders. CBPR
focuses on local public health problems and ecology while
recognizing that there are multiple determinants of health
(Minkler and Wallerstein 2003). This approach creates a
project that is truly community-based and community-driven
not merely community-placed. This approach also provides a
unique opportunity for nurses to engage the community to
generate substantial societal change.
Community transformation works through a social ecol-
ogy model (Stokols 2000; Institute of Medicine 2002). Social
ecology implies that certain behaviors, social roles, and envir-

4. onmental conditions can influence an individual’s well-
being, thus connecting well-being with the sociophysical
environment. The social ecology model appreciates that the
individual is intertwined with the environment in a dynamic
relationship. Individual health behaviors are developed and
reinforced by the personal, physical, and social context of
multiple life domains (Stokols 2000). Health is a result of the
quality of the individual’s fit with his or her environment.
A core assumption of the social ecology model is that
environment is whole and interconnected. All parts of the
whole are equal and mutually influence each other. Individ-
Correspondence: Assistant Professor Lachel Story, The
University of Southern
Mississippi, School of Nursing, 118 College Dr., Box 5095,
Hattiesburg, MS
39406, USA.
E-mail: <[email protected]>
� 2010 Blackwell Publishing Ltd
Nursing Inquiry 2010; 17(4): 373–384

5. ual- and community-level variables influence health as well
as health outcomes. Altering both levels of variables can initi-
ate ecological transformation as well as impact specific
health outcomes. Another key principle of the socioeco-
logical model is that a comprehensive understanding of
health requires a multidisciplinary approach (Freudenberg
et al. 1995). Healthcare providers’ participation in the pro-
cess requires reciprocity and co-operation by all disciplines
involved to bring about transformation (Grzywacz and Fugua
2000).
Considering an individual’s community is a powerful
force in his or her lives, standard individually based interven-
tions may not be suitable for long-lasting change. Innovation
in developing or refining interventions to include broader
community-based dimensions can improve outcomes. Devel-
oping interventions to solve community problems can occur
through social engineering, new knowledge production, and

6. transformational leadership inspired to create a self-reflec-
tive community of inquiry (Minkler and Wallerstein 2003).
Getting on Target with Community Health Advisors
(GOTCHAs) is a cost-effective, community-based participa-
tory research (CBPR) approach that can address a variety of
constructs identified by the social ecological model. Commu-
nity health advisors (CHAs) are lay persons with special train-
ing to provide designated health services and information to
fellow community members. Serving primarily underserved
populations, these health workers provide valuable liaison
services between community members and the formal health-
care delivery system. An accepted characteristic of a CHA is
that the individual is indigenous to the community and famil-
iar with its physical and social characteristics. CHAs also have
local knowledge of community problems and possible solu-
tions (Nemcek and Sabatier 2003; Andrews et al. 2004).
Located in ‘The Stroke Belt’, Mississippi (MS), is a prime
location to initiate grassroots efforts where recognized

7. health disparities, especially in cardiovascular disease (CVD)
and obesity, exceed those in other states and are exacerbated
by a shortage of healthcare providers. Over three-fourths of
the state’s counties, including all of those in the MS Delta,
are designated health professional shortage areas (MS
Department of Health 2004). The MS Delta is an obvious
choice for a CBPR project because of its deep sense of com-
munity along with its rich history of coming together to over-
come obstacles. The depth of community involvement has
varied across CBPR projects with a wide range of success in
their outcomes (i.e. Baker et al. 1997; Earp et al. 2002;
Kegler and Malcoe 2004; Kim et al. 2004; Krieger et al. 2005;
Mukherjee and Eustache 2007). The purpose of this article
is to explore an innovative stroke prevention project in the
MS Delta, GOTCHA, which incorporated CBPR principles
in all phases of the project to engage and work with the com-
munity to address this overwhelming health disparity. At the
conclusion of the article, implications of CHAs to nursing

8. and community health practice are presented.
GOTCHA PROJECT OVERVIEW
In response to a request for proposals by the Delta Health
Alliance (DHA), the Center for Sustainable Health Outreach
staff members convened two informal discussion groups as a
means of initiating the CBPR process prior to writing the
proposal and guide the resulting project. The information
provided in these discussion groups was used in proposal
development. Two discussion groups were held in the MS
Delta area – one with 13 healthcare professionals (social
workers, dietitians, nurses, administrators, and clinic manag-
ers) and one with 10 community members. Participants in
both groups identified CVD – particularly stroke and heart
disease – as well as diabetes, hypertension, and obesity, as pri-
ority health concerns. Participants specifically discussed the
lack of basic knowledge concerning risk factors, prevention
methods, lifestyle, and behavior modification as well as the
lack of access to health-care in the community. Participants

9. were concerned that there was inadequate attention to the
prevention of these chronic conditions.
When asked what type of programs and activities partici-
pants would like to see in their communities, both groups
advocated for programs that incorporated methods that
were participatory, accessible, and free. In addition, both
groups discussed the need for easily understood educational
activities and materials delivered in common language.
Health professionals participating in the discussion group
stressed the need for community residents to have access to
free hypertension and glucose testing in their communities.
Community residents expressed their desire for peer-to-peer
education that was easily understood and without medical
jargon as well as support, especially for caregivers of persons
with chronic diseases and the elderly. Residents wanted prac-
tical information applicable to their daily routines.
Discussion questions were strength-based, explorative,
and focused on the types of programs and services commu-

10. nity members desired. Thus, the GOTCHA project was devel-
oped from the feedback provided in those discussion
groups, input from other community leaders in the targeted
service areas, and MS morbidity and mortality data.
The purpose of GOTCHA was to develop and implement
a CHA project grounded in CBPR that focuses on stroke pre-
vention and early detection methods. Although emphasis has
been placed on the prevention and early detection of strokes
in African American men and women, considerable attention
374 � 2010 Blackwell Publishing Ltd
L Story et al.
has not been focused on the several contributing chronic dis-
eases (diabetes, hypertension, and CVD) to stroke in combi-
nation with lifestyle modification, improved nutrition, stress
management, and increased physical activity. The GOTCHA
service area included 10 of the 18 counties serviced by DHA
in the MS Delta: (i) Coahoma, Quitman, and Tallahatchie

11. counties; (ii) Leflore, Carroll, and Holmes counties; (iii) Sun-
flower and Bolivar counties; (iv) Washington county; and (v)
Humphreys county. Staff and community leaders who live
and work in the Delta area recommended the aforemen-
tioned groups of counties. Location of health services and
resources was an additional consideration for clustering.
Utilization of CHAs as connectors between healthcare
consumers and providers has become increasingly attractive
as a means of promoting health among groups that have
traditionally lacked access to health care. GOTCHA incorp-
orated a training design that was comprehensive and holistic
in nature. Recommendations from previous research guided
GOTCHA program staff in adapting and designing the pro-
ject curriculum. Following recommendations of other lead-
ers in the field, project staff developed a curriculum that
would first train participants with core skills and competen-
cies in outreach, followed by disease-specific training
(Catalani et al. 2009). Project staff did not assume that

12. participants already possessed all necessary outreach skills.
Rather, the training curriculum and educational methods
are more comprehensive in an effort to address the com-
plexities of health outreach.
The GOTCHA project comprised two segments of
training: comprehensive core skills and chronic disease
modules. The Comprehensive Core Skills in Outreach for
CHAs training was adapted from The Community Health
Workers Comprehensive Skills Training (Community Health
Worker Network of NYC n.d.) curriculum and included the
development of core skills and competencies identified by
the National CHA Study (Rosenthal et al. 1998). Upon com-
pletion of a 35-hour core skills training, CHAs would acquire
comprehensive outreach skills and be equipped to under-
stand and translate chronic disease information. After com-
pletion of the Comprehensive Core Skills in Outreach for
CHA training, CHAs selected areas of focus (nutrition,
hypertension, diabetes, CVD, and lifestyle management) that

13. they wished to pursue.
Comprehensive core skills in outreach for CHAs
curriculum
CHAs do not merely educate community members about
their health, and consequently, this CHA training included
more than just health education. CHAs serve in a variety of
roles including community facilitators, lay health educators,
resource referrals, advocates, community organizers, home
visitors, medical interpreters, and patient navigators to name
a few. When working with members of the community, their
efforts are neither pedantic in nature nor didactic in meth-
odology (Community Health Worker Network of NYC n.d.).
Yet historically, CHAs are trained in narrowly defined con-
tent information utilizing methods that are instructive and
didactic with the expectation that they will enable citizens to
assume the responsibility for their own and their commu-
nity’s health. This counterintuitive thought process speaks to
the existing health disparity gaps, and a paradigm shift must

14. occur. Employing participatory and emancipatory educa-
tional methods provide training in more appropriate behav-
iors to meet the goal of community and social
transformation and reinforce CPBR theoretical constructs
(Matos and Mayfield-Johnson 2006).
Contrary to formal pedagogy, an androgogical philoso-
phy or adult education and adult-learning theories should
guide CHA training (Mayfield-Johnson 2007). An emphasis
on experiential learning is crucial because adult-learning
teaching principles and methodology should be grounded
in the learners’ experiences as true learning takes place
when applied to experience (Knowles 1980, 1984; Mayfield-
Johnson 2007). The purpose of adult education is to give
meaning to experience (Lindeman 1989). Lindeman (1989)
has stated, ‘experience is the adult learners living textbook’
(7), and adult education is ‘a continuing process of evaluat-
ing experience’ (85). Through this continual process of eval-
uating experiences, a method of awareness where one learns

15. to become alert in the discovery of meanings is developed.
The goal of adult education is twofold: personal self-
improvement in the short term with changing the social
order in the long term (Lindeman 1989).
Fundamental to adult-learning theory is the realization
that an individual must experience a need to change or to
learn before a change can occur. Lewin (1997) postulated
that people must experience an ‘unfreezing’ of old attitudes
and beliefs before they can consider new ones. Likewise, Nys-
wander (1956) built upon this perspective when she articu-
lated the principle of relevance, or starting where the people
are, as perhaps the most fundamental tenet of health educa-
tion practice. Parallel to this notion of relevance is the
importance of participation and experience (Matos and
Mayfield-Johnson 2006; Mayfield-Johnson 2007). With health
viewed as a resource originating from people within their
social context rather than from the healthcare system, par-
ticipation is critical to ensure the cultural sensitivity of

16. � 2010 Blackwell Publishing Ltd 375
GOTCHA
programs, facilitate sustainability of change efforts, and
enhance health in its own right (Jewkes and Murcott 1998).
CBPR principles support this theoretical framework.
Such emphasis on appropriate pedagogy is fundamental
to the development of a successful CHA training program
including popular education techniques as the primary teach-
ing methodologies. Popular education is an educational
approach designed to raise participant consciousness of the
connection between individual personal experiences and lar-
ger societal problems. Popular education has origins in the
writings of exiled Brazilian philosopher Paulo Freire through
the publication of Pedagogy of the oppressed (Freire 1970) and
other banned writings during the Latin American military dic-
tatorship in the 1970s. Freire expressed that reality was not
objective truth or facts to be discovered but ‘includes the ways

17. in which people involved with facts perceive them … The con-
crete reality is the connection between subjectivity and objec-
tivity, never objectivity isolated from subjectivity’ (Freire
1973,
29). Freire (1970) provided the psychosocial understanding
of how emancipatory knowledge can lead to the power to
make change. As people engage in dialog with each other
about their communities and the larger social context, how
they think and ascribe meaning about their social world
changes, their relationships to each other become strength-
ened and their ability to reflect on their own values and
choices increases (Matos and Mayfield-Johnson 2006; May-
field-Johnson 2007). Social change then begins with persons
reflecting on their values, their concern for a more equitable
society, and their willingness to support others in the commu-
nity. As people learn about root causes to issues and under-
stand their strengths, they are better able to recognize and
understand the political, economic, and social conditions
that surround them. After which, people are able to move

18. from passivity to active participation, to be critical of the status
quo, reject oppression, and affect change (Mayfield-Johnson
2007).
As a result, the GOTCHA training design and curriculum
differs significantly from other CHA interventions and pro-
grams. In most CHA models, an integrative disease-specific
curriculum is developed and implemented with identified
recruits. Because most training participants in CHA pro-
grams are identified as informal leaders in the community,
assumptions are made about their abilities to be a CHA.
CHA models work well in communities because CHAs are
members of their communities with knowledge of the com-
munity’s culture, language, and history. Community resi-
dents often look to these persons for advice and assistance,
and they are informal gatekeepers to the community. How-
ever, funding is rarely non-prescriptive. The collective
assumptions made about an individual’s ability to conduct
outreach by restrictive proposals when submitted to funders

19. are often misguided. Often, these proposals direct little
attention to the core skills necessary to be effective in out-
reach because outreach skills are assumed. Instead, attention
is largely focused on the specific disease or topic. These core
skills are foundational building blocks to personal develop-
ment, program implementation, program evaluation, and
community capacity building.
The National CHA Study (Rosenthal et al. 1998) recom-
mended that CHA programs adopt and refine the following
identified CHA roles and competencies: (i) cultural mediat-
ing between communities and healthcare providers; (ii)
informal counseling and social support; (iii) providing cul-
turally appropriate health education; (iv) advocating for an
individual’s and the community’s needs; (v) assuring individ-
uals receive necessary services; (vi) building individual and
community capacity; and (vii) providing limited direct ser-
vices (e.g. blood pressure readings, glucose testing). CHA
skill competencies identified included: communication

20. skills, knowledge expertise, capacity-building skills, interper-
sonal skills, service coordination skills, teaching skills, advo-
cacy skills, and organizational skills.
Table 1 (Rosenthal et al. 1998) summarizes the imple-
mentation of these roles and competencies into the
GOTCHA training, and these core roles and competencies
encapsulate the functions CHAs can serve in their communi-
ties. For example, many CHAs play an important role as
bridges and mediators between communities and the health-
care delivery system. This cultural mediation may include col-
lecting pertinent and private information from community
members that is often not shared with health and social service
providers. CHAs can ‘translate’ medical and other health ter-
minology into lay language a community member can under-
stand. They may educate community members on changes in
how services are offered, hours and pay rates at community
health clinics, and ways to engage provider interaction. CHAs
provide informal counseling and support through leading

21. support groups, time spent working with community mem-
bers on goal setting, and community resources CHAs have
developed through extensive resource networks. CHAs pro-
vide culturally appropriate health education by often making
it physically available to community members through hand-
ing out pamphlets on street corners, performing door-to-door
outreach, and home visits. CHAs often advocate for individual
and community needs as intermediaries between community
members and bureaucracies, explaining systems in lay lan-
guage and assisting to resolve problems like the lack of insur-
ance or prescription assistance programs.
CHAs do not just put community members in contact
with health services; they go much further to ensure that ser-
376 � 2010 Blackwell Publishing Ltd
L Story et al.
vices are actually obtained. As Table 1 (Rosenthal et al.
1998) specifies, CHAs attempt to ensure that people receive

22. necessary services. Ensuring people receive these services
may include physically locating an individual who lacks a
telephone about test results or providing referrals to food
banks and other support programs. CHAs assist in building
individual and community capacity. CHAs increase the indi-
vidual’s capacity to protect and improve health through edu-
cation and skill development, such as how to prepare
traditional foods with less fat. CHAs also help communities
identify their priority needs and work to resolve identified
problem areas. Finally, some CHAs provide various limited
services such as BMI assessment, cardiopulmonary resuscita-
tion and first aid, and home glucose and blood pressure
monitoring.
Incorporation of a core skills curriculum that included
the identified CHA roles and competences in an emancipa-
tory and participatory curriculum design was vital to the
philosophical foundational for this project. The Community
Health Workers Comprehensive Skills Training (Community

23. Health Worker Network of NYC n.d.) curriculum was
adapted for use with the GOTCHA program. The Commu-
Table 1 Methods for incorporating suggested roles and
competencies into GOTCHA
CHA roles and competencies
Methods for incorporating suggested roles and competencies
into
GOTCHA
Cultural mediating between communities and
healthcare providers
Educating community members on understanding and navigating
the healthcare and social service systems
Translation, interpretation, and facilitation of community-
provider
communication
Gathering information for medical providers
Educating medical and social service providers about
community
needs
Linking health professionals to community needs

24. Informal counseling and social support Helping families
develop social capital
Leading support groups
Providing individual support through active listening techniques
Providing culturally appropriate health education Teaching
concepts of disease prevention and health promotion
Helping manage chronic illness
Integrating concepts of adult learning and popular education
Advocating for an individual’s and the community’s
needs
Knowledge of resources in community
Representatives for community needs
Presentations to community and larger stakeholders
Assuring an individual receive necessary services Linking to
services
Making referrals
Providing follow-up
Building individual and community capacity Individual –
change health-related behaviors
Community – help communities assess their needs and develop

25. action plans
Providing limited direct services Personal height, weight, waist
circumference, body fat percentage,
and BMI awareness; CPR and first aid; home glucose
monitoring;
home blood pressure readings; leading physical activity exercise
sessions and walking groups; and demonstrating how to read
food
labels, control portion sizes, reducing salt, fat, and sugar in
foods,
and translating consumer marketing techniques and food buying
relationships into healthier habits
Assisting with food, employment, and ⁄ or housing resources
Source: Rosenthal et al. (1998).
� 2010 Blackwell Publishing Ltd 377
GOTCHA
nity Health Workers Comprehensive Skills Training is a
35-hour training designed by community health workers to
include the core skills and competencies identified by the

26. National CHA Study (Rosenthal et al. 1998). Additional
examples of cultural humility (Tervalon and Murray-Garcia
1998), popular education methods, reflections of MS Delta
history, and participants’ life stories were included in train-
ing to enhance the application and utility of the curriculum
by MS Delta residents. The resulting Comprehensive Core
Skills in Outreach for CHAs curriculum is consistent with
popular education and adult-learning principles in design,
length, and philosophy.
Table 2 Summary of chronic disease modules
Chronic Disease
Modules Objectives
Nutrition Reinforce key stroke messages
Increase knowledge of basic nutrition knowledge
Identify the functions of nutrients in the body
Demonstrate accurate measurement of height, weight, waist
circumference, and body mass index
Compare and contrast serving sizes and portion sizes
Demonstrate accurate readings of food labels

27. Understand grocery store marketing techniques and consumer
food buying relationships
Translate Delta culture eating habits
Model a supermarket tour and food label reading exercise
Cook heart healthy meals
Explore options for CHA to use knowledge and skills in the
community
Diabetes Reinforce key stroke messages
Increase knowledge of diabetes including risk factors,
prevention, treatment, and complications
Increase knowledge of how to engage healthcare professionals
to improve personal diabetes
outcomes
Demonstrate accurate measurement of blood glucose
Explore options for CHA to use knowledge and skills in the
community
Hypertension Reinforce key stroke messages
Increase knowledge of hypertension including risk factors,
prevention, treatment, and complications
Increase knowledge of how to engage healthcare professionals
to improve personal hypertension

28. outcomes
Demonstrate accurate blood pressure measurement
Explore options for CHA to use knowledge and skills in the
community
Cardiovascular disease Reinforce key stroke messages
Increase knowledge of hypertension including risk factors,
prevention, treatment, and
complications
Demonstrate proficiency in community cardiopulmonary
resuscitation
Explore options for CHA to use knowledge and skills in the
community
Lifestyle management Reinforce key stroke messages
Define stress and understand the body’s physiological responses
Increase knowledge of stress risk factors, prevention,
modification techniques, and potential
complications of unmanaged stress
Demonstrate stress management techniques
Increase knowledge of physical activity basics and potential for
life enhancement and
disease reduction

29. Identify potential home exercise equipment activities
Demonstrate strength training, low impact and stretching
exercises
378 � 2010 Blackwell Publishing Ltd
L Story et al.
Chronic disease modules for CHAs curriculum
Public health professionals, nutritionists, and a nurse affili-
ated with the project developed the chronic disease modules
in collaboration with community members. Specifically,
training modules related to nutrition, hypertension, dia-
betes, CVD, and lifestyle management were developed fol-
lowing input from community consultants (see Table 2).
Table 2 also identifies the content areas and the objectives
for each of the training modules. To obtain this input, pro-
fessionals trained in the content areas met with CHA repre-
sentatives to determine the community’s expectations,
needs, and previous content experiences. The information
gained from these meetings then guided the development

30. of each module. Once the modules were developed,
GOTCHA staff substantiated these chronic disease modules
with the CHAs to determine whether the module accurately
and culturally reflected the information they had shared.
These CHA representatives also received acknowledgement
in authorship of the modules for the critical part they played
in its development. This interdisciplinary partnership,
among both program staff and CHAs, reflects the CBPR
focus and commitment guiding the GOTCHA project.
Key stroke messages including the American Heart Asso-
ciation’s Know Your Numbers (KYN; blood pressure, body
mass index, glucose, cholesterol) underlined each disease
module, and the connection of stroke to each individual
chronic disease area was demonstrated. The premise for all
the chronic disease modules was not only to increase knowl-
edge in these areas but also to equip CHAs with skills that
could be used in the community and at their jobs when
applicable. These skills included the measurement of blood

31. pressure, pulse, weight, height, body mass index, and blood
glucose as well as cardiopulmonary resuscitation. The ultim-
ate goal of the chronic disease modules was to create lay
‘content experts’ that could then go out and train future
CHAs in these areas as well as conduct community-level activ-
ities. CHAs can utilize their familial and peer networks to
share correct stroke prevention and early detection educa-
tion, offer some direct services, and provide social support.
Upon the completion of the core skills and chronic dis-
ease training, participants received continuing education
units (CEUs) from the Office of Professional Development
and Educational Outreach at The University of Southern
Mississippi (USM) in addition to certificates of completion.
By including CEUs as a part of the training design, the sig-
nificance of the training is emphasized with goals, objectives,
content outline, and teaching methodologies submitted and
approved by a governing academic institution. CEU tran-
scripts are from the university, not from the program. Train-

32. ing participants also received a small monetary stipend for
their participation at the completion of the comprehensive
core skills and three of the chronic disease training modules.
At the conclusion of the core and chronic disease training
modules, a graduation ceremony was held at each training
site to celebrate the accomplishment of completing the
extensive CHA trainings. Each CHA group had completed
approximately 95 hours of training over a period of
6 months, and graduation often reflects the deep physical,
emotional, and time commitment each CHA voluntarily
makes. A graduation ceremony also forges a strong CHA
group identity in that it facilitates a strong sense of accom-
plishment and gives value to the training they have received
(Mayfield-Johnson 2007). The ceremony also presented the
CHAs to the community and introduced their new roles.
During this ceremony, the CHAs received a tool kit includ-
ing the necessary equipment (i.e. glucose monitors, strips,
blood pressure cuffs, scales, tape measures, biohazard con-

33. tainers, sanitizing wipes, antibacterial hand sanitizer) needed
to conduct skills acquired in the chronic disease training.
The CHAs can use the toolkits to implement their newly
acquired skills in their community.
RECRUITMENT
Recruitment of GOTCHA training participants involved a
two-step process that began with the identification of com-
munity consultants, who were recognized, informal leaders,
in a community area. These persons represented invaluable
resources and often were gatekeepers in their communities.
An informal method of snowball interviewing, specifically
reputational and decisional analysis, through community for-
ums held in each training area identified community consul-
tants. Identification involved the formal or informal
nomination of residents who play a powerful role in commu-
nity affairs by knowledgeable community members. Addi-
tionally, community informants were asked to describe
recent community decisions and key players in those deci-

34. sions. The following questions were used to help identify
community consultants: (i) Who do people in this commu-
nity go to for help or advice? (ii) What person in this com-
munity do people trust will do what is right for the
community? (iii) When the community has had a problem
in the past, who has been involved in working to solve it?
and (iv) Who would have to be involved to get things done
in the community? Persons designated as meeting the above
criteria were asked to serve as community consultants.
Roles of the community consultants included assisting
GOTCHA staff in publicizing the GOTCHA project, identify-
ing and recruiting potential community members to partici-
� 2010 Blackwell Publishing Ltd 379
GOTCHA
pate in CHA training, and assisting staff with training set up.
The following criteria guided CHA training recruitment:
(i) participants must be at least 18 years old; (ii) participants

35. must hold a high school diploma or equivalent; and (iii) par-
ticipants should display an active interest in improving the
health of their communities. Some community consultants
utilized a convenience sampling method to recruit partici-
pants, often targeting people who attended the same church
or worked in the same business thus limiting representation
of the entire target areas. GOTCHA staff guided community
consultants to broaden their recruiting base to represent the
target service area comprehensively. Changes in marketing
strategies (i.e. local television, radio, and newspapers) were
employed to increase community awareness of the project
and improve recruitment.
Additionally, the consultants worked closely with GOT-
CHA staff in identifying training locations, arranging for
audiovisual equipment needs, and coordinating food for
each training group. The consultants assisted in greeting
participants and providing assistance at each training ses-
sion. Each community consultant received monetary com-

36. pensation for the assistance provided.
COMMUNITY PRESENCE
In addition to reducing the incidence of stroke in the MS
Delta, GOTCHA staff worked to develop and maintain posi-
tive relationships with community members. Prior to begin-
ning training, all GOTCHA staff from the principal
investigator ⁄ director down to the community consultants
attended and facilitated community informational meetings
in the target service areas. To establish positive relationships
with the community, GOTCHA staff recognized the import-
ance of removing distance and unfamiliarity as barriers to
their accessibility and acceptance within the communities.
These meetings provided an opportunity for staff to intro-
duce themselves to the community as well as to share infor-
mation regarding the purpose and design of the project with
the community. During the informational meetings,
GOTCHA staff asked community members to prioritize their
major health issues and identify local community resources

37. and barriers to improving health in the area. Further, com-
munity members were encouraged to ask questions, offer
suggestions, and hold the staff accountable to maintaining
open community dialog so that the project would truly
reflect an equitable community relationship. These meetings
were foundational to the project’s paradigm and would aid
in successful implementation of the project. Staff mailed a
summary of all information obtained during the community
informational meeting to all community members who
attended the meeting. Too often, data shared with academic
intuitions and health programs are not reported back to the
community members from which the information originated
(Minkler and Wallerstein 2003); GOTCHA staff desired to
facilitate an emancipatory model in philosophy and practice.
All communication shared with the program is disseminated
to the community. This approach is one method of ensuring
the ongoing communication and supporting a true CPBR
relationship.

38. Although an employee of USM, the GOTCHA project
program coordinator lives and works in the MS Delta. The
involvement of an MS Delta resident as a project staff mem-
ber allowed community consultants and training participants
to relate to a well-known and recognized person in the com-
munity with the GOTCHA project. The program coordina-
tor successfully developed rapport with community members
because of their similar ethnic and cultural backgrounds.
The program coordinator’s accessibility in the community
enhanced the GOTCHA project’s entry and acceptance in
the community, and the program coordinator’s presence in
the community increased the participants’ trust in the
GOTCHA project and its staff. According to Catalani et al.
(2009), trust represents the most consequential aspect of
community health work that allows access to personal infor-
mation – essential in helping community members make
healthful lifestyle and behavioral changes. Observation of
the trusting and respectful relationships between the pro-

39. gram coordinator and other GOTCHA staff accelerated
entry into the community and increased the probability of
successful project implementation.
EVALUATION
Because of the time limitations of funding for this project,
evaluation of community- and policy-level changes is not pos-
sible. An extensive amount of time is needed to observe and
measure macro-level changes resulting from CBPR projects.
However, from the beginning of the project, GOTCHA staff
sought to evaluate rigorously the impact of the CHA training
on participants. Because implementation of the GOTCHA
project is ongoing, impact or outcome evaluation cannot be
conducted at this time. With these limitations stated, it is
important to review and disseminate information on what
evaluation strategies are being implemented to evaluate the
impact of GOTCHA’s training. A mixed method approach is
being used to evaluate comprehensive core skills training and
training in the chronic disease modules. Quantitative and

40. qualitative approaches are employed to assess how the com-
prehensive core skills training enhanced CHAs competency,
stroke prevention skills, as well as other factors, such as CHAs’
380 � 2010 Blackwell Publishing Ltd
L Story et al.
sense of empowerment. Table 3 defines the data collection
instruments used, identifies whether it is qualitative or quanti-
tative in nature, and specifies when each data collection
method occurs.
To evaluate CHA’s competency in core skills, the CHA
core competency instrument is administered as a traditional
pretest at the first core training session, and again as a retro-
spective pretest at the end of the CHAs’ chosen chronic dis-
ease training. Core competencies evaluated include
leadership, translation, guidance, advocacy, and caring as
related to stroke prevention. Based on previous work, Story
(2008) identified these as skills critical to an individual’s abil-

41. ity to perform as a CHA.
To assess CHA’s competency in a specific chronic disease
module, several instruments are used. These include the
KYN knowledge assessment that is administered at the begin-
ning and ending session of each chronic disease training ses-
sion to evaluate the key stroke prevention knowledge
attainment. Similarly, a brief assessment pertaining to CVD,
lifestyle, diabetes, nutrition, and hypertension is adminis-
tered to participants before they begin a particular chronic
disease module and after they conclude the module. Addi-
tionally, a checklist is used to assess whether CHAs are able
to successfully complete certain skills. These skills include
the accurate measurement of blood pressure, pulse, weight,
height, body mass index, and blood glucose. Periodically,
the project’s registered nurse assesses whether participants
are competent in these skills. If a participant is unable to
meet these basic skills, they receive additional training on
the unmet practices. Participants should be able to perform

42. tasks related to the chronic disease modules they completed.
At the initiation of training and at the end of the chronic
disease training, the CHA lifestyle behaviors instrument is
administered to assess how participating in CHA training
affects personal health behaviors. This instrument assesses
participant’s health-related behaviors, including diet, phys-
ical activity, and smoking. Finally, an assessment of a CHA’s
perceived locus of control instrument is administered at the
first training and repeated at the end of the chronic disease
training. To collect demographic information, training par-
ticipants complete a profile sheet at the initiation of training
– the first core training session.
Talking circles, very similar to the focus group method-
ology, are used to evaluate the CHA training program,
including core skills and chronic disease-specific training ses-
sions. Each CHA group in their respective clustering is
invited to join in this reflective process at the end of the
chronic disease modules. The facilitator, an internal evalua-

43. tor who has not trained any of the CHA groups, moderates
each focus group using the same question guide. Concepts
Table 3 GOTCHA project data collection timeline
Data
Data point
Baseline
End of
core
Beginning of
chronic disease
End of chronic
disease Each session
Quantitative
CHA profile sheet X
CHA core competency X X
KYN knowledge X X
CVD knowledge X X
Lifestyle knowledge (physical

44. activity and smoking)
X X
Diabetes knowledge X X
Nutrition knowledge X X
Hypertension knowledge X X
CHA lifestyle behaviors X X
CHA self-assessment of perceived control X X
Skills checklist X
Qualitative
Session evaluation X
Overall training evaluation X X
Empowerment X
Locus of control X
� 2010 Blackwell Publishing Ltd 381
GOTCHA
explored in the talking circles include the quality of the over-
all training, their perception of being prepared to perform

45. CHA duties, personal empowerment from completing the
program, and additional support needed to perform their
role as a CHA.
Data are also collected to evaluate the process of program
implementation. At the conclusion of each training session,
participants complete a brief, open-ended survey. The survey
asks participants to identify material covered in each session
that is valuable to them and their role as a CHA. Similarly,
participants are asked to identify what segments of the ses-
sion need improvement. The overall delivery of the material
is also assessed. GOTCHA staff members review the com-
ments provided after each training session and seek to
enhance the quality of future sessions based of participant’s
feedback. Findings from each assessment are reported to
training participants at the beginning of the following train-
ing session. Again, this is a method for staff to understand
the importance of participants’ experience, comments, and
reflections. Although the content of each training session

46. remains the same, feedback from the participants directs pro-
ject staff’s delivery of the material. Participants’ honest
responses on these surveys help staff tailor the trainings to
the specific needs and desires of each group, respectively. At
the conclusion of the core and chronic disease training, each
CHA completes an open-ended questionnaire to evaluate all
training sessions as a whole.
IMPLICATIONS?? FOR NURSING AND
COMMUNITY HEALTH PRACTICE
Although there are statewide efforts to recruit and retain
health professionals in the MS Delta, health disparities, and
specifically access to medical providers, remain a barrier.
A major barrier to optimal care is the lack of access to qual-
ity, culturally appropriate preventative health care, which is
exacerbated by the fact that many people who are trying to
manage chronic diseases do not have health insurance cover-
age. Even with medical care, there may be multiple individ-
ual- and community-level barriers to adequate self-care.

47. Healthcare providers, interested community members, and
even policy-makers are continually exploring innovative strat-
egies for filling the healthcare gap.
Many noteworthy CHA programs are currently meeting
the health professional gap among groups that experience
health disparities (Perez and Martinez 2008). As knowledge
about the effectiveness of CHAs increases, greater attention
is being directed toward identifying the specific training
needs of persons preparing to become CHAs. Until recently,
very little attention has been given to standardizing CHA
training as related to critical competencies. CHAs increas-
ingly report that they see themselves as a frontline public
health worker. This perception, and the increasing demand
for CHAs to bridge the gap between health institutions and
communities, suggests that practitioners and researchers
should explore training needs and effectively meet those
needs through competency-based curriculum. Identifying
competencies, documenting training procedures that

48. address those competencies, and measuring the attainment
of competencies will provide a framework for evaluating
training effectiveness.
During the development and implementation of
GOTCHA, program staff considered how to address training
needs related to core competencies and chronic diseases.
Evaluation of this more comprehensive training curriculum,
as well as implementation of adult-learning methods, con-
tributes to the evidence base of CHA training. Specifically,
findings from this project will provide additional insight into
the process, content, and structure of a two-pronged
approach to CHA training.
The GOTCHA project is an initial step toward rigorously
evaluating the process and impact of CHA trainings. Find-
ings from this project have the potential to inform and
enhance the usefulness and relevance of CHA training pro-
grams in the MS Delta and beyond. Documentation and
evaluation of training methods and content will help estab-

49. lish best training practices, and further develop the educa-
tional evidence base of CHA trainings.
The training and practice of CHAs in communities could
be of particular interest to front-line medical providers, such
as nurses. Increasingly, nurses and nurse educators are rec-
ognizing the need for community-based approaches to care
as a means of addressing health disparities. The need for
health practitioners, including nurses, to understand and
incorporate the perspectives of diverse communities is
becoming more relevant as health professionals realize that
many health problems are influenced by factors other than
biological causes (Anderson, Calvillo, and Fongwa 2007).
The relationship between nurses and CHAs is important as
health professionals seek to connect disadvantaged popula-
tions with a fractured healthcare system.
CHAs are a logical partner for nurses who deliver
chronic disease prevention and maintenance education. Par-
ticipatory methods, specifically CBPR, will continue to be

50. invaluable as nurses and community members, including
CHAs, collaborate to meet local needs and harness assets.
For improving the delivery of health care, nursing education
and practice could include the interdisciplinary implementa-
tion and evaluation of CHA-based CBPR programs, such as
the one presented in this study.
382 � 2010 Blackwell Publishing Ltd
L Story et al.
ACKNOWLEDGEMENTS
The Getting on Target with Community Health Advisors
Project is a program of the Center for Sustainable Health
Outreach at The University of Southern Mississippi. Funding
for the Getting On Target with Community Health Advisors
Project is provided by the Delta Health Alliance (DHA), a
501(c)3 non-profit organization, and by the Office of Rural
Health Policy, Health Resources and Services Administra-
tion, Grant No. U1FRH07411, 07 ⁄ 01 ⁄ 08 to 06 ⁄ 30 ⁄ 09.

51. REFERENCES
Anderson, Nancy LR, Evelyn R Calvillo and Maria N
Fongwa. 2007. Community-based approaches to
strengthen cultural competency in nursing education
and practice. Journal of Transcultural Nursing 18: 49S–
59S.
Andrews, Jeannette O, Gwen Felton, Mary E Wewers and
Janie Heath. 2004. Use of community health workers in
research with ethnic minority women. Journal of Nursing
Scholarship 36: 358–65.
Baker, Elizabeth A, Niva Bouldin, Maria Durham, Monica E
Lowell, Maria Gonzalez, Nancy Jodaitis, Leo N Cruz, Tor-
res Idali, Miriam Torres and Sara T Adams. 1997. The
Latino health advocacy program: A collaborative lay
health advisor approach. Health Education and Behavior
24: 495–509.
Catalani, Caricia EC, Sally E Findley, Sergio Matos and
Romelia Rodriguez. 2009. Community health worker

52. insights on their training and certification. Progress in
Community Health Partnerships: Research, Education, and
Action 3: 227–35.
Community Health Worker Network of New York City. n.d.
Comprehensive skills training for community health
workers. http://www.chwnetwork.org/id15.html.
Earp, Jo Anne, Eugenia Eng, Michael S O’Malley, Mary
Altpeter, Garth Rauscher, Linda Mayne, Holly F
Matthews, Kathy S Lynch and Bahjat Qaqish. 2002.
Increasing use of mammography among older rural Afri-
can American women: Results from a community trial.
American Journal of Public Health 92: 646–54.
Freire, Paulo. 1970. Pedagogy of the oppressed. New York: Sea-
bury Press.
Freire, Paulo. 1973. Education for critical consciousness. New
York: Continuum Press.
Freudenberg, Nicholas, Eugenia Eng, Brian Flay, Guy
Parcel, Todd Rogers and Nina Wallerstein. 1995.

53. Strengthening individual and community capacity to
prevent disease and promote health: In search of rel-
evant theories and principles. Health Education Quar-
terly 22: 290–306.
Grzywacz, Joseph G and Juliana Fugua. 2000. The social ecol-
ogy of health: Leverage points and linkages. Behavioral
Medicine 26: 101–15.
Institute of Medicine. 2002. Unequal treatment: Confronting
racial and ethnic disparities in health care. Washington, DC:
The National Academies Press.
Jewkes, Rachel and Ann Murcott. 1998. Community repre-
sentatives: Representing the community? Social Science
Medicine 46: 843–58.
Kegler, Michelle C and Lorraine H Malcoe. 2004. Results
from a lay health advisor intervention to prevent lead
poisoning among rural Native American children. Ameri-
can Journal of Public Health 94: 1730–5.
Kim, Sue, Deborah Koniak-Griffin, Jacqueline H Flaskerud

54. and Peter A Guarnero. 2004. The impact of lay health
advisors cardiovascular health promotion: Using a com-
munity-based participatory approach. Journal of Cardiovas-
cular Nursing 19: 192–9.
Knowles, Malcolm S. 1980. The modern practice of adult educa-
tion: From pedagogy to andragogy, rev. edn. Chicago: Follett
Publishing Company.
Knowles, Malcolm S. 1984. The adult learner: A neglected
species,
3rd edn. Houston, TX: Gulf Publishing Company.
Krieger, James, Tim K Takaro, Lin Song and Marcia Wea-
ver. 2005. The Seattle-King County health homes pro-
ject: A randomized, controlled trial of a community
health worker intervention to decrease exposure to
indoor asthma triggers. American Journal of Public Health
94: 652–9.
Lewin, Kurt. 1997. Resolving social conflicts and field theory
in
social science. Washington, DC: American Psychological

55. Association.
Lindeman, Edward. 1989. The meaning of adult education. Nor-
man, OK: Oklahoma Research Center for Continuing
Professional and Higher Education.
Matos, Sergio and Susan Mayfield-Johnson. 2006. Compre-
hensive skills training for community health workers: A train-
ing program for frontline health and social service workers.
Hattiesburg, MS: Center for Sustainable Health
Outreach.
Mayfield-Johnson S. 2007. Her story through photovoice and
reflective interviews: Describing changes in empower-
ment among community health advisors as research part-
ners in Mississippi and Alabama. PhD diss., The
University of Southern Mississippi.
Minkler, Meredith and Nina Wallerstein, eds. 2003. Commu-
nity-based participatory research for health. San Francisco, CA:
Jossey-Bass.
� 2010 Blackwell Publishing Ltd 383

56. GOTCHA
Mississippi Department of Health. 2004. Mississippi state plan
for heart disease and stroke prevention and control. Jackson,
MS: Mississippi Department of Health.
Mukherjee, Joia S and FE Eustache. 2007. Community
health workers as a cornerstone for integrating HIV and
primary healthcare. AIDS Care 19(Suppl. 1): 73–82.
Nemcek, Mary Ann and Rosemary Sabatier. 2003. State of
evaluation: Community health workers. Public Health
Nursing 20: 260–70.
Nyswander, Dorothy. 1956. Education for health: Some prin-
cipals and their application. California Health 14: 65–70.
Perez, Leda M and Jacqueline Martinez. 2008. Community
health workers: Social justice and policy advocates for
community health and well-being. American Journal of
Public Health 98: 11–14.
Rosenthal, E Lee, Noel Wiggins, Nell J Brownstein, Sarah

57. Johnson, Angelina Borbon and Roberta Rael. 1998. Final
report of the national community health advisor study. Tucson,
AZ: University of Arizona Press.
Stokols, Daniel. 2000. Social ecology and behavioral medi-
cine: Implications for training, practice, and policy.
Behavioral Medicine 26: 129–38.
Story L. 2008. Training community health advisors in the
Mercy Delta Express Project: A case study. PhD diss., The
University of Mississippi Medical Center.
Tervalon, Melanie and Jann Murray-Garcia. 1998. Cultural
humility vs. cultural competence: A critical distinction in
defining physician training outcomes in medical educa-
tion. Journal of Health Care for the Poor and Underserved 9:
117–25.
384 � 2010 Blackwell Publishing Ltd
L Story et al.
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CASE: CAN THE TSA SECURE TOP-FLIGHT
PERFORMANCE?
If you’ve flown in the United States recently, you’ve passed
through security checkpoints staffed by the Transportation
Security Administration, a federal agency created in November
2001 to protect all modes of transportation. TSA agents are best
known for scanning baggage and screening persons headed for
gates in the nation’s airports. Most travelers appreciate the
concern for safety following the 2001 terrorist attacks, but
many also grumble about times they have encountered a TSA
employee who was unpleasant or seemed capricious in enforcing
rules.
For its part, TSA management has been challenged to maintain a
workforce that is knowledgeable, well qualified, ethical, and
vigilant about identifying risky persons and behavior.
Occasional news reports have identified lapses such as items
stolen from luggage (perhaps when TSA agents are inspecting
checked bags) and claims that security screeners have cheated
on tests of their ability to spot smuggled weapons.
In a recent year, TSA received an average of 1,443 claims for
lost, stolen, or damaged items, affecting a small share of the 65
million passengers who travel each month. Geoff Rabinowitz, a
business traveler whose laptop computer disappeared from one
of his bags, worries that theft by TSA or airline employees
could signal a huge security risk: “If they can get away with
taking something out of bags, what can they put in bags without
getting caught?” Lauren Suhre lost jewelry and sees theft as a
sign of poor management: “I can’t imagine working for them.”
TSA responds to such complaints by noting that it has a zero-

59. tolerance policy for employees caught stealing and investigates
charges aggressively.
Cheating on security tests is another problem that raises ethics
questions. One report said agents at airports in San Francisco
and Jackson, Mississippi, allegedly were tipped off about
undercover tests to be conducted. According to the allegations,
TSA employees described to screeners the undercover agents,
the type of weapons they would attempt to smuggle through
checkpoints, and the way the weapons would be hidden.
What is the TSA doing to improve the professionalism of its
employees? Many of the efforts involve human resource
management. One practice involves the design of jobs. TSA
wants employees to see themselves not just as “screeners” who
sit in airports but as part of a larger law enforcement effort. So
that job title was eliminated and replaced with the term security
officers, and career paths were developed. The agency also
improved its training in job tasks such as interpreting X rays
and searching property. It added performance-based pay to its
compensation plan, so high-performing employees are rewarded
in a practical way. Such changes have helped reduce employee
turnover substantially. A survey also found greater job
satisfaction among TSA workers.
These improvements are no small achievement, considering that
government agencies have tended to lag behind many businesses
in creating a focus on high performance. In a government
agency, which is not ruled by sales and profits, it can be
difficult to develop measurable performance outcomes—
measuring what individuals and groups actually achieve, rather
than merely tracking their day-to-day activities. As a result,
employees may not always see how their individual efforts can
help the agency achieve broader goals. Without this vision, they
have less incentive to excel.
TSA, part of the Department of Homeland Security (DHS), has
tried to become an exception, a performance-oriented
government agency. Marta Perez, chief human capital officer of
DHS, says TSA defined its overall objective as “to deploy

60. layers of security to protect the traveling public and the nation’s
transportation system.” To achieve that objective, the agency
set specific goals for individual airports, including goals to
improve the efficiency and effectiveness of airport screening, as
well as safety targets. For example, one goal is that the wait
time for 80 percent of the passengers going through airport
security should be 10 minutes or less. Individuals at each
airport have specific goals aimed at achieving the airport’s
overall goals. According to Perez, the goals help employees and
managers talk about what is expected and how they will be
evaluated.