National Heart, Lung, and Blood InstituteStroke Belt Initiative 1 Belt Initiative

Project Accomplishments and Lessons Learned Overview

Cerebrovascular disease or stroke is the northern border of the Southeast cluster. third leading cause of death in the United The NHLBI designated these 11 States as States. About 500,000 occur each the Stroke Belt. year, and about 150,000 result in death. NATIONAL Age-adjusted stroke deaths are higher in Similar to the national pattern, African HEART, and men. High blood American men and women in the Stroke LUNG, AND pressure has long been established as the Belt have higher death rates than white men BLOOD and women. White men and women in the INSTITUTE major risk factor for stroke. More recently, cigarette and obesity also have Stroke Belt also have a higher stroke death been found to be significant risk factors for rate than their counterparts in other regions stroke. of the country. Thus, the higher death rates in the Stroke Belt cannot be attributed solely Stroke mortality rates differ substantially by to the higher proportion of African Americans State. In the 1950s, epidemiologists docu­ in these States. mented the higher than average death rate from stroke among people living in the In fiscal year (FY) 1991, the NHLBI funded southeastern United States compared to 11 pilot projects through State health depart­ those living in other regions of the country. ments to reduce the risk of stroke in the Stroke Belt. These 1-year projects demon­ The National Heart, Lung, and Blood strated the capacity of the health depart­ Institute (NHLBI) examined the 1980 age- ments to design and implement approaches adjusted stroke mortality rates by State. to reduce risk factors in the community. Eleven States had stroke death rates that In FY 1994, the NHLBI funded the State were more than 10 percent higher than the health departments to deliver effective health U.S. average: , , , education interventions, using the methods , , , , and materials from the pilot projects, to , , , reduce the overall risk of stroke in the and . Ten of these States are in a Stroke Belt. contiguous cluster in the Southeast. Indi­ ana, the remaining State, is located on the These projects, which lasted 2 to 3 years, fell in one of four general education/interven­ tion categories: (1) interventions in health department clinics and outreach services, (2) church-based risk factor intervention programs, (3) community education and intervention programs, and (4) public education campaigns using the mass media. On May 9-10, 1996, the principal investiga­ tors and other key staff members of the Stroke Belt Initiative projects convened at Morgan State University in Baltimore, Mary­ land, to present their accomplishments and lessons learned. This document describes the accomplishments of the 11 projects of the Stroke Belt Initiative. ■

NATIONAL INSTITUTES OF HEALTH ● National Heart, Lung, and Blood Institute 2 Stroke Belt Initiative

Principal Investigators and Other Key Staff

Alabama Arkansas Robert R. Hafner, III, M.H.A., J.D. Barbara Hager, M.P.H. Director, Division Director, Division of Health Education Alabama Department of and Promotion 434 Monroe Street Arkansas Department of Health Montgomery, AL 36130-3017 4815 West Markham Street Little Rock, AR 72205-3867 Susan Bland Special Projects Coordinator Dwight Flanagan Hypertension Division SOS Coordinator Alabama Department of Public Health Arkansas Department of Health 434 Monroe Street 4815 West Markham Street Montgomery, AL 36130-3017 Little Rock, AR 72205-3867 Georgia Jerry Brown Program Manager Georgia Department of Human Resources 2 Peachtree Street, N.E., Room 6-515 Atlanta, GA 30303 Contents Shirley Thomas Physical Therapy Program Advisor Overview ...... Stroke and Heart Attack Prevention Program 1 Georgia Department of Human Resources 2 Peachtree Street, N.E., Room 6-500 Principal Investigators and Other Key Staff ...... 2 Atlanta, GA 30303 Features of the Stroke Belt Initiative Projects ...... 3 Indiana Roger McClain, M.P.H. (Retired) Alabama ...... 4 Director Division of Health Education Arkansas ...... Indiana State Board of Health 6 1330 West Michigan Street P.O. Box 1964 Georgia ...... 7 Indianapolis, IN 56206-1964 Indiana ...... 8 Teri Sinise, M.P.H. Chronic Disease Marion Health Department Kentucky ...... 10 3838 North Rural Street Indianapolis, IN 46205 Louisiana ...... 11 Kentucky Mississippi ...... 13 Carol Forbes Administrator North Carolina ...... 15 Kentucky Department of Health 275 East Main Street South Carolina...... 17 Frankfort, KY 40621 Tennessee...... 19 Louisiana Shirley Kirkconnell, M.P.H. Administrator, Adult Services Virginia ...... 21 Louisiana Department of Health and Hospitals P.O. Box 60630 Summary: Lessons Learned ...... 23 325 Loyola Avenue New Orleans, LA 70160 CHES Continuing Education Quiz ...... 24 Stroke Belt Initiative 3

Janice Burchell, R.N., B.S.N. Virginia Nursing Services Ramona Schaeffer, M.S.Ed. Louisiana Department of Health and Hospitals Director P.O. Box 60630 Division of Chronic Disease Control 325 Loyola Avenue, Room 605 Virginia Department of Health New Orleans, LA 70160 Main Street Station P.O. Box 2448, Room 242 Mississippi Richmond, VA 23218 Robert Travnicek, M.D. District Health Officer Jody Stones, M.Ed. Mississippi State Department of Health Health Education Coordinator Coastal Plains Public Health District IX Virginia Department of Health P.O. Box 3749 Main Street Station Gulfport, MS 39505 P.O. Box 2448, Room 242 Richmond, VA 23218 Patrysha Smith, R.N., B.S.N. District Hypertension Nurse Mississippi State Department of Health Coastal Plains Public Health District IX Features of the Stroke Belt P.O. Box 3749 Gulfport, MS 39505 Initiative Projects North Carolina Below is a quick summary of activities of the 11 Stroke Belt Brenda Motsinger, M.S. Initiative projects. Chief, Disease Prevention Section ■ Automated blood pressure measurement—Georgia and Division of Adult Health Mississippi North Carolina Department of Health P.O. Box 27687 ■ Coalition building—Arkansas, Georgia, and Tennessee Raleigh, NC 27611-7687 ■ Community health centers—Indiana South Carolina ■ Contests—Georgia and North Carolina Frances Wheeler, Ph.D. ■ Health care ministries or church teams—Louisiana, Director Tennessee, and Virginia Center for Health Promotion ■ Health fairs—Arkansas and Mississippi South Carolina Department of Health and Environmental Control ■ Heart-healthy cooking demonstrations—Louisiana, Robert Mills Complex, Box 101106 Tennessee, and Virginia Columbia, SC 29211 ■ Hypertension screening or education—Alabama, Arkansas, Sally Temple, M.S., R.D. Georgia, Indiana, Kentucky, Louisiana, Mississippi, North Director Carolina, South Carolina, Tennessee, and Virginia Division of Cardiovascular Health ■ education—Arkansas, Louisiana, North Carolina, Center for Health Promotion South Carolina Department of Health Tennessee, and Virginia and Environmental Control ■ Poster contests—North Carolina 2600 Bull Street ■ Columbia, SC 29201 Public service announcements—Georgia, North Carolina, South Carolina, and Tennessee Tennessee ■ Quality assurance audits—Alabama Connie Pearson, R.N., M.N. ■ Recipes—Louisiana Director, Prevention and Control Tennessee Department of Health ■ programs—Indiana, Kentucky, Louisiana, 426 5th Avenue, North, 6th Floor Tennessee, and Virginia Nashville, TN 37247-5210 ■ Training manual development—South Carolina, Tennessee, and Virginia ■ Video production—Georgia, Mississippi, Tennessee, and Virginia ■ programs—Louisiana, Tennessee, and Virginia ■ Youth mentors—Tennessee 4 Stroke Belt Initiative

Alabama

The Alabama Department of Public Health ments with low patient loads to increase (ADPH) used the Stroke Belt Initiative patient enrollment. Thus, more patients funding to improve and expand existing received an improved level of care. blood pressure detection, treatment, and followup interventions in health department The quality assurance audits were the clinics. Sixty-three out of 67 local health first line of the two-pronged strategy. The departments offered hypertension manage­ State established 17 clinical standards and ment services, including blood pressure 10 administrative/environmental standards monitoring, free or low-cost medication, for the care of hypertension. Quality assur­ and patient counseling and education. The ance teams visited the clinics and reviewed health departments offered these services patient charts for compliance with the to Alabama’s medically indigent population. 27 standards. The audit focused on defi­ To qualify for services, patients had to be ciencies, or the failure to meet standards. in a low income category and have a The audit team reviewed 10 randomly prescription from a physician that needed selected patient charts for compliance with to be renewed every 6 months. This ensured the 17 clinical standards and then rated the a joint relationship between the physicians clinic on the 10 administrative/environmental and the county health departments. standards. Therefore, the maximum number of deficiencies that a clinic could have was The ADPH employed two strategies to 180 (i.e., 10 times 17 clinical standards plus achieve its goal. During the pilot phase 10 administrative standards). (phase I), the State began a program of quality assurance audits to improve the level The county health departments were of care provided to patients with hyperten­ required to develop a plan of action to sion in local clinics. The quality assurance correct any standard that was more than audits continued during phase II. The 10 percent deficient (2 or more records out second strategy, patient recruitment and of 10). Counties with excessive deficiencies coordination, targeted county health depart­ (40 or more) received followup audits to determine if they had implemented their corrective plan of action. The team audited 42 counties during the pilot phase and 41 counties in the first 2 years of phase II. (Sixty-three out of 67 counties in the State participated.) Twenty-two of the original 42 counties received a second audit during the first year of phase II. A comparison of the 22 counties with two audits provided an early indication of the effect of the project. In the first audit (FY 1991), the 22 counties had a total of 547 deficiencies and averaged 24.9 per county. The number of deficiencies for each county ranged from 9 (5 percent) to 52 (24.9 percent). The 22 counties had a total of 482 deficien­ cies for an average of 22 (12.2 percent) deficiencies per county on the second audit (FY 1994) with deficiencies ranging between 5 (2.8 percent) and 42 (23.3 percent). Thus, Stroke Belt Initiative 5

the total number of deficiencies declined by to work with those from previous years. 65 (11.9 percent). The decline in the number Annual data on the results of this effort are of deficiencies did not reach statistical available for the counties targeted during significance (p=.15) but showed a trend in the first 2 years. the right direction and is possibly of public health importance. To evaluate the effectiveness of the effort, the ADPH compared the number of new A review of the deficiencies related to the patients registered in the clinic during the 17 clinical standards showed that deficien­ project with the number of new patients cies declined by 7.1 percent, from 510 to registered in the year before entry in the 474. The data showed that two standards project. This comparison was deemed accounted for more than 45 percent of the valid because the trend of new patients deficiencies on both audits. The two stan­ had been stagnant or declining since 1991. dards were: The four counties recruited during the first ■ the patient’s blood pressure was below year of the project had data for 2 years 140/90 mm Hg at the last clinic visit; and (FY 1994 and FY 1995) of recruitment efforts. A comparison with the number ■ the patient was scheduled to return to of new patients in FY 1993 showed that the clinic within 2 weeks following the the number of new patients increased last uncontrolled blood pressure reading by 46.3 percent in FY 1994 and by 89.4 (140/90 mm Hg or greater). percent in FY 1995. The number of new patients increased each year in each This information showed the ADPH where county. The overall increase was statisti­ to focus its training and monitoring efforts. cally significant (p=.05). The increase from After a midcourse review, the State health 1993 to 1994 was not significant (p=.08) department made some changes to improve whereas the increase from 1993 to 1995 the quality assurance program. The ADPH was highly significant (p=.006). lowered the benchmark for counties needing additional followup, from greater than 40 The four counties with only 1 year of recruit­ deficiencies to greater than 30 deficiencies. ment (FY 1995) used new patients in FY 1994 as the baseline. The number of new Three counties had excessive deficiencies patients increased by 12.3 percent, which on the first audit, and that declined to only was statistically significant (p=.02). As in one on the second audit. However, with a the above counties, recruitment increased benchmark of greater than 30 deficiencies, in each county. The rate of increase ranged the numbers would have increased to 6 on from 0.7 percent to 59 percent. the first audit and 7 on the second. The ADPH made the change because the The above evidence showed that the purpose of the audits is to improve the level number of deficiencies related to standards of care and not endorse the status quo. for the treatment of high blood pressure in health departments declined based on Patient recruitment and outreach activities the quality assurance audit. Decreasing were the second approach in ADPH’s two- deficiencies should indicate that patients tiered strategy. The project employed a with high blood pressure are getting better patient coordinator/recruiter to work with care in health department clinics. The the targeted county health departments with patient recruitment activities brought in low patient loads. Each year, the project more patients to the hypertension clinics. ■ targeted four new counties while continuing 6 Stroke Belt Initiative

Arkansas

The Stroke Belt Initiative project in Arkansas program and failed to “take ownership” of was an expansion of the work started in the the project. To keep activities going, the pilot phase (phase I). During phase I, the project coordinator joined with established Arkansas Department of Health (ADH) community groups and in some cases conducted extensive data analysis and worked with a committed individual. surveys to document the characteristics of the 10 counties with the highest stroke By far, health fairs were the predominant mortality. These 10 counties are located program activity sponsored in the targeted in the Region. counties. About 9,000 residents partici­ pated in these events, and nurses from the The ADH designed the Strike Out Stroke local health departments and hospitals (SOS) project to form planning groups or screened about 700 people for high blood coalitions in each of the 10 counties to plan pressure. The project coordinator played and carry out activities to reduce stroke an active role in organizing many of the risk. The purpose of the coalition-building health fairs. Many counties also directed strategy was to involve each community in activities toward middle school students. the decisionmaking process and to build Teachers taught special lessons on stroke a long-term commitment to continue the and its risk factors. Stroke survivors spoke project. Each coalition selected the risk in some classes and answered questions factors to reduce or control and the from students. Other activities included program’s strategies for their communities. church-based blood pressure screening, a nutrition workshop, and an interactive The ADH hired a project coordinator to television program on stroke. organize each county. This individual met with the health department administrators The project staff believes that the project in each county to compile a list of potential was successful in educating people in these coalition members and key community high-risk counties about the risks of stroke. organizations. They subsequently convened However, it may have been more prudent to meetings of the targeted community leaders target fewer counties to ensure penetration to form the planning groups. and adoption of the risk reduction activities. It is well known that coalitions take time to The project was successful in forming develop. Thus, by working with one or two planning groups in each of the targeted counties, the project coordinator may have counties. Many of the groups were initially been able to spend more time developing enthusiastic about the SOS project. The the planning groups more fully and facilitat­ groups held monthly or quarterly meetings. ing a shared commitment to the goals of the However, the planning groups generally project. ■ saw the project as the project coordinator’s Stroke Belt Initiative 7

Georgia

The Georgia Department of Human Re­ representatives from the targeted local sources conducted a mass media campaign media outlets. Following the meeting, the to encourage persons who were aware of staff and media representatives initiated the their hypertension to stay on their treatments. campaign. The purpose of this activity was The centerpiece of the campaign was the to develop a core group of media represen­ successful Strike Out Stroke (SOS) cam­ tatives from different areas of the State who paign, which began with the Atlanta Braves would rely on the health department to professional baseball team during phase I provide them with educational messages of the Stroke Belt Initiative. on heart disease and stroke.

The campaign included public service The project installed automated equipment announcements (PSAs) and live coverage on in State office buildings to monitor blood WTBS-TV as well as hypertension screening pressure, pulse rate, and weight. In the and other activities at the stadium during first 18 months, the automated machines selected games. The project also placed recorded 10,457 blood pressures, an a major emphasis on developing a working average of nearly 20 measurements per relationship with smaller television stations day including weekends. The machines outside Atlanta and with the network of also made 16,408 weight measurements African American gospel and talk radio during this period. stations. The print campaign, which targeted small town newspapers, included feature The project joined the Georgia Stroke articles, health reports, human interest Belt Consortium, a coalition of health and stories, and letters to the editor related to medical organizations formed to promote stroke. interventions to reduce the risk of stroke in Georgia. Other members include the In phase II, the SOS campaign with the Association of Black Cardiologists, the Atlanta Braves faced an immediate chal­ Medical College of Georgia, the Centers for lenge to its implementation. The players’ Disease Control and Prevention, the local labor strike at the beginning of the 1994 affiliate of the American Heart Association, season made it impossible to start the the Morehouse School of Medicine, and campaign. Following the strike, the Braves’ Stop Stroke. By participating in this coali­ management focused on baseball-related tion, the Georgia Stroke Belt project became issues for the remainder of the shortened involved in the development of easy-to­ season. They also were not inter­ read materials and in screenings at ested in rekindling the campaign churches, community centers, and State during the 1995 and 1996 seasons. office buildings. Thus, the strike of 1994 ended this highly visible campaign that served The project also held SOS contests in the greater Atlanta area during the churches throughout the State. Each three previous seasons. church had to present a skit, sing a song, or perform another activity. The activity With the SOS campaign on hold, the had to present a stroke prevention message, project focused on the other parts of to be intergenerational, and to last 3 to the mass media campaign. The 5 minutes. The top three winners performed project hired a communications firm at the 1995 Southeastern Regional High to help develop and promote the Blood Pressure Conference. The project campaign. The firm conducted a produced a video of the winning skit, which training and motivational meeting for is being used in senior center nutrition sites local health department staff and and church groups throughout Georgia. ■ 8 Stroke Belt Initiative

Indiana

The Indiana State Department of Health completed a health risk appraisal and intake expanded its emphasis in the pilot phase of form. The health educator also provided the Stroke Belt Initiative project from hyper­ basic education about the risk factors for tension control alone to include smoking stroke and asked the patient to set a behav­ cessation. This 2-year project targeted the ior change goal. low-income populations of two health centers and their adjacent housing projects in Most interventions lasted 3 months and Indianapolis. consisted of a combination of personal sessions with the health educator and Both the Citizen’s Health Center and the followup and counseling on the telephone. People’s Health Center serve low-income Followup interviews were conducted at populations. Patients at Citizen’s are pre­ 6, 9, and 12 months after the intervention dominantly African American, whereas was completed (i.e., made significant 80 percent of those at People’s are white. progress toward the goal they selected Each health center hired a health educator or decided not to see the health educator to conduct the program. The interventions any more) to measure progress and to focused on community awareness and evaluate the services provided. education and individual counseling by a health educator. The health educators received 1,125 refer­ rals—575 at the Citizen’s Health Center The health educators frequently made and 550 at the People’s Health Center. presentations and conducted risk factor At Citizen’s, 210 patients (36.5 percent) screenings for the residents of the targeted enrolled in the program; 235 (42.7 percent) housing projects and the community. The enrolled at People’s. Most of the enrollees presentations provided (306, or 68.8 percent) were smokers—143 information on risk (68.1 percent) at Citizen’s and 163 (69.4 factors for heart disease percent) at People’s. and stroke and the services available at the The smoking cessation component provided health centers to prevent a nicotine replacement patch and behavior or control risk factors. modification counseling to participants who The screenings identified wanted to quit smoking. The patches were potential patients for the provided free of charge. A physician intervention programs referral and prescription were needed to at the centers. get the patches. Patients completed a preassessment and were asked to monitor Some patients who their smoking behavior before starting the entered the counseling patches so they could develop a plan to and followup program handle the psychological challenges of were referred by a doctor smoking cessation. Patients were asked to or other health care return either once or twice a month to get provider; others were their next supply of patches and to meet self-referred. At the with the health educator. initial contact, the health educator explained the The health educators conducted the 1-, 3-, program and asked the and 6-month postintervention surveys to patient to agree to stop identify the quitters and nonquitters. By the smoking or to make end of the project, only 107 (35 percent) of lifestyle changes to help the enrolled smokers had been in the pro­ control their high blood gram long enough for a 6-month followup. pressure. Patients who Of the 107 eligible participants, 13 (12.1 agreed to participate, percent) were not smoking. The quit rates Stroke Belt Initiative 9

were similar at both the People’s Health took more time to educate the health center Center (11.1 percent) and the Citizen’s clinicians about the program and build Health Center (12.9 percent). enough confidence for them to refer pa­ tients. Indeed, referrals started slowly and The health educators found a marked increased steadily to peak near the end of difference in the number of patches used the project. Thus, many patients were not by quitters and nonquitters. Quitters used in the program long enough to complete the 90 patches (the full course of treatment) intervention and reach the appropriate whereas the mean number of patches used followup intervals. by nonquitters was 21 (less than 1 month’s worth of patches). Most of the respondents Second, data collection was a major (88 percent) said that the sessions with the problem. Although the project included health educator were extremely helpful. an adequate data collection system, two factors limited the actual data recording. Health educators also worked with patients Many of the patients refused to complete with hypertension to set goals for lifestyle the intake form and the health risk appraisal. changes. They met with the patients during The health educators, when pressed for regular office visits with their primary care time, frequently chose not to collect the provider. They also followed up on missed necessary data in favor of providing educa­ office visits and worked with the patients to tion at a teachable moment to meet the solve adherence problems. immediate needs of the patient. These factors severely limited the number of The project developed an electronic data­ completed and “matched” records for base for patient tracking and evaluation. The analysis. Fewer than half the participants database contained baseline information from had matching baseline data and risk factor the intake form and the health risk appraisal, status data at the appropriate intervals. data from sessions with the health educators, and periodic measures of risk factor control Despite these problems, if programs like status. this can gain sufficient support from center administrators and clinicians, they can be Although the project provided a valuable integrated into the basic services of the service to low-income populations in commu­ center and are likely to be sustained. One nity health center settings, two problems year after the cessation of funding from limited the full impact. First, 2 years were the Stroke Belt Initiative, the project at the not enough time to organize, conduct, Citizen’s Health Center remains in place. and evaluate the program. It took time to The project and the health educator are get the project started. Securing and main­ supported through the Center’s operating taining staff was difficult. Once the hiring budget. ■ and orientation of staff were completed, it 10 Stroke Belt Initiative

Kentucky

The Stroke Belt Initiative project of the Kentucky Department of Health Services (KDHS) included three components:

■ an inservice training program on the role of community health nurses in ;

■ a smoking cessation program for local health department staff, especially nurses; and

■ extended followup to smokers who agreed to quit and received a prescription for nicotine patches from the health depart­ ment. The State health department employs more than 800 nurses at 153 delivery sites. The training program—developed during phase I of the Stroke Belt Initiative project—targeted public health nurses who did not receive training during the pilot phase. This self- study package consists of four modules— two on hypertension, one on smoking and followup using public health nurses. cessation, and one on obesity. The Univer­ To participate in the free nicotine patch sity of Kentucky College of Nursing approved program, smokers had to attend a support the course for continuing education credits. group. The nurses also attended a 6-hour course on how to give effective smoking cessation Public health nurses conducted smoking advice to patients. cessation classes and support groups at local health departments. They also fol­ The project also conducted smoking cessa­ lowed up these smokers beginning on the tion classes in local health departments to date that the patch prescription expired reduce the number of staff who smoke. and at the 2-week, 1-month, and 3-month The purpose was to increase the number of intervals. The purpose of the followup was nurses and other staff who would routinely to determine their smoking status and to interact with clinic patients who smoke. encourage those who resumed smoking Staff members who smoked were less likely to quit again. Of the 828 participants, to interact with smoking patients. 340 (41.1 percent) completed the nicotine patch therapy. Records indicate that 248 The health department received a free participants (30 percent) quit smoking for allotment of nicotine transdermal patches at least 1 day. At the 3-month followup, for use in an organized smoking cessation 132 (15.9 percent) of the total number of program for low-income smokers. The participants were still not smoking. ■ project devised a program of counseling Stroke Belt Initiative 11

Louisiana

The Louisiana Department of Health and the consultants frequently used other con­ Hospitals (LDHH) has worked with churches tacts within a church to get an introduction for a number of years. During phase I of and initial meeting with the clergy. At the Stroke Belt Initiative project, the LDHH the meeting with the clergy, the consultants established high blood pressure prevention explained the purpose and nature of the and control programs in 26 churches in the project, the benefits to the church, the New Orleans area. The interventions con­ support that the project would provide, and sisted primarily of awareness and education the responsibilities of the church. After the activities, blood pressure screenings and overview, they asked the clergy to commit followup, and heart-healthy cooking demon­ the church to participate in the program. strations. Some churches also conducted weight loss and smoking cessation sessions. Once a church agreed to participate, the first step was to establish a health care The phase II project was a 2-year effort to ministry (HCM), an organization of the church expand the program to churches in other responsible for organizing and implementing areas of the State. The LDHH subcontracted the health programs in the church. The with the National Kidney Foundation of clergy appointed the coordinator of the HCM. Louisiana and the Natchitoches Outpatient The clergy also introduced the program to Clinic to achieve this goal. The latter subcon­ the congregation during regular services tractor concentrated its efforts in northern and asked for volunteers to serve on the Louisiana. The subcontractors hired consul­ HCM. In some churches, the consultant tants from the targeted communities to recruit was allowed to address the congregations churches and help them organize and to promote the program. establish programs. The consultant trained the members of the The consultants followed the procedure HCM. The 4-hour training session consisted established in phase I for recruiting of an orientation to the programs, risk factors churches. In phase I, the project tried for heart disease and stroke, referral and unsuccessfully to followup techniques, and medical record recruit churches systems. The members also attended a through the State course to become certified in blood pressure Soul Food Cooking affiliate of a national measurement. organization of churches. While the The HCMs planned and carried out program organization was activities in their churches. The consultant supportive of the assisted the HCMs in planning and provided project, this did not equipment for program events. The consul­ result in the recruit­ tant was generally onsite for these events to ment of any churches. answer questions and solve any problems. Therefore, the project They also recruited health professionals to had to recruit conduct educational sessions on nutrition, churches individually smoking cessation, exercise, and other through their clergy. topics.

Thus, in phase II, the Thirty churches agreed to participate in the first official contact program and established HCMs. The HCMs with the church was from 22 churches (156 members) attended always made through the 4-hour training workshop and completed The Heart Healthy Way the clergy because the blood pressure measurement course. they usually deter­ Scheduling the training sessions was often mined whether the a challenge. There were many cancellations, Louisiana Office of Public Health often on the night before the scheduled Nutrition Section church would partici­ Chronic Disease Control Section pate or not. However, event. The consultants had to maintain 12 Stroke Belt Initiative

Louisiana flexibility and work with the HCM to resched­ (22.2 months). However, eliminating the ule the training. Still, eight of the churches last three churches that took 18.8, 19.0, and that agreed to participate did not attend a 22.2 months reduced the average time to training workshop. 8.3 months. The patience and persistence of the consultants in getting all the churches The HCMs at 16 churches conducted blood to participate was responsible for the longer pressure screenings and other program time periods. Thus, the process of recruiting events. The consultant supervised the initial churches and moving them into action blood pressure screening event at each takes time. The consultants continue to church. Many of the churches reported work with three other churches to implement a large attendance at their first screening programs. and educational seminars. The remaining six churches with trained HCMs did not The consultants reported that keeping the conduct a program event. Two churches HCM members motivated and committed decided not to conduct a screening because to the screenings and other activities was of the fear of liability issues. Another church difficult in many of the churches. They decided that it was too much work. The three attributed the problem primarily to the other churches did not schedule an event leadership of the coordinator. HCMs with but indicated that they planned to do so. strong coordinators tended to maintain a consistent flow of program activities The project contracted with a nutritionist to whereas those with weak leaders held teach church members to prepare heart- activities much less frequently. Thus, it is healthy meals. Several churches identified very important to select a strong coordinator the members whom their congregations in the beginning because the clergy is considered to be the best cooks. The generally unwilling to replace an ineffective nutritionist worked with these people to coordinator. modify their favorite foods into heart-healthy dishes. They served these heart-healthy The coordinators met with other key HCM selections to the congregations at food members to discuss their experiences and events held by the churches. Church share information between the churches. members were always eager to try foods Difficulties in getting HCM members to prepared by their best cooks. The members participate actively in planning and carrying were not told that the food was heart-healthy out program activities were a common until after they tried the food and said they theme. Some coordinators stated that liked it. sometimes they had to conduct screenings by themselves. The nutritionist also prepared recipes of all the heart-healthy dishes served in the The churches agreed to submit monthly tally churches. The LDHH reproduced the sheets summarizing their screenings and recipes in a cookbook, Soul Food Cooking— other activities. Some churches submitted The Heart-Healthy Way. The consultants these reports, but most did not, even after distributed the cookbook to the churches followup telephone calls and letters from so that all members would have access to the consultant. the recipes. Finally, after the conclusion of the project, The consultants kept a log of the dates of many of the churches continue to hold their initial visits with the clergy, when the screenings and other program activities. clergy committed the church to participate, Three churches that did not hold an event the training of the members of the HCM, and during the project period indicate that they each program event. Analysis of these logs still plan to conduct screenings. This shows showed that it took an average of 46.4 weeks that the benefits of programs to prevent (10.8 months) from the initial visit with the heart disease and stroke are evident to the clergy to the first program event. The times leadership of many churches. Projects like ranged from 2.6 weeks to almost 2 years the Stroke Belt Initiative provide the stimulus for them to get started. ■ Stroke Belt Initiative 13

Mississippi

The Mississippi State Department of Health operation, the number of calls remained at (MSDH) proposed a new initiative for phase 1 or 2 per month. The project nurse, who II of the Stroke Belt Initiative project. A also had experience in marketing, visited hypertension education and intervention several of the sites to observe the usage and program targeted high-risk populations— talk with some of the users. She discovered those with high blood pressure and those at that many users did not see the instructions risk of getting high blood pressure—in the to call the hotline and others thought that State’s six most southern counties. These they would have to pay for the services. counties have a total population of 378,505, of which 68,367 (18 percent) are African To correct this, the staff designed a new American. The rate among African sticker and scorecard (for users to record Americans in these counties is especially their blood pressure reading). The new high—41 percent compared to 16 percent sticker included the following caption, “Free among whites. The counties are also Call, Free Help . . . A Registered Nurse Is at classified as medically underserved. Your Fingertips!” The sticker was printed with red letters on a yellow background to To reach the high-risk population in the make it more noticeable. The new scorecard targeted counties, the MSDH developed its contained the same message and design. program around automated blood pressure The new stickers and scorecards were measurement (ABPM) machines. The placed on all the machines. The number machines provided the targeted communities of calls to the hotline increased to 44 after with a free method of checking blood 3 months and continued to increase pressure. Along with each machine was a thereafter. toll-free telephone number for counseling and referrals. Two machines were initially placed in March 1994 in each county—one in the county courthouse and the other in the local public health department, two areas used by the high-risk populations. The ABPM machines displayed a message instructing persons with elevated blood pressure readings to see a doctor. It further instructed those without a source of care or resources to pay for care to call a toll-free number. The project nurse answered the toll-free calls and helped patients find a source of care. The nurse also arranged for drugs, nutrition counseling, and social services as needed. The automated machines also attracted the The initial 12 automated machines recorded attention of private health care facilities. A about 200,000 blood pressure readings from regional medical center purchased three April 1994 through June 1996. The monthly machines for the project. They placed one total ranged from 4,150 to 10,608. Machine machine in the emergency department and usage was greatest during May through the other two in the community. In 9 months September each year. The lowest usage of operation, these three machines recorded occurred during December, January, and an additional 54,208 blood pressures. Thus, April. the new machines combined with the initial 12 machines recorded a total of 249,644 Although the communities responded readings. This positive experience per­ immediately to the automated machines, suaded several other medical centers usage of the toll-free telephone number was and businesses to make a commitment to less dramatic. After several months of 14 Stroke Belt Initiative

Mississippi purchase additional machines and link them to the project. At the end of the project, 20 machines were operating in the six counties. To complement the automated screening, the project maintains an aggressive tradi­ tional blood pressure screening, counseling, and referral program. Trained teams conduct screenings in churches, community centers, civic organizations, health fairs, schools, banks and other businesses, and other community gatherings. Participants with elevated readings receive counseling and referrals. Those without a source of care or the ability to pay for their health care are given the toll-free telephone number and instructed to call it. Since fall 1994, the onsite screening program has reached more than 5,000 people. Data analyzed on the first 1,594 participants in the onsite screenings showed that 35.9 percent had blood pressure readings greater than 140/90 mm Hg. The rate for men was 41.2 percent compared to 32.6 percent readings, 227 (39.7 percent) knew they for women. As expected, the proportion of had high blood pressure and were taking elevated readings was directly related to medication. Conversely, 345 (60.3 percent) age and range from 13 percent in persons represented potentially new cases of high age 18 to 34 to 64.3 percent in those age 65 blood pressure. and older. Of the 572 persons with high In addition, the MSDH hypertension pro­ gram promoted primary prevention and targeted elementary school children. The staff wrote a one-act play, The Angry Heart, to promote healthy lifestyles. The charac­ ters of the play represent body organs and tissue—Heart, Lung, Brain, Muscle, and Stomach. The play is usually delivered in the auditorium before the entire student body. Teachers serve as impromptu actors, which makes the play entertaining as well as informative. Following the play, the students complete a healthy heart crossword puzzle based on the information presented in the play. During the 1995-96 school year, 9,268 children viewed a live enactment of the play. A videotape of the play is also available to the schools, and the play was selected for presentation at the Prevention ’96 conference in Dallas. ■ Stroke Belt Initiative 15

North Carolina

The North Carolina Department of Environ­ ment, Health, and Natural Resources contin­ ued to focus its Stroke Belt Initiative project on high blood pressure in African Americans. The project combined a mass media cam­ paign with community outreach activities and professional education. The mass media campaign was a statewide effort. Although it included the major televi­ sion and newspaper outlets in North Caro­ lina, the primary targets were radio stations and newspapers that served predominantly or large African American audiences. A First-place winner major emphasis was placed on reaching An-Wár Pace the network of African American gospel (center) from Enloe radio stations. High School with Dr. Dale Simmons The project formed core groups of media of the State health representatives and local community leaders department (left) to develop culturally appropriate educational and NHLBI director messages. Staff members, along with health Dr. Claude Lenfant care professionals and other volunteers, (right); winning were trained to give interviews on hyperten­ poster (inset) sion to local television, radio, and print media in the promotion of the media campaign. Accordingly, the campaign has received success. The theme of the contest was wide and continuous coverage in the major “High Blood Pressure Control Is a Family and targeted media. Affair.” The contest involved ninth- and tenth-grade students in the Raleigh area. The community outreach activities included The staff promoted the contest throughout the dissemination of easy-to-read educa­ local school districts, but only three schools tional materials, blood pressure screenings, agreed to participate. Project staff worked poster and letter- with the teachers in these schools to provide writing contests, students with the background information activities with to prepare fact-based posters related to churches, and risk the theme. A lesson plan focusing on factor reduction hypertension was taught to 727 students classes in community in ninth- and tenth-grade health education centers. They and art classes. compiled the educa­ tional materials into The students designed and submitted 500 a resource guide, posters. The projects established a seven- which was distrib­ person committee to judge the posters. uted to health The committee included teachers and staff agencies across the members from the county and State health State. The agencies departments. The posters were judged on could order the the following criteria: appropriateness, materials in the guide originality, creativity, and neatness. The from the project. winners were determined by the highest scores. The judges chose first-, second-, A poster contest and third-place winners as well as four among high school honorable mentions. Most of the posters students was a major 16 Stroke Belt Initiative

North (350, or 70 percent) came from one school into a High Blood Pressure Sunday kit, as did the three winners. which was distributed to African American Carolina churches across North Carolina. (continued from The project held an award ceremony to page 15) honor the winners and all students who The project also worked with African participated in the poster contest. The top American churches to sponsor letter-writing three winners were awarded plaques and contests for elementary school children. gift certificates ($75 for first place, $50 for The children wrote letters to parents or other second place, and $25 for third place). significant adults asking them to control The honorable mentions received plaques. their blood pressure or change a high-risk Local businesses donated gifts to supple­ behavior, such as smoking cigarettes or ment these prizes. Jonathan B. Howes, eating high- foods. secretary of health for the State of North Carolina, presided over the ceremony, and Local health departments conducted high Dr. Claude Lenfant, NHLBI director, pre­ blood pressure screenings in local conve­ sented the awards. All participating stu­ nience stores and fast food restaurants dents, teachers, and schools received between 5 a.m. and 8 a.m. These screen­ certificates. ings targeted African American men who were waiting for transportation to their jobs. The winning posters were displayed across At first, many were reluctant to participate, the State in public buildings and as PSAs but they became more responsive to on television and in local newspapers. Some screening after the staff returned to follow radio stations used the wording for short up on them. The staff also was able to PSAs as well. In another positive develop­ obtain additional information on and ment, teachers from the two schools that lifestyle behaviors. Based on this limited submitted fewer posters and did not have experience, convenience stores and fast a winner promised to do a better job next food restaurants have potential as screening time to make their schools more competitive. sites for young African American males and Principals and teachers from nonparticipat­ others who do not use local health depart­ ing schools also vowed to participate in the ment services and do not have a regular next contest. source of care. The project collaborated with African Other county health departments set up American ministers to select appropriate nine weekly educational sessions in four educational materials for distribution to community centers and housing develop­ churches during the month of May for High ments that included classes on stress Blood Pressure Sunday activities. The most management, exercise, and nutrition. popular item was a fan—developed during These sites were chosen to improve access phase I of the project—with a health mes­ to these educational opportunities for low- sage printed on one side. Local health income individuals who ordinarily would departments worked with local morticians not be able to take advantage of such to get the fans produced at no cost. The classes in other settings. ■ project compiled the selected materials Stroke Belt Initiative 17

South Carolina

South Carolina has the highest age-adjusted to start or expand health promotion efforts stroke in the United States. In in the church. Although these health 1994, the stroke mortality rate in South promotion efforts included stroke prevention, Carolina was 31.8 per 100,000 for whites the manual included a generic process on and 65.4 per 100,000 for African Americans. how to initiate health promotion efforts, Because of this disparity, the Center for which was useful in implementing a variety Health Promotion of the South Carolina of health-related issues. Department of Health and Environmental Control chose to focus its efforts in the Reaching African Americans Through Media African American community. Channels stresses the importance of the African American media as an avenue to The goal for the South Carolina Strike Out get positive cues and messages out to the Stroke (SC SOS) project was to improve community. This manual was designed for hypertension awareness, treatment, and professionals either who do not know how control among African Americans in the to access this useful channel within their State. The project sought to increase the communities or who are unfamiliar with number of community-based programs to the availability of specific media resources control high blood pressure among African for African Americans. Training using this Americans. manual was offered to health professionals through conferences that attract profession­ The Center for Health Promotion chose to als statewide. work through three channels within the African American community: churches, the Health promotion staff members were media, and beauty shops and barbershops. trained statewide to use this important This capacity-building project included the communication avenue. This activity development of training manuals for health continues beyond the contracted period professionals and lay volunteers to develop of performance. The manual provides stroke prevention initiatives within each specific information on stroke and channel. (continued on page 18) The church-based training manual, Guide­ lines for Working With Black Churches, was developed to train professionals to work with the faith community to implement stroke prevention initiatives. This manual includes many of the do’s and don’ts for different denominations within a community. Training for professionals on the concepts presented in the manual was completed in a variety of settings including the Minority Health Issues Conference, which draws a variety of professionals statewide who are interested in making a difference in the health status of African Americans in South Carolina.

Using the training manual developed for Center for Health Promotion lay volunteers, Guidelines for African and American Church-Based Health Promotion, Office of Minority Health the process of identifying and training local South Carolina Department of Health lay volunteers began. This how-to manual and Environmental Control employs a step-by-step approach to devel­ oping health activities within the church, using trained area health professionals as resources. These volunteers were trained 18 Stroke Belt Initiative

South cardiovascular health, including camera- meetings. The most recent presentations ready articles, PSAs, and additional re­ were made to organizations such as the Carolina sources. One media component addresses Palmetto State Barbers Association, the radio stations and newspapers owned and South Carolina African Methodist Church operated by African Americans. The media Youth Convention, and the State Baptist were encouraged to use the materials as Conference. they are or in developing health education segments. Linking local African American SOS has worked to maximize the impact media personnel with local health profession­ of the project by coordinating with other als is under way. projects that are working on risk factors for stroke, such as and smoking. The project developed two manuals on the SOS is working with the African American use of beauty shops and barbershops as Initiative on Diabetes through the efforts of a resource for spreading the word about the Diabetes Control Program within the stroke prevention. One is a how-to booklet center. The project also is working with for shop owners; the other is a manual for the American Cancer Society on the Beauty health professionals. Information is included Shop Health Advocate Project. on State and local representatives of beauty shop and barbershop associations and hair The framework of the project was capacity- care professionals as contact persons in building of the community—among both every region in South Carolina. health professionals and lay volunteers. This framework has provided opportunities To introduce the concept of SOS activities, to link with a variety of organizations state­ the staff continues to make presentations to wide that are interested in reducing disease statewide organizations about the availability risks among African Americans. The most of training for health advocates. To maximize critical outcome of this project has been the number of people who can take ideas that, because it was based on building back to their communities, the SOS coordina­ capacity, the life and impact of the project tor has given presentations at State conven­ will live well beyond the funding. ■ tions, conferences, and special group Stroke Belt Initiative 19

Tennessee

The Tennessee Department of Health (TDH) ration strategies and issues regarding continued the efforts started in phase I of working with others in the community. The the Stroke Belt Initiative project with the metro­ members wrote two training manuals— politan counties with the largest African Ameri­ Eating Healthy for Spiritual Well-Being and can populations. Nearly 70 percent of all Stop Smoking With Spiritual Power—for use African Americans in the State live in these in church-based programs. three counties—Shelby (Memphis), Davidson (Nashville), and Hamilton (Chattanooga). The PAAST Coalition also recruited and worked with five African American churches The TDH coordinated services of three inde­ to develop and carry out programs for pendent but related projects managed by the smoking cessation as well as nutrition Chattanooga-Hamilton County Health Depart­ education and weight management for their ment, the Metropolitan-Davidson County congregations. The coalition worked with Health Department, and the Preventing African the clergy and other church members to American Strokes From the Use of Tobacco establish a health promotion team in each (PAAST, Inc.) Coalition. The goal of the project participating church. The teams were was to organize and enable African American responsible for planning, conducting, and communities in Tennessee to develop and carry monitoring program activities. The coalition out prevention and control programs targeted also arranged a training program for each at the risk factors of heart disease and stroke. of the health promotion teams. The training included a team-building workshop for skills In Memphis, the PAAST Coalition, formed development in smoking cessation, healthy during phase I, continued to provide leadership eating, and weight reduction interventions. and community involvement to the project. A coalition-building workshop offered coalition Memphis also formed a youth mentor members an opportunity to learn about collabo- program to carry out smoking education, prevention, and cessation activities for adults and youths. Twenty teenagers age 15 to 18 were recruited and trained as youth mentors. The top three reasons given for joining the youth mentor team were helping others, informing people of the dangers of smoking, and helping friends and other people stop smoking. The youth mentors received intensive training to prepare them as smoking cessa­ tion facilitators. The training focused on group facilitation, resistance skills, health behaviors and addiction, and the role of the African American family in health promotion and disease prevention. The youth mentors produced a series of NHLBI director Dr. Claude Lenfant (right) videos including a play called “It’s a Killer,” congratulates seventh grader Terence a PSA called “Is It Worth It?” and a docu­ ment on the hazards of tobacco use. The West after hearing him read his award- Memphis City Schools reviewed these winning letter (inset). Also pictured (left videos and decided to include them in their to right) are Dr. Forrest Harris, Pleasant video library. They also conducted smoking Green Baptist Church pastor, and Ms. cessation classes for adults and teenagers Joan Clayton-Davis, Stroke Belt Program and made presentations on tobacco use coordinator, Nashville Metropolitan to youth groups and adult organizations. Health Department. 20 Stroke Belt Initiative

Tennessee In Nashville, the local health department with the need to lower its risk of heart recruited and worked with African American disease and stroke. High school and churches to set up programs for smoking college students performed the play during cessation, hypertension control, and weight church services, and it was videotaped reduction. During the first year, the staff for future use when the actors were not targeted five churches to implement the available. project. Two other churches were added in Food-tasting events played a major role the second year. In each church, the clergy in building support for and sustaining the appointed health promotion teams to plan program. At a meeting of the clergy from and implement project activities. Each team participating churches, the team from the included a coordinator, also appointed by host church prepared and served a heart- the clergy. healthy meal. The clergy learned how the The project staff trained the church teams food was prepared only after they finished and worked closely with the church teams, eating and acknowledged how good the especially during the early stages, to plan food tasted. The taste of the food so project activities. This included assisting impressed the clergy that most included with the needs surveys of church members messages about heart-healthy eating and and providing ideas for kickoff or initial the program in their Sunday sermons. Many projects. The project staff also attended of the teams also conducted food-tasting team meetings when possible and provided events for their congregations, using the encouragement to the coordinators and the same strategy. members. The Nashville project succeeded in recruit­ The church teams demonstrated that they ing churches, training teams among the could maintain an ongoing program within congregations to carry out program activi­ their congregations. They readily used ties, moving the teams to action, and existing education and risk factor reduction sustaining their actions over time. The staff programs from voluntary health and other kept logs with the dates of the completion community agencies. The teams also were of each milestone in each church. Analysis very creative in devising other ways to of these data showed that it took an average communicate health messages to their of 11.6 weeks (or 2.7 months) from the congregations. initial contact with the church to the point when the pastor commits the church to Innovative activities developed by the teams participate. It took another 20.4 weeks (or included a children’s letter-writing campaign, 4.8 months) from the commitment to partici­ production of a play about risk factors, and pate to the appointment and training of the food-tasting demonstrations. The letter- church team. The first program event took writing campaign was both a contest and place, on average, 10 weeks (or 2.3 months) a health intervention. Children from the after training the church team. Thus, it takes churches wrote letters asking a significant about 42 weeks (or 10 months) from the adult in their life to quit smoking. Each child initial contact with the church to the first followed up at 3, 6, and 12 months to see if program event. the significant adult was still smoking. The planners used the contest format to encour­ The project in Chattanooga also attempted age maximum participation by the children to work with churches, but initial efforts did and cooperation from the significant adults. not meet with much success. The project A panel of church members and health staff sought the counsel of the Nashville department staff judged each of the letters staff. After several discussions, representa­ and selected a winner for each age (age 6 tives from Nashville visited Chattanooga to to 11). The contest winners each received meet with local church leaders. The delega­ $50 and a certificate at a special awards tion from Nashville consisted of clergy ceremony. members, members of the church teams, and staff. Following the meeting, churches One team decided to use drama to communi­ in Chattanooga began implementing the cate health messages to its congregation. program. Overall, activities in these They asked a local playwright to write a play churches continue beyond the official depicting what a typical African American end of the project. ■ family might experience when confronted Stroke Belt Initiative 21

Virginia

The Stroke Belt project in Virginia is a unique BGC-HCM director, three regional coordina­ collaboration between the Virginia Depart­ tors, four blood pressure measurement ment of Health (VDH) and the Baptist (BPM) specialists, and one clergy member General Convention (BGC) of Virginia to developed two training manuals and a promote stroke risk reduction programs in brochure. They designed one manual to African American churches. This 2-year train trainers and the other to certify BPM project expanded the activities of the Virginia specialists (students). A brochure called Cardiovascular Risk Reduction (VCRR) Stroke Busters was an educational piece project to work with the BGC. The VCRR for the congregation. project conducts statewide hypertension detection and control programs. Next, the VDH staff and the BGC-HCM director trained the 10 regional coordinators. The BGC is an association of more than While supporting the churches already 1,000 independent African American involved in hypertension detection, the churches located throughout the Common­ regional coordinators also recruited new wealth of Virginia. These churches have churches and helped them set up HCMs. more than 200,000 members. The BGC This increased the number of participating health care ministry (HCM) has a full-time churches to 100. The coordinators certified director who is an ordained member of the 100 new specialists and recertified 50 clergy. The BGC-HCM has a history of specialists. Seventy-nine additional BPM working with health agencies to implement specialists did not require recertification. programs in member churches. The certified specialists measured the blood The VDH and the BGC-HCM agreed to focus pressures of 3,723 church members in on three risk factors—high blood pressure, FY 1995. Elevated readings were found in smoking, and obesity. For more than 10 265 people who were not under the care of a years, the VDH and the BGC-HCM have physician for high blood pressure. Referrals collaborated to conduct blood pressure were made for 282 individuals with elevated screening in BGC member churches. readings who were already under treatment for hypertension. The director of the BGC-HCM recruited the churches, trained the volunteers, and The VDH and the BGC-HCM selected the supported their efforts. However, the smoking cessation program from Clergy expanded project required more than one United for the Redemption of East Baltimore person to coordinate and support the (CURE)—an NHLBI-funded study. The activities of local churches. Thus, the VDH American Lung Association (the local and the BGC-HCM established a system sponsor of the CURE Program) trained the where regional coordinators worked with regional coordinators to implement the the churches in their area. The BGC-HCM CURE smoking cessation program. The director recruited 10 volunteer coordinators BGC-HCM director and the regional coordi­ from area churches. nators revised the CURE materials to be more suitable to the BGC and renamed the The clergy at the regional coordinators’ home program “Thank God I’m Free” (TGIF). The churches pledged to support the efforts of materials included a TGIF trainer’s manual, the coordinator and to make their church the a guide for church group leaders, a devo­ model for the region. The responsibilities of tional for group participants, a program the regional coordinators were to recruit tracking form, an intake form for participants, churches, assist the churches in organizing an information form for group leaders, to carry out the program, train church team T-shirts, and coffee mugs. members, and deliver the programs and materials selected for implementation. The regional coordinators conducted TGIF training for group leaders in seven regions. To facilitate the high blood pressure compo­ Although it was not difficult to get volunteers nent, a group consisting of VDH staff, the 22 Stroke Belt Initiative

Virginia a new name because the old title was not an acronym for anything. The project staff felt that the program would have more meaning if the letters represented a relevant mes­ sage—i.e., Taking Responsibility in Meal Management (TRIMM). The working group also selected an appropriate exercise video to 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 the end of the project, regional coordinators began training local volunteers to lead TRIMM classes. So far, the volunteer leaders have conducted three TRIMM classes with 100 participants. Twenty-two of the 100 participants lost weight. The VDH and the BGC-HCM continue to implement all phases of the project since to participate in the group leader trainings, it the conclusion of their Stroke Belt Initiative was hard to get church members to attend funding in September 1995. ■ the classes. The volunteers attributed the problem to the employment of many church members in the tobacco industry. Because these persons perceived the program as a T.R.I.M.M. threat to their livelihood, many pastors were (Taking Responsibility In Meal Management) resistant to the program. However, the Nutrition Management Program group leaders conducted 16 courses for 115 participants. Sixty-eight of these For Our smokers completed the course, and 26 (22.6 percent) were not smoking at the end Spirit, Health, Heritage of the course. To increase participation, & local health department clinics offered Culture classes away from the church, which provided greater confidentiality. The group leaders also offered self-help information as an alternative to group classes. The BGC-HCM director convened a group consisting of regional coordinators, a member of the clergy, church volunteers, and VDH staff to select suitable nutrition and weight loss management programs for Baptist General Convention of Virginia the project. The group reviewed existing programs and selected a locally developed Health Care Ministry program called TRIM. The group revised the TRIM materials and gave the program Stroke Belt Initiative 23

Summary: Lessons Learned

The Stroke Belt Initiative projects demon­ ■ The appointment of the right person as strated the capability of State health depart­ coordinator of the health care ministry or ments to plan and carry out health education team is critical to keeping the members interventions to prevent and control risk motivated and committed to the screen­ factors for stroke and heart disease. They ings and other activities in the churches. also provided some valuable lessons that HCMs with strong coordinators tended others can use in planning intervention to maintain a consistent flow of program programs for use in the Stroke Belt and activities whereas those with weak leaders elsewhere. held activities much less frequently. Thus, it is very important to select a strong Several of the projects worked with churches, coordinator in the beginning because the and the many lessons learned from their clergy is generally unwilling to replace an experiences will add to the knowledge base ineffective coordinator. on how to work with churches to implement health education programs to prevent and ■ Church teams or HCMs can be very control risk factors for stroke. They suc­ creative in devising ways to communicate ceeded in recruiting churches, training health messages to their congregations. teams among the congregations to implement Examples seen by the Stroke Belt Initiative program activities, moving the teams to projects included plays during services, action, and sustaining their actions over time. healthful cooking demonstrations, Some lessons learned are described below. “Gospelsize” (exercising to church music), and letters from young people ■ It takes time to organize and carry out urging significant adults to quit smoking. health programs in churches, but patience Project staff should encourage this is rewarded. In some churches, it can take creativity. 10 months or more from the first contact with the church to the time of the first ■ Scheduling training sessions for church program event. Analysis of the combined teams or HCMs is often a challenge. data from 21 churches in Louisiana and Cancellations are frequent. The project Tennessee showed that it took an average staff must maintain patience and flexibility of 44.9 weeks (10.5 months) from the first and work with the HCM to reschedule the contact with the church to the time of the training. first program event. It took an average of 6.4 weeks (1.5 months) from the initial Other major lessons learned: contact with the church to the point ■ It takes time to build coalitions that will when the pastor committed the church to plan and carry out programs to prevent participate. It took another 15.6 weeks and control risk factors in their communi­ (3.6 months) from the commitment to ties. participate to the appointment and training of the church team. The first program ■ Smoking intervention by nurses and health event took place, on average, 20.7 weeks educators with low-income smokers in (4.8 months) after training the church team. health department clinics produces Health professionals must realize that this respectable quit rates. is normal and not give up. ■ Automated blood pressure measurement ■ There is no single best way to recruit machines can make a valuable contribu­ churches and sustain their participation. tion to the hypertension detection and Each church-based project used different control efforts in rural and low-income approaches. communities. ■ Support from the clergy is essential. The It is hoped that the life and impact of many clergy usually decides whether the church of these projects will live well beyond the will participate or not. The level of support funding. ■ for the project by the clergy also deter­ mines the priority that it receives in the church.