PROGRAM PRIORITIZATION TO CONTROL CHRONIC DISEASES: DISCUSSION
Although state and national health statistics ranked noninsulin-dependent diabetes mellitus as the most prevalent chronic disease among American adults—with African Americans disproportionately affected—and despite a community-based diabetes intervention effort that included mass screening and education initiated four years prior—none of the congregation leadership had ranked it as important at baseline. However, following an education providing the leadership with skills to prioritize health needs and plan health-promotion activities most beneficial to their congregations, diabetes was identified as the most serious health concern threatening the well-being of large- and medium-sized congregations. Moreover, most of the leaders had taken advantage of resources available, including Project DIRECT, within their own congregations and in the community to decrease the prevalence of known risk factors.
The coexistence of a parent project, Project DIRECT, whose objective was to reduce the burden of diabetes in this community, may mask the effect of our intervention since increased awareness among the congregation leadership could plausibly be attributed to the effects of the parent project. This is, however, unlikely since in 1997, four years after the parent project was launched, the congregation leadership did not perceive diabetes as an important health concern as would be expected if changes in perception were due to the parent project. Although a cause-and-effect relationship cannot be established, this suggests that observed changes in perception about diabetes were likely a result of the leadership’s ability to assess their congregation needs. Also, because three-to-five years elapsed between leadership education on health needs assessment and the follow-up assessment, it is possible that congregational attitudes may have changed to reflect the importance of diabetes in 2002, independent of our education program. For ethical reasons, this evaluation was not designed with a control group of congregations to which comparisons could be made. In small congregations, diabetes was not perceived to be an important health concern, despite a link between this disease and lower socioeconomic status. This finding suggests that in smaller congregations educating the leadership directed intervention efforts to arthritis and communication problems, as evidenced by the uptake of exercise and counseling activities. Nonetheless, while changes in the prevalence of risk factors (such as low physical activity, obesity, and diets high in fat) as well as chronic diseases (such as diabetes, heart disease, and arthritis) were not measured between 1997 and 2002, these findings strongly suggest that the congregation leadership with skills to prioritize health-promotion activities will make informed decisions before adopting those most beneficial to their membership. tadacip 20 mg
The efficacy of specific researcher-initiated health-promotion activities has been repeatedly demonstrated, at least for the duration of intervention projects. However, to our knowledge, this is the first demonstration project to show the effectiveness of an education geared towards providing needs-assessment skills to the congregation leadership and detecting a sizable change in prioritization years after cessation of the intervention. The advantage of involving the congregation leadership lies in its efficiency at reaching the African-American population, since the congregation tends to be the center of spiritual and nonspiritual activity in most African-American communities. Consequently, the congregation leadership has the capacity to recruit and influence behavioral change in a large number of hard-to-reach populations with little in the form of additional resources. It is, therefore, prudent for researchers to involve the leadership in a meaningful way. These data confirm and extend findings of earlier studies suggesting that communities tend to incorporate health behavioral changes when they perceive the proposed changes to be efficacious and are confident that support will continue to be available. In a study aimed at decreasing the risk of colorectal cancer among African Americans in congregations that received health information on risk factors, Resnicow reported an increase in the adoption of diet changes. However, this occurred only after the congregation leadership was convinced that the membership was at risk and that self-help cooking materials were available.
The limitation of this evaluation is the differential rates of loss to follow-up among congregations. At baseline, 21 of the 41 congregations identified agreed to be interviewed. They also committed to adopt a method of prioritizing their health concerns using the CHAT and to utilize available community resources. However, most of the congregations that refused to participate tended to be very small, female-headed congregations, with no building for a congregation home and presumably of lower socioeconomic status. Such lack of participation is concerning, since the effectiveness of the CHAT and CHAP strategy has been shown mainly in larger, generally male-headed congregations. These differential losses suggest that while African-American congregations are convenient and perhaps compliant recruitment sources, the results obtained from observational or intervention studies are likely not general-izable since nonparticipation is not independent of socioeconomic status (or congregation size) and other risk factors. This finding may explain, at least in part, the slow pace at which behavioral changes are adopted and subsequent disparities persist, despite documented successful intervention efforts. online pharmacy no prescription
Of the 21 congregations that participated at baseline, 14 agreed to a follow-up interview, and again, smaller congregations, who also reported financial difficulties at baseline, were more than two times more likely to be lost to follow-up than the larger congregations. Although loss to follow-up is to be expected among congregations with no physical building, this underscores the problem of selection bias associated with differential follow-up rates. The problem of loss to follow-up in this demonstration project was exacerbated by the small sample size of congregations that agreed to participate. In this and previous studies, congregation size was used as proxy indicators for socioeconomic status. While categorization based on congregation size may appear arbitrary, it has been shown to be a robust proxy for the socioeconomic well-being of congregants. In these analyses, congregational financial difficulties, as reported by the leadership, were highly correlated with congregation size (data not shown).
In summary, decreasing disparities between African Americans and Caucasians will require a continuation of health education efforts. While the African-American congregation can be a powerful vehicle by which health needs are assessed and tailored health programs are implemented, perceptions of the leadership—the enablers—will likely change if they are provided the skills to assess health needs and prioritize intervention activities for their congregations. However, these findings may not be generaliz-able to populations that patronize smaller congregations, because the leadership is difficult to reach and less likely to participate in needs-assessment activities. Populations who patronize smaller congregations may also represent a lower socioeconomic status and perhaps a higher risk group. Future work in this area should explore ways in which smaller congregations can be effectively recruited and provided with needs assessment and prioritization skills that will be most beneficial to members of their congregations. We have shown that availability of information can change risk perceptions in the leadership of larger congregations.
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