Implementing health promotion activities using community-engaged approaches in Asian American faith-based organizations in New York City and New Jersey

Abstract

Faith-based organizations (FBOs) (e.g., churches, mosques, and gurdwaras) can play a vital role in health promotion. The Racial and Ethnic Approaches to Community Health for Asian Americans (REACH FAR) Project is implementing a multi-level and evidence-based health promotion and hypertension (HTN) control program in faith-based organizations serving Asian American (AA) communities (Bangladeshi, Filipino, Korean, Asian Indian) across multiple denominations (Christian, Muslim, and Sikh) in New York/New Jersey (NY/NJ). This paper presents baseline results and describes the cultural adaptation and implementation process of the REACH FAR program across diverse FBOs and religious denominations serving AA subgroups. Working with 12 FBOs, informed by implementation research and guided by a cultural adaptation framework and community-engaged approaches, REACH FAR strategies included (1) implementing healthy food policies for communal meals and (2) delivering a culturally-linguistically adapted HTN management coaching program. Using the Ecological Validity Model (EVM), the program was culturally adapted across congregation and faith settings. Baseline measures include (i) Congregant surveys assessing social norms and diet (n = 946), (ii) HTN participant program surveys (n = 725), (iii) FBO environmental strategy checklists (n = 13), and (iv) community partner in-depth interviews assessing project feasibility (n = 5). We describe the adaptation process and baseline assessments of FBOs. In year 1, we reached 3790 (nutritional strategies) and 725 (HTN program) via AA FBO sites. Most AA FBOs lack nutrition policies and present prime opportunities for evidence-based multi-level interventions. REACH FAR presents a promising health promotion implementation program that may result in significant community reach.

BACKGROUND

In the United States (US), nearly one-third of adults have hypertension (HTN), and cardiovascular disease (CVD) is the leading cause of death [1–3]. Fewer than half of individuals with HTN are under control despite widely available and affordable medications [4, 5]. Moreover, rates of poor control and complications are disproportionately high in some racial/ethnic communities, including Asian Americans (AAs) [6, 7]. For example, Jose et al. [8] examined CVD mortality rates by AA subgroup from the Multiple Cause of Death mortality database 2003–2010 from the National Center for Health Statistics and found that the proportionate mortality burden of hypertensive heart disease and cerebrovascular disease, especially hemorrhagic stroke, was higher in every AA subgroup (Asian Indian, Chinese, Filipino, Japanese, Korean, and Vietnamese) compared to non-Hispanic whites [8].

AAs comprise 5.6% of the US population, corresponding to about 14 million people [9]. They are the fastest growing racial/ethnic minority group and represent a tremendously complex and diverse mix of people [10–12]. CVD prevention and HTN management programs that enable lifestyle changes and enhance linkage to healthcare are an effective method of promoting HTN control [13]. For example, consuming less sodium and more fruits and vegetables and increasing access to healthy foods are important components to reducing the risk of chronic diseases include HTN and CVD [14–16]. There is, however, a lack of culturally adapted programs and educational materials to promote HTN management or healthful behavioral changes for AAs, and existing programs are limited in their sustainability and scalability [17–19]. Further, population- and evidence-based CVD prevention and management strategies, which have demonstrated a positive impact in the overall population [20], may not be effective at reaching racial/ethnic minorities [21–23]. Research on the effectiveness of evidence-based approaches on increasing AA healthy behaviors is limited [24, 25] but suggests a “mismatch” [26] between the general population for whom the strategy was developed and validated and the AA community [27]. There is also substantial diversity in cultural beliefs, language, and socioeconomic status among AAs [28, 29], which have been shown to impede successful implementation of evidence-based strategies [30–32]. Thus, in order to achieve a significant public health impact, benefits of proven lifestyle interventions must be translated to community settings in a culturally sensitive and sustainable manner [17, 20–23, 25, 33–40].

Faith-based organizations (FBOs) represent one such community setting for the implementation of health promotion and prevention strategies in AA communities. According to a nationwide survey of AAs conducted by the Pew Research Center [41], AAs are more religiously diverse than the US population and report substantial differences in religious affiliation across and within AA subgroups, as well as have a high level of weekly engagement with FBOs [41, 42]. Previous studies indicate that FBOs are natural partners for the delivery of health promotion programs due to a number of factors, including their role as community centers; access to large segments of the population, especially underserved groups; supportive infrastructure (e.g., health ministries, communication channels, regularity of contact); presence of support networks (e.g., prayer groups); and personnel resources (e.g., volunteers, lay leaders, and champions) [43–47]. For example, findings from the 2012 National Congregations Study indicate that 28% of FBOs deliver organized health-focused programs (e.g., health education classes, cooking classes) [48]. Despite the potential for establishing health promotion interventions through FBOs [49], few have been implemented in FBOs serving AA congregants [50–54]. Moreover, the majority of these interventions have been limited to changing individual-level behaviors with little or no emphasis on implementing corresponding reinforcing strategies at the organizational level.

The goal of this paper is to describe the efforts of a multi-sector coalition representing diverse AA communities in New York City and New Jersey (NYC/NJ) to adapt and implement multi-level strategies to address HTN control, HTN management, and CVD prevention. Specifically, these strategies have been culturally adapted and integrated to enhance community fit, preferences, and priorities for sustainable implementation. We present baseline results and describe the adaptation process for the implementation of (1) environmental and policy strategies to improve access to healthy foods and beverages and (2) a volunteer-led blood pressure monitoring program in FBO settings in NYC/NJ.

METHODS

Project description

Building upon a substantial history of community-engaged health promotion and prevention efforts in the AA community [55–57], the Racial and Ethnic Approaches to Community Health for Asian Americans (REACH FAR) program is guided by a multi-sector coalition consisting of a lead academic agency, four community-based organizations (CBOs) and groups representing the Asian Indian, Bangladeshi, Filipino, and Korean communities in NYC/NJ, and state and local health departments. Coalition partners leveraged their deep roots in the community, bolstered with technical assistance, training, and resources, to further engage 12 FBO sites in health promotion and prevention strategies. Coalition partners are described in Table 1 below and elsewhere [40, 55–66].

Table 1.

REACH FAR coalition partners, NYC/NJ 2014–2017

Coalition partner	Description
NYU Center for the Study of Asian American Health (NYU CSAAH) (Lead agency)	National Institute of Health-funded research center of excellence dedicated to research, training, and partnership development to address health disparities in Asian American communities
Diabetes Research, Education, and Action for Minorities (DREAM) Project	Partnership between social service agencies, academic partners, and health care organizations that seek to improve the health status of NYC Bangladeshis that has implemented initiatives focused on diabetes, breast cancer, and health access
Kalusugan Coalition, Inc. (KC)	CBO with a mission to improve the health of the Filipino community in the NY/NJ area through network and resource development, educational activities, research, community action, and advocacy
Korean Community Services of Metropolitan NY, Inc. (KCS)	CBO with a mission to support and assist the Korean community to improve the quality of their lives to be healthy and productive individuals through a broad range of professional social services programs in the areas of Aging, Community, and Public Health.
UNITED SIKHS (US)	Social service and advocacy organization with a mission to transform underprivileged and minority communities and individuals into informed and vibrant members of society through civic, educational and personal development programs
New York City Department of Health and Mental Hygiene (NYC DOHMH)	Primary Care Information Project Community Engagement Division, NYC DOHMH Center for Health Equity, which was specifically engaged in REACH FAR, with a mission to strengthen and amplify the NYC DOHMH’s work to eliminate health inequities, which are rooted in historical and contemporary injustices and discrimination, including racism

The coalition worked with FBO sites to implement multi-level strategies that addressed both organizational change and individual and interpersonal behavior change to support HTN prevention and management. At the organizational level, the REACH FAR coalition worked with FBO sites to implement environmental and policy change to increase access to heart healthy foods and beverages served during congregation meals. These changes included the introduction of one or more of the following options during communal meals: (1) one fruit choice, (2) one leafy green salad or fresh vegetable, (3) one whole grain option (e.g., brown rice, whole wheat naan), (4) water availability at no charge at meal time, (5) 1% or non-fat milk/yogurt, and (5) low-sodium dressings/condiments (e.g., soy sauce, lemon, salad dressing). To facilitate community-clinical linkages and to increase individual-level awareness of the importance of blood pressure control, the FBO sites also implemented a NYC Department of Health and Mental Hygiene (DOHMH) program, “Keep on Track” (KOT), which is an evidence-based train-the-trainer, volunteer-led blood pressure monitoring program [67] open to all male and female congregant members who are between the ages of 18 and 85 years and not pregnant at the time of recruitment. To date, NYC DOHMH has implemented KOT in 120 FBOs and CBOs across NYC but not in any AA-serving organizations. FBOs were identified by the three community coalition partners based on their existing relationships, established partnerships, coalition group discussions, and one-on-one meetings with the FBO leadership to determine the site’s interest and feasibility to implement the strategies.

Guiding frameworks

REACH FAR is guided by translation research, a broad domain that encompasses both cultural adaptation and implementation research [68–71]. Implementation research seeks to understand the processes and factors that are associated with successful integration of evidence-based interventions within a particular setting, including how the intervention was adapted to the local context or setting [70]. Cultural adaptation is defined as the systematic modification of an evidence-based program to consider language, culture, and context in such a way that it is compatible with that of the target population’s cultural patterns meanings and values [72], while maintaining scientific integrity [35, 73]. Given the current diversity of the US population, cultural adaptation is an important part of the implementation process [74], and attention to how cultural factors affect the delivery and implementation of health promotion strategies, including in faith-based settings, is crucial. Moreover, meta-analyses of cultural adapted interventions—adaptations that explicitly integrate cultural factors such as language, cultural beliefs, and explanatory models—show improved relevance, acceptability, effectiveness, and sustainability of the interventions [75–78].

The adaptation process was informed by the Ecological Validity Model (EVM) [72], which specifies eight domains for cultural adaptation of the implementation program: language, persons, metaphors, content, concepts, goals, methods, and context. Two complementary approaches, social marketing and community-based participatory research (CBPR), were used to support the adaptation process. Social marketing [79, 80], identified by the Centers for Disease Control and Prevention as a key framework in the dissemination of evidence-based health promotion practices [81, 82], is the application of principles drawn from the commercial sector to influence a target audience to engage in beneficial behavioral change for health promotion [83–85]. Social marketing principles were applied to increase relevancy to cultural norms and knowledge and to identify appropriate messaging, meaning, and channels across the eight EVM domains and to ensure strategies are easy to adopt and integrate into current practice in faith-based settings across denominations and organizational structures. For example, we worked with coalition partners to determine the costs and benefits of healthy eating behavior change for our audience and integrated these concepts where it was appropriate. Finally, we applied the principles of CBPR, an approach in which community stakeholders with various knowledge and expertise partner to understand community concerns and develop action-oriented solutions to address them [86], by partnering with trusted AA-serving CBOs and coalitions. Using a CBPR approach to cultural adaptation and implementation research decreases the gap between research and practice and thus may increase the intervention relevance and true uptake into everyday use in real-world settings [69, 87].

Prior to strategy implementation, a series of organizational-level and individual-level assessments were collected at the 12 FBO sites, including (i) FBO environmental strategy checklists (n = 12); (ii) congregant surveys assessing social norms, attitudes, and access to healthy foods and beverages (n = 946); and (iii) KOT program baseline surveys conducted with congregants enrolled into the KOT program (n = 725). To assess the adaptation and implementation process, community partner in-depth interviews (n = 5) and a review of REACH FAR meeting minutes were conducted.

Organizational and individual baseline assessments: methods and measures

FBO environmental strategy checklists

The checklists were implemented by coalition partners, who underwent an in-person group training on the tool, by on-site observation, and assessment of nutritional policies at each FBO. We assessed congregation size, denomination, and existence of health programming, promotion, and/or health-focused groups and funding at the FBO, such as a wellness coordinator or committee. Measures were adapted from the Nutrition Environment Measures Survey (NEMS) [88]. See Appendix for the checklist.

Congregant surveys

These surveys assessing congregation norms, attitudes, and access to healthy foods and beverages, and included a self-report measure of overall diet, availability of healthy foods at communal meals (fruits, vegetables, whole grains, free water, low-fat or non-fat dairy, and lower salt condiments), difficulty choosing healthy food options at communal meals, and communal meals serving healthy options. Measures were adapted from the New York City Food Standards [89] and from the Perceived Nutrition Environment Survey (NEMS-P) [90]. Surveys were collected anonymously at each FBO site by trained bilingual research interns working closely with coalition partners during a weekly service using a purposive sampling strategy. All congregant members over 18 years of age were eligible to participate.

KOT program baseline surveys

All congregant members who met KOT program eligibility criteria (between 18 and 85 years and not pregnant at the time of recruitment) were invited to participate in the KOT program evaluation through recruitment events held before or after regular FBO services. These consented participants completed baseline surveys which included questions related to HTN diagnosis and HTN medication prescription, the eight-question Morisky Medication Scale [91], and self-efficacy related to accessing healthcare. Individual clinical measures were collected on the survey and include height, weight (self-reported), and blood pressure. BP readings were taken with the Omron Model BP785 [92] by trained volunteers. KOT program participants enrolled into the evaluation study received a $5 incentive.

Both surveys included sociodemographic questions: year of birth (used to calculate age), sex, country of birth, and years in the USA. Measures were culturally adapted in partnership with the coalition as needed. For example, traditional Asian fruits and vegetables were included in the checklist. These surveys were available in English and translated into Bengali, Tagalog, Korean, and Punjabi and administered in-person by trained, bilingual research intern surveyors. Each translation was reviewed by a second bilingual translator and by the coalition partners and discrepancies addressed via a consensus process.

Multi-level strategy adaptation and implementation assessment: methods and measures

Community partner in-depth interviews and coalition meeting minutes

One-hour, tape-recorded in-person interviews were conducted by an external consultant with ten community coalition partners. The interview topic guide assessed project feasibility, including identification and assessment of FBO implementation sites and their leadership structure, as well as the adaptation and implementation process. Measures related to the eight categories of the EVM framework were also assessed [72]. To further supplement the data, we compiled meeting minutes from 189 in-person and telephone meetings conducted with coalition partners over a 21-month span.

All REACH FAR procedures and activities conducted with human participants were reviewed by the NYU School of Medicine IRB and approved as an expedited study.

Analysis

Quantitative

Descriptive statistics were calculated to summarize demographic variables and additional health and nutrition variables. Means and standard deviations were calculated for continuous variables, and frequency and percentages were calculated for categorical variables. Significant differences across Asian subgroups were determined using chi-square analyses for categorical variables and one-way ANOVA for continuous variables. All statistical analyses were performed using SPSS software version 21.0. A two-sided p value <0.05 was considered statistically significant.

Qualitative

Meeting minutes and in-depth interview transcripts were independently reviewed and coded using ATLAS.ti 6 (Scientific Software Development GmbH) by the lead and senior author, and key themes related to the implementation and adaption process were extracted using a constant comparative approach [93]. Reviewers resolved discrepancies in key themes through a consensus process. Themes were shared, reviewed, and refined based on feedback from the multi-sector coalition.

RESULTS

Organizational and individual baseline assessments

Table 2 presents the characteristics of the FBOs. The majority of congregants at Sikh gurdwaras were Asian Indians, while the majority of congregants at Muslim mosques were Bangladeshi. Mainline Protestant churches included a majority of Korean congregants, while Evangelical Protestant churches included a substantial proportion of Filipinos.

Table 2.

Characteristics of REACH FAR faith-based organizations, NYC/NJ 2014–2017

Religious denomination	FBO religious affiliation	Ethnic subgroups represented	Congregation size
Sikh	Gurdwaras (3)	Asian Indian	1400
Muslim	Mosques (2)	Bangladeshi	2050
	Senior center co-located in a mosque (1)	Bangladeshi	150
Mainline Protestant	Presbyterian churches (2)	Korean	1900
	Methodist church (1)	Korean	1100
Evangelical Protestant	Baptist church (1)	Filipino	90
	Seventh Day Adventist church (1)	Filipino	100
	Non-denominational Christian church (1)	Filipino	86

FBO environmental strategy checklists

Table 3 presents data on the environmental and organizational policies that support access to healthy foods and beverages by FBO denomination. All Evangelical Protestant churches and Sikh gurdwaras reported providing congregation-level health promotion activities, such as health fairs or walking clubs. Additionally, two of the Evangelical Protestant churches had a mission or formal policy statement that includes the support of and/or commitment to congregant health and well-being. Few sites labeled foods that were healthy or had signs or posters promoting healthy eating.

Table 3.

REACH FAR faith-based organization environmental strategy checklist: environmental and policy nutrition measures, NYC/NJ 2014–2017

	Mosques (n = 3)	Evangelical Protestant churches (n = 3)	Mainline Protestant churches (n = 3)	Gurdwaras (n = 3)
Site provides health promotion activities for their congregants (e.g., health fairs, screenings, walking clubs, etc.)	33%	100%	33%	100%
Site has a wellness/health coordinator	33%	33%	33%	0%
Site has a wellness/health committee	33%	33%	0%	0%
Site has a health promotion budget	33%	0%	0%	0%
Site has a mission statement (or written policy statement) that includes support of or commitment to congregant health and well-being	33%	67%	0%	0%
Site labels foods that are healthy (e.g., low sugar, low salt, heart healthy)	33%	0%	0%	0%
Site has signs or posters promoting healthy eating (e.g., eat lower sodium/low-fat foods, eat more fruits and vegetables)	33%	0%	67%	0%

Congregant surveys

Table 4 presents select baseline characteristics of the congregants by AA subgroup related to social norms, attitudes, and access to healthy foods and beverages. Overall, respondents had a mean age of 50.6 (SD = 17.2) and 57% were female; 88% were foreign-born. For respondents born outside the US, mean years lived in the US was 18.8 (SD = 11.9). Mean BMI was 25.0 (SD = 5.0), and 10% had a BMI ≥30.0. Overall, 14% reported their diet as fair or poor; Bangladeshis (14%) and Asian Indians (25%) were most likely to report their diet as fair or poor (p < 0.001). Koreans were less likely than the other groups to report that their FBO settings usually or always provided healthy options such as fruit, fresh vegetables, free water, and low-fat or non-fat dairy. Korean congregants, however, reported that their FBO sites were most likely to usually or always have lower salt condiments available. Additionally, Koreans were most likely to answer that it was difficult to choose healthy options at communal meals and that healthy options were not served at the communal meals. All differences across subgroups were statistically significant.

Table 4.

REACH FAR faith-based organization congregant survey select findings on social norms, attitudes, and access to healthy foods and beverages NYC/NJ, 2014–2017

	Bangladeshi (n = 159)	Filipino (n = 207)	Korean (n = 409)	Asian Indian (n = 171)	p value	Total sample (n = 946)
Female	28%	58%	71%	49%	<0.001	57%
Age (years), mean ± SD	56.2 ± 13.6	45.6 ± 16.1	55.5 ± 17.1	41.7 ± 16.2	<0.001	50.6 ± 17.2
Foreign-born	99%	85%	95%	65%	<0.001	88%
Time in the USA (years), mean ± SD	10.0 ± 9.5	15.7 ± 10.8	22.2 ± 11.4	21.8 ± 11.6	<0.001	18.8 ± 11.9
BMI (kg/m2), mean ± SD	26.5 ± 5.8	24.5 ± 4.2	23.9 ± 5.1	26.7 ± 4.3	<0.001	25.0 ± 5.0
BMI categories					<0.001
<25.0	48%	61%	69%	31%		57%
25.0–29.99	37%	29%	24%	57%		33%
≥30.0	15%	10%	7%	12%		10%
How healthy is your overall diet?					<0.001
Excellent/very good	22%	47%	50%	19%		39%
Good	64%	37%	41%	56%		47%
Fair/poor	14%	16%	9%	25%		14%
It is difficult for me to choose healthy food options at community meals at my place of worship—agree	45%	22%	55%	31%	<0.001	42%
Available—usually or always
Fruit	64%	80%	11%	70%	<0.001	46%
Fresh vegetable	75%	76%	24%	77%	<0.001	52%
Whole grain	20%	57%	38%	67%	<0.001	45%
Free water	96%	94%	79%	95%	<0.001	88%
Low-fat or non-fat dairy	45%	34%	17%	47%	<0.001	31%
Lower salt condiments	32%	27%	67%	56%	<0.001	50%

KOT program baseline surveys

Baseline characteristics and measures related to BP management of each AA subgroup and the overall sample for participants enrolled in the KOT program are summarized in Table 5. Overall, participants had a mean age of 56.5 years (SD = 15.0), 60% were female, and the majority were foreign-born (97%). Of those born outside the US, mean years in the US was 18.7 (SD = 12.6). Mean systolic BP was 127.5 (SD = 17.8), and mean diastolic BP was 80.0 (SD = 11.6). In terms of clinical variables, Koreans had the highest mean systolic BP and Asian Indians had the highest mean diastolic BP; Bangladeshis were most likely to present as hypertensive. Overall, 42% had been told by a health professional that they have high BP; this was highest among Bangladeshis (58%, <0.001). Of those told they had high BP, 89% had been prescribed medication to control BP; this was lowest among Asian Indian and Filipinos (82 and 84%, respectively, p = 0.058). Of those prescribed BP medication, 93% were currently taking medication. Medication adherence was similar among AA subgroups; among those taking BP medication, the score was 2.51 (SD = 1.89), indicating medium medication adherence (0 = high adherence, 11 = poor adherence).

Table 5.

Keep on Track Program participants’ baseline characteristics

	Bangladeshi (n = 156)	Filipino (n = 151)	Korean (n = 264)	Asian Indian (n = 154)	p value	Total sample (n = 725)
Female	43%	64%	69%	58%	<0.001	60%
Age (years), mean ± SD	55.7 ± 13.0	48.6 ± 14.8	64.0 ± 12.8	52.0 ± 14.8	<0.001	56.5 ± 15.0
Foreign-born	100%	87%	100%	99%	<0.001	97%
Time in the USA (years), mean ± SD	10.2 ± 10.1	17.5 ± 11.4	24.5 ± 12.1	15.2 ± 10.1	<0.001	18.7 ± 12.6
SBP (mmHg), mean ± SD	128.3 ± 18.9	120.7 ± 17.5	130.1 ± 17.0	128.5 ± 16.8	<0.001	127.5 ± 17.8
DBP (mmHg), mean ± SD	80.6 ± 11.9	77.1 ± 14.2	79.4 ± 10.0	83.3 ± 10.1	<0.001	80.0 ± 11.6
Hypertension categories					<0.001
Hypertensive	33%	17%	31%	29%		29%
Pre-hypertensive	40%	35%	45%	41%		41%
Normal	27%	48%	24%	30%		30%
Had BP taken by a health professional in past year	96%	84%	85%	90%	0.002	89%
Visited a doctor for a routine checkup in past year	96%	78%	80%	89%	<0.001	85%
Told that you have high BP	58%	35%	42%	33%	<0.001	42%
Prescribed medication to control BP (of those told high BP)	94%	84%	92%	82%	0.058	89%
Currently taking medication for high BP (of those prescribed)	93%	93%	95%	91%	0.828	93%
Medication adherence scale, mean ± SD (0–11, lower = better adherence) (of those taking BP medication)	2.64 ± 2.03	2.41 ± 1.74	2.48 ± 2.02	2.43 ± 1.47	0.910	2.51 ± 1.89

Adaptation and implementation process of multi-level health promotion strategies assessment

All FBO sites offer a communal meal to congregants. Although the frequency and timing vary by denomination and site, coalition partners expressed that the meals offer an opportunity to improve access to healthy foods within these settings. Based on New York City Food Standards created by the NYC DOHMH [89], a list of nutrition policies was adapted to implement during communal meals at FBOs. The list was created through consensus-building across community partners and the FBOs, prioritized, and culturally adapted to be meaningful and relevant across all denominations and AA subgroups. As stated by a partner, “We tried to pick strategies that would be easier for our community to adapt.” All 12 FBOs agreed that at least one if not more of these policies would be implemented during their communal meal: (1) at least one fruit choice be available, (2) at least one leafy green salad or fresh vegetable be available, (3) at least one whole grain option be available (e.g., brown rice, whole wheat naan), (4) water available at no cost at meal time, (5) offer 1% or non-fat dairy items, and (6) offer low-sodium dressings/condiments (e.g., soy sauce, lemon, salad dressing).

Each of the 12 FBO sites was also engaged to implement the adapted KOT program. The structure of the KOT program has been described elsewhere but broadly consists of NYC DOHMH-led training of volunteers in FBO settings to lead monthly BP screenings for their congregants [94, 95]. As part of the KOT program implementation, coalition partners worked with FBO leadership in identifying and recruiting 4–10 volunteers to receive the 6–8 hour NYC DOHMH-led training [96]. Upon completion, coalition partners worked with FBO leadership and KOT volunteers to hold the first KOT BP screening event at the FBO, as well as schedule regular screening events. All FBOs decided to hold KOT events after regular FBO services, although the timing and regularity differed by group. For instance, one Korean church held KOT events once a month on Sunday mornings as part of their regular health programming while a Bangladeshi mosque held events on Friday evenings after their large Jummah service. At initial KOT events, trained FBO volunteers explained the KOT program and evaluation study to congregants. All congregants participating in the program received a BP screening from the FBO volunteer, counseling on ways to prevent and/or control their BP, and a pocket-size BP tracker with the reading from the initial event to personally track their BP readings to share with their provider.

All adaptations were guided and implemented using an iterative process to apply the EVM framework [72] by coalition partners supported through in-person and phone meetings and via cross-coalition meetings. Social marketing principles, including the concepts of the cost and benefits of healthy eating behavior change, were used to help tailor messaging and the promotion of strategies. Strategy adaptions and modifications were identified and discussed at regularly scheduled team meetings. Efforts were made to standardize modifications across the AA subgroups. Because multi-level strategies were being implemented in each FBO setting, adaptions were made to strategies that were applied at both the organizational level (through the policy changes) as well as the interpersonal and individual level (through the KOT program). Cultural adaptations are presented below and in Table 6. See Appendix for an example of an adapted plate planner.

Table 6.

Cultural adaptations using the Ecological Validity Model for REACH FAR strategies

Culturally sensitive domain	Adaptations	Examples from the KOT Program Adaptation	Examples from Nutrition Policy Adaptation
Language	All program materials were translated to 4 languages	Translation of Blood pressure “tracking” card	Translation of nutrition posters
Persons	Community and FBO leaders were engaged for program and policy implementation	Volunteer trainers were members of FBOs	Utilized kitchen staff from Korean churches for nutrition education and implementation
Metaphors	Asian and, where relevant, Asian ethnic subgroup-specific idioms and colloquial phrases were incorporated throughout	An existing document on blood pressure control used the metaphor “Blood Pressure Control—It’s in Your Court,” which community partners expressed would not resonate with Asian individuals	Outreach materials to support nutritional campaigns were designed to address Asian condiments and spice mixes as the source of sodium in the diet
Content	Cultural values to frame goals and activities, e.g., the importance of traditional and cultural foods and dishes explicitly acknowledged	Training materials and health education materials also included images of Asian men and women to ensure materials were reflective of the audiences, including images of men and women in traditional and mainstream dress	Outreach materials included posters that highlighted a medley of fruits and vegetables as important in health promotion, including traditional Asian fruits and vegetables common across the subgroups, e.g., bitter melon, guava, cabbage, and starfruit
Concepts	The goal of maintaining one’s individual health for the health of the family—or family harmony and the idea of collectivism was integrated. Traditional foods and dishes used to highlight healthy diets	Training materials incorporated counseling for participants which emphasized engaging in health promotion activities with family and social networks	Incorporated the concept of seva to the Sikh community in promotion of healthy food to serve during langar (shared communal meals) in gurdwaras
Goals	Program goals were bolstered with messaging and framing around collectivism and group harmony	In the Seventh Day Adventist Filipino church, the congregation and leadership shared explicit goals around healthful behavior into their daily practice; this messaging was aligned to KOT program goals	Health education materials incorporated Bible scripture and utilized Bible study guide templates to discuss healthy eating and blood pressure monitoring
Methods	Program activities or procedures were adapted. Given strong leadership and respect for faith leaders, incorporated guidelines, and protocols to enhance faith leadership engagement in the program	Pastors and gurdwara leaders were encouraged to enroll in the KOT study and to incorporate project information through FBO-wide announcements	Nutrition policies in mosques were implemented to align with the month of Ramadan, when FBOs provide daily iftar (breakfast) at sundown to celebrate the breaking of fast by incorporating healthy food options during the meal. In Korean and Filipino churches and Sikh gurdwaras, changes were introduced at weekly meal services and adapted if meals were prepared on-site or donated by congregants
Context	Contextual issues were incorporated into program and policy procedures	Linked congregants to health providers who accepted a variety of insurances and low-cost sliding fee scales	Healthy traditional foods or traditional foods with heart healthy modifications were promoted

Languages

The KOT program materials were translated into four languages: Korean, Bangla, Punjabi, and Tagalog. Translated program materials included the KOT Training Manuals for program volunteers, NYC DOHMH health education materials for program participants and congregants, and program materials that are used to track participation in the program, including BP Tracking Cards and Participant Record Cards. Translation involved an iterative process in group discussions and team meetings with NYC DOHMH, community partners, and a certified translation company. In support of the organizational-level nutrition policies implemented at each site, outreach translated materials including posters and banners were created that highlighted messages to support heart healthy foods.

Persons

A critical element in the implementation of both the KOT and nutrition policies at FBO sites was the engagement of trusted community leaders and gatekeepers within the FBO settings that was reflective of the largely first-generation immigrant congregation of each site. In each community, partners met with FBO leadership to foster engagement and support for health promotion in faith settings and their approval for the nutritional policy and KOT implementation process. Within each FBO setting, leadership structures varied; for example, gurdwaras (Sikh houses of worship) are led by a committee which acts as the decision-making body in overseeing programmatic activities. Some of the Korean churches are comprised of various ministries (e.g., a Health Ministry) which made the decisions on nutrition implementation efforts. For the KOT program specifically, which relies on peer volunteers to deliver the regular BP screening and counseling to congregants, two levels of community leaders were engaged in the program. First, partners identified consultants for the program who were trained by the NYC DOHMH using a train-the-trainer module. Consultants were chosen based on their history of engagement in the target community, ability to speak the target language, and relationships with FBO and other community institutions. Their DOH training bolstered their already existing cultural license to introduce the KOT program to congregations. Second, consultants identified existing health ministry members or other active volunteers in each site who were trained to administer the monthly screening and counseling program.

Metaphors

In translating health education materials, partners engaged in an interactive process of incorporating Asian-specific idioms and cultural colloquialisms into materials that would support health promotion (e.g., in the Bengali language materials, the concept of “niyom” or routine, which has been identified in previous work as supportive of health promotion efforts, was incorporated into KOT training manuals and coaching materials) [97]. Conversely, partners also adapted or removed English language metaphors that were not relevant.

Content

Content was adapted across all materials for both the KOT program and in support of nutritional policies implemented in FBO settings. Specifically, all training materials, health education materials, and outreach materials were edited to remove foods not eaten by the community and explicitly acknowledged the value of traditional cultural dishes and incorporated healthy traditional foods or dishes or heart healthy modifications of these dishes. As stated by a coalition partner about adapted the NYC DOHMH materials and other sources, “Anything that wasn’t relevant to the community, we switched out.”

Concept

Asian cultural concepts related to collectivism, community, and the centrality of the family unit were incorporated into program materials and messaging. For example, nutritional and hypertension educational sessions and events were held during family nights at Bangladeshi mosques, and culturally adapted materials included tips for grandparents and caretakers. Efforts to support nutritional strategy implementation highlighted modifying traditional Asian diets to be heart healthy.

Goals

In engaging faith partners for both parts of the intervention, program goals were aligned closely with the mission and teachings of each setting. The Sikh religion emphasizes the concepts of seva or service to the community as part of their faith. In Sikh gurdwaras, communal meals are donated by congregation members and often hosts health-related activities such as health fairs to improve the health of the community. The gurdwara committee members were educated on the importance of the health promotion strategies and how the REACH FAR strategies aligned with seva or as a service to their community.

Methods

Across all the faith settings and groups, coalition partners emphasized that faith leaders are highly respected and community gatekeepers. Thus, we incorporated guidelines and protocols to enhance faith leadership engagement in both strategies. For example, a series of faith leader engagement meetings were conducted prior to program and policy implementation; memorandums of understanding were jointly developed and reviewed by coalition partners and faith leaders; and leadership was recruited to make announcements in support of program activities during weekly congregation prayers and services. As stated by a coalition partner when describing the implementation process, “We started contacting the church leaders first because that’s where the approval comes from. They’re also able to bring things to the head pastor. We started there.” In addition, program activities or procedures were adapted to address cultural and religious norms and the context of religious service and events. For example, in mosque settings, the KOT procedures for conducting BP screenings were adapted to accommodate modesty concerns for Muslim women by setting up a separate station for the female congregants.

Context

Finally, the KOT program addressed contextual issues related to congregations’ immigrant status, including undocumented status, and the work context of congregants across settings. Referral information was distributed included sliding scale or low-cost resources for immigrants who did not qualify for state or federal health insurance programs.

DISCUSSION

REACH FAR represents a unique multi-sector (academic, community, faith, and municipal health sectors) partnership to ensure local and community sustainability. Practice-based adoption and sustainability is greatly strengthened by using a community-led and community embedded program approach. By implementing and fostering collaboration with the NYC DOHMH, we are further enhancing impact on public health practice. The REACH FAR faith-based strategies represent low-resource sustainable activities delivered by trained congregant volunteers using a collaborative partnership approach to further sustain efforts and enhance community capacity and translation into public health practice. As we are able to assess outcomes across denominations, across AA ethnic subgroups, and congregation size and structure, there is high potential for generalizability and dissemination to other AA-serving FBOs.

Findings from this study present encouraging evidence for the role of FBOs for health promotion and suggest that adapting existing interventions for cultural, linguistic, and organizational/setting-level characteristics using a community-engaged and capacity building approach can result in successful implementation and uptake of health promotion strategies.

Significant modifications and adaptations to the strategies were necessary to ensure relevancy and successful implementation in these underserved communities, underscoring that there exist substantial gaps in translational research. Our study reinforces the growing evidence base in the dissemination and implementation literature that calls for meaningful, well-designed interventions attuned to the needs of diverse audiences, applicable and acceptable for real-world, community-based settings, and scalable for significant reach [69, 98–104]. Implementation research methods aim to promote the systematic uptake of research findings and evidence-based practices into routine practice [105]. The use of cultural adaptation models in implementation science can enhance relevancy, acceptability, and appropriateness of evidence-based programs to the needs and preferences of diverse populations [76]. Our use of a systematic approach of applying the EVM to the cultural adaptation process adds to the knowledge base. Further, incorporating a CBPR approach ensures meaningful engagement of stakeholders and that strategy adaptations are culturally appropriate for the target communities.

Two review articles of FBO health promotion interventions include no examples of intervention studies targeting AA FBOs or congregants [43, 46]. Moreover, our study findings highlight that within our sample, FBOs may be underutilized as sites to encourage healthy environment (e.g., mission or policy statements, labeling providing or labeling healthy food options) and for behavioral health promotion and activities. The majority of the REACH FAR implementation sties did not have the resources or infrastructure for systematic health promotion activities. Furthermore, individual-level findings underscore the need for HTN prevention and control interventions targeting AA-serving FBOs. Both self-reported and measured blood pressure and BMI rates for congregants across the four communities align with or exceed those reported in other published studies [106–108], demonstrating that faith-based settings are an appropriate venue for reaching Asian individuals at high risk for CVD. Despite yearly improvements in CVD mortality rates among non-Hispanic whites, AA subgroups have not shared in the improvements. Jose et al. [8] suggest that CVD prevention and management messages and campaigns may not be effectively reaching this population, highlighting the need to implement strategies that are low-cost, easy to use, culturally relevant, and can successfully reach these underserved population. Our future work will evaluate the efficacy of the multi-level strategies implemented in FBO settings to improve BP control and nutritional practices of congregants. Finally, a key contribution of our study is that findings can guide future implementation efforts in AA FBO settings. Given that there is limited research that has examined FBOs as an appropriate place for intervention with AAs, our study provides important information on how implementation processes vary across diverse AA FBOs given the cultural and structural context of sites across subgroup communities.

Limitations

REACH FAR is a community-based study implemented in self-selected FBOs; thus, finding may not be generalizable across all AA-serving FBOs. Furthermore, our study is being conducted in 12 FBOs, a relatively small sample size, which limits the statistical power to detect differences in group. The implementation program, however, is conducted across four AA subgroups, across denominations, and organizational structures. By collecting FBO organizational data on capacity and existing health promotion activities, this paper adds to the knowledge base on strategies to support uptake and sustainability of faith-based health promotion activities. Our findings provide encouraging evidence for and much needed information on the translation of evidence-based programs for underserved communities.

CONCLUSIONS

Faith-based health promotion initiatives can provide access to people who disproportionately experience poor health outcomes and are not reached by mainstream or traditional health care channels. Our preliminary findings suggest REACH FAR is a promising implementation research study that is feasible and acceptable in FBO settings. Future work which evaluates the efficacy of multi-level strategies to impact health outcomes and behaviors related to CVD may have wider implications for public health practice for underserved AAs and other populations.

Appendix

Compliance with ethical standards

Statement on any previous reporting of data

Findings reported in this manuscript have not been previously published. This manuscript is not being simultaneously elsewhere.

Primary data

The authors have full control of all primary data and agree to allow the journal to review the data if needed.

Funding

This publication is supported by grant numbers U58DP005621 and U48DP005008 from the Centers for Disease Control and Prevention (CDC), P60MD000538 from the National Institutes of Health (NIH) National Institute on Minority Health and Health Disparities, and UL1TR001445 from NCATS/NIH. The contents of this publication are solely the responsibility of the authors and do not necessarily represent the official views of the NIH and CDC.

Conflict of interest

All authors declare they have no conflict of interest.

Statement on human rights

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee.

Statement on the welfare of animals

This manuscript does not contain any studies with animals performed by any of the authors.

Informed consent statement

Informed consent was obtained from all Keep on Track individual participants included in the study. Oral consent was obtained from individuals participating in the nutrition evaluation as no PHI was collected as part of the evaluation. All data presented in this manuscript is deidentified.

Helsinki or comparable standard statement

All procedures performed in studies involving human participants were in accordance with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

IRB approval

All REACH FAR procedures and activities conducted with human participants were reviewed by the NYU School of Medicine IRB and approved as an expedited study