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1/98 mus-p.14

AN ANALYSIS OF COMMUNITY DEVELOPMENT APPROACHES TO
CARDIOVASCULAR DISEASE PREVENTION PROJECTS
FOR AFRICAN AMERICANS

BY

Karen Patricia Williams

A DISSERTATION

Submitted to
Michigan State University
in partial fulfillment of the requirements
for the degree of

DOCTOR OF PHILOSOPHY

Department of Resource Development

1998

ABSTRACT

AN ANALYSIS OF COMMUNITY DEVELOPMENT APPROACHES TO
CARDIOVASCULAR DISEASE PREVENTION PROJECTS
FOR AFRICAN AMERICANS
By

Karen Patricia Williams

Michigan ranks 38th in cardiovascular disease mortality and morbidity rates
among states. Conversely, it ranks in the top third of the states with residents who
have some form of health insurance. Mortality and morbidity numbers have declined
among the Caucasian population in Michigan. However, life expectancy for African
Americans in 1990 was equivalent what it was for Whites in 1950.

Heart disease death rates for African American males and females were 1.5
and 2.5 times higher than for White males and females, respectively. Stroke death
rates for African American males and females were 2.9 and 2.5 times higher than
for Caucasian males and females, respectively.

The study investigates the use of community development strategies to
address the problem of high morbidity and mortality rates among African Americans
in eight Michigan communities. The research is exploratory in nature. A multiple
method model (triangulation) is used to compare findings derived from three

methods—focus groups. coordinators' interviews. and program documents. Based

on the study findings, the author recommends moving from a traditional medical
paradigm to a social behavioral paradigm that incorporates community development
approaches. such as technical assistance and self-help, as a means to foster
appropriate life-style Changes in the African American population. To attract African
Americans to cardiovascular disease prevention and other programs, community
Change agents will have to be culturally competent. In other words, they will have
to understand and respect the residents and their community culture. They will have
to include residents in the various stages of programming with an understanding that
indigenous involvement and leadership is as valuable as input and direction obtained
from professionals. Finally, community developers will have to make community
capacity building a major ingredient in every community-based project. Additional
research is required to understand how different mmmunity-based models apply in
different cultural settings and how community—based prevention methods affect the

patient revenues within medical systems.

Copyright by
KAREN PATRICIA WILLIAMS

1998

To my parents, LeRoy A. and Evelyn P. WIlliams, and my fore-parents, on
whose shoulders I stand. Thank you for setting high standards. I sincerely
appreciate the many sacrifices you made to expose me to the best environments.

To my daughters, Jasmynn Brooque and Ivy Nichole, who have made
unselfish sacrifices for their mother. You have Shared your mother with her school
work and her work in the community with the promise of a better life. To both of you,
I pass the torch of high standards that my parents passed on to me. This torch will
guide your path so that both of you may reach your full potential and take your
rightful place in this world.

To Calvin Roberts, my soul mate, who always provided me with a safe place
to share my emotions. Your quiet strength has been a source of nurturing and

protection for me.

ACKNOWLEDGMENTS

WIth deep gratitude to all of my professors: Dr. Robert C. Anderson, my
major advisor and dissertation Chair. I Sincerely appreciate your consistent gentle
encouragement, as well as guiding me through my academic maze. Dr. Frank Fear
for providing me with special opportunities while department chair and Sharing your
love, respect, and enthusiasm for The Academy. Dr. Paul Nickel for sharing my
dreams and encouraging me to always question. Dr. Patricia Mullan for your
intellect and introducing me to the world of public health. Dr. Maxie Jackson, Jr., for
being a voice of reason, listening, hearing, and helping me to prioritize. Thank you
Dr. James Jay. Assistant Woe-Provost, for providing the support I needed to
complete my research.

Rochelle Hurst, Michigan Department of Community Health, thank you for
providing me with resources and being a ready and willing reference. Charlotte Pratt
of Michigan Public Health Institute. I appreciate your agency funding my research
in part and allowing me free use of the data. Also, thank you for showing me how
to expand my research into presentations and articles. To Wanda D. Lipscomb,
Director of the Center of Excellence in Minority Medical Education and Health, thank
you for going the second, third, and fourth miles to support my research, as my

employer and soror. Thank you Jan Wallace for transcribing all of the data. John

vi

Wulu, thanks for your intellect. dedication, and expertise in statistical analyses. I
sincerely appreciate Sandra Philpott-Burke for making sure that l was at the right
place at the right time to get all the community development leadership experiences
I needed to be considered an expert. Thank you Quindolyn Bradley for always being
a source of encouragement. Dr. Patricia Edwards, Michigan State University
College of Education, thank you for being a role model who has a standard of
excellence and who has motivated me to stay in The Academy. Thank you Marilyn
Cotten for your prayers and the homemade brownies you would send me from

Philadelphia.

Vii

TABLE OF CONTENTS

LIST OF TABLES ................................................ x

LIST OF FIGURES ............................................... xi
Chapter

I. INTRODUCTION TO THE STUDY ........................ 1

Introduction .......................................... 1

Health ............................................. 2

Community Development .............................. 4

Problem Statement .................................... 7

Purpose and Importance of the Study ...................... 9

Research Questions .................................. 11

Research Hypotheses ................................. 11

Assumptions ........................................ 12

Definition of Terms ................................... 12

Overview ........................................... 14

ll. LITERATURE REVIEW ................................ 15

Introduction ......................................... 15

Analytical Framework of the Study ....................... 15

Community Development .............................. 21

Health Promotion .................................... 22

Ill. METHODOLOGY .................................... 26

Introduction ......................................... 26

Research Design ..................................... 28

Subjects ........................................... 32

Research Hypotheses ................................. 32

Data Collection Procedures ............................ 33

Focus Groups ...................................... 33

Interviews With Program Coordinators .................. 35

viii

Secondary Data .................................... 36

Data Analysis Procedures .............................. 36
Limitations .......................................... 39

IV. ANALYSIS OF THE DATA ............................. 41
Introduction ......................................... 41

Results of Hypothesis Testing .......................... 41
Hypothesis 1 ...................................... 41
Hypothesis 2 ...................................... 47
Hypothesis 3 ...................................... 54
Hypothesis 4 ...................................... 63
Hypothesis 5 ...................................... 66
Discussion of Results Regarding the Research Questions ..... 77
Research Question 1 ................................ 77
Research Question 2 ................................ 85

V. SUMMARY. CONCLUSIONS AND RECOMMENDATIONS . . . . 91
Summary of the Study ................................. 91

The Problem ....................................... 91
Methodology ....................................... 92

Findings .......................................... 93
Conclusions ......................................... 94
Recommendations ................................... 96
Research ......................................... 96

Policy ............................................ 97
REFERENCES ................................................ 100

10.

11.

12.

13.

LIST OF TABLES

Sites Applying Various Community Development Strategies

(Combination of Self-Help and Technical Assistance) .............. 42
Sites Applying Self-Help Strategies ............................ 44
Sites Applying Technical-Assistance Strategies .................. 46
CVD Risk Factors by Behavioral Indicators—Row Percentages ...... 49
CVD Risk Factors by Behavioral Indicators—Column Percentages . . . . 53
Frequency and Percentage of Category of Motivation by Site ........ 56
ANOVA Using General Linear Models Procedure ................. 57
Results of the ANOVA for Dependent Variable: Rank for

Variable Count ............................................ 59
Results of the Least Significant Difference Test .................. 60
Results of Tukey's Studentized Range ......................... 6O
Qualitative Results: Individual CVD Programs’ Objectives

and Their Achievement ..................................... 64
Community Development Experience of Coordinators ............. 67

Community or Participant Involvement in Designing the
CVD Program ............................................. 75

LIST OF FIGURES

Dimensions of Exemplary Community Development Projects ....... 17
Dimensions of Health Belief Model Adopted for CVD .............. 20
CVD Programs Site Locations ................................ 27
The Triangulate Methods Used in This Study .................... 31

xi

 

CHAPTER I

INTRODUCTION TO THE STUDY

lnImdufliQn

In 1995. the Michigan Public Health Institute (MPHI) awarded eight
community-based cardiovascular disease (CVD) grants to organizations in Michigan
to address the overwhelming problem of CVD among African Americans. CVD,
which affects the heart and blood vessels, includes heart disease and
cerebrovascular disease (stroke). It is the leading cause of death in Michigan.
Despite declines over the past few decades, CVD remains the leading cause of
death and disability in the United States (Kochanek, 1995). In 1992, more than
861,000 Americans died from heart disease or stroke. the main forms of CVD
(Kochanek, 1995).

Almost 50% of all deaths in Michigan are attributable to CVD. In 1992. the
rates of deaths from heart disease and from stroke per day per 1,000 population
recorded for Michigan residents were 73.4 and 13.9. respectively (total Michigan
resident deaths in 1992: 78,916). In 1993, the rates of deaths from heart disease
and from stroke per day per 1,000 population were 78.1 and 14.5, respectively (total
Michigan resident deaths in 1993: 82,286). In 1994, the rates of deaths from heart

disease and from stroke per day per 1,000 population were 77.2 and 15.6,

1

2
respectively (total Michigan resident deaths in 1994: 82,644) (MDCH, 1992, 1993,
1994). making the state the twelfth worst state nationally with regard to CVD death
rates.

Since 1960. the survival rate for African American males has continued to
deteriorate, unlike that forwhite males, white females. and African American females
(MDPH, 1993). The goal of the MPHI is simple: Involve and empower African
American males to improve their cardiovascular health. However, the task has
proven to be Challenging. The Michigan Task Force on Improving African American
Male Health recommended that the state prioritize its resources, allocating them to
community-based prevention projects that foster and bring about a healthy lifestyle,
basic academic skills, and character and career development among African
American males. An initiative stemming from that recommendation is the
community-based Cardiovascular Disease Prevention Among Afriwn Americans
projects sponsored by the MPHI and supported by the Michigan Department of
Community Health (MDCH). Eight projects have been funded throughout Michigan
communities. Some communities have included females because project
administrators have had problems recruiting men. Moreover, hundreds of men and

women have been given cardiovascular health screenings.

Health
Health is fundamental. Without it, people become disenfranchised, thereby
being relegated to a minimum level of participation in the larger society. Despite

widespread gains in cardiovascular health nationally, Michigan is among the

3

country's leaders in the number of preventable deaths. Yet the number of Michigan
residents who have some type of insurance is higher than the national average. In
1993. nearly 30% of African American males' deaths were caused by some form of
heart disease. When compared to their white counterparts who suffered from heart
disease, Black males’ death rates were nearly a third higher. Several lifestyle and
environmental factors contribute significantly to the morbidity and mortality rates
associated with CVD among Blacks. These include smoking, diet, and various
psychosocial factors. Another factor that has been the subject of current research
is the possibility of genetic variants linked to hypertension among different racial
groups (Francis, 1994). Although the Issue is complex, it is thought that nearly 20
different genes may be involved in the pathogenesis of hypertension, affecting a
wide variety of physiologic systems, including sensitivity to salt. The challenge than
remains: How can health care providers effectively reach these men to educate
them to Change their risk behaviors?

One way to change cardiovascular risk behavior is to use the community
development process to reach targeted populations when administering health-
promotion programs. ”Community development is defined as the process by which
the community defines its own health needs and organizes to make these needs
known to health professionals in order to bring about change“ (Dalziel, 1992, p. 228).
MW (MDPH, 1993) stated that community-based intervention is
an important method for achieving health objectives for the nation. A community

development approach in health promotion has become one of the preferred

4
methods of service delivery in the United States, dating back to the 1972 Stanford

Three-Community Study in California. That longitudinal study focused on reducing
the behavioral risk factors in those communities by using community organizational
strategies (technical assistance), which eventually became the catalyst for
institutional and environmental sustainability. The findings indicated a significant
reduction In Cholesterol and blood pressure levels and cessation of smoking in the
cohort sample (Farquhar, 1990).

Community-based health promotion projects have increased the public’s
awareness of, and willingness to play a proactive role in, the health of their
communities. People have been feeling a growing sense of empowerment, resulting
in a willingness to be part of the solution. "The public mood is now shifting toward
the belief that we, as individuals and as communities. can and must fix the serious

problems that face us" (Healthcare Forum, 1994, p. 7).

CommunltLQeILelonmem

The primary community development approaches applied in the context of
health promotion are self-help and technical assistance. In many ways, community-
based health promotion mirrors community development approaches and principles.
In principle, professionals understand that, for health promotion to be effective, it
must be Implemented at the community level, using local citizen participation. in
1991 , the American Public Health Association acknowledged that, ifthe health status
of Americans was to be improved, the problem would have to be tackled at the

community level; the residents would need to be involved in designing such

5

initiatives. No longer could health professionals administer top—down directives and
expect the nation to follow them. Instead, citizens would have to be involved in their
own health. This is a technical assistance approachuan approach for planned
change. Experts who have the technical background—in this case, health care
providers-have developed a model, health promotion, that enables local
communities to work with the experts in making lifestyle Changes that affect their
health.

Technical assistance aids health promotion administratively, having the power
to manipulate resources, knowledge, and information (Fear, 1989). As early as
1959, health professionals realized that it was effective to focus on individuals’
Changing their lifestyles. However, it was more practical to consider a primary
prevention model to bring about Change at the community level, thus giving rise to
health promotion efforts (Wrnkleby, 1994). The impetus for technical assistance in
health promotion that finds its way into the community is twofold. It is both imposed
and negotiated. It is imposed because a group of national health professionals have
come up with a set of health objectives for communities. However, it is negotiated
because the community can decide which objectives it wants to achieve.

Community-based health promotion projects have made significant
contributions, from the way health care professionals practice to the way people view
health, by causing a paradigm shift in health care. Instead of health professionals
solely treating patients for preventable illnesses, they are educating patients on how

to reduce and eliminate those diseases. Such projects have ranged from individual

6

to small-group interventions to media campaigns and public policy adecacy that
promotes preventive health care. AS MDCH officials View it, the object is to influence
a'greater number of people. In addition, the public has a new concept of health and
what creates healthier communities. The model has moved away from viewing
health as the avoidance of disease to embracing the active pursuit of wellness.
There is an appreciation for the influence of a broader concept of quality of life.
People now tend to feel more empowered and are playing a more proactive role in
the health of their communities. They are beginning to view health as being both the
individual’s and the community’s responsibility.

This twofold view of health is of special interest to resource development
practitioners because it has the potential to increase the understanding of the
community development process and how the community development model
transcends disciplines. Too often, community development approaches are
considered only in the context of the social sciences, such as community economic
development, social welfare, and housing.

In this study, the researcher shows the connections between community
development components such as citizen participation and empowerment, and
health promotion and health empowerment. When community development
practitioners are asked ”What constitutes a healthy community?” their answers will
have to include the health or well being of the residents ifthose answers are to be
complete. Knowing the effect of CVD, while examining the phenomenon of African

Americans’ struggle to gain health empowerment by using grass—roots community

7
development strategies, it was of interest to see how this effort contributes to
communities’ level of citizen participation. In other words, behavioral Change is the
most difficult to bring about. But it is believed that applying community development
approaches can serve as the catalyst to planned change as it relates to health
empowerment, which, in turn, will help this disenfranchised group become more

empowered in making other significant Changes in their communities.

Emblamfiratemant

CVD death rates among African Americans have dropped nationally since
1985, but not in Michigan (MDCH, 1996). According to the MDCH, Center for Health
Promotion and Chronic Disease Prevention, Health Promotion Section, every 15
minutes, one person died of CVD in Michigan in 1994. The same report concluded
that the stroke death rates for African American males and African American females
were 2.9 and 2.5 times higher than those for white males and white females,
respectively. Even more astounding were the heart disease death rates. For Black
males and Black females, the heart disease death rates were 1.5 and 2.5 times
higher than those for white males and white females, respectively.

The fact that many of the CVD risk factors (smoking, high blood pressure,
high Cholesterol, overweight, and sedentary lifestyle) can be controlled makes CVD
a multifaceted problem. In W (MDPH, 1993), the four strategies
recommended for addressing the CVD problem are community development based:

1. Increase the involvement of African American males and their

communities at all levels, including policy development, program
implementation, and evaluation.

8

2. Augment department advisory committees with representation from
African American males.

3. Increase the acceptability of outreach activities and messages
designed to encourage healthy decision making by African American
males.

4. Encourage integrated health systems to utilize urban health initiatives

in conducting community outreach programs to teach conflict
resolution and to support healthy behaviors by African American
males.

Traditional methods of CVD prevention, such as screenings and counseling,
have failed to reach sufficient numbers of African Americans, primarily because of
their negative perceptions regarding public health practices. African Americans have
a general distrust of “clinics" and prefer to be examined by ”their own" or by a private
physician (Williams, 1997). Medical historian Gamble (1 997) argued that the distrust
African Americans have toward the medical community predates the popular notion,
which involves the 40-year (1932 to 1972) US. Public Health Tuskegee Syphilis
Study. This study involved 399 Black men from Macon County, Alabama, who were
deliberately denied effective treatment for syphilis in order to document the natural
history of the disease. In addition, these men were not told they were part of a
medical study (Jones, 1993). ”Black Americans’ fears about exploitation by the
medical profession date back to the antebellum period and the use of slaves and
free Black people as subjects for dissection and medical experimentation," noted
Gamble (pp. 1773-74). Thus, a major concern for health care professionals is the
challenge of practicing preventive medicine, as it relates to CVD, in the Black
community.

Understanding that making lifestyle changes can reduce the morbidity and

mortality rates significantly, one group of health professionals has selected the

9

community-based approach to addressing the CVD problem among African
Americans in Michigan. However, there is a limited understanding among health
professionals as to why some programs are attracting Blacks and influencing their
preventive CVD care, whereas other programs are having problems recruiting Black

participants. This study was undertaken to provide information on this subject.

W

The researcher’s purpose in this study was to (a) document the perception
of participation by CVD project coordinators and participants at eight sites in African
American communities throughout Michigan; (b) measure the knowledge, attitudes,
skills. and behaviors of the participants; and (c) measure the efficacy with which the
community-based CVD programs have been developed.

Understanding the role that community development approaches play in CVD
programs designed for Blacks is crucial. It is particularly relevant to compare the
differences between programs managed by community-based organizations and
those managed by a health institution. Understanding this phenomenon will lead to
the development of a model for designing specialized health education programs
and recruitment efforts aimed at African Americans.

There are several community-based orcommunity development approaches.
In this study, the researcher focused on the self-help and technical assistance
approaches. Self-help or empowerment calls for community members to initiate
their own problem-solving process. In contrast, the technical assistance approach

relies on the expertise of outsiders to help community people solve problems.

10

Although programs of this nature have existed for more than a decade, they
usually have not had a culturally specific design. in other words, health
professionals traditionally have designed community-based CVD intervention
programs for the broad population. Many African Americans have been reluctant to
participate, with any consistency, in programs administered by public health
organizations. Therefore, it has been difficult for health professionals and
researchers to make definitive generalizations from data gathered from the broad
population to specific populations because the numbers of Black participants have
been relatively small. This situation underscores the need to understand the
participation phenomenon among African Americans.

The MPHI has funded programs that have been designed by lay people and
health professionals alike who have ties to the community where the program is
being administered. These community-based groups had the freedom to be flexible
and creative in their design. They were charged, however, with designing a
culturally sensitive program that would address CVD risk factors. It was generally
thought that having a community-based program with local people involved in the
programming would lead to participation in the program. It was hoped that
participation would encourage lifestyle changes that would ultimately lead to a
reduction in risk factors.

Participation in and of itself is not the answer. However, it is the part of the
process that leads to behavioral change. Discerning why African Americans

participate in community-based CVD programs will contribute to a better

11
understanding of the self-help or empowerment approach of community
development. The literature on empowerment and self-help has described
empowerment as the process of increasing personal, interpersonal, and/or political
power so that individuals or collectives can take action to improve their life situation
(Gutierrez, 1988). Moreover, it is held that when self-help is achieved in one area
of life, it can be transferred to other areas, eventually contributing to community
enfranchisement and community ownership. In other words, if a person learns the
skill of community organizing in one setting, he or she can transfer the use of that

skill to another setting, thereby contributing to the betterment of the community.

Winds
The following questions were posed to guide the collection of data for this
study:
1. What contributes to the acceptance and efficacy of community-based
CVD programs for African Americans?
2. Did participating in any of the eight CVD-prevention programs influence

the perceptions, attitudes, and behaviors of the participants? If so, in what way?

BeseamLtlmotbases

The following hypotheses, stated in the null form, were formulated:

1194: There are no differences in the use of community development
strategies for CVD prevention by health institution CVD programs and
community-based CVD programs.

m2: There are no differences between the before- and after-focus group
perceptions of participants about CVD-prevention programs.

12

Haj: There are no differences between the focus group participants’
categories of motivation for adopting healthy lifestyles and preventing CVD.

1124: There are no differences between the individual CVD programs’
objectives and their achievement.

1:115: Coordinators’ previous applied community development experience
does not make a difference in program participation.

Assumptlnns

For the purposes of this study, the following assumptions were made:

1. The eight CVD programs have accurate data-collection and data-
reporting standards.

2. Participants were conscientious and trustworthy in giving their
responses/comments during the focus group sessions.

3. Information from the coordinators’ interviews augmented information
from the focus group sessions in a meaningful way.

4. The perceptions and attitudes that participants expressed in the focus

groups were related to their subsequent behavior.

D (j 'I' [I
The following terms are defined in the context in which they are used in this
study:
Acceptance refers to the participants’ approval of the CVD projects by
assembling with others with the intention and expectation of sharing one’s health
issues.

AfricanAmeflcans are people of African descent, also referred to as Blacks.

 

13

Attitude means the mind-set a participant has in regard to his or her health.

Ballets are core values that guide the participants’ actions and, in turn, affect
their lifestyles.

mum is the development of technical expertise to plan,
implement, and evaluate chronic disease prevention and control interventions
(Schwartz, 1993).

W can be classified as either modifiable
(preventable) or nonmodifiable (Smith, 1993). It includes ischemic heart disease
and cerebrovascular disease. Major risk factors for CVD (i.e., heart disease and
stroke) include physical inactivity, cigarette smoking/tobacco use, alcohol use, drug
abuse, high blood pressure, elevated blood cholesterol, obesity, diabetes, and poor
nutrition (Fletcher, 1992).

CultutaLcomnetenceis a characteristic of individuals who have academic and
interpersonal skills that allow them to increase their understanding and appreciation
of a group’s cultural differences and similarities (Marin at al., 1995).

Efficacy refers to coordinators’ mastery of the community development
approaches to accomplish the CVD project objectives defined in their grant proposal
and by the funding agency.

MW, developed in the 19803, is one of the two
analytical frameworks on which this study was grounded. It is a prototype for
community development projects consisting of three dimensions, all having a

stakeholder component: (a) design, (b) implementation, and (C) consequences.

14
W, developed in the 19503, is one of the two

analytical frameworks on which this study was grounded. It is a conceptual
formulation for understanding why individuals do or do not engage in a wide variety
of health actions. The model has four dimensions: (a) perceived susceptibility, (b)
perceived severity, (c) perceived benefits, and (d) perceived barriers.
WW means that the people affected by a
particular problem have the knowledge that enables them to define the problem
jointly with professionals who have the technical knowledge. Both contribute to the

solution.

mm

Chapter II is a review of literature pertinent to the study. Topics of focus
Include the analytical framework of the study, community development, and health
promotion.

The methodology used in conducting the study is described in Chapter III.
The research design is presented, as are the methods of inquiry used. The subjects
for the study are described and the hypotheses are restated. The data collection
and data analysis procedures are considered next. Limitations of the research are
then discussed.

The results of the data analyses are presented in Chapter IV. Chapter V
contains the conclusions drawn from the findings, and recommendations for further

research and policy.

CHAPTER II

LITERATURE REVIEW

Introduction
This Chapter contains a review of literature on topics pertinent to the study.
The following topics are discussed: the analytical framework of the study,

community development, and health promotion.

AW

Neither community development nor health promotion is the outgrth of one
Specific theory. Rather, both fields have evolved as a result of a societal need rather
than being the outgrowth of academia. Community development draws from the
social sciences. It addresses propositions regarding social technology transfer
(Blackely, 1989). Health promotion, on the other hand, has its roots in public health
education and the need to gain the cooperation of the public (Green, 1990). For the
purpose ofthis research, two models frame this investigation-the Exemplary Project
Model (EPM) and the Health Belief Model (HBM). The rationale for using two
models is that this topic serves as the intersection for two areas of concentration:
community development and health promotion. The EPM addresses socioenviron-

mental intervention, whereas the HBM is focused on disease-prevention

15

16

intervention. Each model challenges the other on the basis of accountability. The
driving question is: Does what the models do, and how they do it, make a difference
in terms of their intervention with those for whom and with whom they do it?

The EPM serves as a guide for designing, implementing, and evaluating
community development projects. Constructed in the late 1980s by Frank Fear, a
professor in Michigan State University‘s Department of Resource Development, the
model is grounded In the thought that community Change agents must be able to
connect theory with practice that is deemed beneficial by the people, the
organization, and/or the community experiencing the Change. One of the
components of the EPM that distinguishes it from other project models is its
emphasis on participation by local stakeholders. In the three dimensions of the
model—design, implementation and consequences-there is a stakeholder
component, which is a guiding principle in community development (see Figure 1).

The EPM comprises the following three dimensions, each of which has
several components:

1. Project-design dimension. This dimension includes five
components: (a) the problem-analysis component—the extent to which local
problems and needs, to be addressed in the project, are documented and action is
justified; (b) the situational-analysis component-the extent to which project
designers demonstrate that they understand the ”culture” of the place(s) in which the
project isto be implemented; (c) the substantive component-the degree of expertise

held by the designers relative to the issues to be addressed in the project; (d) the

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18

design-coherence component-the extent to which the design elements (e.g., goals,
methods, budget) are coherently related; and (e) the local-stakeholderoparticipation
component—the extent to which key loml groups are actively involved in and
Influence the project design.

2. Project-implementation dimension. The three components of this
dimension are (a) tuming design intentions into action; (b) making in-course
modifications (as deemed necessary) in project operations because of design flaws
or unexpected consequences resulting from initiating a project; and (c) monitoring
stakeholders’ perceptions about “how the project is going" and using that information
to modify project operations.

3. Project-consequences dimension. This dimension has two
components: (a) the impact component represents two effects—the primary
(intended) effects, vis. the extent to which each project objective is achieved, and the
secondary effects, including unintended and spin-off effects; and (b) the outcomes
component. Outcomes include the following: To what extent do project
stakeholders believe the project to be successful? Is the project, in whole or in part,
sustainable following the termination of external funding? Has the project
contributed to local understanding about how to design and implement a successful
change project (Fear, 1990)?

The HBM is a psychosocial formulation developed to explain health-related
behavior at the level of individual decision making (Mikhail, 1981). In the 1950s,

social psychologists at the US. Public Health Service developed the HBM in an

19

attempt to understand 'the widespread failure of people to accept disease
preventatives or screening tests for early detection of asymptomatic diseases”
(Rosenstock, 1974, p. 328). The model helps explain why individuals do or do not
engage in a wide variety of health-related actions. Essentially, the HBM is a
framework for explaining and predicting the acceptance of health and medical-care
recommendations. The basic components of the HBM were derived from a well-
established body of psychological and behavior theory, whose various models
hypothesize that behavior depends mainly on two variables: (a) the value an
individual places on a particular goal and (b) the individual’s estimate of the
likelihood that a given action will achieve that goal (Janz 8 Becker. 1984).

The HBM has four major dimensions that were developed to explain
motivation: (a) perceived susceptibility, (b) perceived severity, (c) perceived
benefits, and (d) perceived barriers (see Figure 2).

1 . Perceived susceptibility. Individuals vary in theirfeelings of personal
vulnerability to a condition. Thus, this dimension refers to one’s subjective
perception of the risk of contracting a particular condition.

2. Perceived severity. Feelings concerning the seriousness of
contracting an illness (or of leaving it untreated) also vary from person to person.
This dimension includes evaluations of both medical/clinical consequences (e.g.,
death, disability, and pain) and possible consequences (e.g., effects of the

conditions on work, family life, and social relations).

20

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21

3. Perceived benefits. Although acceptance of personal susceptibility
to a condition believed to be serious was held to produce a force leading to behavior,
this did not define the particular course of action that was likely to be taken; this was
hypothesized to depend on beliefs regarding the effectiveness of the various actions
available in reducing the disease threat. Thus, a “sufficiently threatened” individual
would not be expected to accept the recommended health action unless it was
perceived as feasible and efficacious.

4. Perceived barriers. The potential negative aspects of a particular
health action may act as impediments to undertaking recommended behavior. A
form of cost-benefit analysis is thought to occur, wherein the individual weighs the
action’s effectiveness against perceptions that it may be expensive, dangerous (e.g.,
side effects, iatrogenic outcomes), unpleasant (e.g., painful, difficult, upsetting),

inconvenient, time consuming, and so forth (Janz 8. Becker. 1984).

CommunitLQeILelnnmem

In community development, three approaches are generally used—self-help,
technical assistance, and conflict. When applying community development
approaches or strategies (some literature refers to them as community-analysis
methods) to health promotion, self-help and technical assistance are used most
often. However, the conflict strategy is most often used when health promotion
policy is at issue.

The self-help or empowerment approach is used when the community

initiates its own problem-solving process. When the process is initiated by an

22

outsider, it may also foster empowerment. Neighbors (1994) argued that, in the
African American community, empowerment is the most critical and highly valued
benefit that can be attained by participating in self-help organizations. Similarly,
Bilinski (1969) suggested that self-help should be viewed as a goal in and of itself,
as well as a strategy for accomplishing broader objectives.

Technical assistance, another approach used in community development,
relies on the expertise of outsiders to help the community solve problems. Although
the expert has the knowledge regarding the process, the community must still be
involved. ”It takes place within a larger process where community residents make
a shared decision to initiate a planned change process—a process that is based on
a mutually agreeable set of role relationships between community members and

outside providers” (Fear, 1989, p. 85).

fleaflhfimmmion

In health promotion, lifestyle change is the most popular of the three
approaches or theories that is generally discussed. The other two are the germ and
environmental theories (Schwartz, 1994). Although these approaches may be
viewed as complementary, they usually are seen as competing with one another.
For example, Conrad (1994) argued that the worksite health promotion model tends
to deflect attention away from the worksite environment as an agent of disease. The
model typically focuses on blood pressure screenings, exercise, smoking cessation,
and nutrition programs, often omitting health hazards that are job related or caused

by the job.

23

The germ-theory approach to disease prevention focuses on health as a
technical problem, not a societal one. The health problem can be cured in the
laboratory by scientists; it is synonymous with science. For example, the
identification of certain microorganisms being linked to specific diseases has made
it possible to develop means of supplying the body with defenses against their
invasion. In some instances, this has meant injecting people with a vaccine that will
lead the cells to produce antibodies. As a result, it is the scientists who are credited
with ridding the public of these diseases. One criticism of this theory is that it fails
to consider the complex interactions of people with their social and physical
environments.

It means that the real cause of disease, the fundamental cause, is tangible,

identifiable, and individual. It makes logical the idea that the most efficient

method of disease prevention provides the individual human body with a way
to fight invasions of microscopic particles, and it expands to advocate
behavioral Change only when no such particles have been identified. (T esh,

1994, p. 521)

The environmental theory Challenges the chain of causality implied by the
germ theory. It holds that significant numbers of Chronic diseases are caused by
toxins in the environment and implies that disease prevention, instead of requiring
personal change or medical treatments, demands changes in industrial production
(Tesh, 1994). One distinguishing aspect of the environmental approach is that its
sources of hazards continue to expand. They surround us in our work and in our

homes and affect what we eat. It has been estimated that nearly 1,000 new

Chemicals are affecting our health, unbeknownst to us.

24

One of the most popular health promotion theories is the lifestyle theory. In
essence, this theory sees disease as the result of an unhealthy lifestyle. This places
the responsibility for one’s health directly on personal behavior, whereas from the
germ-theory perspective, personal behavior is of secondary importance. The
lifestyle theory views stress, lack of exercise, and overconsumption as contributing
to disease. Like the germ theory, though, it focuses on the individual. Its popularity
has made itthe centerpiece of chronic-disease-prevention policy because itstresses
personal control and responsibility and Claims that lifestyle behaviors can reduce
medical-care expenditures. This approach is not without its critics, however. Many
sociologists view the lifestyle approach as ”blaming the victim” and are afraid it
deflects attention from societal causes of disease. That is, how can individuals be
held responsible when unhealthy lifestyles are portrayed so positively in the media
toward those who are most vulnerable to such appeal (Schwartz, 1994)?

A review of the literature revealed that health care professionals who
administer community health programs are using community development
strategies. However, gaps do exist. One is in the area of community health care
professionals’ influencing policy. A Second issue involves data, knowledge,
attitudes, beliefs, and actions of the professional. Conversely, writers on the social
model of community development have not considered the role that community
development is playing in health. Finally, literature on African Americans'
participation in and satisfaction with community-based health projects seems to be

almost nonexistent.

25
In an article published in the JQumaLQLCnmmunflLfleanh. Altman (1991)

chided funders and researchers alike for focusing mainly on the participation aspect
of health promotion. "Indeed, participation is in vogue as a method for enhancing
the effectiveness of community health promotion programs. yet very little data exist
on the knowledge, attitudes. and beliefs and action of health promotion program
planners.” Altman suggested that a coalition of health professionals and community
advocates should identify critical elements, processes, and challenges in the
development of effective community programs.

Although Altman’s argument has merit, it is not without difficulties. The
overwhelming majority of the studies he was referring to were conducted on the
general population, mainly Caucasians. The literature does not contain many
studies that have addressed the issues associated with Blacks’ participation. The

efficacy of selected community—based CVD programs was examined in this study.

CHAPTER III

METHODOLOGY

[mitosis-Minn

This research is an exploratory, descriptive study with multiple measures.
The purposes are to (a) document the perception of participation by CVD project
coordinators and participants at eight sites identified as African American
communities throughout Michigan; (b) measure the knowledge, attitudes, skills, and
behaviors of the participants; and (C) measure the efficacy with which the
community-based CVD programs have been developed and implemented.

Four of the proposed study sites are located in tva Michigan cities with the
densest Black populations, Detroit and Benton Harbor-76% and 92%, respectively.
Detroit, a home to three community-based CVD projects, is located in the
southeastern area of the state; Muskegon Heights is the only site located on the far
western side of the state. Other sites are located in Lansing, which is in mid-
Michigan; Ypsilanti, which is in the southeastern corner of the state; and Covert and
Benton Harbor, located in the southwestern section of Michigan. The only project

that is in a rural community is in Covert (see Figure 3).

26

27

 

/

CVD Programs Site Locations

 
   

 

Site Locations

CVD Programs by County
- Countlos
o

40 no 1 20

* Incl-una-

 

 

 

lunk-gon "nights (1)

Court (1)

lemon Harbor (1)

Dotrofl (3)
Ypolhnfl (1)

 

Lansing (1 )

 

 

Figure 3: CVD Programs Site Locations.

28
Besearcbfleslgn

Two competing research paradigms are the conventional and the
constructivist. Lincoln and Guba (1989, 1990) depicted the conventional paradigm
as the positivist-reductionist approach to inquiry. Its ontology consists of a belief in
a single reality independent of any observer, a mechanical explanation of cause and
effect, and a belief that universal truths Independent of time and place exist and can
be discovered. The epistemology is based on a subject-object dualism, in which the
subject, the researcher, should and can investigate the object, a phenomenon, free
of values and biases. Its methodology favors experimental designs that test specific
hypotheses and strive to render the research object, also known as a dependent
variable, free of its ”confounding context.“ The conventional paradigm is concerned
with predictions made through certainty and proof. This paradigm is dominant in
medicine, epidemiology, behaviorist psychology, and social marketing, among other
health promotion-related feeder disciplines.

The other paradigm referred to by Lincoln and Guba (1989, 1990) is
constructivist. Its ontology is relativist, meaning that realities are socially
constructed, ”locally and specific, dependent for their form and content on the
persons who hold them." Given this, the epistemology is one in which the
researcher is part of the reality that is being researched. Therefore, the research
findings are a creation of the inquiry process itself, rather than a collection of

external, already existing facts. Its methodology is heuristic. It involves a constant

29
comparison of differing interpretations. 'It is a process of iteration, analysis, critique,
reiteration, reanalysis, synthesis, and so on" (Labonte & Robertson, 1996, p. 434).

The conventional research of ”hour“ and 'what" is fairly understood in health
promotion, but is less tme in the constructivist research, according to Labonte and
Robertson (1996). They further stated that constructivist research owes much of its
heritage to ethnography. Simply put, constructivist research methodology focuses
on people’s lived experiences. Applications of the constructivist paradigm are in
“critical” or interactive approaches to education, community development,
community psychology, and other social science feeder disciplines to health
promotion. As a result, this study was designed primarily using a constructivist
paradigm; qualitative as well as some quantitative research methods were used.
Labonte and Robertson argued thatqualitative methods can be used in conventional
ways like anthropology’s old "View from the tent” attempt at objectivity—just as
quantitative methods can be used by constructivists. They said it is easy to
triangulate methods, but it is Clearly another issue to triangulate different
methodologies and their epistemologies.

The constructivist paradigm was used in this research because (a) this is an
exploratory study, in which the researcher attempted to uncover a host of subtle
factors that might have a significant relationship to a complex problem; and (b)
effectively addressing the research questions that emerged during the course of

developing the research problem called for a thorough investigation.

30

Data for this study were obtained from primary and secondary sources. The
primary data are from focus group transcripts and transcripts of interviews with the
program coordinators. The secondary data are from the CVD program files located
at the MPHI. These files contain CVD program quarterly reports, annual reports,
and MPHI-CVD request-for-proposal materials.

A triangulated measurement (multiple-method) model was adapted to
compare and correlate the results from three different measures with one another.
According to Cohen and Manion (1980), there are several instances in which the
triangulation approach in research is especially appropriate. They argued that
triangulation is useful when an established approach yields a limited and frequently
distorted picture. They also suggested that triangulation might be preferable
because of its possible enhancement of the research process itself. They wrote,
”Exclusive reliance on one method, therefore, may bias or distort the researcher’s
picture of the particular slice of reality she is investigating” (p. 175). As to how
methods should be combined, they concluded, 'No simple directive can be given for
the question, how are the methods to be combined, for the answer will depend to a
A great extent on the objective of the study, the particular situation, and the relative
weighting, which the researcher considers desirable to assign to the methods
providing her with data” (p. 175). Thus, in using the triangulate measure as
proposed by Cohen and Manion, the researcher compared the data gathered
through three different methods—focus groups, coordinators’ interviews, and

program documents (see Figure 4).

31

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32
Subjects
The primary subjects for the study were African American participants from
selected CVD programs. Each of the eight program coordinators also was
interviewed for the study. These were the people who administered the program
and wrote the quarterly reports for the funding agency. Because of limited
resources, the coordinators were the only people (at most sites) who had regular

contact with the program participants.

Reseamtlxpotbeses
The following hypotheses, stated in the null form, were tested using various
techniques based on the data collected for this study:
Hg_1: There are no differences in the use of community development
strategies for CVD prevention by health institution CVD programs and

community-based CVD programs.

H92: There are no differences between the before- and after-focus group
perceptions of participants about CVD-prevention programs.

Hg_3: There are no differences between the focus-group participants’
categories of motivation for adopting healthy lifestyles and preventing CVD.

Hg_4.: There are no differences between the individual CVD programs’
objectives and their achievement.

Haj: Coordinators’ previous applied community development experience
does not make a difference in program participation.

33

Ems-Cranes

Focus groups were conducted with the CVD program participants at the eight
study sites. The focus groups involved group discussions among people from
similar ethnic backgrounds and experiences concerning the specific topic of CVD.
The researcher served as the facilitator for the focus groups, using a protocol of
sequence questions in a discussion. Each focus group session lasted a maximum
of one hour and had five to ten participants. An advantage of using a focus group
approach is that it does not prohibit people with literacy problems from participating.

Using the focus group technique allowed the researcher the opportunity to
elicit exploratory or confirmatory information (Williams, 1997). Focus groups provide
immediate feedback. Their group dynamics create an atmosphere in which
participants can express ideas and feelings that might otherwise be missed by using
a survey. Goodman and his colleagues (1993) found that, at times, behavioral risk
factor surveys are considered to be intrusive, ”especially by marginalized groups
who see data-gathering exercises as another state invasion into their lives” (p. 10).
In addition, people often feel intimidated by the technical nature of a survey
(Goodman et al., 1993). By using a focus group, the researcher can gain an
understanding of the meanings participants assign to concepts. One group’s
concept of barriers, community development, or empowerment may not be

meaningful for other communities. What is of value, what is generalizable, is the

34

process used in developing the measures and Involving the stakeholders (Labonte
8. Robertson, 1996).

The researcher provided the program coordinators with written information
aboutthe focus groups. The coordinators were asked to recruit program participants
for this study.

Data gathered from the focus groups were validated by the external
stakeholders-the funders of the project, the MPHI CVD Resource Center director,
and the MDCH Health Promotion section Chief. This validation was done by
comparing the transcripts with the researcher’s analysis. At various times, reliability
can suffer due to differences in the facilitators tone of voice when asking the
questions or by the environment in which the session is being concluded.

The protocol for the focus group consisted of five open-ended questions:

1. Tell me about yourself prior to being a participant in this program and
your lifestyle now.

2. How has the program made a difference in your life (specifically related
to CVD)? Any knowledge, skills, attitudes you’ve gained as a result of the program?

3. What challenges did you face while being a participant?

4. Why do you think you will be able to continue to improve your well
being?

5. If you had to do this program again, what would you like to see done

(changed)?

35

W

The second method of data collection was to conduct interviews with the
program coordinators. The researcher conducted eight face-to—face Interviews (one
per site). The principal advantage of conducting interviews is adaptability (Borg 8.
Gail, 1979). According to Borg and Gail, ”The well-trained interviewer can make use
of the responses of the subject to alter the interview situation” (p. 316). Another
advantage of interviews is that they allow for immediate follow-up and Clarification.
WIersma (1985) contended that good rapport between the interviewer and the
interviewee is essential if one is to obtain accurate and truthful responses. He
argued that ”the interview should be structured to obtain the necessary information
efficiently in a friendly but businesslike atmosphere. if possible, there Should be
some accuracy Checks on the responses' (p. 65). Care was taken with regard to
data-recording procedures to guard against interfering with the interview itself.

Each coordinator was asked the same questions in the interview. The
questions were:

1. Have you ever coordinated a community-based program before this?

2. Have you coordinated a community-based program for African
Americans before this?

3. What have you learned from your experiences as a coordinator of this
program?

4. Tell me about the successes and challenges you have faced.

36

5. Was the community or were the participants involved in designing this
program?
6. If you had the opportunity to redesign this program, what would you

Change? Why?

Secondaruzata

The third method of data collection was the use of secondary data. The
program quarterly reports, the criteria for those reports, and the Request for
Proposal were used as secondary data. In general, these sources contained

information on program goals, objectives, participation, and evaluation.

DataAnalxsiSEmceduLes

The focus group sessions were tape recorded and transcribed. The
transcriptions were analyzed using codes and a log. The codes consisted of CVD
risk factors—hypertensionlhigh blood pressure, diet/nutrition, CPR, smoking,
alcohol/drugs, exercise, cholesterol, and weight. Each transcript was labeled to
indicate the specific risk factors mentioned. In addition, a log was created to
compare focus group responses that correlated with the objectives of the CVD
program and topics revealed in the group sessions. For example, the transcripts
revealed that attitude change was mentioned more than 10 times.

The same recording and transcribing methods were used for the interviews
with program coordinators and employed with the focus groups. To ensure validity,

the data collected were shared with the external stakeholders.

37

The data from the coordinator interviews were compared to those from the
focus groups with regard to the perceptions of the program. Although there were
times when the program-coordinator data were studied alone, these data also were
analyzed in connection with the secondary data. These data revealed the amount
of experience the coordinators had in using community development approaches.
The researcher analyzed the interface of community development strategies with
program participation.

Specific data-analysis techniques that were used in this study are as follows:

t—test: This test was used to determine whether there was a significant
difference between the means of groups (the groups were health institutions and
community-based organizations). This test was used for Hypothesis 1.

' Analysis of variance (ANOVA): This test was performed to determine
whether there was a Significant difference within or between groups and/or
categories. ANOVA was performed on Hypotheses 3 and 4.

Friedman test: This is a nonparametric test that relies on ranks and does
not make assumptions of normality. It was used to determine that there was no
group effect (e.g., no group effect due to various categories of motivation for
adopting healthy lifestyles and preventing CVD). This test was used for
Hypothesis 3.

Qualitative induction: Participant focus groups and coordinators provided
primary qualitative information. Participants were encouraged to reflect on their past

experience and lifestyles and to recall their perceptions of the intention of the CVD

38
program(s), their beliefs and attitudes about preventing CVD, and their perceptions
regarding health screenings and CVD educational training provided during the
program time period. This was used for Hypotheses 4 and 5.

Comparative periodic report analyses: Quarterly and annual reports from
CVD programs were analyzed to detect differences. similarities, and consistency
within and among the CVD programs with regard to the following data elements:
progress review, financial status, difficulties encountered and solutions, Changes in
key personnel, planned activities, and evaluation of ability to complete remainder of
the project on time.

Chi-square test: The chi-square goodness-of-fit test is appropriate for
comparing the distribution of one population across levels of a single categorical
variable. For instance, the distribution of participants in the CVD programs who had
self-reported experience with CVD risk factors (e.g., high blood pressure, high
cholesterol levels, overweight, and so on) was compared to the known or estimated
distribution for the particular community in which the CVD project was located. This
test was used to determine, for example, the proportions of participants reporting
that they engaged in physical exercise none of the time, some of the time, or most
of the time (or regularly). This test was performed on Hypothesis 2.

A contingency table was constructed showing the number of participants
reporting CVD risk factors versus those reporting categories of motivation. The chi-
square test was used to examine relationships between the variables and was used

for Hypothesis 3.

39

Fisher's exact test: This test was used instead of the Chi-square test where
cells and contingency tables had expected counts less than five. This test was used
to obtain accurate results and was performed on Hypothesis 2.

Least significant difference (LSD) test and Tukey’s test: Both of these
multiple comparison tests were conducted to compare means of categories of
motivation for the eight sites. Both tests confirmed the same results for

Hypothesis 3.

Limitations

Participants volunteered and were recruited to participate in the CVD
programs. It is possible that the participants’ level of change was a result of their
knowledge of, or exposure to, another health promotion effort. The possibility also
exists that the participants and/or the coordinators will not be completely honest in
their responses.

The following limitations also may affect the accuracy of the study results:

1. Data were collected from the program participants and coordinators
after the program had ended.

2. The CVD projects were not uniformly or similarly structured, and they
were coordinated differently.

3. No written standard pre- and post-survey tools were designed for
program participants and coordinators.

4. Participants were not randomly sampled from targeted populations.

40
5. The majority of the participants were African American males, making
their perceptions, beliefs, attitudes, and behaviors about CVD prevention dominant.
6. Because of limited resources, the site coordinators were the only
persons assigned to work with the project. Therefore. these were the only

administrators who could be interviewed.

CHAPTER IV

ANALYSIS OF THE DATA

IDILQdIICflQD

The data were gathered using multiple data collection methods. This form of
data collection recognizes that no single technique will yield the information
necessary to conduct an in-depth investigation. Data were gathered through three
different methods—focus groups, coordinators’ interviews, and program documents.
Two questions framed the formulation of five hypotheses, and, in turn, the
hypotheses brought knowledge to bear in regard to the questions. For instance, the
questions were answered by reviewing the test results from the appropriate
hypothesis, as well as raw data from the focus groups, coordinators’ interviews,
and/or program documents.

The five hypotheses were tested using various statistical methods. In the
following section, each hypothesis is restated, followed by the results for that
hypothesis. The chapter concludes with a discussion of the findings regarding each

research question.

B I! [II II 'II'
11mm

There are no differences in the use of community development strategies for
CVD prevention by health institution CVD programs and community-based
CVD programs.

41

42

Results. Based on the t-test results, Null Hypothesis 1 was rejected. A
significant difference was found between community-based organizations (C803)
and health institutions in their use of community development strategies for CVD
prevention.

W. Of the eight sites included in the study, five were
identified as health institutions (sites 1, 3, 4, 7, and 8) and three as CBOs (sites 2,
5, and 6). According to the coordinators’ reports, each agency used community
development strategies in the implementation of its CVD program. The strategies
were categorized as either self-help or technical assistance. The t-test results
Indicated that CBOs and health institutions differed significantly in the mean number
of strategies they used in implementing their CVD programs (p < .005). The
standard deviation of the number of combined community development strategies
used by health institutions was more than two times that of the community-based
organizations (see Table 1).

Table 1: Sites applying various community development strategies (combination of
self-help and technical assistance).

 

 

 

 

 

 

 

 

 

IF
. Sample .
Type of Srte Size (0) Mean SD MIn. Max.
Health Institution 5 10 2.12 7 12 [I
Community-based organization 3 16 1.00 15 17 I
_

 

Discussion. These statistics gave rise to two implications. One is that 0803

have well-established community development interventions. Each of the three

43

CBOS in this study had had experience with community-based health-promotion
projects. Their experience in handling the distrust the Black community has in
regard to medical and public health agents had proven to be successful. What the
CBOS appeared to have done was to build on their previous track record of
managing health-promotion projects. In turn, this cemented the foundation for the
CVD project. According to Airhihenbuwa (1992), ”Cultural beliefs and experiences,
when properly understood, can be used to promote the success of health education
programs in African American communities“ (p. 271).

Also in this regard, coordinators who were interviewed for this study indicated
that:

This is probably our third one [health-promotion project]. . . . Health care is

what we are about and working in the communities. We find out the needs

of the community . . . then we go to them and ask them what can we do for

you? The reason we do that [is] because we want them to have that

ownership of that program, but we just want to always be on the sideline to

support them for resources and pull them together. But this is their program.

(Site 2)

The coalition has been involved with various community-based programs.

They were involved with teaching adolescents and teenagers about health

care. (Site 5)

We had a community-based program before, back in the late 80s and early

90s, called the Black Church Health Connections Projects. . . . We’ve been

involved in another project working on issues of infant mortality and

cardiovascular disease. (Site 6)

The second implication gleaned from these statistics is that the health
institutions should collaborate with the CBOS to provide services to the community.

Traditionally, health institutions do not have an established community-based record.

As previously mentioned, African Americans distrust health are providers; therefore,

44

it Is imperative for health institutions to solicit technical assistance from the CBOS in
developing and applying culturally appropriate community development
interventions. Using a collaborative model in providing services that reduce the risk
of CVD in the African American community is cogent. It would allow each sector, the
CBOS and the health institutions, to operate from Its strengths and learn from the
other. The CBOS provide indigenous technical assistance, and, at the same time,
the professionals become the learners. Each would provide technical assistance to
the other, supplying the community with more resources and a stronger program
than either would have alone.

AddflimaLflndings. The following findings provided a better understanding
of the linkages between the community development approaches applied by health
institutions and CBOS. The t—test indicated that CBOS and health institutions did not
differ significantly In the mean number of self-help strategies that they applied (:2 >
.03). The standard deviation of the number of self-help strategies used by
community-based organizations was approximately 1.8 times that of the health

institutions (see Table 2).

Table 2: Sites applying self-help strategies.

I . Sample .
Type ofSIte Size (01 Mean SD Min. Max.

lHealth institution 5 3.80 0.84 3 5
ICommunity-based organization 3 4.67 1.53 3 6 I

 

 

 

 

 

 

 

 

 

 

45

One strength of health institutions is that they promote self-help interventions,
which include targeted media campaigns, self-help literature, and counseling. On
the other hand, the results Indicated there was no significant difference in the
number of self-help strategies being used by C308 and health institutions. This
demonstrates that CBOS with a track record of addressing health care issues in the
African American community are as effective as health institutions in administering
the self-help approach. This raises the question of why the difference between
health institutions and CBOS was not significant, given the factthat health institutions
have an established track record, which is considered their hallmark.

A possible explanation for these findings is the level of understanding that
CBOS have in working with their communities. The CBO coordinators in this study
were experienced in administering health-promotion projects, as well as in working
within the African American community. The researcher believes these coordinators
learned valuable lessons in self-help approaches from their previous experience;
moreover, the CBO coordinators were stakeholders in the process. These were
African Americans who recognized that they, too, could be affected by CVD. All of
the CBO site coordinators involved their families, friends, and members of their
Churches, thereby increasing the intensity of the self-help strategy and thereby
making that strategy effective. This underscores the importance of collaboration
between the health institutions and the CBOS. They are stakeholders and should

be viewed as such.

46

Fear(1990) argued that stakeholders’ Involvement accomplishes three major
objectives: (a) It guards against ”outsiders“ (health institutions) making decisions
that are insensitive to the community’s culture and/or their preferences; (b) it
communicates to the residents that the project is theirs, which can minimize
resistance to change; and (c) peOple are more likely to support what they create.
Similarly, Wandersman and Giamartino (1980) found that participation was more
likely among those who were concerned about their neighborhood, had more
experience in community leadership, and thought that competent colleagues could
be enlisted for their support of the project.

The t-test indicated that CBOS and health institutions differed significantly in
the mean number of technical-assistance strategies they applied (:2 < .01). The
standard deviation of the number of technical-assistance strategies used by
community-based organizations was approximately 1.7 times that of the health

institutions (see Table 3).

Table 3: Sites applying technical-assistance strategies.

 

 

 

- Sample .
Type of Srte Size (II-I Mean SD Min. Max.
Health institution 5 6.20 1.48 4 8
Community-based organization 3 11.33 2.52 9 11

 

 

 

 

 

 

 

 

The findings indicated that CBOS were more effective than health institutions

in administering technical-assistance strategies. The CBOS recognized the

47
community's needs and adapted their technical assistance to meet those needs. In
one community, the site coordinator understood that rescue workers were very slow
in rendering services to that community; therefore, cardiopulmonary resuscitation
(CPR) training was made available to peer educators. In addition, the CBOS used
the 'train the trainer“ model more than did health institutions. In this model,
coordinators train lay workers or peer educators, who, in turn, pass their skills and
knowledge on to others in the community. This form of capacity building goes to the
heart of community development by addressing the issues of personal growth and
program sustainability. According to Christenson and Robinson (1989), the primary
goal of community development is to help people improve their well-being. These

results suggest the level of influence CBOS have in this regard.

Hypothesisz

There are no differences between the before- and after-focus group
perceptions of participants about CVD-prevention programs.

Results. The p—value from Fisher's exact test indicated that there was a
statistically significant relationship between the behavioral indicators and CVD risk
factors. Therefore, the null hypothesis was rejected.

mm. It was observed that there was a statistically
significant relationship between risk factors (i.e., cholesterol, diet, exercise, high
blood pressure, and weight) and behavioral indicators (attitudes, knowledge, prior
illness, participation, skills, self-motivation, and sustainability). In reviewing the

transcripts from the focus group discussions, it was observed that 242 times

48

participants made salient comments (points) that cross-referenced key features of
behavioral indicators with CVD risk factors. For the purpose of testing this
hypothesis, the researcher examined relationships that were cross-referenced in
20% or more of the comments by participants. For example, diet was cross-
referenced with the behavioral indicators in 33% of the comments; exercise was
cross-referenced with the behavioral indicators in 27% of the comments, and high
blood pressure was cross-referenced in 23% of the comments (see Table 4).

HoriszaLanalysis. Viewing the tabulated data from a horizontal perspective
lends insight into what the participants received while they were in the program. It
reveals how much a specific risk factor affected a behavioral indicator.

Diet by behavioral indicators: Of the 79 times (33%) comments were
focused on diet, about 22% of the comments had a relationship to attitudes, whereas
32% were associated with knowledge (see Table 4). When comparing the program
records, this is not surprising, given that all eight of the sites had strong nutrition
emphases. Purposes of the presentations regarding diet were to give the
participants knowledge or to educate them concerning nutrition and Change their
attitudes about healthy eating and cooking. Participants were given low-fat and low-
sodium recipes. Cooking demonstrations were held and food samples given out,
and participants were taught how to modify their eating habits when they dined out.
In some cases, participants who were malnourished received information regarding

their Circumstances. Participants commented:

49

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.8. $8. $.. $2 $m $9 $8 $2 $8 6.28.9.0
2.... 8298.2 2.20 8...... 8.8... 88.265. 8222
a. .28 8.980 .80 . 8.8.. 8.... . .98”. 8.”. o>o

 

 

 

 

 

 

 

 

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0002:0200 30.10.2020... 5.030500 .3 0.200.. 0.0.. o>0 a. 030k

 

50

It [the program] made me more self-aware of my lifestyle as far as eating. Off

and on I did start eating regularly. . . . I became more aware that I needed to

put more food In my body to give more nourishment to my body. I think once
the awareness came in there, then the attitude also followed. I took an

attitude that I'm going to try to do better personally. (Site 8)

Me and the Colonel [Colonel Sanders Kentucky Fried Chicken] has a love

thing. But I found out that I didn’t have to go and get the fried chicken; I could

get the roasted chicken. I really changed my eating habits, and I feel better.

I don’t feel sluggish like I use to. I have a lot more energy. So I really think

that has improved my life in that area. (Site 1)

Exercise by behavioral indicators: Of the 66 times (27%) comments were
focused on exercise. nearly 32% pertained to knowledge with exercise, whereas
almost 21% related to self-motivation with exercise (see Table 4). Exercise was also
a major focus at the sites. The purpose was to make participants aware of how they
could incorporate exercise into their daily lives. With this purpose in mind, it was
hoped that the participants would be motivated to continue exercising after the
program ended.

I use to weigh 286 pounds; now I [weigh] 254. I walk all the time. Sometimes

my foot still bothers me, but I still walk ifthe Lord gives me strength. I walk

through the house, sometimes I walk outside to the driveway. (Site 2)

I’m a little more active than I use to be. Like I said, I use to sit around here

and now I’ve gotten away from that. Now I go out and walk, if It’s nothing but

two or three blocks. . . . I’m a lot more active than I was. (Site 3)

High blood pressure by behavioral indicators: Ofthe 55 times (23%) that
focus group participants made comments about high blood pressure. nearly 30% of
the comments pertained to knowledge about high blood pressure, whereas 22%

focused on skills with high blood pressure (see Table 4). Although it is commonly

understood in the African American community that disproportionate numbers of

51
Blacks suffer with high blood pressure, many times they are not aware they have it.
Much ofthe educational emphasis in the programs was centered on myths regarding
high blood pressure and how it can be controlled—through diet and exercise. The
knowledge/skills these participants gained included how to understand a high blood
pressure reading, how to shop for and cook foods with less sodium and fat. and how
to make exercise part of their regular routine. At site 5, peer educators were trained
to be lay health educators; they learned how to take a blood pressure reading,
developed specialized presentations on specific risk factors like high blood pressure,
and were given an opportunity to earn CPR certification. Therefore. the responses
from the focus group sessions regarding skills overwhelmingly came from that site.
Two of those responses were as follows:
I speak on high blood pressure and was trained. . . . When I saw that Black
men and women have a higher rate than any other group in America in high
blood pressure, that astounded me. It worries me. In talking with the guys
that do have high blood pressure, I really responded well. They wanted
someone to pull them out and let them know about this. (Site 5)
I had an occasion where, after I finished CPR, approximately two weeks, on
a Sunday morning . . . a little girl about 3 to 4 years started choking. Her
grandmother grabbed her. . . . I said, "What’s wrong with her?“ She said,
“She’s choking.“ . . . So ljust took her and did the Heimlich maneuver, but I
didn’t have to get in the full position because she was so small. After four

thrusts, I was able to dislodge the hard candy. . . . EMS was not going to get
here fast enough. (Site 5)

ManiQaLanalyfi'Ls. Analyzing the data vertically gives sagacity to the program

participants’ before and afler perceptions regarding the program.
Prior illness by risk factors: Of the 47 times (20%) that prior illness was

mentioned, nearly 32% of those comments related to diet; exercise was mentioned

52
about 20% of the time. The other risk factors—cholesterol, high blood pressure, and
weight—were mentioned less than 20% of the time (see Table 5).

In the health belief model (H BM), prior illness relates to diseases experienced
by the participants or their families members that motivated them to be in the
program. It may also refer to the diagnosis participants received once they were in
the program. In this instance, the illnesses, which also happened to be risk factors,
such as high blood pressure. high cholesterol, and obesity, were mentioned as a
disease rather than a CVD risk factor. It was a description of themselves rather than
a cause of or a factor contributing to their CVD because other diseases also were
mentioned that were not risk factors. This category encompassed two dimensions
of the HBM—the perceived susceptibility and the perceived severity of participants.

Perceived susceptibility adds insight into the participants’ personal
vulnerability. In the case of medically established illness, this dimension pertains to
the resusceptibility, the belief in the diagnosis and the susceptibility to CVD. These
prior illnesses become cues that instigate action and vary with the level of
psychological readiness to act (Mikhail, 1981 ). 'The individuals psychological state
of readiness to take action is determined by both perceived susceptibility to [CVD]
and the perceived severity of the consequences of contracting [CVD]." according to
Mikhail.

After I went to the screening, then I found out I was a diabetic. (Site 8)

Well, I really don’t have any health problems, not yet. . . . So basically I took

this [program] because my brother-in-law had a mild heart attack and end up

having a stroke. I’m trying to better understand the field; I plan to go back to
school to be a cardiovascular technician. (Site 3)

53

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0......Mfi30 Emma... 0.....0 uh...“ 88.: BE 080.265. 08...... .28. .2”. o>o

 

 

 

 

 

 

 

 

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.5 0.0.. .0 02.02.000.00. .8...0>. 0000.50.00 050.000.200.00. .0.0.>0..0n .5 0.0.00. .0: o>o .0 0.00..

 

54

Knowledge by risk factors: Of the 69 times (29%) that participants made
knowledge comments. 36% of those comments were diet related, about 31% were
exercise related, and 23% were related to high blood pressure. Cholesterol and
weight were mentioned less than 20% of the time (see Table 5).

In the HBM, this topic relates to the dimension of perceived benefits. It is not
enough to be "afraid” of contracting CVD or being in a high-risk category, like African
American, for individuals to participate in a CVD program. There must be benefits.
Blacks, like other people, must understand the effectiveness of various actions like
exercising and changing one’s diet to reduce the threat of CVD. This is self-efficacy.
It appears that the participants believed they had the requisite tools to make a
difference in their lives. Hence it seems feasible that they can reduce the threat of
CVD.

I’m happy to be in the program. It learned me how to do my lifestyle better.

since I’m bothered with high blood pressure and high cholesterol. I’m walking

up to two miles an hour. I wasn’t doing that at first, but I started back and I

hope to get up to four miles. (Site 2)

The Pearson chi-square test comparing behavioral indicators with risk factors
showed a p—value of < .02. Fisher's exact test (two-tailed) was performed as an

alternate test because most expected frequencies were less than 5. On this test, p

< .0001.

Hypotheslfl

There are no differences between the focus-group participants’ categories of
motivation for adopting healthy lifestyles and preventing CVD.

55

Results. Based on the various tests performed. the null hypothesis that there
are no differences between the focus group participants’ categories of motivation for
adopting healthy lifestyles and preventing CVD was not rejected.

W. The Pearson chi-square test for independence was
used to determine whether the distribution of categories of motivation for adopting
a healthy lifestyle and preventing CVD was independent of the site. The distribution
of categories of motivation for adopting a healthy lifestyle and preventing CVD was
found to be independent of the site. The p-value of .223 of the test was obtained.
Because the p—value was greater than .05, the null hypothesis was not rejected.
That is, there was not sufficient evidence to indicate that the distribution of the
categories of motivation for adopting a healthy lifestyle and preventing CVD was
dependent on the given groups (see Table 6).

Analysis of variance (ANOVA) was used to determine whether there were
significant differences within or between the groups and/or categories. Results are
shown in Table 7, using the general linear models procedure.

The ANOVA results indicated that category of motivation was significant; the
p-value was .0316 (< .05). That is, differences were suspected between (or within)
the counts for categories of motivation for adopting a healthy lifestyle and preventing

CVD rather than between given sites.

56

 

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0. 0. 0 0. .. e 0 m. .28
$8.2 $8... $8.. $8.. $00... $8.. $8.0 $00.0 8.228
.0 0 . 0 e . 0 .. .80.... 8.5.2.00
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0 o . 0 o . N N .008. 8......
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57

Table 7: ANOVA using general linear models procedure.

Sum of Mean
I Source 01‘ Squares Square E-Value E: > E

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Model 9 84.28571429 9.36507937 2.43 0.0522

Error 18 69.42857143 3.85714286

Corr. total 27 153.71428571
B—Square Coeff. of Variation Root MSE COUNT Mean
0.548327 72.35646 I 1.9639610 2.71428571

Mean
I Source (11 Type 1 SS Square E-Value
Category 3 4257142857 14.19047619 3.64
Site 6 41 .71428571 695238095 1.80

 

 

 

 

 

 

 

 

Mean
Square

42.57142857 14.19047619 3.68
41 .71428571 695238095 1.80

Type III SS E-Value E: < E

 

 

 

 

 

 

 

   

 

 

58

The third method used in analyzing the data was the Friedman Fr test. a
nonparametric test that relies on ranks and does not make an assumption of
normality. The method is straightforward. Within each of the four categories, the
observations were ranked. This method was used to test the null hypothesis that
there was no group (or agency) effect, that is, no effect due to the factors
corresponding to the columns of the table. The results using this method indicated
that category was significant because the p-value was .0108 (< .05). In other words,
differences were suspected between (or within) the counts for categories of
motivation for adopting a healthy lifestyle and preventing CVD rather than between
given groups (or agencies) (see Table 8).

Finally, two multiple-comparison tests (least significant difference [LSD] and
Tukey’s test) were used to compare means of categories of motivation for groups
(agendas). Both tests revealed that the means (or counts) of improvement of
dietary habits, living longer, and control of stress did not differ significantly among
the seven groups. The most participants pointed out improvement ofdietary habits
as their number-one choice for adopting a healthy lifestyle and preventing CVD
(improving dietary habits was followed by performing physical exercises in terms of
rank, but improving dietary habits stood out from the rest of the categories (see

Tables 9 and 10).

59

Table 8: Results of the ANOVA for dependent variable: rank for variable count.

 

 

 

...... .. .1322. ems
Model 9 15.21428571 1 .69047619 1.66 0.1710
Error 18 1828571429 1 .01587302

Corr. total 27 3350000000

 

I B-Square

 

 

 

 

 

Coeff. of Variation

 

Root MSE

 

    

 

  

RANCOUN Mean .

 

 

 

 

     

 

 

 

 

 

 

 

 

 

   

 

   

 

 

 

 

0.00000000

 

  

0.00000000

L 0.454158 40.31621 1.0079052
*7 “WM" —*Mea __ "7— ‘1
Source df Type I SS Square E-Value E: < E }
Category 3 1521428571 5.07142857 4.99 0.0108 ‘
Sites 6 0.00000000 0.00000000 0.00 1.0000 I
Source at T emss M93"
yp Square

Category 3 15.21428571 5.07142857 4.99 0.0108
Sites 6

 

 

 

60

Table 9: Results of the Least Significant Difference (LSD) test.

 
 

 

  
  
 
 
   

 

  

 

 

 

 

 

Improving dietary habits
A
2.7857 7 Performing physical
B A exercises
B
B 1.9286 7 Living longer
8
B 1.7143 7 Control of stress

 

Notes. This test controls for the Type I comparisonwise error rate, not the
experimentwise error rate. In terms of pairwise comparison, the mean of improve-
ment of dietary habits was not significantly different from the mean of performing
physical exercise. Means with the same letter were not significantly different.

Alpha = 0.05 df = 18 MSE = 1.015873
Critical value OfI=2.10 LSD= 1.1319

Table 10: Results of Tukey’s studentized range (HSD).

   

 

 

 

 

 

 

 

 

Mean " “ ’ ” " Caegryo "
A 3.5714 Improving dietary habits
A

2.7857 Performing physical

B A exercises

B

B 1.9286 Living longer

8

B 1.7143 Control of stress

 

Notes. This test controls for the Type I comparisonwise error rate. but it generally
has a higher Type II error rate. Means with the same letter were not significantly
different.

Alpha = 0.05 df = 18 MSE = 1.015873
Critical value of standardized range = 3.997 Minimum significant diff. = 1.5227

61
Qismssign. The implication from these tests suggests that participants’

primary source of motivation for adopting a healthy lifestyle and preventing CVD was
their understanding of improving their dietary habits. This finding was consistent
with the comments from the focus groups and the programs' emphases. There was
a high concentration on exposing participants to the nutritional aspects of CVD.

When using the HBM to explain these findings, all four dimensions are
brought into play. This model is an example of the value-expectancy theory
(Campbell. 1996). The first dimension is perceived susceptibiliol, an individual’s
belief that he or she is susceptible to contracting the said disease. In this case,
program participants were given information in oral and written form on the mortality
and morbidity rates of African Americans in regard to CVD. Apparently. they
internalized the information and perceived that they were at risk. Some participants
thought they were at risk because they had been diagnosed with a particular illness
related to CVD and/or because a family member had a certain illness that led to
CVD. Other participants understood that they were indulging in one or more of the
CVD risk factors.

The second dimension, perceived severity, addresses the deep feelings an
individual has regarding personally contracting the disease. Nearly half of the focus
group participants identified previous CVD-related illness as a factor influencing
program participation. They thought that such illnesses as high cholesterol would

eventually result in their contracting CVD or that a hereditary illness, like obesity,

62

would lead to the disease. In turn, this belief became a reality for them. What
people believe is as important as what they know (Breckon, 1982).

One can see that these two dimensions are closely related. In fact, they
should be considered together because people evaluate their personal susceptibility
and perceived severity as a threat (Campbell, 1996). A higher perception of threat
predicts greater likelihood of action. However, Campbell argued that too much fear
can lead to paralysis and fatalism.

The last two dimensions-perceived benefits and perceived barriers-should
be viewed in tandem. Individuals will weigh the benefits of changing their lifestyles
against the costs of changing their lifestyles. When benefits outweigh barriers,
people are likely to adopt the behavior (Beckon, 1982; Campbell, 1996). In this
case, the coordinators must have presented nutrition education in a way that
increased the self-efficacy of the focus group participants. In other words, they
helped build participants’ confidence in their ability to purchase, cook, and eat
healthier foods. Campbell explained that self-efficacy is a strong predictor of
success in behavioral change, including weight control and smoking cessation. and
also predicts the likelihood of attempting behavioral change. In this case, as in other
situations, personal experience and vicarious observation were the two main factors
for increasing self-efficacy, thereby leading to motivation for adopting a healthy

lifestyle and preventing CVD.

63
Hypothesisfi

There are no differences between the individual CVD programs’ objectives
and their achievement.

Results. This hypothesis was analyzed using qualitative induction because
of the small counts. When comparing the health institutions with the 080s, it was
found that the latter experienced a 99% achievement rate, whereas the health
institutions had a 50% achievement rate. Based on these percentages, the null
hypothesis was rejected because there was a difference between individual
programs’ objectives and their achievement. The qualitative results are shown in
Table 11.

Collectively. health institutions were successful in achieving their objectives
in the areas of conducting referrals/follow-ups, establishing community coalitions.
and training lay health workers. Two sites (sites 1 and 8) listed four objectives.
They achieved one objective, making medical referrals and conducting follow-ups.
This is not surprising because health professionals are skilled in making referrals
and follow-ups. This is a part of health institutions’ structure. However. achieving
this objective should not be taken lightly, given that these two sites were in
economically distressed locations. In their interviews, the coordinators revealed that
the CVD project participants were relying on health professionals as their primary
health care workers because they did not have a primary physician. Clearly, the
CVD project is meeting a community need. Achieving this objective addresses the
issue of providing services to an underserved population. The EPM identifies this

within the project consequences dimension, in the project impacts component. In

64

Table 11: Qualitative results: individual CVD programs’ objectives and their

 

 

 

 

 

 

 

 

 

 

 

 

 

Rating scale: «H = achieved objective

1». = nearly achieved objective
-+ = attempted to achieve objective
- = did not achieve objective

achievement.
. . Researchers f
Srte Objectives Rating .
1 1. Provide screening/300 people + -
2. Medical referrals/follow-ups + +
3. 18 risk-reduction workshops + -
4. Train 2 volunteers per organization + -
2 1. 6 workshops at different sites by lay health workers + +
2. Conduct 4 health-promotion activities + +
3. Follow up on high-risk participants + +
3 1. Implement CVD basketball program at 2 to 3 sites + -
2. Implement program at 2 adult ed sites + -
3. Implement program at 2 community sites + +
4 1. Adaptfimplement program to be culturally based + +
2. Train lay health workers to implement exercise program + +
3. Train lay health workers to implement nutrition program + +
4. Lay health workers collect data on eating patterns - +
5. Promote program sustainability - +
5 1. Recruit 50-100 male participants + +
2. 50% peer educators conduct 3 workshops each + +
3. Train 24 peer educators + -
4. 10% of participants show decrease in 2 risk factors + +
6 1. Educate African American community on CVD risk factors + +
2. Conduct workshops at churches + +
3. Conduct screening + +
7 1. Establish community-based coalition + +
2. Work with churches to educate/train lay health workers + +
3. Implement screening and education program - -
8 1. Conduct 6 screenings for 180 people + -
2. Conduct secondary screenings for 54 people - +
3. Perform 150 hours of ed/referral/follow—up + +
4. Perform on-site health ed/referral/counseling - +

 

65

this component, a project has two effects, a primary effect and a secondary effect.
The former concerns the objective at hand. whereas the latter is an unintended
occurrence, known as a tangible effect. “Tangible effects include actual end-
products and accomplishments that would not have likely occurred had it not been
for the project“ (Fear, 1990, p. 9). An end-product was a teen pregnancy prevention
group comprising community mothers and daughters at site 8. Without question, this
is not related to the goal of reducing CVD in the African American community. but
it does contribute significantly to building good rapport between the community and
the health institution.

Establishing community coalitions and training lay health care workers were
objectives at two sites. Achieving these objectives addresses the issue of making
a contribution to the local capacity, a segment of the outcomes component in the
EPM. Fear (1990) argued.

The exemplary project is a learning experience for local participants. It gives

them practical exposure, and lessons on the process of organizing and

carrying out a successful community development effort. This “residue”
contributes to increasing the level of community competence.

When examining the 0806, one can see that the site coordinators
established three to four objectives; conversely, the health institutions established
four to five objectives. Program documents showed that actual program
implementation began three to six months after receiving the grant award. Sites that
had established rapport with the Black community were able to begin actual program

implementation one to three months faster, whereas other sites spent a lot of time

trying to establish rapport. Moreover, they lagged behind in being able to achieve

66
their objectives. Also, not understanding the culture of the community and not
involving them during the design process seemed to result in establishing overly
ambitious objectives. This leads the researcher to conclude that setting a few
objectives that can be attained in half of the grant cycle contributes to the
achievement of objectives.

Project coordinators had 12 months to implement this community-based
project. Site 7, a health institution, had not achieved its objective of implementing
a screening and educational program. In other words, they had not implemented the
actual program within the 12-month grant cycle. They ran into serious problems with
the community. The coordinator did not have any community development
experience. nor had she conducted a program specifically designed for African
Americans; therefore, she did not understand the culture. Moreover, had the
stakeholders been involved during the design process, the coordinator would not
have spent time ”redesigning” the screening and education objective with the
community coalition.

I think we set our sights [objectives] a little bit high. . . . I think it is very difficult

, to try to develop a whole new program with new people, and getting
information into the community and getting the support of the community and

getting a grasp of the group organizations to be involved. . . . We just couldn’t
get there. (Site Coordinator 7)

mm

Coordinators’ previous applied community development experience does not
make a difference in program participation.

67
Results. Because of the small numbers, qualitative induction was used. It
appears that applied community-based experience, along with understanding the
culture ofthe community, made a difference in program participation. Therefore, the
null hypothesis was rejected.

”'1..- .“ ;.. . :9. .'.. “I" m n = ”H” :.o:.':. .: .
coordinators. Five out of eight site coordinators had community development
experience; two were health institutions (see Table 12). The coordinators at sites
4 and 5 said they did not have the experience directly, but worked with others who
had community development experience to administer the program. One site (site
4) was a health institution, and the other (site 5) was a CEO. The coordinators of the
remaining three health institutions (sites 1, 7, and 8) said they did not have any

community development experience.

Table 12: Community development experience of coordinators.

 

 

 

 

 

 

 

 

 

   

 

 

 

 

Community Devel5pment Community Development Experience
Site Experience? With African Americans?

Yes No Yes No I
2 X X I
3
4 I
5 x x |
6 x x |
8 X X I

 

 

 

 

 

 

 

68
According to the quarterly reports, lack of participation was not a problem for
the coordinator at site 1 , who did not have any community development experience.
Under Difficulties Encountered and Solutions, one report stated:

During the last quarter, we reported that our obstacle was in recruiting
participants to the program. This obstacle was overcome when we began to
hold screenings at individual church sites rather than at the centrally located
street ministries office. Our difficulty now is that we are too successful.
Taking the screening to the churches tremendously increased the
participation. In fact, in February. 97 individuals were screened. and the
budget allows for 300 to be screened throughout the fiscal year. Our agency
has responded by affirming its commitment to this project and pledging to the
community that we will aggressively seek additional funding sources. (Site 1)

However, at site 7, it appeared that the coordinator’s lack of community
development experience made a significant difference in regard to getting
participants in the program. As late as July, in the second-quarter report, under
Difficulties Encountered and Solutions, it can be seen that there were obvious
problems with understanding the community culture. According to the report, there
was not complete buy-in from the Black church community. In addition, it appears
that the focus group participants had a better understanding of community
development than did the coordinator:

It was noted that the churches proposed to participate in the CVD Prevention
Project needed more time to understand the implementation plan and the
future sustainability of the project. More time was given to hold Individual
meetings with pastors to discuss the project implementation plans and its
future direction. This problem has significantly eased.

The preparedness of participating churches to support the training of
wellness leaders and appropriateness of the curriculum presented a concern.
It was resolved that the project coordinator take the lead in development of
a culturally appropriate church-based CVD prevention curriculum that would
be used in training wellness leaders. More time has also been spent in
promoting pastors’ awareness of the planned CVD prevention project and the
churches’ role in the project implementation. There is support for the project

69

now from the four first targeted churches. The project coordinator has
teamed with the curriculum advisory group. and the curriculum will be ready
before the next quarterly report. (Site 7 report)

I would like to see more health care people In the community have a part In
implementing the program itself . . . rather than for the packet to be put
together and say. “This is what we have for you.” It’s like throwing something
out to [us]; maybe what you think is needed, is not what we feel we need. . . .
It does not take much time initially to understand both needs and those who
want to work with you to develop strategies to meet those needs. (Site 7)

The coordinator at site 8 experienced a low rate of participation. It appeared
that she was not willing to be flexible and to go to the community:

Participation of the area churches is progressing slower than projected, but
progress is being made. With the advent of better weather and familiarity of
the program and Its components. initial suspicions are being overcome. . . .
The women in the area are forming a women’s group that meets weekly and
are interested in some of the classes that the health educator provides, along
with a beginning aerobics class. Lack of participation by the community
during this quarter ls evident by the lack of participants that use the facility
and its services. Again, poor weather. . . [has] hampered access to the site
with mud and puddles. The end-of-the—school-year functions were also a
factor in participation as many persons attended those functions rather than
those at the center. (Site 8)

According to the focus group reports. participation suffered because the
coordinator did not have an understanding of the culture of the community.
Sending letters don’t work in this community. It’s more than one-to-one

contact. It’s certain hit places in this community that you can catch a crowd
of people—church and school. If you don’t catch that person at church, you

will catch them at school because they support all the games. . . . This
community is more school based and church based, and there is nothing
else. (Site 8)

The site coordinators who said they did not have direct community
development experience, but worked with others who had such experience, did not

record any problems with participation in their quarterly reports. They cited

70

challenges in working with peer educators' (volunteers who were also participants)
skill levels to perform the given task. For example, the coordinator at site 4 identified
literacy problems, which would affect the peer educators’ ability to present as well
as read the heaith material. In addition, this also would hinder their completing
internal surveys given by the administering health institution. The solution was that
they would have team presentations. The health institution would mail the peer
educators their surveys. This would allow them to complete the survey with the aid
of a friend, and they would be required to mail it back. At site 5, where the program
was administered by a C80, the report stated that peer educators were
uncomfortable with taking blood pressures. Their solution was to continue having
a medical technologist take the blood pressure readings until the peer educators
were comfortable with their skills.

The three sites (sites 2, 3, and 6) where the coordinators had community
development experience did not have any participation problems. However, they
cited administrative problems. such as underbudgeting. The only health institution
site with a coordinator who had applied community development experience
reported that there were some literacy concems. This was in regard to an lntemal
survey the health institution wanted. In an attempt to resolve the problem, they
lowered the literacy level of the questions that appeared to be stumping the
participants.

Discussion. Health institution site 1, where the coordinator did not have any

community development experience or experience with the African American

71

community, did not have a problem attracting participants. It was evident that the
coordinator changed her strategy when she saw it was not working. In her report,
she noted that she had been having a hard time attracting participants to the original
location. She had changed days to coincide with a free food giveaway, but
participation was still low. Therefore, the next quarter, she made significant changes
by using multiple locations. This gave her more access to the community. She sent
a message to the community that the health department was flexible and willing to
work with them.

This change in strategy should not be taken lightly. The typical public health
model is to render services from a single location in the community, allowing
community members equal access. However, the problem is that access is not
equal in underserved communities. Lack of transportation becomes a major barrier
because of (a) limited money to use available transportation or (b) the location of the
site in relation to public transportation lines. When people cannot access an
intervention, even though it is free, it might as well cost money. One perception in
the African American community in regard to the public health department is that
“they really don’t care about us.” Making a major paradigm shift in rendering
services sent a message that “This CVD program is important, so important that we
are willing to come to you.“ This sent a message, not only that the program was
Important, but also that the community’s well being was valued.

In contrast, another site coordinator (site 8), who was affiliated with a health

department, chose not to be flexible and change the public health paradigm.

72

Inability to be flexible is a serious problem that plagues many well-meaning health
professionals who work with community-based intervention programs. “Currently,
culturally sensitive educational and behavioral change models for health promotion
in the African American communities tend to be based primarily on the Caucasian
experience” (Airhihenbuwa, 1992, p. 270). The focus group participants were
emphatic in their statements regarding how to reach their community. These
participants said they had told the coordinator that evening prayer meetings and
choir practices were good times to reach church members. In addition, they
recommended that she should work with the high school coaches to have a health
promotion night as a half-time activity. For whatever reason, the coordinator was
reluctant to listen to the participants’ advice. However, she eventually held sessions
at the high school for staff and faculty during the day, and some of those individuals
participated in the focus group.

The coordinator at site 7 also had no community development experience.
She was able to attract a limited number of participants, the peer educators,
because she used “community elites” (people who had a reputation for being
involved in community activities) to form a minority health coalition. However, she
was not able to attract participants outside the coalition.

Comments made by the focus group participants, as well as what was
documented in her site reports, indicate that this coordinator also lacked cultural
competence. However, her saving grace wasthat the participants who became peer

educators had community development experience and had an intimate relationship

73

with their community. In turn, they taught her the norms of the community and
community development strategies. The participants lnsisted that they be involved
in writing a curriculum for the community and its pastors, rather than using one that
did not have their input. As a result, the coordinator realized that it takes time to
build relationships and that it is through those relationships that one begins to
understand the culture of the community. This was not an easy lesson for this
coordinator to learn. She said it was very difficult because she had a set of goals
and a timeline that did not yield results. In this coordinator’s interview, she said the
community had not been involved in any way before writing the proposal, and she
realized that, in the future, that would be a key to getting community buy-in.

Two of the eight site coordinators who said they did not have direct
community experience, but had worked with someone who did, never mentioned in
their reports that they were challenged with getting the community to participate in
the CVD program. Neither coordinator revealed who her community development
consultant was, such as someone from her agency or organization. These two sites,
although they were very different (one a health institution—site 4—and the other a
CBOusite 5), used similar models for attracting participants. The initial participants
were trained as peer educators and served as recruits for the program. In addition,
the peer educators were given a stipend for their time. At site 4, peer educators
were recruited from several local churches and 0803, in order to build capacity to
sustain the program after the funding cycle ended. The coordinator said this

strategy had worked to get participation, but she was concerned that the satellite

 

74

sites would not be able to sustain the program. She thought that the volunteers
eventually would become burned out or lose Interest. In addition, most did not have
the skills to seek additional funding. On the other hand, site 5 used peer educators
who were family and friends of the CBO sponsoring the CVD program. They, too,
went to various sites to present the CVD program and were quite successful. Peer
educators from both sites who participated in the focus group sessions indicated that
being a peer educator was a great responsibility because it was so time consuming.
The remaining site coordinators who indicated that they had community
development experience demonstrated an abilityto attract African Americans to their
programs as participants.

0 O O O ’ O. ’
1010 ole-1.. :0. on I: M111 It 0 0.: 0-I I 0 :11:1

Wm. When the coordinators were asked whether the
community or any of the participants had been involved in designing this program,
three out of five responded in the affirrnative (see Table 13). One indicated that she
had solicited input from future participants but did not receive a response. The other
two coordinators said they had not requested any input from the community or
prospective participants.

The community’s input had been solicited at various points in the process,
with varying degrees of involvement, thereby leading to conclusions regarding
community involvement. One coordinator said that the health institution had solicited
community participation after receiving the grant. It was a person from a partnering

agency, whose responsibility it was to help locate outreach workers (volunteers);

 

El _

75
they, in turn, would help spread the CVD message and get community members to
participate In the screenings. Other sites used existing models from a previous
community-based program or from Healthy Michigan 2000, or they used health
professionals to advise them. At only one site was participation solicited before

writing the proposal.

Table 13: Community or participant involvement in designing the CVD program.

 

 

 

 

 

 

 

 

 

 

Community or Participants Involved
Site in Program Design?
Yes No

2 x
3 :3'
4
5 x
6 x
8

 

 

 

 

 

”Tried but received no input.

Discussing. Some of the methods of Involving community members raise
certain questions. At what point should the community be involved, before writing
the proposal or afterwards? According to the EPM, the community should be

involved from the beginning. ”Projects are not done to the community but rather, are

76

done in cooperation with communities" (Fear, 1990, p. 9). This is a serious process
issue that needs to be addressed on a case-by-case basis. In fact, all of these
strategies involved some form of community participation. Even when considering
those sites that adapted preexisting models, those models were tested on the
community. Bracht (1990) explained that local values or legislative considerations
frequently determine the degree to which citizens are engaged. In addition, time Is
a reality that must be given serious attention. Engaging the community can be done
formally or informally. Bracht defined citizen participation as ”the social process of
taking part (voluntarily) in formal or informal activities, programs, and/or discussions
to bring about planned change or improvement In community life, services, and/or
resources” (p. 110).

In essence, It is Important to understand that time and values are a driving
force in the issues of citizen participation and who will participate. In this case,
proposal writers had only two months between the announcement and the deadline.
This does not allow much time in which to schedule meetings with various
community members to gain their input. Sites that had a previous relationship with
other agencies or with key community people had an advantage. They could use
their past associations for propositions. In most cases, the health institutions’ site
coordinators had other job-related responsibilities aside from writing the proposal.
Further, it takes much time to coordinate volunteers’ schedules in order to gain their
input. This was the first round of funding. Because three of the site coordinators did

not have any experience with the Black community or with community organizing,

77
it was only natural that they should consider using an existing community
development model and try to solicit input at various points while Implementing the
program. Although this approach is not completely in accord with the EPM, It
certainly does not negate the citizen participation component Moreover, the beauty
of this model is that at any point in the model one can make changes in the project
with input from citizens.

There is evidence that the site coordinator who had no previous community
development experience tried to solicit community input before writing the proposal.
It also appears that she made adjustments in her approach, based on community
input. Although she was inexperienced, obtaining local stakeholder participation
before designing the project appeared to make a difference in this coordinator’s

participation outcome.

0' iIBIIB I'IIB IDI'
Besserdnfiuestionj

What contributes to the acceptance and efficacy of community-based CVD
programs for African Americans?

In this study, three factors contributed to the acceptance and efficacy of
community-based CVD programs for African Americans. These factors are based
in community development principles and methods, which are people centered.
They are (a) cultural factors, (b) citizen participation/stakeholder factors, and (c)
capacity-building factors. Although community development principles and methods

are elementary in their application, they often are overlooked or misunderstood by

78

professionals, in this case health care professionals. The community development
paradigm often goes against the grain of the professional mind set. Chambers
(1993) described professionalism as being embodied In norms, methods, and
behaviors that are taught, Ieamed, and rewarded. To maintain that mind set,
professionals have certain defenses. Many operate from the belief that they and
only they have the expertise to define and solve the problem, never considering that
those affected by the problem possess ”indigenous technical knowledge" 'I define,
I solve because I’m the expert.” Indigenous technical knowledge means that the
people affected by the problem have the knowledge that enables them to define the
problem jointly with the professional and contribute to the solution. In the community
development paradigm, the participation of local people and/or prospective program
participants Is paramount In all stages of the solution process. "We define, we solve
because we both have valuable knowledge.” Christenson (1989) stated, ”The key
debate is the difference between working for people and working with people, that
is, helping people or enabling people to help themselves” (p. 38).

The literature is filled with articles about organizational culture, organizational
environment, and organizational climate. Just as organizations have a culture, so
do communities; that culture is not limited to the ethnicity of the residents, but is
Ieamed largely through the socialization process and symbolic interaction among the
residents (Anderson, 1993). Mazuri (1986) stated that culture Is a system of
Interrelated values active enough to influence and condition perception, judgment,

communication, and behavior in a given society. Those who are conducting health-

79
promotion programs In Black communities must understand the community culture
as well as the African American culture.

To a large extent, culture and health coincide. Each culture gives shape to

a unique Gestalt of health and a unique conformation of attitudes towards

pain, disease, lmpainnent, and death, each of which designates a class of

that human performance that has traditionally been called the art of suffering.

(Illich, 1976, p. 88)

In essence, this means that health care professionals who want to effectively
influence the behaviors of the Black community In the case of community-based
CVD projects need to understand the culture of African Americans In general,
understand the specific community culture in which they plan to operate the
program, and understand the local Black residents’ perspective on health. Culture
becomes a major underpinning in the acceptance and efficacy of community-based
CVD programs for African Americans. Airhihenbuwa (1992) argued that, in order to
have an aggressive health promotion campaign that will increase health knowledge
In the Black community, frameworks that guide the issues of cultural sensitivity to
educational Intervention are needed.

It is hard to imagine a successful community development project in which
there Is limited understanding of the people and their environment. Surely, the
health professional would need to gain such knowledge directly or indirectly at some
point during the project’s implementation. Thus, the issue becomes one of the
health professional's gaining cultural competence before program implementation.

Marin (1995) defined cultural competence as a ”characteristic of individuals who

have academic and interpersonal skills, which allow them to increase their

80

understanding and appreciation of a group’s cultural differences and similarities.“
Cross, Bezion, Dennis, and lsaacs (1989) and Davis and Voegtle (1994) named five
factors that culturally competent health care systems and professionals need to
possess: (a) Be aware and accepting of cultural differences, (b) have the ability for
cultural self-assessment, (c) be sensitive to the dynamics Inherent when cultures
interact, (d) have the required cultural knowledge of the target group, and (e)
develop skills that facilitate adaptation to diversity. Developing cultural
understanding and sensitivity will guide the design of community-based CVD
projects, from gaining citizen participation to having Afro-centric health education
materials.

Citizen participation is another major factor that contributes to the acceptance
and efficacy of community-based CVD programs for African Americans. It is a
matter of full participation by African Americans in their respective communities. A
cornerstone of community development, citizen participation, Is fundamental to
effective community development projects. It acknowledges that the African
Americans in the community are the stakeholders. In addition, it sends the message
that they are valued for their knowledge regarding their community and that they
have something meaningful to contribute to solving the problem of CVD mortality
and morbidity.

Conveying the message that Black residents are stakeholders means they
have a vested Interest In the CVD project and its message, as well as In the project

methodology. This was very helpful to coordinators who did not have community

81

development experience and did not have experience working with African
Americans. These coordinators seemed to have good intentions in designing their
programs without input from the community; however, they quickly realized they
would not be successful in Implementing those programs without the Black
community's participation. At some sites, the community residents taught the
coordinators how to organize the community, how to gain buy-In, and how to Ieam
what works well and what does not. The Black residents shared with the
coordinators their indigenous knowledge about implementing a community-based
project, as well as knowledge pertaining to the culture of their community. These
residents understood that they were stakeholders as well as gatekeepers. At one
site, the residents acted in both capacities and would not allow the program, which
had been designed without their input, to be implemented in the community. In this
instance, they took the lead in redesigning a curriculum that was more appropriate
for their community. These were residents who had been actively involved in their
community for years. Some of them were retired health care professionals, as well.
Wilkinson (1992) described the benefits of using indigenous health care workers as
follows: “The indigenous workers have been able to interact successfully with and
speak the ’language’ of the people in their communities, a feature that remains
essential for viable projects with urban and low-income African Americans' (p. 260).

The natural question with regard to citizen participation is who should be
involved and when they should be involved. The EPM suggests that citizens be

involved as early as In the design dimension. Constraints like project proposal

 

82
deadlines may not always allow full participation at that stage; however, key
stakeholders should have input. This will foster goodwill within the community and
guard against the likelihood of having to redesign the entire project. This was the
case at one of the sites. As a result, the coordinator was unable to implement the
program during the grant cycle. Instead, the health institution had to find Internal
resources for implementation.

As with most community development methods and principles, including
people In various dimensions of the project is time consuming. However, It helps to
ensure community buy-in. The goal should not be limited to conducting large
numbers of CVD screenings; rather, it should be to influence behavior. Screenings
alone cannot achieve that goal; ifthey could, there would be no CVD problem. Like
people in developing countries who have been disenfranchised and are living on the
periphery, Blacks in the United States are considered to be part of the underserved
population when It comes to health care. Researchers have found that African
Americans, with or without health insurance, do not receive the same state-of-the-art
treatment as do their Caucasian peers when they have been diagnosed with CVD
or when they are deemed at high risk for the disease.

The coordinators mentioned time as being a challenge in implementing the
CVD projects. This was true of coordinators from both 080s and health institutions
and held true no matter what their experience was in implementing community-
based projects. There Is no short cut. The coordinators without community

development experience spent much precious time during the grant cycle trying to

 

83

establish a relationship with the community. Coordinators who had an established
track record with the community, meaning they had community development
experience, found the length of the grant cycle to be prohibitive. Time invested Is
time well spent in reaching the African American population about CVD. The focus
group participants were aware of, and appreciated the time commitment made by,
the coordinators; It was viewed as valuable. In addition, It underscored the
seriousness of the CVD problem and sent a message that Black residents in that
community were worth saving.

Capacity building is the third major factor that contributes to the acceptance
and efficacy of community-based CVD programs for African Americans. Fischer
( 1989) argued that capacity building should be the primary concern ofthose involved
in community development. Relating capacity building to health promotion,
Schwartz (1993) defined It as the development of technical expertise to plan,
implement, and evaluate chronic-disease prevention and control interventions. He
added that the areas of expertise Include problem identification, epidemiologic and
behavior risk factor analysis, coalition building, program planning, marketing,
program implementation, knowledge of intervention methodologies, evaluation, and
the development of capabilities to obtain ongoing support and funding through
administrative and legislative means. According to Fear (1990), the EPM is a
learning experience for local residents, and the benefit is that they have acquired
skills that will outlive the project. Moreover, Fear suggested that capacity building

“contributes to increasing the level of community competency“ (p. 13).

34

The focus group participants were recipients of capacity building. Together
the eight CVD programs demonstrated capacity building in all of the aforementioned
areas except administrative and legislative. Although these skills were not
distributed equally among sites or participants, there was evidence, based on the
test results for Hypothesis 2, that focus group participants received knowledge and
skills related to CVD. Gaining this new knowledge and skills increased the
participants’ confidence and gave them a sense of control. The skills they acquired
ranged from being certified in CPR, to Ieaming how to give a technical presentation
regarding CVD risk factors, to Ieaming how to understand the results of blood
pressure screenings, to Ieaming how to prepare low-fat soul-food dishes. Wilkinson
( 1992) asserted that, regardless of the participants’ backgrounds, the principal
objective of such programs is to demonstrate how nonprofessionals from the
community can encourage positive health attitudes and behaviors.

The focus group participants shared the knowledge and skills they acquired
with their family and friends and others In the community. In some instances in
which the focus group participants were involved in formal training (often called peer
educators or lay health care workers), they were amazed at the knowledge and skills
they received. Not long after becoming CPR certified, one man was forced to use
his skills at his church to dislodge hard candy from a child’s throat. Other scenarios
were not as dramatic but were equally influential, like the young men who Ieamed
how to control their tempers under stressful conditions. While playing basketball,

they used stress-controlling techniques to avoid fighting a biased referee and the

85

opposing team. Often, African Americans live in environments in which their
perceived control Is limited. Undoubtedly this affects their lifestyle choices. Madden
et al. (1992) found that the inclusion of perceived behavioral control enhances the
prediction of behavioral intention and behavior. Capacity building in whatever form
gives people positive options and helps to influence their choices.

In summary, there is not one easy answer concerning what contributes to the
acceptance and efficacy of CVD programs for African Americans. However, the
research conducted on eight community-based CVD programs in Michigan indicated
that applying community development strategies positively influenced participants’
acceptance of the program, as well as their efficacy. The researcher found that
African Americans are Insulted when people come into their communities, with
whatever good intentions, and have not bothered to Ieam the culture of the people
and their community, do not include them In the planning process, and do not
provide or leave them with self-help resources. When this happens, the community

seriously questions the motives of those who come bearing gifts.

Win02

Did participating In any of the eight CVD-prevention programs Influence the
perceptions, attitudes, and behaviors of the participants? If so, in what way?

This question can be answered In the affirrnative by examining the results
from testing Hypothesis 2 and from focus group Question 4: There was no
difference between the before- and alter-focus group perceptions of participants

about CVD-prevention programs. Why do you think you will be able to continue to

86

improve your well being? The purpose of this hypothesis and question was to
measure and understand particlpants’ before- and after-focus-group perceptions,
rather than to predict long-term behavior.

Avis, Smith, and McKinlay (1989) found that people tend to underestimate
their own risk of developing certain conditions or diseases, and Weinstein (1982)
referred to this as having an “optimistic bias.” However, perceived susceptibility Is
essential In motivating a change in behavior (Janz, 1984). lfAfrimn Americans do
not perceive themselves as vulnerable to CVD, they are less likely to adopt the
recommended behaviors.

From this it follows that each of the eight coordinators in this study had the
challenge of raising the consciousness of the program participants. They were
responsible for delivering the message of CVD morbidity and mortality among
Blacks. To influence behaviors, the coordinators had to provide the participants with
practical alternatives. This they did by using community development approaches
(self-help or empowerment and technical assistance) focusing primarily on nutrition
and exercise. The self-help or empowerment strategy Involves helping people gain
understanding and control over the factors that affect their lives (Airhihenbuwa,
1994; Gibson, 1991). Clark and McLeRoy (1995) asserted that strategies to imbue
community residents with a sense of efficacy and capacity, often referred to as
empowerment strategies, have been found to contribute to changes In health
outcomes. Conversely, technical assistance refers to the application of expertise to

aid the client (Fear, 1989). The coordinators at each of the eight sites used both of

87

these strategies in their programs to raise the consciousness of African Americans
about CVD and to influence their behavior. This was done by having CVD
screenings to detect hypertension, cholesterol levels, and diabetes in churches and
community centers. If necessary, individual counseling was provided in follow-up
sessions.

The way that coordinators implemented CVD screenings was a combination
of self-help and technical-assistance strategies. It wastechnical assistance because
the health professionals were providing a specialized service, whereas at the same
time they were teaching the participants new skills that would Increase their level of
self-efficacy. Participants were taught to understand the screening results, how to
take their own blood pressure, and, if necessary, how to manage the results.
Coordinators addressed myths surrounding hypertension and emphasized that it can
be controlled. In some cases in which participants were referred to physicians or
clinics, those individuals were more confident about their ability to understand their
health status.

It wasn't up to the doctor, it was up to me and the good Lord to do something
about that. (Site 2)

She Ieamed me how to take care of my health much better, 'cause I have

high blood pressure and It’s suppose to be permanent. I Ieamed to take care

of it very well, and I lost weight behind it. (Site 2)

Screenings usually served as a gateway to introduce nutrition and exercise
information. Program participants were given information regarding nutrition in

various creative and practical ways. When addressing these risk factors,

coordinators used a combination of technical assistance and empowerment

88

strategies. Participants were taught how to eat healthily at home, at work, and when
dining out. In addition, some sites provided cooking demonstrations, showed
participants how to shop for healthy foods by reading food labels, and taught them
to include more fruits and vegetables in their diets. The chi-square and Fisher's
exact tests indicated that participants’ attitudes and knowledge were affected by this
nutrition education.

I found out different things that I can eat. I’ve changed my diet and I found

out that l have to take my high blood pressure medicine every 24 hours. I

didn’t at first, now I’m on it. (Site 1)

I Ieamed you can eat too much sugar, and I don’t eat that much anymore. I

kind of watch what I eat. I eat certain foods. I have certain things that I really

like, and I eat It once a month and that’s about it. (Site 3)

I would never drink water until one day the nurse sat down and showed me

an ugly picture of a kidney. The thought of being on a kidney machine and

all that stuff, it stays on my mind. Drinking water is a challenge. (Site 8)

Exercise was also strongly emphasized. Coordinators helped participants
realize the benefits of exercise by demonstrating simple routes, emphasizing walking
at the mall, at work, and around the neighborhood. At some sites, exercise classes
were offered. Participants were taught not to berate themselves ifthey missed days
of exercising. Focus group participants who actively took part in the exercise
component and changed their eating habits realized a weight loss, had more energy,
and were sleeping more soundly; as a result, they were motivated to continue
exercising.

The diet and eating properly has changed me physically. [It] you eat properly

and exercise, you sleep better and you have more energy during the day. It’s

all around. It moves Into other areas in your life to do more positive things.
When you feel good, you just want to live as long as possible. (Site 5)

"v

89

I used to weigh 286 pounds, now I [have] lost 32 pounds. I walk all the time
. . . l have to. Sometimes my foot bothers me, but I still walk ifthe Lord gives
me strength. I walk through the house, sometimes I walk outside to the
driveway. (Site 2)

It [the program] came at a good time. It has added to my support group. I
said I wanted to ride my bide because I lived like three or four miles from my
factory, where I use to work. I use to ride my bike back and forth to work, and
then the sickness came and I was not able to ride my bike anymore. . . . [The
coordinator] and I got together, and she said, ”Why don’t you try to get back
on the bike again? Why don't you make that one of your goals?“ . . . Having
a little push from her and everyone else was encouragement. She saw me
a couple of times a week at the health club to help me achieve this goal. I did
achieve it; I was able to ride my bike this summer. It has been a long time
since I was able to ride my bike. . . . This was the biggest benefit I have
gotten from this program. (Site 8)

Focus group participants were asked why they thought they would be able to
continue to improve their well being. Their responses reflected the fact that they had
been taught how they could take control of their health status. This is important
because many of the focus group participants had no health insurance and were
living in environments where they had no control.

I think that I will be able to continue doing this because when I start
something ldon’t like to have to give up. Because if I like it and I think that
it is straight, I will continue doing It. (Site 4)

I think that we have made a difference. I feel that we will continue to make
a difference in the years to come as we continue to embark upon new
avenues of health care. I think CVD was just a point for us to start, but I think
in our development this year and the years to come It will grow. I think the
community will be receptive to what we are doing as we are receptive. We
are working together to build a strong Afro-American community. (Site 7)

I’m going to Improve because I feel better. Too. see, some of the results In
our high blood pressure and cholesterol, it went down. It’s not down like I
think It should be, but I’m working on it. And I think we are all working on it.
(Site 2)

90
In summary, there was conclusive evidence, both statistical and anecdotal,
that the eight CVD programs did, in fact, influence the perceptions, attitudes, and
behaviors of the focus group participants. This was done by using a combination of
community development approaches—self-help and technical assistance—Woughout

the programs.

f

CHAPTER V

SUMMARY. CONCLUSIONS AND RECOMMENDATIONS

W
IheJZLoblem

CVD death rates among African Americans have dropped nationally since
1985, but not in Michigan (MDCH, 1996). Every 15 minutes, one person died of
CVD in Michigan in 1994, according to the MDCH, Center for Health Promotion and
Chronic Disease Prevention, Health Promotion Section. The same report concluded
that the stroke death rates for African American males and African American females
were 2.9 and 2.5 times higher than those for White males and White females,
respectively. Even more astounding were the heart disease death rates. For Black
males and Black females, the heart disease death rates were 1.5 and 2.5 times
higher than those for White males and White females, respectively.

Traditional methods of CVD prevention, such as screenings and counseling,
have failed to reach sufficient numbers of African Americans, primarily because of
their negative perceptions regarding public health practices. In general, African
Americans have a general distrust of the medical and health profession.

The fact that many of the CVD risk factors (smoking, high blood pressure,

high cholesterol, overweight, and sedentary lifestyle) can be controlled makes CVD

91

92

a multifaceted problem. Understanding that making lifestyle changes can reduce the
morbidity and mortality rates significantly, one group of health professionals has
selected the community-based approach to addressing the CVD problem among
eight African American communities in Michigan.

Understanding the role that community development approaches play in CVD
programs designed for Blacks Is crucial. It is particularly relevant to compare the
differences between programs managed by community-based organizations and
those managed by a health department. Understanding this phenomenon will lead
to the development of a model for designing specialized health education programs
and recruitment efforts aimed at African Americans.

The purpose of this study was to (a) document the perception of participation
by CVD project coordinators and participants at eight sites in African American
communities throughout Michigan; (b) measure the knowledge, attitudes, skills, and
behaviors of the participants; and measure the efficacy with which the community-

based CVD programs have been developed.

Methodologv

In this study, multiple data collection methods (often referred to as
triangulation) and multiple analysis techniques were used. The data used were from
participant focus group sessions, coordinators’ interviews, and program documents.

Appropriate qualitative and quantitative methods were employed.

 

93
findings

The study revealed three factors that contributed to the acceptance and
efficacy of community-based CVD programs for African Americans—cultural
competency, citizen participation/stakeholder participation, and capacity building.
CVD program participants deemed it important for the program coordinators to have
academic and interpersonal skills that allowed them to respect and understand the
differences and similarities of African Americans. In addition, It was Important for
coordinators to understand the culture of the specific community in which they would
be operating the program. When coordinators were not culturally competent, the
residents expressed feelings of disrespect and felt devalued. Citizen participation
was another factor that influenced program participation. At most of the sites,
residents wanted to be involved in the program design and even recruitment. In
cases where this did not happen, there was either low participation or no
participation until the residents were involved to their satisfaction. Capacity building
was also an influence on participation. Residents expressed high program
satisfaction when they Ieamed a new skill, like CPR, that would benefit their family
and their neighborhood.

To influence behaviors, the coordinators had to provide the participants with
practical alternatives. This was done by using community development approaches,
self-help and technical assistance, that focused on nutrition and exercise. In
addition, participants were taught how to understand CVD screening results, how to

take their own blood pressure, and, when necessary, how to manage the results.

94
mansions

It Is important to understand the complexity of CVD In relation to African
Americans in general. The researcher understands that the Black population Is not
monolithic in nature, but the discussion that follows is expressed in generalities. In
addition, each community has its own nuances, thereby adding another layer of
complexity to the problem. The grant writers of the eight CVD projects approached
the CVD problem from a lifestyle framework. This means that they believed that if
Blacks changed their lifestyles, they could reduce their risk of CVD. This is a
practice approach that requires ownership on the part of the project participants. It
also lends itself to sustainability and to influencing the whole Black family, rather
than a single individual. However, the lifestyle approach becomes somewhat of a
rubric, In which issues of safety, family traditions, cooking, and economics must be
considered.

Beginning with safety, It is unrealistic to ask people to exercise by running or
walking in their neighborhoods If they do not feel safe. Some of the site locations
were in high-crime areas. Second, the tradition of gathering together to eat a big
meal is quite common in Black families, as it is in other ethnic groups. Fried meats,
well-cooked vegetables seasoned with pork, and butter-rich baked goods are
served. Third, when considering the issue of cooking and Its relationship to CVD,
the person shopping for food and doing the cooking is the one who needs to be
reached. It Is hard for a child or even an adult who is not responsible for this

household chore to give the other family member directives. It could be viewed as

95

insulting. Finally, when giving forethought to issues related to lifestyle, economics
must be considered. Although placing a CVD project in a community adult Ieaming
environment seems prudent, one must realize that the adult students are concerned
primarily with earning their GEDs so that they can obtain employment. This was
certainly the case at one study site. In that instance, although the program
participants were concerned with making a lifestyle change, their primary focus was
employment rather than CVD. In addition, the cost of changing one’s eating habits
and Ieaming a new way of life can exacerbate a person’s stress level.

Bringing these issues to the forefront is not intended to imply that effective
community-based CVD projects are impossible to manage. On the contrary,
benefactors and health professionals should understand the parameters when
embarking on community-based CVD projects for African Americans.

The effect of the community development strategies on community-based
CVD programs for African Americans is significant. The strategies of technical
assistance and self-help address the problem of reaching Blacks in a comfortable
environment. In contrast, traditional methods like one-on-one doctor visits are
limited In their effectiveness. The combined community development strategies go
beyond the protocol visit of patient and doctor or health professional in the clinic.
These strategies encourage and welcome African Americans to be part of the CVD
solution. Further, these strategies help empower Blacks, whereas with traditional
methods, power lies with the health professional and not the patient. This makes

patients passive about their health care.

96

The strength of community development approaches, whether they are
administered by a health institution or a 080, is that they are people centered. For
instance, in a traditional paradigm, the professional gives technical assistance to the
nonprofessional. However, in the community development paradigm, both the
community and the professional offer technical assistance. When the professional
renders technical assistance, he or she does it in relation to CVD; when the
community renders technical assiStance, they are rendering indigenous technical
knowledge that relates to the community and its culture. This is a critical difference
between the traditional paradigm and the community development paradigm. Self-
help, the other approach, is a ”bonus strategy.‘ The traditional paradigm does not
have a matching approach. This approach directly gives African Americans skills
and knowledge regarding CVD that they would not receive in a clinical setting
because of time, personnel, and priority constraints. In addition to giving knowledge
to the Black community, it is building capacity. It is highly likely that those skills and

knowledge will be translated into other community-based projects.

Recommendations
Research .

To date, there have been no longitudinal studies involving African Americans
and CVD. Such research is critical if one is serious about reducing the morbidity and
mortality rates among this population. Longitudinal studies will provide a wealth of
knowledge regarding best-practice clinical methods, capacity building, and

sustainability, as well as specific educational and cultural approaches. Without

 

97
serious long-term research, there will continue to be large gaps in the literature.
Moreover, African Americans will continue to sufler and die from CVD at alarmingly
higher rates than other people in the United States.

With respect to African Americans, CVD should be investigated In relationship
to other illnesses and living and working environments. This would be appropriate
in both clinical outcomes research and applied research settings. It is important that
we understand how people who have CVD respond to various treatments and how
they manage their illness within their personal environment.

Another area that can be addressed is in testing and developing culturally
specific community-based models for health care delivery, so that they move past
the conceptual stage Into practice. Airhihenbuwa (1992) developed a conceptual
model, PEN-3, that is culturally specific and promises to be applicable at the
community level, Integrating the individual, the extended family, and the

neighborhood. It should be tested, and appropriate adaptations should be made.

Balls!

With regard to funding short-terrn projects, it is critical that benefactors include
in their request for proposals that the personnel responsible for the community-
based CVD project have cultural competence. This seems to be of particular
concern with health Institutions. Therefore, It would be prudent for the Michigan
Department of Community Health and any other benefactor to offer training to local
public health departments. Because Michigan’s population is so diverse, this

training should not be limited to the African American culture.

“

98

Community-based projects should be funded for a minimum of two years. It
has been established that people generally go through several stages before
changing their behavior. These stages depend on people’s readiness to change and
their perception of the situation they need to change. Therefore, It Is Imperative and
wise to build more time Into the grant cycle. Some experts have predicted that It
takes a minimum of six months to be able to maintain a new behavior. It is
unrealistic to expect large numbers of African Americans to make major lifestyle
changes in a few months or after a few visits to a community center. The important
factor regarding time Is that it needs to be long enough to provide support, but not
so long that it creates dependency.

Finally, it is necessary forthe RFPs to foster partnerships between CBOs and
health institutions. This means going beyond receiving a letter of support from the
CBO or health institution. It requires that each organization have a distinct role,
each operating from its strengths to serve the community in a more efficient and
effective manner. A collaborative partnership is necessary, to debunk the myths and
address the fears that the African American community has about the health
profession. Collaborative partnerships also are important If we indeed want to
impactthe problem of exaggerated CVD mortality and morbidity rates among Blacks.

In addition, these collaborative partnerships with the local health departments
and the community should put a structure into place that assures sustainability-
neighborhood or village health councils. These councils would include residents,

local merchants, school and church officials, as well as representatives from the

99

local health department. This structure empowers the community, helping them
define and prioritize their own health problems. Moreover, it will allow the community

to work in harmony with health professionals to solve those problems.

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