Formative Evaluation of a Hepatitis C Virus Computer Assisted Instruction Tool for Communities of African Descent

Hepatitis C Virus (HCV) has become increasingly prevalent within traditionally undeserved communities. The paper describes the formative evaluation of a HCV Computer Assisted Instruction (CAI) tool. Specific aims are to describe the feasibility of a CAI tool with a high-risk population, and the use of Nigrescence Theory to develop targeted messages. Three participants, recruited at an all-male substance abuse halfway house, reviewed the CAI in a mini-focus group. A Health History/HCV Knowledge Questionnaire, The Cross Racial Identity Scale and a focus group question route were used to collect qualitative and quantitative data. The analysis plan utilized descriptive statistics, content analysis and profile analysis. Results suggested that the CAI was acceptable to this segment of the population, and Nigrescence Theory provided a context for targeting messages to differing segments of the target group. Recommendations are offered to health promotion programs targeting people of African descent. © 2005 Californian Journal of Health Promotion. All rights reserved.


Introduction
Hepatitis C virus (HCV) is highly associated with disease of the liver and represents a serious health risk for residents of the United States.The National Center for Infectious Diseases (NCID) reports that HCV is the most common chronic bloodborne viral infection in the United States (NCID, 2001).Among adults, chronic liver disease is the tenth leading cause of death, the most frequent indication for liver transplantation, and 40 to 60% of chronic liver disease is due to HCV (NCID, 2001).Although two different therapy regimens have been approved (monotherapy with Alpha Interferon, and combination therapy with Alpha Interferon and Ribavirin), treatment adherence has been meager at best (Abreu, 1999).HCV is now notably associated with HIV/AIDS, and increasingly prevalent within traditionally underserved communities (Abreu, 1999).
Efforts to disseminate HCV-related information to high-risk communities have been hampered by multiple barriers including, reading level and substance abuse related behavior (McNair, Roberts, 1997;Quirk, 2000).Moreover, recent statistics suggests that segments within communities of color have been less receptive to traditional approaches to health promotion and disease prevention than their counterparts of western European descent (Brathwaite, 1992).In the case of HCV therapy, a study by Muir, Bornstein, and Killenberg (2004) suggests that combination treatment was less successful with people of African descent in comparison to their counterparts of Western European descent.The failure of traditional approaches to halt these deteriorating health indices has led some health professionals to argue for health promotion efforts in these communities utilizing new, innovative approaches in order to attain success (McNair, Roberts, 1997).This article describes the development of a HCV-based Computer Assisted Instruction (CAI) tool, a novel approach to health promotion that is gaining increasing popularity among professionals (Thorkildsen, Allard, Reid, 1983).The specific aims of this report are to: a) outline the steps in the development of an HCV-based CAI tool, and b) describe the response of targeted individuals to the CAI tool in the context of a formative evaluation.

The Hepatitis C Information Dissemination Project (HCVIDP)
The HCVIDP represents a partnership between an urban college and a community-based substance abuse treatment facility to disseminate HCV information to communities of African descent.The aims of the project were to: a) describe the HCV-related knowledge, attitudes, and behaviors of a high risk segment among people of African descent, b) develop a HCV CAI tool to disseminate HCV information to this target population, and c) evaluate the feasibility of the CAI in the context of a formative evaluation.
The Community Diffusion Model (CDM) was used as the guide in developing a community partnership.The CDM was developed by the National Heart, Lung, and Blood Institute as a method of disseminating health related information to communities of color (NHLBI, 1987).A key element in this model is a respect for the cultural mores and community norms of the target population (Bowman, l991;Weston, Rapkin, Potts & Smith, 1998).A detailed account of the use of the CDM in developing community partnerships has been provided elsewhere (Weston & Stayton, 2004).A brief description of the use of CDM in the current project is presented in Appendix A.
Theoretical Perspectives.Two basic premises guided the development of the investigation.First, a CAI could present an innovative method to disseminate HCV information in communities of African descent.Second, the development of the CAI could be guided by an understanding of the racial identity of the viewer.Each of these premises is described below.

Computer Assisted
Instruction.An approach to health promotion that is gaining increasing popularity among professionals is the CAI (Levin, 1983;Thorkildsen, Allard, & Reid, 1983;Schinke, Gordon, & Weston, 1990).The use of multimedia computer-based learning models offers a method to overcome many traditional barriers to the delivery of effective health promotion messages, such as reading level, cultural mores, and community norms (Freeman, 1990;Orlandi, 1989;Quirk 2000;Weinrich, Reynolds, Tingen, & Starr, 2000).However, even such a novel approach must be guided by an awareness of the multiple determinants existing in communities of African descent (Cross, 1991;Weston, Rapkin, Potts & Smith, 1998).One vital determinant, racial identity is described below.
Nigrescence Theory.A developmental model of racial identity in people of African descent, Nigresence Theory was developed by William Cross and his colleagues (Cross 1991, Cross, Parham, & Helms (1991).For an excellent review of Nigresence Theory, the reader is referred to the work of Cross, Parham, & Helms (1991).The cornerstone of Nigresence Theory is the four-stage process through which individuals proceed in developing high levels of awareness.These stages can be found in Table 1.
Two additional elements of Nigresence Theory should be mentioned.First, Cross (1991), suggests that the impact of racial identity is most evident when the target issue is clearly related to race.In the current study, this factor was accounted for by focusing the CAI content on the health disparity of HCV on communities of African descent.
Second, Helms (1990) suggests that the stages of Nigrescence should be viewed as ego states rather than as discreet and separate entities.Thus, some elements of each of these stages are present in all persons of African descent at any given time.This perspective has a critical impact on the interpretation of the Cross Racial Identity Scale (CRIS) for the current study, as will be evidenced in later sections.Incentives.The participating agency received a $600 stipend for participants to decide on a facility purchase.Focus group participants were given two $5.50 gift coupons redeemable at a local fast food restaurant.
Instrumentation.Three instruments were used in the investigation, A Health History/HCV Knowledge Questionnaire, the CRIS and a Focus Group Question Route.Each of these forms is described below.

Health
History/ HCV Knowledge Questionnaire.Each participant completed a 99 item questionnaire which focused on six areas: a) sociodemographic characteristics, b) health history, c) HCV knowledge, substance abuse history, and d) high risk sexual behavior, and e) readiness to change high risk behavior for HCV infection.The survey included modified items from the Michigan Alcoholism Screening Test, and the University of Rhode Island Change Assessment Scale.

Cross Racial Identity Scale (CRIS).
A modified version of the CRIS was used to assess the racial identity stage of each participant.The CRIS is a 63-item scale that measures three of the identity stages predicted by Nigresence Theory, Pre-Encounter, Immersion-Emersion, and Internalization.The CRIS is comprised of 23 items that provide basic sociodemographic information, and 40 items that include six subscales representing racial identity attitudes.Subscales cannot be summed to produce a global CRIS, hence profiles must be examined.
Worrell and his colleagues report fairly high Cronbach's alpha reliability estimate for the subscales, ranging from .78 to .89.The authors provide results of discriminant validity analyses that demonstrate low intercorrelations between CRIS subscales and scores on, "measures of global self-esteem, personality, and social desirability" (Worrell, Vandiver, & Cross, 2000, p11).CRIS scores were calculated by totaling the items across each subscale.Scores can range from 5-45 with higher scores reflecting stronger scale agreement.
Focus Group Questioning Route.Ten focus group questions were developed using the format suggested by Kruger, (1988).Targeted areas included: scope of HCV information, source of HCV information, influential models regarding HCV treatment decisions, factors promoting persuasive messages regarding HCV, barriers to HCV treatment, feasibility of HCVbased CAI mode, and impact of CAI on people of African descent.Content analysis was used to analyze the focus group data, following the recommendations of Patton (1987) by creating case records, and reviewing for themes, patterns and categories.Cases were then compared to each other to identify areas of similarities as well as areas of divergence.

Results
Sociodemographic characteristics of the four participants who meet all criteria are presented in Appendix B. The mean age of the participants was 47.5 years and all were born in the United States.Additionally, results indicated that one participant possessed a very high level of knowledge regarding the risk, symptoms, and treatment of HCV; one possessed a high level of HCV knowledge; and two had a low level of HCV knowledge.Two participants reported HCV positive status, one did not know his status, and one reported negative status.Two participants indicated a history of serious alcohol use, and all indicated a history of serious illicit substance use.All reported the use of marijuana, cocaine/ crack, and heron, while two reported use of methadone, and methamphetamine.Finally the sexual history of the participants indicated multiple high risk behaviors, i.e., multiple partners and unprotected sex.
Racial Identity Levels.Racial Identity score are presented for the three individuals who agreed to participate in the mini-focus group.CRIS score data were assessed in a manner consistent with the suggestion of Cross, i.e., profile analysis of the six subscale scores (Worrell, Vandiver, & Cross, 2000).Results of the analysis can be found in Figure 1.Subscale scores.An evaluation of subscale scores revealed distinct differences among the participants.As shown in Figure 1, Participants 1's Pre-Encounter subscale profile presented very high Assimilation scores (30), the highest of all participants; a very low Miseducation score (5); and low Self-Hatred score (8).His Immersion-Emersion subscale score, Anti-White, was very low (5).Finally, a review of the Internalization subscale scores revealed that Afrocentric was also very low (5), the lowest of all participants; and Multiculturalists Inclusive was high ( 28), the highest of all participants (see Figure 1).Based upon this profile, the participant was place in Stage 1, the Preencounter Stage.
Alternatively, Participant 2's Pre-encounter subscale profile presented a high Assimilation score (24); low Miseducation score (10); and while his Self-Hatred score (11) was low, it was the highest of all participants.His Immersion-Emersion sub scale score, Anti-White, was very low (5).Finally, Internalization subscale scores, Afrocentric was low (11); and Multiculturalist Inclusive was high (23) (see Figure 1).Based upon this profile, the participant was placed in Stage 1, the Pre-encounter Phase.
In contrast, Participant 3's Pre-Encounter subscale profile presented a moderate Assimilation score (17), the lowest of all participants; a low Miseducation score (10) and a very low self-hatred score (2), the lowest of all participants.His Immersion-Emersion sub scale score, Anti-White, was very low (5).Regarding his Internalization Subscales, Afrocentric was moderate ( 16), the highest of all participants; and Multiculturalist Inclusive was high (25) (see Figure 1).Based upon this profile Participant 3 was placed in the Internalization Stage.
Focus Group Responses.As indicated above, three individuals agreed to participate in the mini-focus group.The overall response of the participants suggested that the CAI format required modification.However, suggestions for the form of these modifications often differed sharply as a function of level of racial identity.Several themes emerged from the focus group including: a) role of medical personnel as providers of information, b) lack of HCV knowledge in community; c) HCV myths and misconceptions, d) global vs. targeted population messages, e) attention grabbing elements of effective messages, f) personal experience vs. vicarious experience of messenger, and g) strategies to improve the CAI.A review of each theme is presented below.

Role of Medical Professionals in HCV
Dissemination.Each participant identified the medical team of their facility (psychiatrist, physician, nurse) as his main source for health related information.Each mentioned several health issues that directly affected them, most often discussing Hepatitis C and hypertension.They expressed satisfaction with the way that medical information was communicated within the facility, such as one-to-one and bulletin board notices.One participant mentioned word of mouth as a secondary channel of information, such as when residents diagnosed with specific maladies shared their experiences and knowledge with newly diagnosed residents in the facility.However, two of the participants (2 and 3) also expressed negative attitudes towards medical professionals, stating that a lack of concern for patients was evident in communities of African descent.Illustrative comments from these participants follow: • Dr. C from X Hospital.He helped me a lot and gave me information.• In here, (substance abuse facility) Nurse X keeps me informed • In our community, with public assistance places, it seems like doctors don't really care much.They don't give the information to patients there • They are Medicare Mills Lack of HCV Knowledge in Community.The participants suggested that HCV information is underexposed in communities of African descent.Consequently, the lack of HCV knowledge has led to both inattention and fear of the health consequences of this disease.Finally, available HCV information comes from very specific sources, such as the prison system.Illustrative comments follow: HCV Myths and Misconceptions.Participants agreed that myths and misconceptions regarding the etiology and consequences of HCV infection were common due to the underexposure of HCV related information.They further suggested that in order to counter these myths and misconceptions, information must be available in visual form.The visual channel was deemed a more acceptable medium to the community.One Pre-Encounter participant (1) suggested that his style of seeking information was based upon his perception of need, i.e., issues were of interest to him only as they directly affected him.This response is suggestive of the Health Belief model's view of vulnerability as a key factor in the adoption of health promoting behavior (Janz, Becker, 1984).Illustrative comments follow: • People think like in myths, which is part of lack of information.Then I learned about it.I learn about things only if it's related to me Global Versus Targeted Population Messages.A specific question regarding the impact of HCV on people of African descent led to a divergence of opinions.The Internalization Stage participant (3) focused on the high-risk status of people of African descent.This participant objected to a stereotypical view of people of African descent with HCV as intravenous drug users, stating that a person could become infected with HCV through multiple routes.Alternatively, the Pre-Encounter Stage participants took exception to viewing the problem from the perspective of any one group.Participant 1 also objected to stereotypes, but broadened his concerns to include all group, and ages.Illustrative comments follow: • And there are stereotypes, especially of drug users who get it, or African Americans.The information is not broad enough.• No pigeonhole type should be used in advertisements in the media or in the paper.
They should use all groups, the Chinese, Spanish people, all times and have it filtered back way to the community with no age barriers.

Stimulus Value of Effective Message.
Effective messages were described as having eye-catching qualities that demanded the attention of the observer.Factors affecting message effectiveness included forcefulness of delivery (fear message), and scope.There was disagreement regarding the focus of the message.The Internalization stage participant (3) and one of the Pre-Encounter participants (2) felt that appeals to protect the family would be most effective in message delivery.However, the remaining Pre-Encounter Stage participant (1) opted for a more individualized, universal approach that went beyond a specific racial group.After some discussion, it appeared that the other Pre-Encounter stage participant (2) adopted the latter approach.Illustrative comments follow: • I'll give you an example, like that commercial, this is your brain, this is your brain on drugs, and it's frying in the pan.That's direct, it might be rude, but it has to be.That mentally woke me up.You have to be forceful.Strategies to Improve the CAI.All participants stated that the CAI could be a useful method of disseminating information regarding HCV.A Pre-Encounter stage participant (2) suggested that CAIs could be placed in physician's offices.The discussion soon shifted to improvements in the prototype.All participants indicated a need to make the presentation more appealing.This included the use of music as a means of initially capturing and maintaining attention.
The messenger, that is the face and the voice of the CAI, was the next area of discussion.The Internalization participant (3) stated that the speaker in the prototype was not interesting, and that a more dynamic speaker was necessary.Suggestions from a Pre-Encounter stage participant (2) and the Internalization stage participants (3) immediately focused on celebrities and popular entertainers.The remaining Pre-Encounter participant (1) suggested that the level of respect for the speaker was more important than their celebrity status.
He identified political figures as potential speakers.
The focus shifted to other aspects of an effective messenger.The Internalization Stage and one of the Pre-encounter stage participants (2 and 3) stated unequivocally that the messenger should have a positive HCV diagnosis.The Pre-Encounter participant (1) rejected this criterion, again pointing to the need for the speaker to be respected by a wide range of viewers.All participants responded positively to the idea of incorporating more than one messenger into the CAI.Recommendations included: multiple races, multiple ages, professional, HCV positive, celebrity, and individuals who are widely respected.
A sharp divergence of opinions arose regarding the glossary feature of the CAI.Technical terms had been hot wired in the text, and placed into a glossary.A viewer had two options when confronted with a hot word: he could access the glossary in order to view more information on the term, or she could skip the hot word and continue through the remaining slides.The Internalization Stage participant (3) agreed with this structure, stating that it allowed the viewer the option to obtain more information or to skip sections that might be difficult to understand.A Pre-Encounter stage participant (2) appeared to accept this approach, but the other Pre-Encounter stage participant (1) vehemently objected to this statement, saying that the implication was that people of African descent were too stupid to read technical terms.Illustrative comments follow: • Yeah, like in the doctor's office on those TVs in the waiting room, where they advertise stuff • What about those who don't know and may not want to bother to click it to learn about it?"• Keep it simple • You're saying people in my community are stupid, that people in my community are too stupid to use that.Some people might want it simple, and some might be smart and not use it, and for some people it might be too simple • Yeah, mosaics are best.Don't pigeon hole." • Yeah, different ethnic groups

Discussion
Two findings emerged from the investigation.First, the results of the mini-focus group suggested that a CAI could be a feasible approach to disseminating health promotion information to people of Africa descent.Second, the response to the CAI demonstrated the heterogeneity that existed within the minifocus group and Nigrescence Theory provided a framework for understanding these divergent reactions.However, areas of divergence between the Pre-Encounter stage participants, (1 and 2), suggest that the effect of racial identity is a complex interaction of attitudes and values that cannot be simply categorized.Each of these findings is discussed below.

Feasibility of CAI to Reach Divergent Segments Among People of African Descent
Consistent with the Tenets of Nigrescence Theory.The CRIS responses suggest that health promotion efforts targeting a homogeneous community of African descent would miss important segments of the population.Indeed, the basic premise of Nigresence Theory is the need to understand differences that exist within communities of African descent.These differences are depicted visually in Figure 1.While the differences between the Pre-Encounter participants are extremely subtle, there is a perceptible increase in the Internalization stage scale scores.A review of the subscale analysis, suggests that the identified difference is a function of the Internalization -Afrocentric subscale, in which Participant 1 is lower.
Differences between Pre-Encounter (1) and Internalization (3) are the most noticeable.The scale analysis, demonstrate differences between Pre-Encounter scores, where Participant 1 is higher, and Internalization scores, where Participant l is lower.These differences are made more striking by a review of the subscale profiles.Differences of two scale units are seen between Pre-Encounter Assimilation scores, with Participant 1 noticeably higher; and Internalization-Afrocentric scores, with Participant 1 noticeably lower.Differences between Pre-Encounter (2) and Internalization (3) are again subtle, with no subscale difference of more than one scale unit.How such subtle differences may influence attitudes and preferences will be discussed next.

Divergent Reactions to a HCV CAI within the
Context of Nigrescence Theory.The participants endorsed the CAI as a strategy for information dissemination.However, there were several areas of clearly divergent reactions to the CAI, most notably between Participant 1 (Pre-Encounter) and Participant 3 (Internalization).The first of these oppositional reactions revolved around the use of global message versus a targeted message.The Pre-Encounter stage (1) participant felt strongly that it would be a mistake to focus on any one group.Instead, he opted for an inclusive message that would feature members of various racial groups, ages, etc.This response is consistent with his Pre-Encounter scale scores of Assimilation (30), the highest score of all participants; his Internalization Multiculturalist Inclusive (28), the highest of all participants, and Afrocentric (5), the lowest of all participants.Thus the preference for an inclusive, multi-targeted message is consistent with Nigrescence Theory expectations.
Likewise, the response of Participant 3 (Internalization Stage) is predictable from a Nigrescence context.The preference for a message targeting people from "his community" is consistent with his Internalization Afrocentric subscale score ( 16), the highest of all participants.The Internalization person, according to Nigrescence theory, views the world from an Afrocentric perspective.This perspective would make participant 3 more responsive to a messenger who "looked like him".
A second area of disagreement occurred around the importance of personal experience with HCV for the credibility of the messenger.The Internalization Stage participant (3) insisted that a positive HCV diagnosis was critical for credibility.Again, this response is consistent with this participant's score on the Afrocentric subscale.Likewise, one of the Pre-Encounter participants (1) vehemently disagreed, stating it was the level of respect that the individual elicited far outweighed HCV status.This response was also consistent with the lower Afrocentric subscale score and higher Multiculturalist Inclusive subscale score.In this context, it is interesting to note that the other Pre-Encounter participant (2) agreed with Participant 3, Internalization stage, rather than the other Pre-Encounter stage participant (1).A review of his subscale scores revealed midway scores in Pre-Encounter Assimilation (24), and Internalization Afrocentric (11).
It is also interesting to note that all three of the participants responded favorably to the presence of multiple messengers from various racial groups.This is consistent with their scores on the Internalization Multiculturalist Inclusive subscale, Participant 1(28), Participant 2 (23) and Participant 3 (25).More research is needed to identify transitional points and specific issues.

Summary and Conclusions
The results of this investigation must be reviewed in the context of its limitation: the small sample size, while appropriate for a formative investigation, suggests the need for additional focus group to corroborate these findings.
At this time, based upon the current results, the following recommendation are made to individuals and organizations developing health related interventions targeting people of African descent: Nevertheless the CDM provided a sound roadmap for the development of a partnership between a college and a community-based substance abuse program.The shared goal of disseminating information regarding Hepatitis C virus to high risk population led to the development of a HCV CAI tool targeting people of African descent.
1. Program planners are urged to acknowledge the diversity that exists within communities of African descent, and to develop their interventions accordingly.The scope of diversity is increasing as a result of the influx of diverse ethnic groups into the United States (Caribbean, African, and British).Messages must be developed that incorporate the community norms and values, which will make partnership with community-based organization all the more important to the success of the program.As described above, the CDM presents an effective strategy for the development of partnerships with the community.
Additionally, the use of Nigrescence Theory to understand differences within men of African descent was equally instructive.Mini-focus group results suggested that Nigrescence Theory provided a context for predicting variance in the response of people of African descent.However, the moderating effect of racial identity is complex and requires an understanding of sub levels (Assimilation, Miseducation, Self-Hatred, Afrocentric, and Multiculturalist Inclusive) as well as major levels (Pre-Encounter, Immersion-Emerson, Internalization).The task appears to be, to paraphrase of Paul's (1967) observation regarding the efficacy of psychotherapy: Which aspect of racial identity level is affected by which messenger targeting what health concerns through which method.
2. Researchers are urged to incorporate diversity into their intervention models.
Nigrescence Theory provides a blueprint to maximize participants' response to the intervention.However, additional research into the impact of racial identity sublevels is required to match messenger to the multiple observers who may view the CAI.

Future Directions and Recommendations
CAI prototypes are currently being developed focusing on other diseases (prostate cancer) and other potential community partners (Black Church).The results of this formative investigation suggest the need for additional focus groups with additional segments of the target population to identify similarities and differences in their responses to CAI.Of specific interest will be the response to the idea of multiple presenters representing various racial, ethnic, age, and occupations.
3. Both researchers and program developers are urged to seek partners in the target community.A successful partnership will require both sides of the partnership to surrender a measure of control in the development process, but the loss of autonomy is more than compensated for by the ability of the product to reach the target audience.
Appendix B Figure 1 Cross Racial Identity Scale Scores of Focus Group Participants

Table 1
Stages of Nigrescence Theory Participant confidentiality was protected by unique identification numbers known only by the participants (month of birth, second initial of last name, driver's license [Y/N], number of brothers).

•
But you have to get attention.Like use rap music, or fashion, like put a message on jeans, or in comic books, or older 60's music for older people.It [message] could be crass, or straight to the point, or raw, use anyway to get people to think twice about it.• It's human nature to take care of family.Like a message to do something to help yourself so that you can help your family.I love them first -them now, me after.• This is a diverse world.If it is for me, and so universal, even though it's hitting my culture hard, it [message] should be geared to everyone in general.When geared to human race, it's better.