WORKING WITH

REL IG IOUS

CONGREGATIONS:

A GUIDE FOR HEALTH

PROFESS IONALS

N A T I O N A L I N S T I T U T E S O F H E A L T HN A T I O N A L H E A R T , L U N G , A N D B L O O D I N S T I T U T E

O f f i c e o f P r e v e n t i o n , E d u c a t i o n , a n d C o n t r o l

WO R K I N G WI T H

RE L I G I O U S

CO N G R E G AT I O N S :

A GU I D E F O R

HE A LT H

PR O F E S S I O N A L S

NIH PU B L I C AT I O N

NO. 97-4058

JU LY 1997

NAT I O N A L IN S T I T U T E S

O F HE A LT H

NAT I O N A L HE A RT, LU N G,

A N D BLO O D IN S T I T U T E

iii

Target Activity Group on Church-BasedHealth Interventions

Janice Boatner-Burchell, R.N., B.S.N.Nurse ConsultantLouisiana Department of Healthand Hospitals

325 Loyola Avenue, Room 605New Orleans, LA 70112

Joan Clayton-Davis, M.A.Program DirectorNashville Prevention Marketing Initiative1219 Ninth Avenue, NorthNashville, TN 37208

Shauna Hicks, M.H.S.Marketing and Health Promotion ConsultantOffice of Minority HealthSouth Carolina Department of Healthand Environmental Control

2600 Bull StreetColumbia, SC 29201

Jody Stones, M.Ed.Health Education CoordinatorDivision of Health Promotion/Chronic

Disease PreventionVirginia Department of Health1500 East Main Street, Room 242Richmond, VA 23218

Contribution and Review From the Staff ofStroke Belt Projects

Robert HafnerDirector, Hypertension BranchAlabama Department of Public Health434 Monroe StreetMontgomery, AL 36130-1701

Shirley Kirkconnell, M.P.H.Adult ServicesLouisiana Department of Health & HospitalsP.O. Box 60630325 Loyola AvenueNew Orleans, LA 70160

Cornelia M. Pearson, R.N., M.N.Director, Tobacco Prevention and ControlTennessee Department of HealthHealth Promotion/Disease Control426 Fifth Avenue, NorthNashville, TN 37247-5210

Frances Wheeler, Ph.D.Director, Center for Health PromotionSouth Carolina Department of Healthand Environmental Control

Robert Mills ComplexBox 101106 Columbia, SC 29211

ACKNOWLEDGMENTS

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External Reviewers

The Reverend Ces’ Cook, D.Min.CEO and PresidentFaith-Based Centers of ExcellenceNashville, TN

B. Waine Kong, Ph.D., J.D.Executive DirectorAssociation of Black CardiologistsAtlanta, GA

Rabbi Lynne LandsbergDirector of the RegionMid Atlantic CouncilUnion of American Hebrew CongregationsWashington, DC

The Reverend Eric C. PearsonPastorSt. Andrew Lutheran ChurchFranklin, TN

National Heart, Lung, and Blood Institute

Stroke Belt Team

Glen Bennett, M.P.H.Team Leader

Caleb Smith, Ph.D.Special Expert

Mary Stewart, M.H.S.Student Intern

Sandy KamisarChief, Publication Management Section

Molly WolfeR.O.W. Sciences, Inc.

Iris Harley, M.P.H.R.O.W. Sciences, Inc.

Amy Nelson, M.A.R.O.W. Sciences, Inc.

We would also like to thank Barbara Shine,Donna Cay Tharpe, and Donna Selig fromR.O.W. Sciences, Inc., for their contributions to this publication.

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INTRODUCTION . . . . . . . . . . . . . . . . . . . . . .1

BACKGROUND . . . . . . . . . . . . . . . . . . . . . . .3

History of NHLBI Involvement in Church- Based Programs . . . . . . . . . . . . . . . . . . . . . .3

The NHLBI Stroke Belt Initiative . . . . . . . . .4

HEALTH AGENCY PREPARATION . . . . . . . .6

RECRUITING CONGREGATIONS . . . . . . . . . .8

Basic Strategies . . . . . . . . . . . . . . . . . . . . . . .9

MAKING INITIAL CONTACTS . . . . . . . . . .10

Contacting the Clergy . . . . . . . . . . . . . . . . .10

Meeting With Clergy . . . . . . . . . . . . . . . . . .11

Agreement to Participate . . . . . . . . . . . . . . .12

ORGANIZING FOR ACTION—REMINDERSFOR HEALTH PROFESSIONALS . . . . . . . . . .13

Selecting a Coordinator . . . . . . . . . . . . . . . .13

Training the Coordinator . . . . . . . . . . . . . . .14

Selecting the Team . . . . . . . . . . . . . . . . . . . .15

Orienting and Training the Team . . . . . . . . .15

CONDUCTING THE INITIAL ACTIVITY . . . .16

Surveying the Congregation . . . . . . . . . . . . .16

Developing a Preliminary Plan and Getting Started . . . . . . . . . . . . . . . . . . . . .17

FOLLOWING UP THEINITIAL ACITIVITY . . . . . . . . . . . . . . . . . .20

Team Meeting After Initial Activity . . . . . . .20

Soliciting Feedback on the Activity . . . . . . . .21

Planning the Next Activity . . . . . . . . . . . . . .21

Conducting the Activity . . . . . . . . . . . . . . .21

MAINTAINING THE PROGRAM . . . . . . . . .22

ASSESSING AND EVALUATINGTHE PROGRAM . . . . . . . . . . . . . . . . . . . .24

APPENDICES . . . . . . . . . . . . . . . . . . . . . . .26Appendix A—Checklist for the

Health Professional Working With Congregations . . . . . . . . . . . . . . . . .27

Appendix B—State Profiles: Louisiana, South Carolina, Tennessee, and Virginia . . .28

Appendix C—Sample Congregation Plan . . .35

Appendix D—Sample Congregation Survey . . . . . . . . . . .36

Appendix E—NHLBI Educational Materials . . . . . . . . . .37

TABLE OF CONTENTS

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I

Working With Religious Congregations: A Guidefor Health Professionals builds on lessons learnedfrom church-based demonstration programs sup-ported by the National Heart, Lung, and BloodInstitute (NHLBI). While the recommendationsare based on intervention activities in churches,reviews and comments from members of othercongregations suggest that the strategies are use-ful in a variety of religious settings.

Today, a variety of health agencies such as Stateand local health departments, voluntary healthorganizations, managed care organizations, com-munity hospitals, health coalitions, and othersinclude congregations among the target audi-ences for their programs. This guide is designedto help professionals in health agencies reach outto religious congregations and work with them

to implement programs to reduce the risk of cardiovascular disease (CVD), especially highblood pressure and stroke. It does not instructthe health professional about the basics of devel-oping a CVD risk reduction program (e.g., highblood pressure screening, smoking cessation).Instead, it provides information about how to:

■ contact and recruit congregation members,

■ train volunteer teams within congregations,

■ implement effective CVD prevention programs,

■ sustain momentum for continued activity, and

■ monitor and evaluate congregation-based programs.

INTRODUCTION

■ Working With Religious Congregations: A Guide for Health Professionals was prepared by theNational Heart, Lung, and Blood Institute as part of its Stroke Belt Initiative.

■ The term “congregation,” for the purposes of this book, means any house of worship—church,synagogue, temple, mosque, chapel, or other place where members of religious groups gather.

■ “Clergy” includes pastors, ministers, priests, rabbis, and other leaders of religious congregations.

■ “Health professional” refers to professionals in health agencies who want to implement cardiovas-cular risk reduction programs in congregations.

■ “Health agencies” refer to State and local health departments, voluntary health organizations,managed care organizations, hospitals, health coalitions, and others.

■ This guide offers health professionals the benefits of lessons learned from cardiovascular riskreduction activities in churches.

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Health professionals can use the guide to incor-porate congregation-based programs into existingor new efforts within their agencies to reduceCVD risk in the community. If a CVD planwith a defined target audience is already in place,the implementation of selected program compo-nents in religious congregations should fit in easily with current goals and objectives.

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HISTORY OF NHLBI INVOLVEMENT INCHURCH-BASED PROGRAMS

The NHLBI has a long history of promotingCVD intervention demonstration programs inchurches. From the 1970’s through the early1980’s, the NHLBI supported church-based pro-grams in Georgia, Maryland, North Carolina,Illinois, and Tennessee. Those early programsfocused on high blood pressure education, detec-tion, and control, primarily in black churches. In1987 the NHLBI produced a guide for workingwith churches, Churches as an Avenue to HighBlood Pressure Control, which provided informa-tion on the development and implementation ofhigh blood pressure programs. Representativesfrom many of the early church-based programscontributed substantially to the 1987 guide.

In 1990 the NHLBI funded a project at JohnsHopkins University to study the effectiveness of church-based interventions for CVD preven-tion and control. Initially the project focusedon smoking cessation but later expanded toinclude nutrition and weight reduction. Theinterventions were effective, and the churchesdeveloped a strong ownership of the program.The members of Clergy United for theRevitalization of East Baltimore (CURE) wanted to disseminate what they had learned to other churches, so they joined forces withthe American Lung Association to implementthe project in churches in 15 targeted commu-nities. This activity was supported by theNHLBI in 1992.

BACKGROUND

■ The NHLBI has a history of promoting church-based programs for preventing cardiovascular disease.

■ The earliest church-based programs were in Georgia, Maryland, North Carolina, Illinois, and Tennessee.

■ Lessons learned from early church-based projects and the Stroke Belt can be valuable to planners of new programs:

• There is no single best approach.• Support from the clergy is essential.• The coordinator should be a person of vitality, vision, and

commitment and have the trust and confidence of the clergy.• Project teams in churches can be very creative.• Church-based programs take time, but patience is rewarded.

■ Reaching at-risk audiences through targeting congregations is a strategy that works.

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THE NHLBI STROKE BELT INITIATIVE

In 1990 the NHLBI funded 11 pilot projectsthrough State health departments (SHDs) toreduce the risk of stroke in the southeasternUnited States in the region called the “StrokeBelt.” At that time, the age-adjusted stroke mor-tality rates in the region were more than 10 per-cent higher than the U.S. average. These 1-yearpilot projects demonstrated the capacity of

SHDs to design and implement approaches toreduce risk factors in the community. In 1993the NHLBI provided extended funding to theSHDs to reduce the overall risk of stroke in theStroke Belt. Four States (Louisiana, SouthCarolina, Tennessee, and Virginia) targeted blackchurches to implement programs. The lessonslearned from the Johns Hopkins Universitystudy and the earlier NHLBI-supported church-based projects played a major role in the devel-opment of strategies for the more recent projects.Each project succeeded in recruiting churches,training teams within the congregations to carryout program activities, moving the teams to

action, and sustaining their actions over time.Moreover, the church teams were creative indevising ways to communicate health messagesto their congregations.

The average time needed to complete each taskwas calculated based on the experience of theprojects in Louisiana and Tennessee. It tookabout 2 months from the initial contact with thechurch to the point when the church leadercommitted the church to participate. It took 4months from this commitment to the appoint-ment and training of the church team. The firstprogram event took place about 3 months afterthe church team’s training. Thus, it took about 9months from the initial contact with the churchto the first program event. This experience sends aclear message to health professionals: It takes timeto implement health programs in churches. Somechurches had programs up and running in severalweeks; others took longer to recruit and set up.

Each Stroke Belt project used a differentapproach to recruit churches. The SHD inVirginia collaborated with the Baptist GeneralConvention (BGC). The staff of the BGC didthe actual recruitment among its affiliatedchurches. In Louisiana, the project coordinatorstarted the program in her church. She then con-vinced the minister of her church to call theministers of other churches to promote the pro-gram and to encourage them to implement asimilar program.

The project in Tennessee initially approachedfive churches. After setting up their programs,clergy from the participating churches told otherclergy about the project, and the project staff fol-lowed up with those who showed the greatestinterest. In South Carolina, the project staffattended the main services of targeted churches.During the service, when visitors were recog-nized, they introduced themselves and their pur-pose; later they approached the clergy to ask thechurch to participate in their project.

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The major lessons learned about church-basedprograms are the following:

■ There is no best way for recruiting churchesand sustaining their participation. Eachchurch-based project used different approaches.

■ Support from the clergy is essential. The clergy lend authority to the program, help promote and encourage participation, and can be advocates for other congregationsinterested in developing programs.

■ The appointment of the right person as coordi-nator of the health care ministry or team iscritical to keeping members motivated andcommitted to the screenings and other activi-ties in the churches. Strong coordinators main-tain a consistent flow of program activities.

■ Project teams, working with the coordinator,can be creative in devising ways to communi-cate health messages to their congregations.Some ideas include conducting plays duringservices; healthful cooking demonstrations;“Gospelsize” (exercising to church music); andletters from young people urging parents,guardians, and others who are significant inchildren’s lives to quit smoking. The healthprofessional should encourage this creativity.

■ Organizing and conducting health programsin churches take time, but patience is reward-ed. In churches, a few volunteers do most ofthe work. Health professionals should knowthat this is normal and not give up.

■ It is important to respect the church’s indepen-dence and attitudes toward health issues. Forinstance, churches may already have healthprograms in place and prefer not to adopt anew plan for designing health activities.

Working through congregations, as demon-strated by the churches involved in the StrokeBelt Initiative projects, is an effective way toconvey CVD and stroke prevention messagesand improve the community’s health. A fewreasons are:

■ A congregation offers, through its member-ship, a clearly defined and accessible audience.

■ Congregations influence their members’ values and behaviors. Many address healthand healing in their teachings.

■ The clergy are motivated to help improve thewell-being of congregation members, andmembers can be motivated through concernfor each other.

■ Congregations are an acceptable avenue forpromoting health programs. Black churcheshave been especially receptive to such efforts.

■ A health promotion program supported bythe clergy will gain credibility among congre-gation members.

■ Congregations offer access to populations thatare of high priority for CVD preventionefforts—families, minorities, older people,and women.

■ Congregations have members who volunteerto work on important projects.

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Preparation within the health agency for work-ing with congregations on CVD risk reductionprograms involves both staff preparedness andthe identification of resources available to theproject.

Health professionals should consider the following questions:

■ Do they have available time and a flexibleschedule? Working with staff members andvolunteers in congregations often requiressome evening or weekend hours.

■ Are they comfortable working in the religioussetting and responding to questions aboutpersonal beliefs?

HEALTH AGENCY PREPARATION

■ The health agency must plan to have an adequate number of staff members and otherresources for working with congregations to reduce cardiovascular disease risks.

■ Health professionals should be knowledgeable about area churches, temples, and otherhouses of worship and understand

• the link between faith and health,

• the hierarchy of the congregation,

• the authority of the clergy, and

• the culture and customs of the congregation.

■ The health professional should work with the congregation to determine what resources arenecessary to implement programs; including funding, educational materials, and supportfrom potential contributors in the community.

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■ Are they knowledgeable about CVD risk factors and intervention programs for at-riskpopulations and a credible presenter of healthinformation?

■ Do they have adequate knowledge about thecongregation? Such knowledge would include

• basic religious beliefs that relate to healthissues (Does the congregation teach personalresponsibility for health? Acceptance ofhealth problems?)

• the organizational hierarchy (For example, isthere a single member of the clergy or arethere associate pastors? Do decisions requireregional or diocesan approval?)

• authority of the clergy in the congregation(Is the pastor or rabbi the uppermostauthority, or is there a board or committeeto which they answer? Does the congrega-tion take instruction and advice from theclergy?)

• specific culture and customs of individualcongregations (Are members of the congre-gation conservative or casual in their dressand demeanor? How do they address theclergy and other members? What is the pre-vailing etiquette before, during, and afterservices?).

■ Are they sensitive to their position as out-siders, and do they recognize the requirementsfor interaction with congregation members?

Preparation also requires estimation of the needfor physical resources and how those needs willbe met:

■ What funds are available for congregation-based programs? What kind of monetary sup-port will the health agency ask the congrega-tion to provide?

■ Will the health agency provide appropriateeducational materials? Are there other avail-able sources (for example, voluntary organiza-tions) of booklets and other materials?

■ What resources are available inside and out-side the agency for data processing and evalu-ation?

Once the agency has contacted a selected congre-gation to start a CVD prevention program,members of the congregation and active volun-teers may be able to suggest additional sourcesfor funds, materials, and services to support theprogram.

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This section describes the information thatshould be gathered before contacting a congrega-tion and strategies that the Stroke Belt Initiativeprojects used to recruit churches. Much of thisinformation about a congregation can beobtained from directories, religious organiza-tions, and census data. Calling congregations tolearn of their involvement with health agenciesmay also be helpful.

Initial information about the number, size, anddenominations of congregations in the commu-nity and the racial/ethnic groups they serve willhelp the health professional focus on the targetpopulation.

The clergy decide whether their congregationswill participate in health programs; therefore, itis important that the health professional learnas much as possible about the congregationleaders. Gather information on:

■ the number of clergy at each congregation;

■ the special interests of the clergy;

■ their education and training;

■ their involvement with health agencies (Hasthe congregation worked with local organiza-tions to conduct activities? If so, any estab-lished ties may be helpful for the initiation ofhealth activities.); and

■ the level of their interest in CVD preventionprograms.

Religious organizations and interdenomina-tional alliances at the local, State, and nationallevels can provide important information aboutcongregations and clergy in the target area.Interdenominational alliances are groups ofclergy from diverse denominations within thecommunity; they work together on religious,social, civic, political, and health concerns.Some offer theological courses or training.

Many congregations have worked with healthagencies and other community organizations to conduct health programs. The health professional should identify health agencies in the community that are working or haveworked with congregations. Those agencies can provide valuable

RECRUITING CONGREGATIONS

■ The health professional needs to gather information about the congregations and the clergy before selecting a community and making contacts for recruiting.

■ There are two basic strategies for selecting and recruiting congregations:

• working through organizations of affiliated congregations; or • approaching congregations individually.

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information on their experiences. The followingpoints describe the basic information to collect:

■ types of programs offered and types of activi-ties conducted,

■ number of participants,

■ demographic characteristics of participants,

■ partnerships with health agencies,

■ partnerships with other organizations, and

■ successes and failures.

BASIC STRATEGIES

The Stroke Belt projects used two basic strategiesto recruit churches: (1) collaboration with theState affiliate of a national religious organizationand (2) targeting individual churches. Ideally,the staff of an organization of congregationswould agree to recruit affiliates. The organiza-tion’s prestige and its active participation oftencan persuade a substantial number of congrega-tions to take part. However, it takes time toestablish such a relationship with an organizationof congregations, so the health agency may have

to take the initiative in approaching the congre-gations. The health professional should alwaysdiscuss the project with local organizations ofcongregations and obtain their support, regard-less of their direct involvement.

The Virginia Department of Health (DOH)worked with the health care ministry of theBGC of Virginia to gain access to churches forits Stroke Belt Initiative project. The VirginiaDOH’s relationship with the BGC dates backmany years; agencies that do not have such arelationship might have less success with thisstrategy. Moreover, the BGC of Virginia is oneof a few organizations with a fully staffed healthcare ministry.

In other Stroke Belt projects, as mentioned previously, the health professionals contacted the churches directly. In Louisiana, the project coordinator started the program in her churchand expanded it to neighboring congregations. The Tennessee SHD initially approached threechurches where some of their staff were membersor knew someone who introduced them to theclergy. This recruitment method involved fewerchurches initially, but more churches joined inover time.

The South Carolina Department of Health andEnvironmental Control formed a church-basedworking group to develop a strategy for recruit-ing churches. The group included health profes-sionals and representatives from churches—bothclergy and church officers. Following the group’sadvice, health professionals attended church ser-vices to introduce themselves and the project tothe clergy and congregation members.

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5MAKING INITIAL CONTACTS

Health professionals must discuss the programwith the clergy before working with a congrega-tion. By gaining the support of the clergy, partic-ularly the leader of the congregation (minister,priest, or rabbi), other clergy and the congrega-tion usually will embrace the vision of the pro-gram and work toward its success.

CONTACTING THE CLERGY

Usually, the most effective way to meet the cler-gy is through a friend who is a member of thecongregation and who can recommend theagency and the program to the clergy. A healthprofessional among friends or colleagues in thecongregation also can be of great help. A healthprofessional can understand program goals,inform the agency of programs already in place,and provide proper introduction to the clergy.

This person often understands the culture of thecongregation and can help persuade the clergy tobegin a CVD program.

Another effective way to meet the clergy is forthe health professional to make a personal intro-duction when attending the worship service.Getting on the agenda of a meeting of the localministerial alliance is another avenue. This canincrease communication and program visibilityand may provide contact with and references tocongregations interested in health care programs.The most common ways to contact the clergyinclude the following:

■ Personal introduction—Identify a congrega-tion member (such as a health professional orcommunity leader) who will introduce thehealth agency and the program to the clergy;identify a member of a community organiza-

■ Support from the clergy increases the success of congregation-based programs.

■ There are several ways to make initial contact with the clergy:

• personal introduction by a congregation member;• a visit to services, with self-introduction, or a telephone call; and• an introductory letter and followup phone call.

■ After contacting the clergy, set up a meeting to describe the project and ask the congregation to participate.

■ In the first meeting, explain the benefits to the congregation and discuss the expectationsof what the health agency will do and what the congregation will do. Together, the healthagency staff and congregation members should make a formal commitment to workingtogether in the CVD prevention program.

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tion working with the congregation who sup-ports the health agency or program and willintroduce the agency staff; or form a workinggroup that includes health professionals andclergy from participating congregations whocan lend credibility to the health project andintroduce agency staff. Once the program isimplemented in a congregation, ask the clergyof the participating congregation to introducethe health agency staff and the program toclergy of other congregations. The clergy fromparticipating congregations can be strongambassadors for the program.

■ Visit—Attend the worship service and make apersonal introduction to the clergy. Thisshows an interest in the congregation and itsmembers. This approach to contacting clergyrequires timely followup and can be difficultif the personal introduction is omitted. Bothmethods—visiting the congregation and call-ing before the visit—have been successful inpast projects.

■ Introductory letter and followup call—Send aletter of introduction to the clergy and followup with a telephone call within a week to setup a meeting. This method is less productivethan a personal introduction, but it hasworked. Having the name of a member whocan serve as a reference for health agency staffcan facilitate the necessary introductions.

■ Research the clergy’s title (reverend, pastor,rabbi) and make sure the letter is addressedappropriately.

MEETING WITH CLERGY

Once the introduction has been made, thehealth professional should set up a time todescribe the project and its benefits for the con-gregation and the community. During the meet-ing, it is important to explain clearly what thehealth agency will do and what is expected of thecongregation when it agrees to participate.

In explaining the project, the health professionalshould:

■ Describe the benefits to the congregation.

■ Increased awareness and know-ledge of CVD risk factors and waysto lower risk.

■ Ability to identify behaviors thatput members at high risk of CVD.

■ Potential to reduce risk factorsassociated with heart attacks orstrokes among congregation mem-bers.

■ Decreased numbers of sick andshut-in members over time.

■ Assistance in organizing supportgroups, exercise classes, andweight reduction programs toimprove quality of life.

■ More trained volunteers for edu-cating members about CVD pre-vention activities.

■ Strengthened community spiritamong congregation members asthey work together to achieve acommon goal and open avenuesinto the larger community.

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■ Emphasize that members of the congregation,with support from the health agency staff, will need to organize and carry out programactivities.

■ Ask the clergy to name a coordinator (stressthe importance of this role in membershipparticipation and successful program imple-mentation) who will

• Establish a health team or ministry to planand carry out activities,

• Keep records of all program activitiesincluding participant outcomes,

• Discuss and commit to confidentiality,

• Analyze records and make reports, and

• Provide the health agency with recommen-dations for translating new knowledge intoeffective actions.

■ Describe typical health intervention activities—for example, screenings, demonstrations,followup activities, and surveys.

■ Discuss program costs—the resources that will be provided by the health agency andways the congregation can provide in-kindand supplemental funding to initiate activitiesand keep them going once the program isestablished.

■ Explain the importance of including messagesabout health and the program in sermons andannouncements.

■ Talk about using witnesses (people who haveCVD or their family members) and other keyparticipants to promote the program.

■ Suggest that program activities be announcedin bulletins, newsletters, flyers, and other publications.

Points to mention about the health agency rolemay include:

■ Training and orienting the coordinator,

■ Assisting with training the health team orministry,

■ Providing program guidelines and materials,

■ Assisting with evaluating the results of theprogram and training the health team to workindependently of the agency,

■ Providing information on the activities ofother congregations participating in healthprograms, and

■ Identifying potential network partners.

AGREEMENT TO PARTICIPATE

Once the clergy and/or governing board of thecongregation agree to participate and the respon-sibilities of the health agency have been clarified,confirm the points of agreement in a letter to thecongregation. The letter should clearly specifythe discrete responsibilities of the congregationand the health agency. Emphasize the impor-tance of clergy participation, appointment of aprogram coordinator, and the establishment of ateam of congregation members to plan and orga-nize activities. Also, be sure that the healthagency can deliver what is promised.

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SELECTING A COORDINATOR

Selecting a coordinator is the first step in startinga program in a congregation. This person is criti-cal to the success of the program. The coordina-tor is the leader who generates program interest,trains the team members, and mobilizes supportand participation by congregation members. Thecoordinator is usually appointed by the clergy; ifnot, the method of selection is decided by theclergy. The health professional can offer advicein the selection of the coordinator and shoulddescribe the characteristics and skills of a success-ful coordinator. The health professional should:

■ Explain the importance of appointing theright person—the coordinator is the key tothe overall success of the project.

■ Provide a list of the personal attributes of asuccessful coordinator (see below).

■ Provide a job description or a list of the coor-dinator’s roles and responsibilities.

Typically, a successful coordinator is someonewho is an involved member of the congregation,is known to the clergy, and is recognized andrespected by the congregation. The coordinatorshould have the following skills and attributes:

■ Leadership skills—has vision, can providedirection and guidance, can delegate responsi-bilities, and can encourage and inspire others.

■ Organizational skills—can provide structure,make plans, and arrange meetings and activi-ties.

■ Communication skills—can speak comfort-ably with the clergy and the congregation toprovide and facilitate the exchange of infor-mation.

■ Respect of peers—is liked by others and heldin high regard.

■ Experience—has directed and managed otherprograms in the congregation.

ORGANIZING FOR ACTION—

REMINDERS FOR HEALTH PROFESSIONALS

■ The first step in organizing a congregation-based program is selecting a coordinator. The clergy should make the appointment or decide how the coordinator will be chosen.

■ A variety of people with different skills and backgrounds can contribute to the program.

■ Team members must be oriented to the project goals, their responsibilities, supporting roles of health professionals, and background information from other projects.

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Specific roles of the coordinator include:

■ Generating enthusiasm—building interest topromote positive changes in health and creat-ing an atmosphere that encourages congrega-tion members to get involved.

■ Promoting the program to the congregation—speaking to the clergy and congregation togive visibility to the program as well as man-aging the development of promotional mes-sages, flyers, and bulletins.

■ Assisting with the training of team mem-bers—working closely with the health profes-sional to give the team an overview and ratio-nale for health programs.

■ Creating a program plan and timeline—work-ing with the team to develop the activities fora CVD prevention program and assigningresponsibilities and maintaining schedulesaccording to the timeline.

■ Helping to carry out program evaluation—making sure that a member of the team assistswith distributing and collecting evaluationforms after each activity.

■ Working with businesses in the community,such as pharmacies and health clubs, andrecruiting organizations to provide resources(e.g., national organizations with local chap-ters, such as the American Heart Association,American Lung Association, and theAmerican Red Cross). These organizationsand others, such as the NHLBI, can provideskilled volunteers, educational brochures, andother materials.

■ Implementing the program—working withthe team to set the start date and accomplishgoals on time, which lends credibility to theeffort and influences the clergy and the con-gregation to stay involved.

TRAINING THE COORDINATOR

The health professional can use this guide totrain the coordinator. Information in the guidewill teach the coordinator how and why healthagencies work with congregations to conductCVD risk reduction programs. As described inthis guide, especially in Appendix B, the StrokeBelt projects give background on effective CVDchurch programs and the lessons learned fromthese projects, and the other appendices to thisguide provide valuable tools for implementingthe program.

The health professional should have a one-on-one orientation meeting with the coordinatorand cover the following topics:

■ roles, responsibilities, and expectations of all players;

■ goals of the project;

■ description of the activity/project;

■ support from the health agency;

■ experience in other congregations;

■ continuous communication with the clergy to keep them informed and involved;

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■ data on the prevalence of CVD and its riskfactors;

■ appropriate education, prevention, and control activities; and

■ other background information.

SELECTING THE TEAM

The team should consist of individuals whowork well with people, are willing to be trained,and are interested in health issues. Team mem-bers must make commitments of their time tobe trained and assist with program activities.Volunteers need to feel valued and know thattheir contributions are making a difference.Laying out clearly-defined expectations andexpressing appreciation by the coordinator,health professional, and sometimes an outsideperson such as a doctor will ensure the success ofthe team.

Many different people with a wide variety ofskills and backgrounds can contribute to theprogram and assist the team. Health profession-als in the congregation such as nurses, nutrition-ists, and health educators can provide assistancewhen necessary, such as with blood pressurescreenings. Other professionals and properlytrained individuals can serve in other roles.

The clergy usually appoint team members orannounce the formation of a team and invitevolunteers. In some churches involved in theStroke Belt projects, the coordinator recruitedteam members who were then appointed by theclergy. However, based on experience in manychurches, the Stroke Belt project staff concludedthat teams selected and appointed by the clergyenjoyed greater support and generally performedbetter. Members who are known and trusted bythe clergy will have the greatest success in imple-menting the program and stimulating participa-tion by other members.

ORIENTING AND TRAINING THE TEAM

The purpose of the team is to plan and carry outspecific activities to implement the program.Team members are involved in all parts of theprogram, including planning, recruiting othervolunteers, preparing promotional materials,meeting with community groups for assistance,setting up activities for implementation, andevaluating the effectiveness of the project. Thecoordinator should convene a group orientation,usually conducted by the health professional, todiscuss the following:

■ roles, responsibilities, and expectations;

■ goals of the project;

■ confidentiality issues;

■ assessment of team members’ skills and talents;

■ support from the health professional;

■ experience in other congregations; and

■ other background information.

The training sessions that follow the orientationshould emphasize educating the team aboutCVD risk factors and effective ways to worktogether to achieve program goals. The teamshould devise strategies for planning, managing,and implementing the program. Specific tasksshould be assigned to team members, and atimeline should be developed. Lines of commu-nication must be delineated, so that after dele-gating responsibilities, the coordinator will knowthe appropriate points of contact. Future meet-ing dates should also be identified.

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7CONDUCTING THE INITIAL ACTIVITY

This guide gives health professionals insightabout how to direct congregation teams tobegin health promotion and CVD preventionprograms in congregations. It is assumed thatthose deciding to implement activities using theguide already have established CVD preventionprograms in other settings.

In work with religious congregations, commu-nity resources often determine the scope andcontent of the project. If CVD prevention andeducation programs already exist in the com-munity, consider using them. The steps fordeveloping the program include the following:

■ Conduct a survey of the congregation to helpthe team understand the members, theirknowledge of CVD risk factors, their interestsand availability, and other pertinent informa-tion. The survey should be anonymous andself-administered and take no more than 5 to10 minutes to complete. The member survey

can be useful in motivating the clergy and thecongregation.

■ The team should decide on goals and objec-tives, the congregation activities, and the nec-essary steps for implementation.

■ Get started—move quickly to schedule andcarry out the first and subsequent activities.Implement all activities as scheduled in theplan to maintain the program’s credibilityamong congregation members and leaders.

SURVEYING THE CONGREGATION

A survey of the congregation provides the teamwith baseline information on the demographiccharacteristics, knowledge, interest, and availabil-ity of church members. The team can use thisinformation to select risk factors to target and tochoose activities of interest to the members whowill attract the greatest participation. Data fromthe survey are also useful in scheduling programevents at times convenient for members.

■ Users of this guide will assist congregations in implementing established CVD preventionprograms.

■ Working with established community programs in CVD program planning is more efficient.

■ The team should follow three major steps to develop a congregation-based program:

• survey the congregation to learn about CVD knowledge and interests,• set goals and objectives and plan a congregation activity, and• be creative with startup of congregation activities.

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The survey should include the following items:

■ demographics such as age and sex,

■ knowledge/beliefs about CVD risk factors,

■ existence of modifiable risk factors,

■ interest in education and intervention activities, and

■ availability for participation in education and intervention activities.

The method of administering the survey isimportant to ensuring a high rate of response.Poor response rates often result from long ques-tionnaires, take-home questionnaires, open-ended questions, and concerns about confiden-tiality (especially if questions are personal or asignature is required). To improve response rates:

■ keep questionnaires short, no more than onepage;

■ use simple questions; and

■ have questionnaires completed prior to, during, or immediately following services.

The strategies used by the Stroke Belt projects todistribute surveys included printing the surveyon the back of the church program, placing aninsert in the church program, and telephoningmembers absent from service (although this canbe time-consuming and is usually limited toimpersonal questions).

Based on the experience of the Stroke Belt pro-jects, an announcement from the clergy request-ing members to complete the survey during orimmediately following the service is the bestmethod. The coordinator or other team memberalso may introduce the questionnaire and ask forthe congregation’s cooperation. Members mustbe assured that personal information will be heldin confidence by the health agency and the teamand that project reports will not include namesof individuals.

Survey forms should be distributed and collectedby a team member, or the congregation canplace the forms in a designated box. Analysis ofthe survey results (including frequencies andcross-tabulations) can give the team insight forplanning and can aid in evaluation. The resultsof the survey should be reported back to thecongregation through a brief presentation afterthe worship service or through an insert in thecongregation bulletin.

DEVELOPING A PRELIMINARY PLANAND GETTING STARTED

A preliminary plan should include the followinginformation:

■ targeted risk factors,

■ goals and objectives,

■ strategies or action steps,

■ timeline,

■ evaluation indicators,

■ resource list for materials and services, and

■ followup activities.

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An appropriate startup or kickoff event is animmediate activity that can show early success. Asuccessful kickoff builds the morale and commit-ment of the team, ensures momentum for futureactivities, and stimulates interest and participa-tion. For these reasons, this activity must be heldas soon as possible. As previously mentioned,many churches in the Stroke Belt Initiative took9 months or longer to conduct the first activity.Therefore, a good strategy to help overcome thisdelay is to pick a simple activity that the teamcan readily start and finish in a brief period.Then regular activities keep up the momentum.Targeting segments of the congregation (e.g.,screening members of the choir) helps focusefforts and reach particular audiences.

Promotion strategies can include word-of-mouthand advertisements in the congregation bulletinand radio, television, and newspapers. Planningthe activity requires several steps:

■ Identify a specific kickoff activity for the con-gregation and for the community. For exam-ple, conduct a simple blood pressure screeningevent, healthy cooking demonstration, food-tasting event, or an event such as “HighBlood Pressure Sunday” to raise awareness.

■ Identify outside resources, suppliers of educa-tional materials, and sponsors for gifts, ifappropriate. The Stroke Belt projects usedincentives to increase participation and gener-ate enthusiasm. Food, prizes, games, and give-aways may spice up the event.

■ Identify the duties and responsibilities of allteam members.

■ Schedule the activity. Check with communitycalendars in local newspapers to avoid sched-uling conflicts with other events.

■ Discuss with the clergy the importance oftheir role in facilitating the kickoff event.Kickoff and other events were more successfulin the Stroke Belt projects when the clergywere involved in promoting the event. Theclergy included a message in their sermonsand gave the team full access to the communi-cation media of the congregation. Mentioningthe incentives (prizes and giveaways) alsoincreases interest and involvement.

The clergy should endorse the activity enthusias-tically. Congregation members who share per-sonal experiences and testimonials are particular-ly helpful. For example, members can describethe experience of being told by a doctor thatthey were at risk of a heart attack and howlifestyle changes, such as losing weight and quit-ting smoking, have reduced their risk. One ofthe earlier church-based programs developed 52brief health messages, “Minutes for YourHealth.”1 A team member or the clergy read oneof these soundbites during the church service toraise health awareness and motivate members tomodify their lifestyles.

1 B. Waine Kong, Ph.D., J.D., Association of Black Cardiologists, Inc.,225 Peachtree Street, NE, Suite 1420, Atlanta, GA 30303.

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Ideas for building program interest and partici-pation include the following:

■ short announcement or presentation duringthe major religious services;

■ announcements in the congregation’s media,such as weekly bulletins, newsletters, andcomputer-generated announcements to mem-bers;

■ flyers that are posted or handed out;

■ information given by word-of-mouth; and

■ announcements via local religious radio andTV broadcast programs, area newspapers (e.g.,in the religious calendar of events), communi-ty bulletin boards, and congregation advertise-ments.

Once the activity is under way, all participantsshould sign in, and assigned team membersshould record relevant data about each partici-pant. Participants’ concerns about confidentialitycan be lessened by providing a statement indicat-ing that all information collected during pro-gram activities will not be shared outside theproject team and that reports to the clergy willnot include participants’ names. The activityshould be evaluated by developing an activityassessment form. After participants complete theform, their feedback should be used to improvefuture activities. Finally, if feasible, a followupsystem should be designed to track persons iden-tified as “at risk” to determine the outcome andeffectiveness of the event.

The health professional can work with the congregation to determine whether there is inter-est in followup and whether there are resourcesto conduct followup activities. Some congrega-tions may want to conduct only a few activitiesand have intensive followup; others may wantmore activities with less followup. The issue ofconfidentiality in followup must also be

addressed. A permission form at a screening site(e.g., for persons with high blood pressure) caninclude a statement requesting permission tomake a followup call to remind participants tosee a doctor. Followup activities greatly improveoutcomes but are not always feasible.

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8FOLLOWING UP THE INITIAL ACTIVITY

TEAM MEETING AFTER INITIAL ACTIVITY

After the initial activity, the coordinator shouldschedule a team meeting to discuss team mem-bers’ observations about the activity to determinewhat went right and what went wrong and comeup with ideas to improve the next event. A sum-mary report should be developed describing theevent and the results, including:

■ number of participants,

■ demographics—age and sex,

■ number and percentage of participants withself-reported or measured CVD risk factors,and

■ number and percentage of participantsreferred.

To ensure confidentiality, keep records stored ina secure place where access is limited to those

responsible for record-keeping. In determiningthe best way to group data for routine dataanalysis, a program evaluator may be consulted.Evaluating these results will help:

■ identify effective activities,

■ pinpoint areas where additional effort is needed,

■ compare different approaches,

■ gain and maintain support for the program,

■ share experiences with others, and

■ plan the next event.

Activities should continue to be scheduled with-in a month after the initial activity or accordingto the plan’s timeline. It is important to keep upmomentum and team morale, maintain the pro-ject’s visibility for the congregation and clergy,and target individuals found to be at risk for

■ The team should continue working after the initial activity.

■ Hold a team meeting to discuss observations and analyze the project.

■ Develop a summary report (including number of participants, demographics, and findingsabout their CVD risk factors) to provide feedback to the clergy and congregation.

■ Schedule another activity soon after the first to maintain project momentum, team morale,and congregation interest.

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CVD in the initial activity. Identify tasks andassign responsibilities to these areas:

■ lead organizer,

■ promotion,

■ resource acquisition, and

■ scheduling.

SOLICITING FEEDBACK ON THE ACTIVITY

The coordinator should arrange a meeting withthe clergy to present a copy of the summaryreport and discuss the collective findings. Theclergy are more likely to enthusiastically supportfuture activities when they know that past activi-ties went well and produced useful results. After

discussing the findings with the clergy, ask theclergy to announce the major findings to thecongregation; in addition, a team member canprovide details. Also, a description of the activityand the major findings can be published in thebulletin or newsletter. The publicity and theenthusiasm it generates will help encouragemembers to participate in future activities.

Team members and others who helped make theevent successful should be acknowledged. It isalso a good idea to review the goals of the pro-gram and announce the next program event.

PLANNING THE NEXT ACTIVITY

At this point, the team should be busy planningfuture activities. The health agency professional’srole should be to provide direction and serve in amore consultative role (e.g., how to findresources, how to get members involved).

The coordinator and team should keep themomentum going by initiating the next activityas soon as possible and following the steps takenbefore the first event, which include:

■ obtaining approval if necessary,

■ scheduling the activity,

■ promoting the activity, and

■ contacting and securing outside resources.

The team should work to reach program goalsand meet the needs of the congregation mem-bers, keep communication lines open, be cre-ative, and have fun.

CONDUCTING THE ACTIVITY

The coordinator and team members should startthe next program event and repeat steps to eval-uate, follow up, and initiate future activities.

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9MAINTAINING THE PROGRAM

The health professional should encourage andsupport the coordinator to work with the team tomaintain the health activities in the congregation.He or she should serve as a coach and consultant,as well as help provide necessary resources such asinformational materials and community contacts.As more congregations become involved in theprogram, the most important role of the healthprofessional is communicating with the coordina-tor. It is essential to maintain contact with partici-pating congregations to assist the coordinator withstrategies for maintaining the program.

An effective way to stay in touch and keep theprogram going is through telephone calls to theproject coordinator. These calls serve multiplepurposes: assessing how program activities arebeing implemented, identifying needs, solving

problems, praising performance, and reportingon activities at other congregations. The healthprofessional also should encourage the coordina-tor to maintain communication with the teamand the clergy.

The health professional should attend teammeetings when possible. Team meetings offer an opportunity for the health professional toprovide support in several ways—praise teamperformance, provide ideas for new project activ-ities, report on activities at other congregations,and provide guidance for program planning andpromotion. This usually results in a consistentflow of project activities. The health professionalshould arrange periodic meetings with the coor-dinators and key team members from all partici-pating congregations to share experiences andideas, promote joint ventures, and provide

The health professional should

■ communicate with the project coordinator to help maintain ongoing program activities,

■ set the precedent in the initial activity for the project coordinator to take the lead and beprepared to maintain ongoing health projects,

■ call the coordinator and attend some team meetings to offer encouragement and continu-ing support, and

■ provide resources to help the team sponsor regular health activities.

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encouragement. Church members in the StrokeBelt projects found these meetings to be helpfulin generating ideas for new program activitiesand motivating team members to keep workingwith the program. These meetings also createdhealthy competition among the congregations.In addition, the health professional shouldalways deliver promised resources and supporton time.

The coordinator is responsible for keeping theclergy informed of progress and praising the teammembers for their accomplishments. In addition,the coordinator is responsible for staying in touchwith the health professional to obtain neededresources and support for the program.

The team should continue to sponsor healthactivities regularly—at least once a month andmore frequently if possible. The team and coordi-nator should maintain a steady flow of informa-tion about the program events to the congregationthrough announcements in newsletters and bul-letins as well as through special flyers and posters.Other strategies include word-of-mouth commu-nications from the team to the congregation andannouncements during religious services by thecoordinator, team members, and the clergy.

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10ASSESSING AND EVALUATING

THE PROGRAM

Assessment and evaluation are important to thecongregation-based health program. They helpensure continued support of the program by doc-umenting the number of participants and identi-fying participants who need followup with healthcare providers. They also provide important infor-mation for improving the health program.

For each activity, a form should be developedthat includes each participant’s demographicinformation (e.g., age, sex), history of CVDrisk factors, status of risk factors and otherobservations at the event, and knowledge ofrisk factors. A separate form for participants tograde their satisfaction with each activityshould be included in the evaluation. Results of

this satisfaction survey should indicate whetherthe team reached its goals in terms of benefitsto the congregation and individual members.All participants should complete the forms ateach activity, and personal information shouldbe confidential. Written reports should notinclude the names of any participants. Data can be coded (e.g., using letters, numbers) as a precautionary measure.

The team should plan how the activity formswill be stored and develop a filing system forrecords. Computer storage will be needed whenthere are a large number of participants. A teammember with computer skills can help develop a record storage system.

■ Assessment and evaluation of the congregation-based program are important to ensurecontinued support.

■ Evaluation forms should be developed for each activity to record participation and status of risk factors and permit participants to assess the activity’s effectiveness.

■ Confidentiality of participants’ information must be ensured.

■ Certain measures (e.g., blood pressure) are needed repeatedly to assess changes in risk factors of participants and aid in planning future activities.

■ The team should evaluate each activity as it happens and the entire program at least onceeach year and determine if the benefits to the congregation are achieved.

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A member of the team, the coordinator, or thehealth professional should analyze the activityforms. The following items may be included inthe summary report, depending on the type ofactivities conducted:

■ number and type of program activities,

■ total number of participants,

■ age and sex of participants,

■ number of participants with elevated bloodpressure or taking medication for high bloodpressure,

■ number of participants with high blood cholesterol,

■ number of participants who are overweight,

■ number of participants who have a high-fatdiet,

■ number of participants who have a high-sodium diet, and

■ number of participants who use tobacco.

Sources for data analysis experts include:

■ sponsoring health agencies,

■ voluntary health agencies,

■ university volunteers (e.g., graduate studentsor faculty members),

■ team members with data analysis skills, and

■ congregation members with data analysisskills.

The overall program should be evaluated at leastonce a year, and each activity should be evaluat-ed as soon as it is completed.

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11APPENDICES

A. Checklist for the Health ProfessionalWorking With Congregations

B. State Profiles: Louisiana, South Carolina,Tennessee, and Virginia

C. Sample Congregation Plan

D. Sample Congregation Survey

E. NHLBI Educational Materials

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AP P E N D I X A

CHECKLIST FOR THE HEALTH PROFESSIONAL WORKING WITH CONGREGATIONS

Recruiting Congregations

Gather information on the clergy _____Identify and contact health agencies in the area that

have worked with congregations _____Determine the availability of resources

(i.e., funding, educational materials) _____Develop a strategy for recruitment _____

Making Initial Contacts

Introduce yourself to the clergy _____Meet with the clergy to describe the program and gain support _____Confirm the agreement between the agency and the congregation _____

Organizing for Action

Offer counsel in the selection of a coordinator _____Educate and train the coordinator and team _____

Conducting the Initial Activity

Facilitate the efforts of the coordinator and team to:Survey the congregation _____Establish goals and objectives _____Develop forms for evaluation and discuss confidentiality issues _____Plan a kickoff event _____Promote and carry out the activity _____

Following Up the Initial Activity

Provide direction and consultation to the coordinator and team as they:Evaluate the program activities _____Inform the clergy and congregation of each event’s success _____Schedule and promote the next activity _____

Maintaining the Program

Establish regular communication with the coordinator _____Attend team meetings when possible to offer encouragement

and continuing support _____

Assessing and Evaluating the Program

Teach the assigned team members to analyze the data and use the information for followup and to improve future activities _____

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APPENDIX B

STATE PROFILES: LOUISIANA, SOUTHCAROLINA, TENNESSEE, AND VIRGINIA

Louisiana

The Louisiana Department of Health andHospitals (LDHH) has worked with churchesfor a number of years. During phase I of theStroke Belt Initiative, the LDHH establishedhigh blood pressure prevention and control pro-grams in 26 churches in the New Orleans area.The interventions consisted primarily of aware-ness and education activities, blood pressurescreenings and followup, and heart-healthy cook-ing demonstrations. Some churches also con-ducted weight loss and smoking cessation ses-sions.

The phase II project was a 2-year effort toexpand the program to churches in other areas ofthe State. The LDHH subcontracted with theNational Kidney Foundation of Louisiana andthe Natchitoches Outpatient Clinic to achievethis goal. The latter subcontractor concentratedits efforts in northern Louisiana. The subcon-tractors hired consultants from the targeted com-munities to recruit churches and help them orga-nize and establish programs.

The consultants followed the procedure estab-lished in phase I for recruiting churches. Inphase I, the project tried unsuccessfully to recruitchurches through the State affiliates of nationalorganizations of churches although the organiza-tions were supportive of the project. Therefore,the project had to recruit churches individuallythrough their clergy.

Thus, in phase II, the first official contact withthe church was always made through the clergybecause they usually determined whether thechurch would participate or not. However, theconsultants frequently used other contacts withina church to get an introduction and initial

meeting with the clergy. At the meeting with theclergy, the consultants explained the purpose andnature of the project, the benefits to the church,the support that the project would provide, andthe responsibilities of the church. After theoverview, they asked the clergy to commit thechurch to participate in the program.

Once a church agreed to participate, the firststep was to establish a health care ministry(HCM), an organization of the church responsi-ble for organizing and implementing the healthprograms in the church. The clergy appointedthe coordinator of the HCM. The clergy alsointroduced the program to the congregation dur-ing regular services and asked for volunteers toserve on the HCM. In some churches, the con-sultant was allowed to address the congregationsto promote the program.

The consultant trained the members of theHCM. The 4-hour training session consisted ofan orientation to the programs, risk factors forheart disease and stroke, referral and followuptechniques, and medical record systems. Themembers also attended a course to become certi-fied in blood pressure measurement.

The HCMs planned and carried out programactivities in their churches. The consultant assist-ed the HCMs in planning and provided equip-ment for program events. The consultant wasgenerally onsite for these events to answer ques-tions and solve any problems. They also recruit-ed health professionals to conduct educationalsessions on nutrition, smoking cessation, exer-cise, and other topics.

Thirty churches agreed to participate in the pro-gram and established HCMs. The HCMs from22 churches (156 members) attended the 4-hourtraining workshop and completed the bloodpressure measurement course. Scheduling thetraining sessions was often a challenge. Therewere many cancellations, often on the nightbefore the scheduled event. The consultants had

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to maintain flexibility and work with the HCMto reschedule the training. Still, eight of thechurches that agreed to participate did notattend a training workshop.

The HCMs at 16 churches conducted bloodpressure screenings and other program events.The consultant supervised the initial blood pres-sure screening event at each church. Many of thechurches reported a large attendance at their firstscreening and educational seminars. The remain-ing six churches with trained HCMs did notconduct a program event. Two churches decidednot to conduct a screening because of the fear ofliability issues. Another church decided that itwas too much work. The three other churchesdid not schedule an event but indicated thatthey planned to do so.

The project contracted with a nutritionist toteach church members to prepare heart-healthymeals. Several churches identified the memberswhom their congregations considered to be thebest cooks. The nutritionist worked with thesepeople to modify their favorite foods into heart-healthy dishes. They served these heart-healthyselections to the congregations at food eventsheld by the churches. Church members werealways eager to try foods prepared by their bestcooks. The members were not told that the foodwas heart-healthy until after they tried the foodand said they liked it.

The nutritionist also prepared recipes of all theheart-healthy dishes served in the churches. Theconsultants distributed the recipes to the church-es so that all members would have access tothem.

The consultants kept a log of the dates of theirinitial visits with the clergy, when the clergycommitted the church to participate, the train-ing of the members of the HCM, and each pro-gram event. Analysis of these logs showed that ittook an average of 46.4 weeks (10.8 months)from the initial visit with the clergy to the first

program event. The times ranged from 2.6 weeksto almost 2 years (22.2 months). However, elim-inating the last three churches that took 18.8,19.0, and 22.2 months reduced the average timeto 8.3 months. The patience and persistence ofthe consultants in getting all the churches to par-ticipate was responsible for the longer time peri-ods. Thus, the process of recruiting churches andmoving them into action takes time. The consul-tants continue to work with three other churchesto implement programs.

The consultants reported that keeping the HCMmembers motivated and committed to thescreenings and other activities was difficult inmany of the churches. They attributed the prob-lem primarily to the leadership of the coordina-tor. HCMs with strong coordinators tended tomaintain a consistent flow of program activitieswhereas those with weak leaders held activitiesmuch less frequently. Thus, it is very importantto select a strong coordinator in the beginningbecause the clergy is generally unwilling toreplace an ineffective coordinator.

The coordinators met with other key HCMmembers to discuss their experiences and shareinformation between the churches. Difficultiesin getting HCM members to participate activelyin planning and carrying out program activitieswere a common theme. Some coordinators stat-ed that sometimes they had to conduct screen-ings by themselves.

The churches agreed to submit monthly tallysheets summarizing their screenings and otheractivities. Some churches submitted thesereports, but most did not, even after followuptelephone calls and letters from the consultant.

Finally, after the conclusion of the project, manyof the churches continue to hold screenings andother program activities. Three churches that didnot hold an event during the project period indi-cate that they still plan to conduct screenings.

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This shows that the benefits of programs to pre-vent heart disease and stroke are evident to theleadership of many churches. Projects like theStroke Belt Initiative provide the stimulus forthem to get started.

South Carolina

South Carolina has the highest age-adjusted strokemortality rate in the United States. In 1994, thestroke mortality rate in South Carolina was 31.8per 100,000 for whites and 65.4 per 100,000 for African Americans. Because of this disparity, the Center for Health Promotion of the South Carolina Department of Health andEnvironmental Control chose to focus itsefforts in the African American community.

The goal for the South Carolina Strike OutStroke (SOS) project was to improve hyperten-sion awareness, treatment, and control amongAfrican Americans in the State. The projectsought to increase the number of community-based programs to control high blood pressureamong African Americans.

The Center for Health Promotion chose to work through three channels within the AfricanAmerican community: churches, the media, andbeauty shops and barbershops. This capacity-building project included the development oftraining manuals for health professionals and layvolunteers to develop stroke prevention initia-tives within each channel.

The project trained professionals to work withthe faith community to implement stroke pre-vention initiatives. The training for professionalstook place in a variety of settings, including theMinority Health Issues Conference. Trained areahealth professionals also taught local lay volun-teers to start or expand health promotion effortsin the church.

The media channel stressed the importance of theAfrican American media as an avenue to get posi-tive cues and messages out to the community. It

targeted professionals either who do not knowhow to access this useful channel within theircommunities or who are unfamiliar with theavailability of specific media resources forAfrican Americans. Training was offered tohealth professionals through conferences thatattract professionals statewide.

Health promotion staff members were trainedstatewide to use this important communicationavenue. This activity continues beyond the con-tracted period of performance. The media pack-age provides specific information on stroke andcardiovascular health, including camera-readyarticles, public service announcements, and addi-tional resources. One media component address-es radio stations and newspapers owned andoperated by African Americans.

Beauty shops and barbershops are importantchannels to conduct health education aboutstroke prevention in African American commu-nities. The project provided information tohealth professionals and State and local represen-tatives of beauty shop and barbershop associa-tions and hair care professionals in every regionin South Carolina.

The staff made presentations to introduce SOSactivities to statewide organizations about theavailability of training for health advocates. Tomaximize the number of people who can takeideas back to their communities, the SOS coor-dinator gave presentations at State conventions,conferences, and special group meetings. Theseincluded the Palmetto State Barbers Association,the South Carolina African Methodist ChurchYouth Convention, and the State BaptistConference.

The framework of the project was capacity-building of the community—among both healthprofessionals and lay volunteers. This frameworkhas provided opportunities to link with a varietyof organizations statewide who are interested inreducing disease risks among African Americans.

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The most critical outcome of this project hasbeen that, because it was based on buildingcapacity, the life and impact of the project willlive well beyond the funding.

Tennessee

The Tennessee Department of Health (TDH)continued the efforts started in phase I of theStroke Belt Initiative project with the metropoli-tan counties with the largest African Americanpopulations. Nearly 70 percent of all AfricanAmericans in the State live in these three coun-ties—Shelby (Memphis), Davidson (Nashville),and Hamilton (Chattanooga).

The TDH coordinated services of three indepen-dent but related projects managed by theChattanooga-Hamilton County HealthDepartment, the Metropolitan-DavidsonCounty Health Department, and the PreventingAfrican American Strokes From the Use ofTobacco (PAAST, Inc.) Coalition. The goal ofthe project was to organize and enable AfricanAmerican communities in Tennessee to developand carry out prevention and control programstargeted at the risk factors of heart disease andstroke.

In Memphis, the PAAST Coalition, formed dur-ing phase I, continued to provide leadership andcommunity involvement to the project. Theyrecruited and worked with five African Americanchurches to develop and carry out programs forsmoking cessation as well as nutrition educationand weight management for their congregations.The coalition worked with the clergy and otherchurch members to establish a health promotionteam in each participating church. The teamswere responsible for planning, conducting, andmonitoring program activities. The coalition alsoarranged a training program for each of thehealth promotion teams. The training included ateam-building workshop for skills developmentin smoking cessation, healthy eating, and weightreduction interventions.

Memphis also formed a youth mentor programto carry out smoking education, prevention, andcessation activities for adults and youths. Twentyteenagers age 15 to 18 were recruited andtrained as youth mentors. The top three reasonsgiven for joining the youth mentor team werehelping others, informing people of the dangersof smoking, and helping friends and other peo-ple stop smoking.

The youth mentors received intensive training toprepare them as smoking cessation facilitators.The training focused on group facilitation, resis-tance skills, health behaviors and addiction, andthe role of the African American family in healthpromotion and disease prevention. They con-ducted smoking cessation classes for adults andteenagers and made presentations on tobacco useto youth groups and adult organizations.

In Nashville, the local health department recruit-ed and worked with African American churchesto set up programs for smoking cessation, hyper-tension control, and weight reduction. Duringthe first year, the staff targeted five churches toimplement the project. Two other churches wereadded in the second year. In each church, theclergy appointed health promotion teams to planand implement project activities. Each teamincluded a coordinator, also appointed by theclergy.

The project staff trained the church teams andworked closely with them, especially during theearly stages, to plan project activities. Thisincluded the needs surveys of church membersand providing ideas for kickoff or initial projects.The project staff also attended team meetingswhen possible and provided encouragement tothe coordinators and the members.

The church teams demonstrated that they couldmaintain an ongoing program within their con-gregations. They readily used existing educationand risk factor reduction programs from volun-tary health and other community agencies. The

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teams also were very creative in devising otherways to communicate health messages to theircongregations.

Innovative activities developed by the teamsincluded a children’s letter-writing campaign,production of a play about risk factors, andfood-tasting demonstrations. The letter-writingcampaign was both a contest and a health inter-vention. Children from the churches wrote let-ters asking a significant adult in their lives toquit smoking. Each child followed up at 3, 6,and 12 months to see if the significant adult wasstill smoking. The planners used the contest for-mat to encourage maximum participation by thechildren and cooperation from the significantadults. A panel of church members and healthdepartment staff judged each of the letters andselected a winner for each age (ages 6 to 11).The contest winners each received $50 and acertificate at a special awards ceremony.

One team decided to use drama to communicatehealth messages to their congregation. Theyasked a local playwright to write a play depictingwhat a typical African American family mightexperience when confronted with the need tolower its risk of heart disease and stroke. Highschool and college students performed the playduring church services, and it was videotaped forfuture use when the actors were not available.

Food-tasting events played a major role in build-ing support for and sustaining the program. At ameeting of the clergy from participating church-es, the team from the host church prepared andserved a heart-healthy meal. The clergy learnedhow the food was prepared only after they fin-ished eating and acknowledged how good thefood tasted. The taste of the food so impressedthe clergy that most included messages aboutheart-healthy eating and the program in theirSunday sermons. Many of the teams also con-ducted food-tasting events for their congrega-tions, using the same strategy.

The Nashville project succeeded in recruitingchurches, training teams among the congrega-tions to carry out program activities, movingthe teams to action, and sustaining their actionsover time. The staff kept logs with the dates ofthe completion of each milestone in eachchurch. Analysis of these data showed that ittook an average of 11.6 weeks (or 2.7 months)from the initial contact with the church to thepoint when the pastor committed the church toparticipate. It took another 20.4 weeks (or 4.8months) from the commitment to participateto the appointment and training of the churchteam. The first program event took place, onaverage, 10 weeks (or 2.3 months) after train-ing the church team. Thus, it takes about 42weeks (or 10 months) from the initial contactwith the church to the first program event.

The project in Chattanooga also attempted towork with churches, but initial efforts did notmeet with much success. The project staffsought the counsel of the Nashville staff. Afterseveral discussions, representatives fromNashville visited Chattanooga to meet withlocal church leaders. The delegation fromNashville consisted of clergy members, mem-bers of the church teams, and staff. Followingthe meeting, churches in Chattanooga beganimplementing the program. Overall, activitiesin these churches continue beyond the officialend of the project.

Virginia

The Stroke Belt project in Virginia is a uniquecollaboration between the Virginia Departmentof Health (VDH) and the Baptist GeneralConvention (BGC) of Virginia to promotestroke risk reduction programs in AfricanAmerican churches. This 2-year project expand-ed the activities of the Virginia CardiovascularRisk Reduction (VCRR) project to work withthe BGC. The VCRR project conducts statewidehypertension detection and control programs.

33

The BGC is an association of more than 1,000independent African American churches locatedthroughout the Commonwealth of Virginia.These churches have more than 200,000 mem-bers. The BGC health care ministry (HCM) hasa full-time director who is an ordained memberof the clergy. The BGC-HCM has a history ofworking with health agencies to implement pro-grams in member churches.

The VDH and the BGC-HCM agreed to focuson three risk factors—high blood pressure,smoking, and obesity. For more than 10 years,the VDH and the BGC-HCM have collaboratedto conduct blood pressure screening in BGCmember churches.

The director of the BGC-HCM recruited thechurches, trained the volunteers, and supportedtheir efforts. However, the expanded projectrequired more than one person to coordinateand support the activities of local churches.Thus, the VDH and the BGC-HCM establisheda system where regional coordinators workedwith the churches in their area. The BGC-HCMdirector recruited 10 volunteer coordinatorsfrom area churches.

The clergy at the regional coordinators’ homechurches pledged to support the efforts of thecoordinator and to make their church the modelfor the region. The responsibilities of the regionalcoordinators were to recruit churches, assist thechurches in organizing to carry out the program,train church team members, and deliver the pro-grams and materials selected for implementation.

A group consisting of VDH staff, the BGC-HCM director, three regional coordinators,four blood pressure measurement (BPM) spe-cialists, and one clergy member planned thehigh blood pressure component. To carry outthe plan, the VDH staff and the BGC-HCMdirector trained the 10 regional coordinators.While supporting the churches already involved inhypertension detection, the regional coordinators

also recruited new churches and helped them setup HCMs. This increased the number of partici-pating churches to 100. The coordinators certified100 new specialists and recertified 50 specialists.Seventy-nine additional BPM specialists did notrequire recertification.

The certified specialists measured the blood pressures of 3,723 church members in FY 1995.Elevated readings were found in 265 people whowere not under the care of a physician for highblood pressure. Referrals were made for 282 indi-viduals with elevated readings who were alreadyunder treatment for hypertension.

The VDH and the BGC-HCM selected thesmoking cessation program from Clergy United for the Redemption of East Baltimore(CURE)—an NHLBI-funded study. TheAmerican Lung Association (the local sponsor ofthe CURE Program) trained the regional coordi-nators to implement the CURE smoking cessa-tion program. The BGC-HCM director and theregional coordinators revised the CURE materialsto be more suitable to the BGC and renamed theprogram “Thank God I’m Free” (TGIF).

The regional coordinators conducted TGIF train-ing for group leaders in seven regions. Although itwas not difficult to get volunteers to participate inthe group leader trainings, it was hard to getchurch members to attend the classes. The volun-teers attributed the problem to the employmentof many church members in the tobacco industry.Because these persons perceived the program as athreat to their livelihood, many pastors were resis-tant to the program. However, the group leadersconducted 16 courses for 115 participants. Sixty-eight of these smokers completed the course, and26 (22.6 percent) were not smoking at the end ofthe course. To increase participation, local healthdepartment clinics offered classes away from thechurch, which provided greater confidentiality.The group leaders also offered self-help infor-mation as an alternative to group classes.

34

The BGC-HCM director convened a group con-sisting of regional coordinators, a member of theclergy, church volunteers, and VDH staff to selectsuitable nutrition and weight loss managementprograms for the project. The group reviewedexisting programs and selected a locally developedprogram called TRIM. The group revised theTRIM materials and gave the program a newname because the old title was not an acronym foranything. The project staff felt that the programwould have more meaning if the letters represent-ed a relevant message—i.e., Taking Responsibilityin Meal Management (TRIMM). The workinggroup also selected an appropriate exercise videoto complement TRIMM.

The BGC-HCM director and the VDH nutrition education coordinator conducted the first TRIMM training session for regional coordinators and assistants. Shortly before theend of the project, regional coordinators begantraining local volunteers to lead TRIMM classes.So far, the volunteer leaders have conductedthree TRIMM classes with 100 participants.Twenty-two of the 100 participants lost weight.

The VDH and the BGC-HCM continue toimplement all phases of the project since theconclusion of their Stroke Belt Initiative fundingin September 1995.

35

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36

APPENDIX D

SAMPLE CONGREGATION SURVEY(ADAPTED FROM THE TENNESSEE STROKE BELT PROJECT)

Please take a few minutes and complete this survey. The information will be used to plan health activitiesfor the congregation and in the community. DO NOT PUT YOUR NAME ON THIS FORM.

(Family means mother, father, sister, brother, aunt, uncle, grandparents)

Yes No

1. Have you ever had a stroke? _____ _____

2. Has anyone in your family ever had a stroke? _____ _____

3. Do you have high blood pressure? _____ _____

4. Does anyone in your family have high blood pressure? _____ _____

5. Do you have diabetes? _____ _____

6. Does anyone in your family have diabetes? _____ _____

7. Do you smoke cigarettes? _____ _____

8. Are you overweight? _____ _____

9. Do you drink alcohol? _____ _____

10. Do you add salt to your food after it is cooked? _____ _____

11. Do you season your vegetables (e.g., greens, green beans)with salt pork, fat back, or bacon? _____ _____

12. BEFORE TODAY, did you know that there are ways youcan reduce your risk of stroke? _____ _____

General Information

Age: _____ Sex: ___Male ___Female ZIP Code: _____________

37

APPENDIX E

NHLBI EDUCATIONAL MATERIALS

The NHLBI Information Center is a service of theNational Heart, Lung, and Blood Institute(NHLBI) of the National Institutes of Health.The Information Center provides information tohealth professionals, patients, and the publicabout the treatment, diagnosis, and preventionof heart, lung, and blood diseases.

NHLBI Information CenterP.O. Box 30105Bethesda, MD 20824-0105Telephone: (301) 251-1222Fax: (301) 251-1223

In addition, the National Heart, Lung, andBlood Institute maintains a World Wide Web(WWW) site at:http://www.nhlbi.nih.gov/nhlbi/nhlbi.htm

The publications listed below are available onthe NHLBI web site. To obtain printed copies ofthese publications, contact the NHLBIInformation Center for price and availability.

#55-745Colección de Ocho Folletos Fáciles de LeerSobre las Enfermedades del Corazón (Package of Eight Easy-To-Read BilingualBooklets in Spanish and English on PreventingHeart Disease)

Take Steps—Prevent High Blood Pressure

Cut Down on Salt and Sodium

Learn Your Cholesterol Number

Protect Your Heart—Lower Your BloodCholesterol

Watch Your Weight

Cut Down on Fat—Not Taste

Stay Active and Feel Better

Kick the Smoking Habit

#97-4050De Corazón a Corazón: Guía para Organizaruna Charla Sobre la Salud del Corazón (From Heart to Heart: A Heart-Health GroupDiscussion Guide)

#96-4049Libro de Recetas: Platillos latinos ¡sabrosos ysaludables!(Delicious Heart-Healthy Latino Recipes)

#55-832Package of Seven Easy-To-Read Booklets onCoronary Heart Disease in African Americans

Stay Physically Active—Energize Yourself!

Eat Less Salt and Sodium—Spice Up YourLife!

Lose Weight If You Are Overweight—EmbraceYour Health!

Prevent High Blood Pressure—Protect YourHeart!

Learn Your Cholesterol Number—EmpowerYourself!

Eat Foods Lower in Saturated Fats andCholesterol—Be Heart Smart!

Stop Smoking—Refresh Yourself!

#97-3792African American Heart Healthy Recipes

Discrimination Prohibited:Under provisions of applicablepublic laws enacted by Congresssince 1964, no person in theUnited States shall, on thegrounds of race, color, nationalorigin, handicap, or age, beexcluded from participation in,be denied the benefits of, or besubjected to discriminationunder any program or activity(or, on the basis of sex, withrespect to any education programor activity) receiving Federalfinancial assistance. In addition,Executive Order 11141 prohibitsdiscrimination on the basis ofage by contractors andsubcontractors in the perfor-mance of Federal contracts, andExecutive Order 11246 statesthat no federally funded contrac-tor may discriminate against any employee or applicant foremployment because of race,color, religion, sex, or nationalorigin. Therefore, the NationalHeart, Lung, and Blood Instituemust be operated in compliancewith these laws and ExecutiveOrders.

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Public Health ServiceNational Institutes of HealthNational Heart, Lung, and Blood Institute

NIH Publication No. 97-4058July 1997