HEALS: A Faith-Based Hypertension Control and Prevention Program for African American Churches: Training of Church Leaders as Program Interventionists.

Abstract

Background. A 12-session church-based HEALS program (healthy eating and living spiritually) was developed for hypertension control and prevention program in African Americans (AAs). This study presents specifics of training lay health educators to effectively deliver HEALS to high-risk AAs. Methods. A one-day workshop was conducted by the research experts in an AA church. Five church members were recruited to be program interventionists called church health counselors (CHCs). Results. Using principles of adult education, a training protocol was developed with the intention of recognizing and supporting CHCs skills. CHCs received training on delivering HEALS program. The process of training emphasized action methods including role playing and hands-on experience with diet portion measurements. Conclusion. With adequate training, the community lay health educator can be an essential partner in a community-based hypertension control programs. This may motivate program participants more and encourages the individual to make the behavior modifications on a permanent basis.

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SAGE-Hindawi Access to Research
International Journal of Hypertension
Volume 2011, Article ID 820101, 7 pages
doi:10.4061/2011/820101
Research Article
HEALS: AFaith-Based HypertensionControl andPrevention
Program forAfricanAmericanChurches:Trainingof Church
Leadersas Program Interventionists
SunitaDodani,1DebraSullivan,2Sydney Pankey,3and CatherineChampagne4
1Center for Post Polio Rehabilitation (A Nonprofit Organization), 2308 W, 127 Street, Leawood, KS 66209, USA
2Department of Nutrition, University of Kansas Medical Center, Kansas City, KS 66103, USA
3Department of Preventive Medicine, University of Kansas Medical Center, Kansas City, KS 66103, USA
4Pennington BioMedical Research Center, Baton Rouge, LA 70808-4124, USA
Correspondence should be addressed to Sunita Dodani, soni.dodani@gmail.com
Received 27 February 2011; Accepted 17 March 2011
Academic Editor: Samy I. McFarlane
Copyright © 2011 Sunita Dodani et al. This isan openaccess article distributedunder theCreative CommonsAttributionLicense,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Background. A 12-session church-based HEALS program (healthy eating and living spiritually) was developed for hypertension
control and prevention program in African Americans (AAs). This study presents specifics of training lay health educators to
effectively deliver HEALS to high-risk AAs. Methods. A one-day workshop was conducted by the research experts in an AA church.
Five church members were recruited to be program interventionists called church health counselors (CHCs). Results. Using
principles of adult education, a training protocol was developed with the intention of recognizing and supporting CHCs skills.
CHCs received training on delivering HEALS program. The process of training emphasized action methods including role playing
andhands-onexperiencewithdietportionmeasurements. Conclusion.Withadequatetraining,thecommunitylayhealtheducator
can be an essential partner in a community-based hypertension control programs. This may motivate program participants more
and encourages the individual to make the behavior modifications on a permanent basis.
1.Introduction
Hypertension (known as the “silent killer”) prevalence is
highly variable among populations worldwide. In the US,
there is a disproportionate burden of hypertension and its
complications in African Americans (AAs) [1]. Not only are
AAs more likely to suffer from hypertension than are whites,
but they also experience a higher complication rate, greater
severity, and earlier disease onset. From 1988–1994 to 1999–
2002,theprevalenceofhypertensioninadultsincreasedfrom
35.8% to 41.4% among AAs, and it was particularly high
among AA women, at 44.0% compared to 28.1% in whites
[2]. Hypertension is more common in middle-aged or older,
less-educated, overweight or obese, and physically inactive
AAs [3]. As a result, compared with whites, AAs have a 1.3-
times greater rate of nonfatal stroke, a 1.8-times greater rate
of fatal stroke, a 1.5-times greater rate of heart disease death,
anda4.2-timesgreaterrateofend-stagekidneydisease[4,5].
Many AAs, however, remain unaware of their blood pressure
status [5].
It is common, asymptomatic, readily detectable, and eas-
ily treatable. Yet it burdens our economy substantially. Hy-
pertension is the most common primary diagnosis in the
US and accounts for over 38 million office visits per year
[6]. Most patients will require two or more antihypertensive
medications to achieve the goal of blood pressure less than
140/90 or 130/80 for patients with diabetes or kidney disease
[7, 8]. Poor adherence to medication regimens is a common
problem with AAs who have hypertension, perhaps because
it is often asymptomatic in the early stages [9]. A high-cost
prescription can further decrease adherence to antihyperten-
sive medications. Therefore, emphasis on disease prevention
and control are the primary means by which we can begin
to reign in unnecessary medical expenditures and promote a
healthier society.
Besides medications, lifestyle interventions are also effec-
tive in lowering blood pressure (BP), and the “dietary ap-
proach to stop hypertension” (DASH) diet has been shown
to lower systolic BP (SBP) by 6–14mmHg, equivalent to
one antihypertensive agents [10]. However, in the PREMIER

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2International Journal of Hypertension
trial, DASH with lifestyle modifications was less effective in
AAs with regard to BP lowering effects [11].
Ithasbeenshownthatpromotingtheadoptionofhealthy
lifestyles, ones that involve best practices of diet and exercise
and abundant expert support, can, in a healthcare setting,
reduce the incidence of hypertension in those who are
at high risk and as well to its control [11]. Using faith-
based settings and adopting community-based participatory
research (CBPR) approach, especially for AAs, hypertension
control programs can be developed and offered by faith-
communities. For a number of years, there has been a trend
to have lay health leaders rather than health professional to
deliver health promotion and disease prevention programs
to hard-to-reach community [12]. Normally, these lay edu-
cators are residents of the same communities in which they
conduct the program. There are several strengths to using lay
health educators/advisors (supported by experts and church
pastors)indeliveringCBPRprograms:(i)theyareacceptable
to hard-to-reach community residents, (ii) they provide a
ready support network, (iii) they serve as efficacious peer
models, (iv) they promote community ownership, and (v)
they are cost-effective [12]. Many members of AAs churches
may have significant experience dealing with people who
have hypertension as patients or as caregivers to relatives
and friends. The potential for developing church health
counselors (CHCs) who devote their time to hypertension
preventionandmanagementremainsvirtuallyuntappedand
is a potential future offshoot of this effort. The idea of having
the church health leaders educate and support at-risk and
healthy individuals and not just pray for the sick is consistent
with the CHC model.
We have developed HEALS (healthy eating and living
spiritually), a hypertension control and prevention program
with the help of the AA community, CBPR experts and com-
munity advisory board (CAB) input. HEALS has been modi-
fied from the DASH [10] and PREMIER [11] studies. Results
of focus groups and program development will be published
elsewhere. HEALS program, a church-based approach, if
successful, may be utilized to reduce the incidence and
consequences of hypertension in large communities with
potentially huge impact on public health by implementation
in community settings such as church venues.
The sizeable AA communities in the Kansas City Metro
area (Kansas and Missouri) make it an ideal population in
which to implement a hypertension control and prevention
program. For this reason, we have proposed the implemen-
tation of a faith-based hypertension control and prevention
program be piloted in a small Kansas City church.
Lay health educators have been used successfully in a
wide range of community settings and with a variety of tar-
geted health issues. For example, lay health educators were
usedinFitBodyandSoulstudy[12],ProjectJoy[13],PATH-
WAYS [14], Pawtucket Heart Health Program [15], Stanford
FiveCityProject[16],andmanymore.TheproposedHEALS
is a multilevel CBPR intervention for hypertension control
and management of high risk AAs in churches. The program
started in different phases [13, 14]. An abundance of liter-
ature exists on the outcome of community based health
promotions programs that use community lay educators as
interventionists. However, very little has been published on
the specifics of training lay health educators to effectively
delivercommunity-basedprograms.Theobjectiveofcurrent
study is to share the experience of training church lay health
educators as HEALS interventionists who will deliver a 12-
session program under the supervision of the research team
and DASH and PREMIER experts.
2.MaterialsandMethods
This was a one-day workshop conducted by the research
team members and experts of DASH and PREMIER studies
at the Allen Chapel A.M.E. church in Kansas City, Kansas.
For this pilot study, the 200 member Allen Chapel A.M.E.
was selected for several reasons (i) members having lower or
middle lower socioeconomic and demographic characteris-
tics,(ii)ahighlevelofinterestintheproject,(iii)existenceof
a health awareness programs within the church, (iv) Church
is part of university community advisory board (CAB), and
(v) PI’s existing relationship with the church pastor. The
church pastor was asked to nominate at least 4-5 health
ministers who are at least 25 years old, preferably belonging
to the health profession, have effective communication skills,
and are willing to make a 6 month commitment to the
study. There were no requirements for the prior training
in health education or in health care, but the importance
of church-based lay health educators being viewed as role
models among program participants was emphasized. Five
church members were recruited and were called church
health counselors (CHCs). All five CHCs (four females and
one male) are usually known “influence leaders” who were
highly respected in the church and often included in the
major church decisions. CHCs ranged in age from 35 to
63 years (average age=50 years) one of the CHCs had
nursing experience however, none had any formal training
or experience in conducting small group faith-based lifestyle
program. All five received the HEALS program training
(described below) and are part of the church advisory panel.
Because of their time commitment, CHCs are provided with
a small stipend to offset their out-of-pocket expenses and to
serve as an incentive for participating in the study. The focus
group meetings were held prior to the start of the project.
The church pastor and five CHCs with the PI discussed
the project concept, set an outline of activities, and marked
dates for all activities. Because of the pilot nature of this
study, power analysis was not conducted and a convenience
sample of 20–25 overweight or obese church members who
are either high risk for hypertension (with high normal and
stage 1 hypertension) and/or are known hypertensive’s will
be enrolled in the study after screening. For this study, all
participants are members of Allen Chapel A.M.E. church.
Before describing the experiences of training CHCs, we
briefly discuss here the community advisory board (CAB).
3.HealthDisparityCommunity
AdvisoryBoard (CAB)
The Kansas University Medical Center (KUMC) under the
leadership of the Dr. Dodani established a Health Disparities

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International Journal of Hypertension3
Community Advisory Board (CAB), funded by the KUMC-
Department of Internal Medicine and Center for Out-
come Research and Education (CORE)—http://www2.kumc
.edu/internalmedicine/.
The 45 member CAB has more than 70% representa-
tion of AA communities. In addition, CAB also includes
(i) other ethnic minority representation, (ii) local pub-
lic/private/government organizations serving low-income
ethnic minority groups, (iii) churches, and (iv) non-profit
organizations. The primary functions of the CAB are to (1)
identify health issues from the perspective of community
members, (2) promote communication among commu-
nity leaders and researchers, (3) promote partnership and
ownership by community members in research projects
that involve, and have an impact on, the overall health
of the AA community, and (4) bring together community
leaders and researchers to design, implement, and evaluate
culturally sensitive, practical research projects. The CAB
already provided significant input and oversight towards the
development of the current application. In addition, CAB
(majority AA members) participated in the HEALS program
development and provided appropriate bible scripture for
the program sessions [12]. Indeed, the CAB perceives
the faith-based settings as having the strongest and most
credible influences among AAs in the community. During
theproposedstudy,theCABwillcontinuetomeetonaverage
3-4 times per year and play a critical role in promoting
mutual understanding and cooperation between researchers
and participant community members. The CAB will also
strongly encourage and develop long-term commitments
to various health-promoting activities that will be self-
sustained by the participants in the study, thereby improving
the overall health of the AA community far beyond those
achieved by merely participating in the study. In this regard,
in close collaboration with the researchers, the CAB will
develop various potential strategies of sustainable life-style
modifications that can be applied to this unique setting of
AA community.
4.Development of 12-Session HEALSProgram
Briefly, the HEALS is a small-group, behavior-oriented hy-
pertensioncontrolandpreventionprogramtargetedforhigh
risk AA church members who are either at the risk of future
hypertension (those with high normal blood pressure or
stageIhypertension)forthosewhoareknownhypertensives.
HEALS is a faith-based hypertension control and prevention
intervention, developed using CBPR approaches and input
from members of AAs churches; it was developed during
a multistep process and was approved by the University
of Kansas Medical Center institutional review board. The
basis of the HEALS was DASH (a feeding study-clinical
trial) and PREMIER (an 18-lifestyle-month) intervention
which focused on the DASH dietary pattern [11]. Sessions
of PREMIER were modified with modification of DASH
diet to make a culturally appropriate diet plan without
compromising the integrity of DASH caloric contents. Faith-
based strategies of Fit Body and Soul [12] were used to
addfaithcomponentsinthemultilevelHEALSchurch-based
program. Members of the original DASH and PREMIER
lifestyle team and CAB active members from more than 10
churcheswereinvolvedinthemodificationanddevelopment
of the program. This group of church leaders and experts
modified the PREMIER sessions, using the experiences of
the Fit Body and Soul study [12] and input from the CAB
advisory panel. They developed the 12-session faith-and
culture-based program for the participants in the study (the
full program can be provided upon request). The HEALS
program was formed within a spiritual framework. Working
with the advisory board of church leaders, we facilitated
the development of the content and design of the manual.
Board members selected the spiritual themes and scripture
to frame the 3 themes of the intervention—weight loss,
increased PA, behavioral change—and wrote messages to be
included in the manual. The spirituality was seen as a source
of emotional support, a positive influence on health, and
contributing to life satisfaction. Overall feedback from the
advisory panel and 3-4 focus groups regarding this multi-
level, spirituality-based, behavioral lifestyle intervention for
AA congregations was generally consistent, showing strong
preferences for design and content. In order to achieve
outcomes and goals (Table 1), the multi-level spiritually
based HEALS behavioral lifestyle intervention was designed
to be delivered using three different approaches: church level
(led by pastor); group level (led by CHCs), and individual
level approach (led by CHCs).
5.Results and Discussion
5.1. CHCs Training Workshop on HEALS Program. The
purpose of this training workshop was to familiarize CHSs
with all HEALS material as well as appropriate intervention
measures.Themodelfordevelopingandconductingtraining
was based on the principles of adult education [17]. Adult
learners bring to training a wealth of experience and well-
developed skills. As such, the training of adult learners
should reinforce and expand upon the learner’s prior
experience and direct existing skills to new applications. This
process of adult learning is facilitated by instruction that
is goal oriented and personally relevant to the learner one
that actively involves the learner in role playing and other
learningexercisesandthataffordsfrequentfeedback.Ablend
of lecture, hands-on practice, in person demonstrations, and
other methodologies consistent with adult learning theories
were employed as teaching techniques. CHCs received the
program manual guides, checklist protocols, and the ratio-
nale behind these approaches. These key features of adult
learning were emphasized in the training program.
The learning objectives of the workshop were to
(1) understand the importance of the HEALS program
and its intended outcome,
(2) have knowledge of healthy meals and how to prepare
them with understanding of calory counts,
(3) understandtheimportanceofproperdocumentation
and completion of instruments for diet recalls, phys-
ical activity, and other questionnaires,

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4International Journal of Hypertension
Table 1: HEALS Goals at 3 levels: (1) Church, (2) Group, (3) Individual.
HEALS
Recommend
Intervention
emphasis
Self monitoring Outcome assessment
Blood pressure
Systolic ≥4mmHg.
Diastolic ≥2mmHg.
150min/wk
≤100mmol/d
≤1oz/d-female
≤0.5oz/d-male
≥5lbs loss at 15 months
Individualized
≤25%
≤7%
7–9 servings
2-3 servings
YesYes
BP measurement at 3 and 12
month after intervention
7-day activity recall
24-hr recall
Physical activity
Sodium
Yes
Yes
Yes
Yes
Alcohol
YesNoAlcohol questionnaire
Weight∗
Total calory
% Kcal fat
% Kcal sat fat
Fruits+vegetables
Dairy
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
Weight at 12 weeks
24-hr diet recall
24-hr diet recall
24-hr diet recall
Food groups from 24-hr recalls
Food groups form 24-hr recall
∗Weight loss recommended only for those with BMI≥25, daily number of servings adjusted for individual caloric intake.
(4) know how to take blood pressure, height, weight,
pedometer readings, waist circumference, and BMI
measurementsandrecordinparticipants’dataforms,
(5) maintain log dairies,
(6) understand barriers to and provide acceptable solu-
tions to study participants on maintaining a healthy
lifestyle.
This one-day workshop was conducted at the Allen
Chapel A.M.E. church in the Kansas City, Kansas. Within
the church, all 5 CHCs were provided a one-time (approx
8hrs) formal training. Training sessions were conducted by
research experts including a PREMIER and DASH investiga-
tors with background in behavioral education, psychology,
nutrition, and faith-based CBPR programs (Figure 1). The
training protocol was developed with the intention of
recognizing and supporting our CHCs existing skills and
experiences. The process of training emphasized action
methods including simulation, role playing, and hands-on
experience with diet portion measurements.
In the first session (by study PI), the project overview,
timelines, CHCs responsibilities and the roles of research
team were clarified. The clarification of roles and respon-
sibilities served to establish a collaborative partnership and
positioning university project personnel in a supportive role
while affording each CHC the opportunity with autonomy
and at the same time be supervised by the research team
within the parameters of study protocol. In these negotiation
roles,eachCHChadasignificantinputonanumberofissues
including program session timings, program scheduling,
design of participant recruitment activities, and materials.
Thefirstsessionalsoincludedtheoverviewofthephilosophy
of HEALS program, the importance of faith-based approach,
behavioral goal setting, and the importance of multilevel
approach:church,group,andindividuallevel.AllCHCswere
provided with the copies of HEALS manual which included
learning objectives of each session, instructors scripts, and
participants materials for all 12 sessions.
After reviewing the overall objectives and goals of
HEALSprogram,thePREMIERandDASHteaminvestigator
presentedtheoverallobjectivesofeachofthe12sessionswith
emphasis on the approach, method of delivery and outcome
measures. A majority of the emphasis was made on the
achievementofhealthybehaviorsandhowtomaintainthem.
CHCs discussed some of eating habits in the church settings
and provided examples how those habits could be modified
into healthy eating. Enough time was provided to CHCs to
make sure they understood the basics of each session and
received clarification. CHCs also brainstormed on strategies
forrecruitingprogramparticipantsfromamongtheirchurch
congregation and neighboring communities. CHCs then
practiced conducting HEALS session and received feedback,
guidance and tips from the research team members.
The third session was conducted by the research team
nutritionists (study coinvestigator) who introduced CHCs
to different types of foods, food servings, calory content
measurement method, measurement of portion sizes, and
the importance of portion of fat, carbohydrates, proteins,
and vitamins in making meal menus (Figure 2). The CHCs
also performed some hands-on exercises by role playing.
The use of role playing method in the training provided
them with the type of challenging questions and group
scenariosthattheywouldlikelyencounter,basedontheprior
program experience of the research team. These included
easy methods of measuring portion sizes, how to read and
understand food labels, knowledge of alternative foods to
reduce fat intake, helping participants set reasonable goals,
and promoting self-efficacy for behavior change. The hands-
on exercises also encouraged team building among the
CHCs through shared session preparation and planning and
allowed for self-evaluation and constructive feedback from
their fellow CHCs and research team.
Finally, CHCs were briefed about methods and protocols
of anthropometric measurements. All CHCs also received
refresher training before the screening kickoff event and
CHCs practiced taking anthropometric measurements on

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International Journal of Hypertension5
Figure 1: HEALS Team with CHCs (from left to right front row).
Alexis Belcher (CHC), Ivey Brown (CHC) Catherine Champagne
(study Co-I), and Sunita Dodani Debra Sullivan (study PI). Back
row: Debra Sullivan (study Co-I), Thaerius Berry (CHC), Sydny
Pankey (study coordinator), and Vera Brown (CHC).
Figure2:Demonstrationoffoodservingsandcalorycontentmeas-
urement method.
eachother, aswellas on researchteam members.In addition,
CHCs continued role playing and reviewing HEALS sessions
in order to have a full understanding of the program. CHCs
received feedback from the research team designed in such
a way that it was both collaborative and constructive while
allaying any potential for embarrassment and defensiveness.
In addition to conducting program sessions under the
supervision of experts, CHCs were asked to be responsible
for a number of activities involved in operating the program
therefore,cleardemonstrationandeducationrelatedtoother
activities were also included in the training. These respon-
sibilities included, but were not limited to (a) publicity and
awarenessoftheprogramwithinthechurch,(b)participants’
recruitment from the church, (c) scheduling sessions and
notifying participants of meetings, (d) planning, organizing
and conducting the 12 program sessions, (e) making weekly
calls to participants for followup, diary check, and providing
solutions to any barriers towards achieving program goals,
and(f)maintainingfollow-upcontactswithanyparticipants
who missed session/s. The research team served as the source
of information and advice to the CHCs throughout the
program activities. More practice time and skill testing with
standardized checklist protocols were incorporated in other
church/program-related activities, for example, screening
and participant recruitment events.
5.2. Discussion. With cardiovascular disease the leading
cause of death and disability in the US, economically feasible
and effective methods of prevention are needed. Despite
more than 30 years of intense activity to improve control
and more recently prevention, high blood pressure (hyper-
tension) continues to be a major public health problem.
Evidence-based reviews have identified best practices and
quality-improvement strategies to address prevention and
control [5]. Since the 1970s, community-based programs
have been instrumental in raising awareness, increasing
knowledge, and promoting changes in health behavior to
improve blood pressure control. Most of these programs
have emphasized the use of partnerships and involvement of
community residents in conducting screening and referral
activities, implementing clinical practice guidelines, and
increasing healthy eating and physical activity. Many have
also used health care team approaches, including the use
of trained community health workers to deliver targeted,
culturally sensitive health education, particularly related
to the prevention of cardiovascular disease risk factors in
general and hypertension in particular.
Health education programs that target hard-to-reach
communities are often delivered by lay community persons
who are trained to serve as lay health educators. While these
community lay health educators bring a number of strengths
to CBPR programs, the effectiveness of these volunteer-
delivered programs in community and church settings
is to large extent dependent upon the training afforded
to the lay health educators. Without the proper training
and practice, the delivery of the program and anticipated
outcomes may be unnecessarily compromised. The amount
and type of training required for the church-based lay
health educators to reliably and effectively implement a
faith-based hypertension control and prevention program
are likely to be affected by several factors. Some of the
important factors are (a) the complexity of the targeted
health behaviors, (b) full understanding of the program
participants and community, (c) the specialized knowledge
and skills required to implement the program, and (d)
relative independence of the community health educators
to implement the program. Unfortunately, the literature
on lay health educator’s training often fails to discuss the
specifics of training and/or importance of training. This
paperwasanattempttoshedlightonspecificcomponentsof
training HEALS program lay health educators called CHCs
(church health counselors). This paper also describes the
training used to prepare church-based CHCs to conduct
HEALShypertensioncontrolandpreventionhealthylifestyle
program, modified from DASH and PREMIER studies to