UCLA staff conducted a Spanish language one-day training, consisting of a focus group with Mixtec promotores to explore health needs among their clients, with the dual purpose of having promotores experience focus group participation (2 hours), a focus group skill building training session (4 hours), and training in rights and protection of research participants (90 minutes).

Prior to beginning the focus group, the leader obtained verbal informed consent from participating promotores. Because almost no data exist on health related information for this group, the focus group covered a number of health topics such as physical activities and diet, access to care and health issues in the Mixtec community. The focus group was audiotaped, transcribed and translated into English.

The next two training components were delivered through an interactive slide presentation. The focus group skill building training was developed based on available materials (e.g., http://www.omni.org/docs/focusgrouptoolkit.pdf) and included: (1) what is a focus group? (2) the purpose of a focus group, (3) when to use a focus group as opposed to a survey, (4) ethical considerations when planning and conducting a focus group, (5) overview of focus group planning and scheduling, (6) how to develop a seating chart, (7) how to record a focus group discussion, and (8) debriefing and self-assessment forms for focus group leaders. Four core aspects of a focus group were discussed: introduction, rapport building, in-depth discussion, and closure. Promotores discussed the health issues and questions they wanted to explore in the focus groups they planned to conduct with community members, which were incorporated in the focus group guide. The presenter also elucidated the roles of a facilitator; how to prepare for a group facilitation; important skills of a facilitator in a discussion (e.g., eye contact, waiting); and resolving unique personalities (e.g., disruptive or shy participants).

The training in rights and protection of research participants, modeled after the social and behavioral research modules of the Collaborative Institutional Training Initiative, included history and ethical principles of research, research with human subjects, social and behavioral science regulations, determining risk in social and behavioral sciences, informed consent, privacy and confidentiality, and research with vulnerable subjects.

Promotores received copies of all slides used in the training, focus group note taking forms, a sample focus group guide and sample verbal consent documents (see Table 1). Promotores completed a brief evaluation immediately after the training in which they rated their skills to conduct a focus group on a 5-point Likert scale. After the training, each promotore received a stipend of $120 and a personalized certificate of completion. Community members who participated in a focus group received a $25 incentive.

MICOP and UCLA members of the research team reviewed the transcript of the focus group with promotores and summarized key issues that were discussed. Subsequent promotores-led focus groups with Mixtec community members were audiotaped, a Mixtec college student completed a seating chart and recorded responses and observations during the focus group on the note-taking forms, discussed the focus group conversation with the promotores that led each focus group and provided a summary in English.

All project activities were approved by the Institutional Review Boards of the University of California, Los Angeles and the Centers for Disease Control and Prevention.

Ten promotores (9 females and 1 male) participated in a focus group discussion and completed the focus group training. During the training, they demonstrated understanding of contents by responding to questions and suggested health issues they wished to explore with their fellow Mixtec community members and probes to encourage discussion. These were included in the focus group guide (see Table 2). Evaluations revealed that most (7/10) promotores agreed or strongly agreed that they had the skills to plan and lead a focus group, take notes, and probe for additional information. In the three weeks following the training, five pairs of promotores conducted five focus groups with a total of 42 Mixtec adults (16 males and 26 females). They explained that participation in the focus group discussion was voluntary, that information discussed should not be shared outside the group, obtained verbal informed consent, and followed the focus group guide.

The following health and cultural issues concerning Mixtec community members emerged in the focus group comprised of promotores: Pervasive soda consumption, perceived as a symbol of socio-economic status; limited exercise and exercising viewed as assimilation to American culture; outdoor exercise among women viewed as flirtatious and inappropriate; embarrassment/unwillingness to obtain mammograms or pap smears, believing that private body parts are to be touched by husbands only; widespread lack of knowledge regarding cancer; reluctance to seek health care due to lack of insurance; common use of herbalists or naturalists for health care; and perception of education as unimportant for children, as children should start working beginning at 13 years of age.

The five promotores-led focus groups substantiated some of the same issues. Additional themes that arose included: Reluctance to ask for governmental assistance due to fear that children will have to pay back later; they receive exercise from working in the fields; women go outside and to parks only to play with their children; most parents perceive education as important for their children and encourage them to obtain education; and belief that they are here to work, make money and support their family; everything else (e.g., exercise & health) is secondary.

At a monthly community meeting hosted by MICOP, promotores described to several hundred Mixtec attendees what they had learned and the community concerns that were identified. They were interested in conducting additional focus groups to explore some of the community concerns in more depth. The community was exposed to a first-hand account of some of their peers being involved in research. Subsequently, the research team applied for and was awarded research funding to address women’s health concerns.