PROGRAM PRIORITIZATION TO CONTROL CHRONIC DISEASES: METHODS
Project DIRECT
Project DIRECT (Diabetes Interventions Reaching and Educating Communities Together), is a community-based demonstration project first funded by the Centers for Disease Control and Prevention in 1993. Its overarching goal was to reduce the burden of diabetes among African Americans in southeast Raleigh, NC. Recruitment and intervention methods for the parent project are detailed else-where. Briefly, community leaders from a predominantly middle- and upper-middle class African-American community in southeast Raleigh, NC, formed a committee to spearhead diabetes control activities in the community. Using the PRECEDE-PROCEDE model to plan the intervention, predisposing, reinforcing, and enabling factors related to chronic disease prevention were identified through formative focus group discussions. The resulting intervention focused on three main areas: a) primary prevention through community-based health promotion aimed at improving diet and physical activity; b) secondary prevention through outreach education to improve diabetes awareness, screening to detect undiagnosed diabetes, and case management to ensure that diabetics not receiving continual care were integrated into the healthcare system; and c) tertiary prevention through diabetes care and education aimed at physicians to improve the quality of diabetes care received within the healthcare system. These objectives were achieved through mass diabetes screenings, media campaigns, and community outreach activities in southeast Raleigh.
Four years after launching Project DIRECT, congregation leaders continued to be inundated with requests from local research organizations, including universities, to participate in health-promotion-related activities. In order to help them to systematically select programs most beneficial to their congregations, the authors sought to provide the leadership with technical skills that enabled them to assess their health needs using a semistructured questionnaire, the Congregation Health Assessment Tool (CHAT). Based on needs identified using CHAT, the authors provided the leadership with skills to analyze the data, as well as prioritize, plan, and implement health-promotion programs tailored to benefit their congregations based on the Congregation Health Action Plan (CHAP). canadian pharmacy cialis
Recruitment of the Congregation Leadership
In January 1997, a list of all congregations (n=41) that met in southeast Raleigh, NC, was compiled by a congregation leader who served as the community representative for the intervention. Between January 1997 and December 1999, baseline interviews and educational activities directed at congregation leaders were conducted. All respondents were contacted by one of the investigators to schedule an appointment to discuss and complete the CHAT. Respondents’ titles ranged from congregation leaders, secretaries, and health-committee leaders to congregation-designated, long-term members of congregations—the choice of respondent depended on the capacity of the person to make health-related program decisions in the congregation. In smaller congregations, congregation leaders tended to be the respondents, whereas in large-and medium-sized congregations, members other than the head of the congregation tended to be responsible for health affairs, and, hence, were more appropriate respondents. On the day of the interview, the investigator who scheduled the appointment met with the congregation representative at the place of worship or other place of the respondent’s choice. All but two respondents from large congregations met at the place of worship. Recruitment and interview strategies used were approved by the Institutional Review Boards of the Centers for Disease Control, North Carolina Department of Health and Human Services, and North Carolina Central University.
Baseline Data Collection
The CHAT was a semistructured, in-person interview administered during a one-to-two-hour session. The structured aspect of the interview comprised questions on the demographic composition of the congregation (i.e., age, sex, and whether congregations drew their memberships from within the catchment area of the parent project). Using Likert-scale response options, other questions elicited information about membership stability and the leadership’s opinions on barriers and enablers to healthful lifestyles. Lifestyle-related barriers included in the questionnaire related to mental health, chronic diseases, psychosocial stress, other health concerns, and the congregation’s understanding of disease prevention, faith, and healing. The open-ended aspect of the interview included questions on the availability of enabling factors, such as human and infrastructural resources, the congregation had at its disposal. Following the interview, a member of the project team summarized the information and made explicit health-promotion recommendations that were shared with a multidisciplinary congregation review team (CRT). The CRT consisted of a nutritionist, nurse, physician, health educator, clergy person, and a Project-DIRECT board member, all of whom were residents of southeast Raleigh. For example, for a congregation reporting heart disease as a major concern, recommendations made and reviewed by the CRT would include addressing known risk factors, such as low physical activity and a diet high in fat, followed by identification of nutrition or exercise programs available locally The CRT would then recommend launching new programs or identify existing ones, demonstrating low-fat cooking strategies and/or community walking or an aerobic exercise program to increase physical activity convenient to congregation members. These recommendations were either accepted or modified by the congregation who then adopted a CHAP (the plan) focusing on one or two interventions to address their priorities. Twenty-one of the 41 eligible congregations agreed to be interviewed using the CHAT and adopt a health-promotion plan (CHAP). While 20 represented several Christian denominations, one was Islamic.
Follow-Up Survey
In 2002, all 21 congregations who participated at baseline were contacted to determine whether health needs identified three-to-five years prior, remained important to the congregation. Participants were also asked whether the CHAP had been implemented in their respective congregations. All but two large congregation leaders interviewed were the same individuals interviewed at baseline. online pharmacy no prescription
Statistical Analyses
Database management and analyses of quantitative data were conducted in Microsoft Excel. However, because the unit of analyses was the congregation (n=21), it was possible to analyze text fields manually. The size of the congregation membership has previously been used as a proxy indicator for the socioeconomic well-being of African-American congregations. Hence, analyses presented are categorized by congregation size: small, medium, or large. For these analyses, congregations with a membership under 300 were categorized as small, those with a membership between 300 and 599 were categorized as medium, and those with 600 or more members were considered large. Frequencies and ranks were used for analyses.
