DOI: https://doi.org/10.21203/rs.3.rs-2833788/v1
We developed a curriculum for community health workers (CHWs) using an innovative, community-engaged focus group and Delphi process approach. Equipping CHWs with knowledge of Hereditary Breast and Ovarian Cancer (HBOC) and genetics could help enhance identification of women at risk for HBOC, referral, and navigation through genetic services. Focus groups of five CHWs were conducted on two separate occasions. A three round Delphi process study involving eight experts was conducted. In Round 1 participants rated and commented on draft modules. The second round involved live video discussion to highlight points of confusion and concern in the modules. The third round followed the same process as Round 1. Eight individuals participated in the Delphi process. The curriculum was revised and refined based on quantitative and qualitative data and reassessed by the experts in Round 3. Agreement was achieved on eight of 10 modules when assessing for clarity of learning objectives, seven out of 10 when assessing for adult learning theory, and nine out of 10 when assessing for participants’ ability to learn desired knowledge and the Delphi process concluded. High levels of agreement were attained for most modules, and if not, they were altered accordingly. We plan to virtually deliver this curriculum to CHWs to enhance their HBOC and genomic competencies. By equipping CHWs to understand and participate in genomics education, we can enable more equitable participation in genomics-informed clinical care and research. Beyond this curriculum, the Delphi methodology can further be used to design content for new CHW curriculums.
Individuals with a BRCA1/2 genetic mutation have a 10-times greater risk of developing breast or ovarian cancer than the general population.(Dietze, Sistrunk, Miranda-Carboni, O'Regan, & Seewaldt, 2015; John et al., 2007). If identified early, an individual at risk for hereditary breast and ovarian cancer (HBOC) because of deleterious BRCA1/2 mutations can be provided with more intensive prevention measures (e.g., breast MRI, screening initiation at a younger age), greatly reducing cancer incidence and mortality (Domchek et al., 2010; Nelson et al., 2013; Nelson, Pappas, Cantor, Haney, & Holmes, 2019; Schrag, Kuntz, Garber, & Weeks, 2000). Unfortunately, disparities exist in early detection of these individuals. For example, less than half of eligible Black women are assessed for genetic risk and only 28% engage in recommended HBOC risk-reducing interventions such as genetic counseling and testing (Halbert, McDonald, Vadaparampil, Rice, & Jefferson, 2016; Khoury et al., 2018; McDonald et al., 2012; Scherr, Ramesh, Marshall-Fricker, & Perera, 2019; Sheppard et al., 2014; Smith et al., 2016). Additional data have shown that racial and ethnic minority groups are not benefiting from genetic testing and improved clinical outcomes at the same rate as White populations. Further, racial and ethnic minorities remain underrepresented in genetic research, with most genome-wide association study participants (81%) being of European ancestry (Halbert et al., 2016; McDonald et al., 2012).
Reasons for poor uptake of genomic medicine among racial and ethnic minority groups are complex and include: concerns about privacy and disclosure of results, historical transgressions and mistrust, and being unaware of research opportunities. Notably, a growing body of research suggests that minority participation in genomic services is not due to lack of interest, but rather due to deployment of unsuccessful and inconsistent recruitment and retention strategies that do not adequately address engagement preferences of diverse populations (Allen, McBride, Balcazar, & Kaphingst, 2016; Brandford, Adegboyega, Combs, & Hatcher, 2019; Chen et al., 2015; Chen et al., 2018; Pierce & Stevermer, 2020; Shah, Nakagawa, & Lieblong, 2020). Community capacity building or equipping already established, trusted groups to understand and participate as partners in genomic research can enable more equitable minority representation.
Addressing disparities in identification and navigation of individuals with HBOC also requires use of health information technologies (IT). Health IT tools, including family history collection applications to assess for risk profiles, patient portals to share information between patient and provider, electronic health records to track screening activities, and telehealth for genetic counseling and testing are essential to support the identification and manage the health of women with HBOC(Ojinnaka & Adepoju, 2021; Tarver & Haggstrom, 2019). National initiatives recommend accelerated adoption and optimization of health IT to promote digital health equity and enhancing identification of high-risk individuals (Halbert et al., 2021; Thompson et al., 2013; Walker, Hefner, Fareed, Huerta, & McAlearney, 2020). Despite these efforts, there has been low uptake of critical health technologies, with recent findings suggesting that racial and ethnic minority groups are 45% less likely to use health IT tools compared to Whites (Pierce & Stevermer, 2020). Alternative, models to facilitate the appropriate identification of individuals at high-risk for HBOC, followed by referral, and navigation through genetic services using health IT tools are urgently needed.
Equipping the community health worker (CHW) workforce with knowledge of HBOC and genetics could help enhance identification of women at risk for HBOC, referral, and navigation through genetic services. As a workforce, CHWs have been effective in improving cancer screening behaviors; however, limited research has evaluated the use of CHW education to increase awareness and use of health IT to support identification of women at high-risk for HBOC and increase access to services(Allen, McBride, et al., 2016; Brandford et al., 2019; Shah et al., 2020). As trusted members of communities, CHWs are a well-positioned but overlooked workforce in HBOC and genomics, and therefore lack the necessary competencies needed to identify high-risk women (Chen et al., 2015; Chen et al., 2018). Our prior research found that, despite high levels of interest, training opportunities for CHWs about HBOC and genomics are limited. CHWs have largely not been engaged in interventions or training to support genomic literacy building or precision health.43,4445 While training programs offer targeted cancer genetics education for clinical health care professionals (e.g., nurses and physicians), no programs exist specifically for CHWs (Chen et al., 2018). Development of a specialized training curriculum for CHWs has been suggested as a clear next step to support CHW engagement in genomics (Allen, McBride, et al., 2016).
To address this gap in training CHWs, we developed a curriculum called KEEP IT (Keeping Each other Engaged Program via IT) CHW Training. This training was specifically designed to address the unmet needs of CHWs by: 1) enhancing their ability to identify individuals at high-risk for HBOC, 2) increasing their awareness of available resources, and 3) providing skills for navigation of genetic services. In this manuscript, we report the process used to develop the KEEP IT training, which included a community-engaged process, including focus groups and a three-round Delphi process. This academic-community partnership approach can be used to inform the development of CHW curriculum.
We used a focus group and a modified Delphi process to guide the development of a curriculum to educate CHWs. Focus groups were conducted on February 9, 2022 and February 16, 2022. The modified Delphi process took place from May 9, 2022 to August 8, 2022. All aspects of the curriculum development process were approved by the Medical University of South Carolina Institutional Review Board.
We facilitated two focus groups with CHWs from various background to better understand CHW training needs to support competencies in understanding hereditary breast and ovarian cancer (HBOC) and genetics (see Supplemental Materials: Focus Group Interview Guide). Participants were provided with PowerPoint slides and an outline of the proposed training topics prior to the focus group meeting they were attending. Facilitators used a semi-structured interview approach to gain clarity on the course topics and future directions for the CHW training. The focus group sessions were recorded and transcribed for a proper reference of topics and experiences discussed during the focus groups. After the focus groups, the recordings and transcription were reviewed by the study team to identify common experiences voiced by the participants and common themes about each topic.
We used a modified Delphi Process to reach agreement on and finalize the content of a training focused on the identification of hereditary cancers. The Delphi process is an iterative approach designed to solicit and build consensus by converging recommendations from experts using a series of surveys and feedback (O'Toole et al., 2020; Powell, 2003). We engaged a panel of individuals with expertise in genetics, community-engagement, CHW training, and telehealth to complete the three-round Delphi process. Participants rated and commented on aspects of the curriculum, including the organization relevance, content, and scope. The process was conducted online over a three-month period to allow sufficient time to gather data, aggregate and communicate group responses, and to alter content and surveys as data were collected and analyzed. The surveys were developed and designed using Research Electronic Data Capture (REDCap), an online survey database. Participants received an invitation email at the start of each round that included a description of what they are expected to do and how long each round will be open. After the completion of each round, the participants were compensated for their participation.
Round 1 served as an assessment round where the experts could rate and comment on the different aspects of the training. The first link was comprised of a series of surveys with 5-point Likert scale questions and open response questions based on the Kirkpatrick Model of Training Evaluation (see Supplemental Materials: Delphi Process). An instrument was created for each of the proposed modules (n = 10) as well as an instrument for the overall curriculum. The surveys for the individual modules contained three 5-point Likert scale questions: 1) The module has clear learning objectives 2) The module uses adult learning theory and 3) Participants will learn desired knowledge. The survey assessing the experts’ experience with the overall curriculum contained ten 5-point Likert scale questions capturing aspects of reach, learning, behavior, and results from the Kirkpatrick Model of Training Evaluation: 1) The course materials are aligned with adult learning theory, 2) The length of the training is appropriate for materials covered, 3) The materials are presented in a way that is accessible to CHWs, 4) The course will help participants learn desired knowledge about HBOC, 5) The course will help participants learn desired skills related to health IT, 6)There is a clear integration of health IT and hereditary cancers, 7) Sequencing of topics is appropriate, 8) The course will help CHWs identify individuals at high risk for HBOC, 9) The course content is relevant to CHW practice, and 10) The course content will help empower CHWs to help change client’s behaviors. A link to each module was provided in the survey. The first round also captured contact information in order to monitor which participants responded. After the completion of Round 1, participants received a summary of the results including their individual ratings and comments, group median, group IQR, and comments from the group in an Excel spreadsheet. Results were sent prior to Round 2 to allow participants time to review all responses to the curriculum. We considered Delphi questions to reach consensus if they had greater than 75% agreement (rated as agree or strongly agree on Likert Scale).
Round 2 was a qualitative feedback and discussion round conducted over Microsoft Teams. Prior to the Teams meeting, a When2Meet survey was sent to all participants to determine the best day and time for the Round 2 session. Two members of the study team (CA and AH) facilitated the session, which was recorded and transcribed. A meeting guide with a review of the modules, the ratings, and the comments was presented to the experts. This session focused on areas of disagreement and confusions among the participants’ feedback of Round 1. All experts were given the opportunity to voice their suggestions, comments, and concerns with the curriculum. Broad recommendations from this meeting and major themes in the comments from Round 1 were used to adjust the curriculum prior to the Round 3 Reassessment round.
The Round 3 survey served as a reassessment round where the experts had the opportunity to revise their Round 1 answers based on Round 2 feedback and discussion or leave them unchanged. After the curriculum was revised, a final survey was sent to the participants. The participants were asked again to complete 5-point Likert scale questions and open response questions on the individual modules and the overall curriculum, which aligned with Round 1 questions. The surveys for the individual modules contained three 5-point Likert scale questions. The survey assessing the experts’ experience with the overall curriculum contained 10 5-point Likert scale questions capturing aspects of reach, learning, behavior, and results from the Kirkpatrick Model of Training Evaluation. A comparison of the original modules and the updated modules was included with this survey. The study team reviewed the individual ratings and comments, group median, group IQR. We considered Delphi questions to reach consensus if they had great than 75% agreement (rated as agree or strongly agree on Likert scale). The study team finalized the curriculum upon completion of the Delphi process.
A total of five CHWs participated in the focus groups over the two sessions. All participants were Black/African American women. Years of experience as a CHW varied as follows: two participants had 0–2 years of experience, one participant had 3–5 years of experience, one participant had 5–10 years of experience, and one participant had 10 + years of experience.
We assessed focus group participants’ views on four topics related to the planned training: cancer, genetics, family health history, and telehealth and health technology (Table 1). When discussing cancer, focus group participants indicated having personal experience with cancer via family and friends, concern about loss, and fear and anxiety related to the topic. Recommendations for training on the topic of cancer included lack of formal training about the topic and perceived need to incorporate training on grief counseling, how to provide family support and resources, and disease progression. When discussing genetics participants noted genes, hereditary, DNA, and family lineage as common associations. Another common theme was they indicated they had not received any formal training in this area. Recommendations for training on the topic of genetics includes incorporating conversations focused on types of cancer and correlation with genetics. For the topic of family health history, participants indicated personal experiences of getting asked questions at the doctor’s office, knowing both sides of the family’s histories, feeling disconnected and also uncomfortable sharing family health history with strangers (healthcare professionals), and having no formal training in this subject. Recommendations for training on family health history include focusing on the importance of family health history and what types of information are important to share with other family members. When discussing telehealth and health technology, participants identified feelings of connectedness and convenience, and a recognized shift in the way care is delivered. They also noted having some training in telehealth. Recommendations for training focus on ways to build rapport with clients through telehealth platforms, improving user experience, and training on how to assist patients when they experience trouble such as logging in or maneuvering through the platform.
| Topic | Common Themes | Recommendations for KEEP IT Training |
|---|---|---|
| Cancer | • Negative undertones • Loss • personal experiences of family/friends • fear anxiety • No formal CHW cancer training in subject | • Would like training on grief counseling, providing family support and resources, and disease progression |
| Genetics | • Genes, • Hereditary • Family lineage • DNA • No formal CHW training in subject | • Conversations are needed on types of cancer and correlation with genetics |
| Family Health History | • Getting asked questions at doctor’s office • Knowing both sides of family • Feeling disconnected • Feeling uncomfortable sharing family health history with strangers (healthcare professionals) • No formal CHW training in subject | • Family health history is extremely important to share hereditary information to know and share with other family members |
| Telehealth and Health Technology | • Feeling Connected • Shift to way care is provided • Convenient • Some telehealth CHW training | • Would like additional training on building rapport with clients through telehealth/health technology platforms, improving User Experience, Assisting patients with logging on and maneuvering platform. |
Our Delphi panel consisted of eight individuals with a range of experience and expertise. This panel included three CHWs, experts in health technology, a genetic counselor, advocacy organization representative, and two clinicians.
Overall Ratings of Course Materials. In Round 1 only 5 of 7 participants considered the course materials to be well-aligned with adult learning theory, to be an appropriate length, that it would help participants learned desired and knowledge and skills about HBOC and health IT, and that the content would empower CHWs to change clients' behaviors. Four of 7 individuals agreed or strongly agreed that there is clear integration of health IT and hereditary cancers and that sequencing of topics were appropriate. Three overarching aspects of the curriculum were rated well: the materials are presented in a way that is accessible to CHWs, the course will help CHWs identify individuals at high risk, and the content is relevant to CHW practice. In the third round, after updating modules based on feedback, only one component: the length of the training is appropriate for materials covered did not receive a sufficient score. The experts received all of the module slides to review at once and comments on the overall curriculum included the point that the presentation seemed long. The length of the training was addressed through the delivery of the curriculum, which the study team decided to deliver over the course of three days (4-hour session each day) rather than in 1.5 days (see Table 2).
|
Table 2. Overall Ratings of Curriculum in Rounds 1 and 3 |
||||||
|
Round 1 |
Round 3 |
|||||
|
Median |
IQR |
% Agreement |
Median |
IQR |
% Agreement |
|
|
The course materials are aligned with adult learning theory |
4 |
0.5 |
71% (5/7) |
4 |
0 |
86% (6/7) |
|
The length of the training is appropriate for materials covered |
4 |
0.5 |
71% (5/7) |
4 |
1 |
71% (5/7) |
|
The materials are presented in a way that is accessible to CHWs |
4 |
0 |
86% (6/7) |
4 |
0 |
100% (7/7) |
|
The course will help participants learn desired knowledge about HBOC |
4 |
0.5 |
71% (5/7) |
4 |
0.5 |
100% (7/7) |
|
The course will help participants learn desired skills related to health IT |
4 |
0.5 |
71% (5/7) |
4 |
0 |
86% (6/7) |
|
There is a clear integration of health IT and hereditary cancers |
4 |
2 |
57% (4/7) |
4 |
0 |
100% (7/7) |
|
Sequencing of topics is appropriate |
4 |
1 |
57% (4/7) |
4 |
0 |
100% (7/7) |
|
The course will help CHWs identify individuals at high risk for HBOC |
4 |
0 |
86% (6/7) |
4 |
0 |
100% (7/7) |
|
The course content is relevant to CHW practice |
4 |
0.5 |
100% (7/7) |
5 |
0.5 |
100% (7/7) |
|
The course content will help empower CHWs to help change client’s behaviors |
4 |
1 |
71% (5/7) |
4 |
0.5 |
86% (6/7) |
|
75% had to agree or strongly agree to be considered converged |
||||||
Module by Module Ratings and Modifications. We began the curriculum review with ten modules (see Table 3). Each module was assessed in three areas: 1) clarity of learning objectives, 2) use of adult learning theory, and 3) whether the participant will learn desired knowledge.
In Round 1, no modules received a score greater than 75% agreement when assessing for clarity of learning objectives, six modules received greater than 75% agreement that the module uses adult learning theory, and six modules received greater than 75% agreement that the participants will learn desired knowledge. At the conclusion of Round 3, participants re-ranked modules, and 8 modules received a score greater than 75% agreement when assessing for clarity of learning objectives, 7 modules received a score greater than 75% agreement when assessing for adult learning theory, and 9 modules received a score greater than 75% agreement when assessing for participants ability to learn desired knowledge.
The modules that did not receive a score greater than 75% agreement for clarity of learning objectives included Genetics 101 and Genetic Testing and Counseling. For Genetics 101 there were no comments left specifically mentioning learning objectives but there were still concerns for the overall direction of the module. For Genetic Testing and Counseling, the experts felt that the learning objectives were not specific. The modules that did not receive a score greater than 75% agreement for using adult learning theory included Genetics 101, Genetic Testing and Counseling, and Ethical Legal and Social Issues. While there were fewer comments pertaining to Genetics 101 by Round 3, some comments that remained included: a need to address differences between genetics for research and genetics for clinical care, language should be simple, and both positives and negatives should be discussed in this area. For Genetic Testing and Counseling comments stated there should be additional content in the module and it may not provide CHWs a full understanding of genetic testing and counseling. Some examples of additional content that was suggested included: expanding the focus from just BRCA and adding further explanation for the role of a genetic counselor. This was also seen in the comments for Ethical Legal and Social Issues where it was noted there should be more activities and tailored content. The modules that did not receive a score greater than 75% agreement for participants will learn desired knowledge included Genetics 101. Genetics is a complex topic that is difficult to collapse into a single module. The comments for this module, as mentioned above, indicate this topic needed refining in order for CHWs to properly learn from this module.
| Round 1 | Round 3 | |||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| The module has clear learning objectives | The module uses adult learning theory | Participants will learn desired knowledge | The module has clear learning objectives | The module uses adult learning theory | Participants will learn desired knowledge | |||||||||||||
| Module Name | M | IQR | % Agree | M | IQR | % Agree | M | IQR | % Agree | M | IQR | % Agree | M | IQR | % Agree | M | IQR | % Agree |
| Module 1: Hereditary breast and ovarian cancer | 2.5 | 2 | 25% (2/8) | 4 | 0.25 | 75% (6/8) | 4 | 0 | 88% (7/8) | 4 | 0 | 100% (8/8) | 4 | 1 | 86% (6/7) | 4 | 0 | 100% (8/8) |
| Module 2: Family history* | 3.5 | 2 | 50% (4/8) | 4 | 0 | 88% (7/8) | 4 | 1 | 100% (8/8) | 5 | 1 | 100% (8/8) | 4 | 0.5 | 86% (6/7) | 4 | 1 | 100% (8/8) |
| Module 4: Family history collection and online risk assessment content* | 4 | 1.25 | 63% (5/8) | 4 | 0 | 88% (7/8) | 4 | 0 | 100% (8/8) | |||||||||
| Module 3: Communitcating about HBOC | 4 | 1.5 | 63% (5/8) | 4 | 1 | 88% (7/8) | 4 | 0.25 | 100% (8/8) | 4 | 1 | 100% (8/8) | 4 | 1 | 86% (6/7) | 4 | 1 | 100% (8/8) |
| Module 6: Genetics 101 | 2 | 1.25 | 25% (2/8) | 3 | 1.25 | 38% (3/8) | 3 | 1.25 | 25% (2/8) | 4 | 0.5 | 71% (5/7) | 4 | 1 | 57% (4/7) | 3 | 1 | 43% (3/7) |
| Module 5: Electronic Health Records** | 2 | 2 | 38% (3/8) | 4 | 0.25 | 75% (6/8) | 3.5 | 1.25 | 50% (4/8) | 4 | 0 | 100% (8/8) | 4 | 0 | 86% (6/7) | 4 | 0 | 86% (6/7) |
| Module 9: Telehealth and telegenetic platforms** | 2 | 0.5 | 14% (1/7) | 4 | 1 | 57% (4/7) | 3 | 1 | 86% (6/7) | |||||||||
| Module 7: Genetic testing and counseling | 3 | 1.25 | 38% (3/8) | 3 | 1 | 38% (3/8) | 3.5 | 1 | 50% (4/8) | 4 | 2.5 | 57% (4/7) | 4 | 1 | 57% (4/7) | 4 | 0 | 86% (6/7) |
| Module 8: Ethical legal and social issues | 3 | 1.5 | 57% (4/7) | 3 | 2 | 25% (2/8) | 3 | 1.5 | 29% (2/7) | 4 | 0.5 | 86% (6/7) | 4 | 1 | 57% (4/7) | 4 | 0 | 86% (6/7) |
| Module 10: Navigating Resources*** | 4 | 1.5 | 57% (4/7) | 4 | 0.5 | 86% (6/7) | 4 | 0 | 86% (6/7) | 4 | 1 | 100% (8/8) | 4 | 0.5 | 86% (6/7) | 4 | 0 | 100% (8/8) |
| *Module 2 and Module 4 were combined for Round 3 | ||||||||||||||||||
| **Module 5 and Module 9 were combined for Round 3 | ||||||||||||||||||
| ***Module 10 was split into 2 modules for Round 3 (but analyzed as one topic) | ||||||||||||||||||
75% had to agree or strongly agree to be considered converged
The final modules that were to be included in the training of CHWs were: 1) Hereditary breast and ovarian cancer 2) Family history, family history collection tools 3) Communicating about hereditary breast and ovarian cancer 4) Genetics 101 5) Genetic Testing and Counseling 6) HIT (Telehealth and Telegenic Platforms/EHR/Patient Portals) 7) Ethical, Legal, and Social Issues 8) The CHWs Role in cancer care and prevention 9) Supportive Resources and 10) Locating Resources and Making Referrals. All modules were rated with the exception of the module on The CHWs Role in cancer care and prevention as this pertained specifically to CHWs and the Delphi Process experts would not need to comment on. These modules were refined based on the experts’ comments and ratings from Round 3.
Using focus groups and the Delphi method, we built consensus among an expert set of panelists to design the KEEP IT CHW Training focused on building competencies for CHWs to support identification of individuals at high risk for HBOC and genomics broadly. This resulted in a 10-module training designed to be taught in 12 hours over the course of three days.
We found that it is feasible to create a curriculum focused on fundamentals of genomics education and tailored for CHWs. CHWs have been engaged in a wide range of health promotion and health education topics; however, to date, there are limited trainings available to support competencies in genomics and specific hereditary conditions (Allen, Brownstein, Satsangi, & Escoffery, 2016; Anderson et al., 2015; Attipoe-Dorcoo et al., 2021; Brandford et al., 2019; Chen et al., 2018; Shah et al., 2020; Vadaparampil et al., 2021; Viswanathan et al., 2009). A number of initiatives and curriculums also exist to support genomic competency building among clinical staff (e.g., providers, nursing assistants), but CHWs fulfill a unique role in that they are trusted members of the community that work within community and health settings. Thus, empowering CHWs to understand genomics can help expand opportunities for genomic literacy building among community members (Allen, McBride, et al., 2016). This is especially important among communities that historically do not participate in genomic-related care and research (Kikut & O'Brien, 2018). By building capacity and equipping CHWs, who are already established, trusted individuals, to understand and participate as partners in genomics research and education, we can enable more equitable participation in genomics-informed clinical care and research. Aside from curriculum development, these efforts should be supported with additional infrastructure, such as supervisor training and support for CHWs receiving training in genomics, development of clear evaluation framework to assess impact of training CHWs on proximal and distal health outcomes, and ways to re-engage CHWs in genomic education to keep up to date with emerging topics in genomics(Allen, McBride, et al., 2016).
From a methodological perspective, our study demonstrated the utility of the Delphi process to design a curriculum. We enhanced the Delphi process through a robust, formative focus group process, which included input from CHWs to develop an initial outline for the course. Through the feedback from the initial assessment to the reassessment of the curriculum, modules were combined, added, and edited to provide necessary, detailed information in an engaging, yet succinct training. The Delphi approach has been used in a wide variety of settings and topics and we found that this was an innovative method for us to receive feedback about a complex topic from many sources. We were able to engage the learners (CHWs) and ensure that the materials were relevant to the learners while also ensuring that the content was accessible. Our approach is reproducible and could be used in future curriculum development where multi-specialty expertise is required.
Our study has several limitations to consider. The Delphi process is a strength in that in provides a systematic approach to designing the curriculum. Our panel was composed of majority-CHW members and had a wide range of scientific and practical expertise. However, we were limited in the total number of panelists (n = 8). To help offset the reduced number of panelists, we worked to increase engagement of those selected for the panel by providing incentives during each round of the Delphi and having regular communication. In addition, we opted to remove the anonymous aspect of the second round of the Delphi process (qualitative feedback). While the anonymity of the Delphi process is considered a strength, due to the small size of our panel and our focus on capturing in-depth information about the modules, we opted to provide an open forum for qualitative data collection. To help reduce concerns about individuals dominating the session, we provided ground rules and facilitated discussion during Round 2. Finally, three modules, Genetics 101, Genetic Testing and Counseling, and Ethical Legal and Social Issues, did not reach consensus across the three learning objectives assessed. These modules were altered after Round 3 to account for the new feedback as the curriculum was finalized.
The results from this study provided a comprehensive curriculum to enhance CHW’s understanding about genomics and HBOC. We demonstrated that it is feasible to develop an interactive course for CHWs and recommend these initiatives are bolstered with additional infrastructure support for CHWs working in this space. The KEEP IT CHW Training will be delivered to CHWs virtually and include a full pre- and post-course evaluation to ensure all competencies are met and assess the impact of the training on key outcomes.
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