Exploring the Readiness of African-American Churches to Engage in a Community-Engaged Blood Pressure Reduction Research Study: Lessons Learned from the Church Challenge

Abstract

Introduction:

The Transtheoretical Model (TTM) has been used to assess individual readiness for health behavior change. We describe our use of the TTM to assess organizational readiness of African-American churches to participate in the Church Challenge (CC) in Flint, Michigan; the processes of change that moved churches toward readiness for change; and lessons learned.

Methods:

The CC was a faith-based, multilevel intervention to reduce chronic disease risk. A community-based participatory approach was used to engage and recruit churches. We used the TTM to capture church readiness for change and track church progress through the five stages.

Results:

We engaged with 70 churches: 35 remained in Stage 1 (precontemplation), 10 remained in Stage 2 (contemplation), 3 remained in Stage 3 (preparation), 5 made it to Stage 4 (action), and 17 finished within Stage 5 (maintenance). Churches engaged in several processes of change as they moved through the various stages of change.

Lessons Learned:

Utilizing processes of change, establishing rapport, and having previous participants share success stories helped move churches from stage-to-stage. However, certain barriers prevented progression, such as burnout/trauma from the Flint Water Crisis and scheduling conflicts.

Discussion:

Faith-based organizational readiness greatly impacted participation in the CC. Researchers should utilize established social capital, build rapport, and remain flexible when working with African-American churches.

Conclusion:

Although traditionally used at the individual level, the TTM works well at the organizational level to assess and monitor church readiness to participate in community-engaged research and health programming to improve health in an African-American faith community.

Introduction

African-Americans are disproportionately impacted by hypertension (Ferdinand et al., 2020; Heard et al., 2011; Rigsby, 2011), a common chronic condition that can lead to cardiovascular disease, stroke, chronic kidney disease, heart failure, and mortality (Pickering et al., 2008; Rodriguez et al., 2010; Weber et al., 2014). Numerous studies suggest that physical activity and healthy eating are vital for hypertension prevention and management (Appel et al., 1997; Appel et al., 2003; Lemacks et al., 2013). However, resources that promote physical activity and healthy eating (e.g., parks and full-service grocery stores) are often lacking in African-American communities (Lamichhane et al., 2013; Powell et al., 2006). Research suggests that community-engaged research and health programs implemented within churches are effective for reducing blood pressure in African-American communities (Baskin et al., 2001; Dodani, 2011; Schoenthaler et al., 2018; Wilcox et al., 2010; Zoellner et al., 2011). African-American churches are invaluable partners in community-engaged research and health programming (Campbell et al., 2007; Baskin et al., 2001), as they are influential and trusted organizations within the community (Markens et al., 2002). Thus, churches are essential partners in reaching and engaging African-Americans to improve health (Ammerman et al., 2002; Demark-Wahnefried, 2000). However, not all churches or organizations are ready to engage in research or intervention implementation.

Successful implementation of new evidence-informed practices within an organization is determined by the organization’s readiness, defined as willingness to commit to organizational change (DeMarco et al., 2011; Weiner et al., 2008; Weiner, 2020). Several published articles report the successful implementation of organizational-level interventions after assessing organizational readiness in the clinical setting (Hamilton et al., 2009; Ober et al, 2017). Although numerous studies have been conducted to assess faith-based organizational readiness to change (DeMarco, et al., 2011; Maxwell et al., 2019;), there is little information in current literature linking the assessment of faith-based organizational readiness to implement successful interventions.

Various instruments and models have been used to assess readiness for change. One well-known model is the Transtheoretical Model of behavior change (TTM), a biopsychosocial framework that uses constructs from several theories to predict an individual’s or organization’s readiness to change (Prochaska et al., 2001). The model includes five stages of change: 1) precontemplation – no intention of making the desired change in the next six months, 2) contemplation – thinking about making the desired change in the next six months, 3) preparation – preparing to make the desired change in the next 30 days, 4) action – currently making the desired change for less than six months, and 5) maintenance – maintaining the desired change for more than six months. A natural phenomenon that occurs when changing a health behavior is regression from the action or maintenance stages to an earlier stage of change (Prochaska & Velicer, 1997). These stages of change are non-linear and occur in more of a spiral pattern, where a person may relapse multiple times before progression is halted or they make progress before relapsing again. This spiral pattern shows the back-and-forth nature of decisional balance. Part of moving through the stages of change is to get to a point where the pros outweigh the cons, which can be affected by the level of self-efficacy and temptation at each stage (Prochaska & Velicer, 1997). Self-efficacy pertains to the notion that an individual feels confident in their ability to make a change, while temptation refers to the urge to engage in an unhealthy behavior (Prochaska & Velicer, 1997). The goal is to elevate self-efficacy while depressing temptation.

The traditional stages of change reflect individual-level readiness to change behaviors. However, the parameters of the model have been adapted to reflect organizational readiness, acknowledging the psychology of organizational change in ways that other models may not (Castañeda et al., 2012; Prochaska et al., 2001). For each stage, there are distinct processes of change that can be utilized to move organizations from one stage to the next (Prochaska et al., 2013), shown in Table 1.

Table 1.

Processes to Move Organizations from One Stage of Change to the Next Stage

Stages of Change	Processes of Change
Precontemplation	Consciousness Raising: Becoming more aware of a problem and potential solutions
	Dramatic Relief: Emotional arousal, such as fear about failures to change and inspirational for successful change
	Environmental Reevaluation: Appreciating the change will have a positive impact on the social and work environment
Contemplation	Self-Reevaluation: Accepting that change is important to one’s identity, happiness, and success
Preparation	Self-Liberation: Believing a change can succeed and making a commitment to the change
Action	Reinforcement Management: Finding intrinsic and extrinsic rewards for new ways of working
	Helping Relationships: Seeking and using social support to facilitate change
	Counter Conditioning: Substituting the new behaviors and cognition for old ways
	Stimulus Control: Restructuring the environment to elicit new behaviors
Maintenance	N/A

Note. Stages of Change adapted from Prochaska & Velicer (1997). Processes of Change adapted from Prochaska et al. (2013).

The purpose of this paper is to describe the application of the principles of the TTM framework to evaluate and improve organizational readiness to implement the Church Challenge (CC), a multilevel intervention that integrated community-based participatory research (CBPR) principles and faith-based health programming to reduce blood pressure and improve health among adults attending predominantly African-American churches in Flint, Michigan. Our goal was to demonstrate that the TTM could be utilized to assess and improve organizational change. We were specifically interested in determining if the processes of change described in the TTM could be utilized to improve organizational readiness. Here, we describe our use of the TTM to assess organizational readiness, the implementation of the processes to move churches through the stages of change, and the lessons learned from the experience.

Methods

Study Design

An Overview of the Church Challenge

The CC was a multilevel intervention designed to promote health equity and reduce chronic disease risk in Flint, Michigan’s African-American community (Johnson-Lawrence et al., 2019). It had 3 components: 1) a community-level component focused on engaging faith leaders in health policy and advocacy work designed to promote health and well-being in the community, 2) a church-level intervention that involved training church-based health teams to promote wellness within their congregations, and 3) a 16-week randomized-control trial (RCT) that evaluated the impact of a Physical Activity and Nutrition Program (PANP) intervention relative to a control Health and Wellness Program (HWP) on blood pressure outcomes among individual participants. Churches had the option of participating in one, two, or all three components. The current paper focuses on our efforts to assess and improve organizational readiness to participate in the 16-week RCT. The PANP included weekly nutrition and cooking workshops that encouraged participants to read food labels to reduce sodium intake. Participants were also encouraged to follow the Dietary Approaches to Stop Hypertension (DASH) diet (Appel et al., 1997), especially stressing the importance of increasing consumption of fruits and vegetables and only low-fat dairy products. The physical activity component also included a weekly, one-hour exercise class that focused on low-impact aerobic activity. The CC was approved by the Michigan State University Institutional Review Board (IRB #17–728).

Study Setting

The CC took place in Flint, Michigan, a vulnerable, majority minority community. Flint has suffered decades of divestiture, worsening the economic and physical well-being of its residents. The 2014–2015 Flint Water Crisis exacerbated the hardships this community was already experiencing (Johnson et al., 2018). This man-made disaster intensified the community’s mistrust in government (Morckel & Terzano, 2018) and larger organizations (Cuthbertson et al., 2016; Roy, 2017), making it difficult to successfully implement community-based research activities.

African-American churches play an important role in health promotion within the community as trusted community organizations (Santos et al., 2017; Scheirer et al., 2017). The Flint Water Crisis further expanded this role. Churches quickly found themselves taking on public health roles, disseminating health information and setting up water distribution sites and food pantries. This overburdened churches and their overextended faith leaders who were already serving as community counselors and mentors while also maintaining careers and personal responsibilities outside of the church. This made it even more difficult for researchers to successfully implement community-based research activities.

The CC was conceptualized in 2012 as part of a collaboration between the Genesee County Health Department and the Centers for Disease Control and Prevention (CDC) Racial and Ethnic Approaches to Community Health (REACH) program (CDC, 2021) – the Reach Across the Nation Committee (RANC). However, the concept of the CC expanded as a result of the Flint Water Crisis.

Church Recruitment

The first step in our recruitment process was to engage with church faith leaders to seek their approval for church membership to participate in the project. To successfully build rapport and obtain full support from faith leaders, the research team optimized CBPR approaches. The research team collaborated with faith-based community partners who were longtime residents and had established relationships with faith leaders in the Flint community. Church recruiters contacted faith leaders and informed them about the CC. Thereafter, a meeting was scheduled between the research team, church, and community partners. During the meeting, the research team discussed the project and the faith leader verbally agreed or declined to participate.

Health Team Recruitment

Upon verbal agreement to participate in the RCT, faith leaders designated one or two members of their health ministry to be health team leaders for the CC. In collaboration with the research team, these leaders assisted with participant recruitment, scheduled and facilitated data collection with study participants, and provided an opportunity for church-based conversations regarding practices that study participants found helpful in promoting healthy living in their daily lives.

Participant Recruitment

Participant recruitment was a collaboration between the church health team and research team. The research team provided the health team with recruitment flyers to incorporate into church service itineraries and for placement on bulletin boards throughout the church. In addition, the health team coordinated with the research team to schedule visits to the church. The research team attended church services and other church activities (e.g., bible study, church events) to promote and discuss the program and to enroll individual church members.

Assessment of Stages of Change

Participation in the Church Challenge RCT required partnerships with key individuals within each church, including the faith leader (e.g., pastor, priest, bishop), the church-based health team, and participating church members. Using the TTM, we were able to identify their readiness and track their progress through the stages of change. No instrument was used to appraise readiness. Instead, organizational readiness was assessed based on verbal expressions of familiarity with the program and intent to participate, as well as actions observed by the research team. Individuals normally go through the processes of change on their own (e.g., a person may raise their own consciousness by seeking out health information). We attempted to move them through the processes of change ourselves.

Precontemplation

We designated churches in the precontemplation stage when/if the church leaders did not confirm intentions to participate in the CC. Church recruitment was our primary research activity with churches in the precontemplation stage. Church recruitment occurred by collaborating with faith-based community partners, a method used successfully in past studies (Whitt-Glover et al., 2016). With the assistance of our community partners, we utilized several church recruitment strategies that were successful in previous studies (Ceasar et al., 2017; Lemacks et al., 2018; Williams et al., 2013). These strategies included hosting interest meetings and making personal phone calls to faith leaders, sending emails with project informational materials, making phone calls to church offices, attending community and church engagement events, placing an advertisement in the local courier newspaper, and through word-of-mouth. We also partnered with faith leaders and church health teams to develop a recruitment video that was disseminated to faith leaders and church representatives for broadcast during Sunday services. The video described the CC design and included live-action footage of intervention activities. It also featured testimonials from church health team leaders about the importance of the project for the local faith community.

Precontemplation to Contemplation

We utilized three processes of change to support the church partners to progress from precontemplation to contemplation: consciousness raising (increasing awareness about the health behavior change), dramatic relief (emotional arousal about the health behavior change, positive or negative), and environmental reevaluation (assessing the effects of personal decisions on the surrounding social environment) (Prochaska & Velicer, 1997). To increase awareness and knowledge about the project and the benefits of participation (Velicer et al., 1998), we shared pertinent informational materials with church leaders. We anchored the need for health behavior change to the central problem of high prevalence of hypertension among African-American adults in the U.S. We also shared information with key participants about the prevalence of hypertension in the Flint community and the benefits of physical activity and healthy nutrition for blood pressure reduction. As a community-based study, it was equally important to clearly identify who and how key people from the community and church settings would be involved. The informational details included who the key participants were (faith leader, health team, and church members), their role in the project, length of participation, locations for all program activities, descriptions of materials to be utilized during the program, and the benefits of participation (e.g. increased knowledge, improved health, free training, group support and interaction, prizes and financial incentives). However, it was incumbent upon them to raise their consciousness and progress to subsequent stages.

Our community partners were essential to the RCT as church recruiters. By sharing their testimonies to emphasize the significance of the RCT, the church recruiters elicited dramatic relief, a process of change, from faith leaders. The first church recruiter shared her personal testimony on the impact that positive health behaviors (physical activity and healthy eating) had on her health, emphasizing her positive experience of reduced pain and mobility restrictions. The second church recruiter shared a testimony on how the pilot study for the CC was successful and positively impacted churches that participated. The third recruiter discussed the importance of self-care and how churches are instrumental in impacting the health within the community. The fourth recruiter shared the importance of health within the church and among parishioners. All four shared personal stories of how health research studies can have a positive immediate and future impact on the church and the community. Our recruitment video also included powerful testimonies from participants, who were leaders in their faith groups, about the benefits of the program.

Our team promoted environmental reevaluation through direct communication with church leaders, most often during face-to-face meetings. We emphasized the importance of promoting healthy habits among church members, noting, for example, that healthy church members live longer and healthier, which allows them to engage wholeheartedly in church activities. Church leaders acknowledged that promoting health and wellness is good for church business as well. Subsequently, faith leaders would spend less time visiting people in the hospital and conducting fewer funerals due to the adverse effects caused by unhealthy behaviors.

Contemplation

We designated churches in the contemplation stage when the church leaders expressed intention to participate in the CC but had not yet enrolled. The three research activities in this stage included appointment of a health team, random assignment into one of the two health programs, and presentation of a Memorandum of Understanding (MOU). The MOU outlined expectations of researchers and churches. Such expectations included recruiting participants, participating in study workshops, and participating in data collection. During this stage, the first goal was verbal commitment from faith leaders. Once the faith leader verbally agreed to participate, they identified a health team. Health team members were selected by faith leaders and acted as liaisons between the church and the research team, as reported in previous studies (Wilcox et al., 2013). In some churches, there was an existing health ministry. In others, there were church members who were responsible for health activities within the church. If there was no existing health team ministry, the faith leader appointed a member from the church who was either a healthcare professional or was involved or interested in other health-related activities. After church leaders identified a health team, the church was randomly assigned to one of the two health programs (intervention or control) and the MOU was reviewed by the faith leader.

Contemplation to Preparation

To successfully progress from contemplation to preparation, the faith leaders utilized self-reevaluation. Self-reevaluation is described as cognitive reappraisal of how behavior change is part of one’s identity (Prochaska & Velicer, 1997). After persistent reassuring contact between the community partners and faith leaders, faith leaders and health teams slowly learned and appreciated the benefits that would come to their churches and communities as a result of promoting good health and well-being through the program. This led to realization that health promotion and improvement was an important aspect of the church’s mission, congruent with previous studies (Webb et al., 2013). Additionally, to help promote self-reevaluation, we referred faith leaders to scriptural passages that referenced the importance of physical health (e.g. the body is a temple). Thus, faith leaders found that encouraging people to take care of their bodies is part of the church’s spiritual mission as well.

Preparation

Churches were designated in the preparation stage once they completed three activities: signing of an MOU agreeing to participate in the study, hosting of a formal meeting between the health team and research team, and providing contact information to initiate individual participant recruitment. After the faith leader reviewed the MOU and agreed to participate in the project, representatives from the University and the church provided their signatures. After signing the MOU, the faith leader and research team member identified a health team member to serve as the point-of-contact for the research team, and arranged a meeting with the appointed health team member(s). During the meeting with the health team member(s), the research team provided the church a health team handbook outlining expectations, discussed project details, and provided recruitment flyers. The health team handbook served as a tool to recruit and retain participants, thereby improving self-efficacy among the church health teams. After reviewing pertinent material, the health team planned activities and logistics within the church, identified as an important step in previous studies (Berkley-Patton et al., 2018).

The first planned research activity with the health team was participant recruitment. Several strategies were implemented to successfully recruit church members to participate in the research project, including providing Sunday morning announcements during services, posting recruitment flyers within the church, providing announcements during bible study, having church leaders send text messages to church members, and posting announcements in Sunday bulletins and on bulletin boards, similar to previous studies (DeMarco et al., 2011).

Preparation to Action

To successfully progress from preparation to action, the health team utilized self-liberation. Self-liberation is an individual’s belief that they can change, followed by a commitment to pursue that change (Prochaska & Velicer, 1997). In collaboration with the research team, the health team planned activities and logistics for the research activities, similar to previous studies (Berkley-Patton et al., 2018). The research activities included participant screening, participant enrollment, data collection, and health workshops. Other self-liberation activities included faith leaders committing to the goals laid out in the MOU and participants making New Year’s Resolutions.

Action

A church was designated as in the action stage when people within that church were attending CC activities after random assignment to the PANP or HWP arms of the RCT (further described below). The research activities were similar, but the programs differed in health content. The research activities in these programs included participant screening, participant enrollment, data collection, health information dissemination, and participation in workshops. Participant screening involved obtaining informed consent and conducting a list of cognitive and physical health screening questions to determine eligibility. Participant screening interviews were conducted over the phone, after Sunday service or bible study, and/or at arranged data collection events. Once participants provided informed consent and were deemed eligible to participate, they were assigned a subject identification number. Data collection for both programs consisted of a self-administered survey and collection of physical health data (blood pressure, weight, height, waist circumference, and hemoglobin A1c [HbA1c]) by trained data collectors. Data was collected at baseline and at 16 weeks in both the HWP and PANP arms. Additional data were collected from the PANP participants at 8 weeks.

The 4-month HWP arm consisted of four (4) one-hour monthly workshops that focused on various health topics (e.g., cancer, dementia, mental health, stroke) identified by the church health team as relevant within their congregation. The workshops were led by health professionals and held at individual churches. The dates and times of the workshops were selected by the churches’ health teams.

The 16-week PANP arm included weekly fitness classes, hands-on nutrition education, and cooking workshops. The sessions were led by trained community members and held at the Community Outreach for Family and Youth Center (COFY), a local community center (Community Outreach for Family and Youth, n.d.). During the program, the church health team members were provided health education materials to disseminate within their churches on a monthly basis.

Action to Maintenance

In support of the churches maintaining their participation in the RCT activities, it was important to foster bidirectional relationships with the church health team members. Working together, the church health teams and the RCT research team continued to engage with church participants and to ensure research activities were completed. The CC was a community-based research study that we implemented because community members saw the added health benefits that supplemented/complimented the research. As a result, the research team helped the health teams remain engaged in the program beyond data collection by maintaining constant communication and support.

Maintenance

We designated churches in the maintenance stage when they continued to host activities within their churches that were part of the RCT program activities six months after the 16-week data collection was complete based on the timeframes outlined by Prochaska & Velicer (1997). During the maintenance stage, the final RCT activity was the data collection at 26 weeks after baseline data collection for individual participants from the churches.

The church health teams and the RCT research team held planning meetings to prepare for the 26-week follow-up data collection. To encourage church attendees to participate, health teams made announcements during Sunday church service and bible study and the research team made phone calls to participants. Some churches held follow-up data collection events after church service to ensure most of the participants were in attendance. Other churches scheduled a weekday for data collection at the church participants attended. The research team followed up individually with the participants who did not attend the church-based data collection events.

The research team facilitated training sessions for church health team members to learn or collect health resources to support health and wellness within their churches. We used social media to disseminate information about local community resources, such as food banks, telemedicine options, and health insurance enrollment. A Facebook page was developed to provide weekly health tips, recipes, and exercises for church members to use at home.

During the COVID-19 pandemic, health and wellness activities incorporated social distancing measures. “Church Chat” support groups were held for health teams to promote self-care during the pandemic. Several churches participated in the support groups. The “Church Chats” addressed the COVID-19 virus and related health effects, stroke prevention, and back-to-school information during the pandemic. Additionally, the research team hosted “Policy Prep for Pastors,” a webinar series for local faith leaders to learn more about how to advocate for improving health and wellness within their own communities.

Results

During the project, we reached and engaged with 70 Flint-area churches. The majority of the churches started within the precontemplation or contemplation stage. Ultimately, 22 churches progressed to the action stage, of which 17 churches reached the maintenance stage. At the end of the RCT phase of the CC, 35 remained in the precontemplation stage, 10 remained in the contemplation stage, and 3 remained in the preparation stage.

While some churches quickly moved to the preparation stage from the precontemplation and contemplation stages of change, the majority of the churches we reached did not ever progress to preparation. Some churches progressed to the preparation and action stages but relapsed to earlier stages (precontemplation and contemplation).

Lessons Learned

Precontemplation

Most churches were not thinking about participating because they were not aware of the project. The most effective strategies for church recruitment included in-person meetings with and phone calls to faith leaders, word-of-mouth, and church/community events. These strategies would not have been effective without our community partners, who served as church recruiters, especially our faith-based community partners, such as pastors. The church recruiters were invaluable during this stage because they had established relationships with faith leaders, which proved to be critical for recruitment. Because of their previously established relationships and for their relatability, the faith leaders trusted the community partners, especially the faith-based community partners, and the information they shared. In addition to sharing information about the project, recruiters shared the benefits of involvement for individuals, the congregation, and the community. Sharing information about the project and the benefits of involvement emotionally moved faith leaders and encouraged them to participate.

One method that proved to be ineffective was utilizing contact information from phone books, both in print and online, as many of the phone numbers were outdated. Many were wrong phone numbers, disconnected, and/or no one answered.

The processes of change (consciousness raising and dramatic relief) in the precontemplation stage were effective together in moving churches to the next stage. However, some churches did not move from this stage for various reasons, such as burnout/trauma from the ongoing Flint Water Crisis; lack of trust in research/academic institutions; participation in other research studies and health programs, causing scheduling conflicts; forming competition between church activities; and inability of church recruiters to contact and reach faith leaders, all of which echoed findings from previous journal articles and studies (Corbie-Smith et al., 1999; Cuthbertson et al., 2016; Gamble, 1997; Lancaster et al., 2014; Masten et al., 2016; Scharff et al., 2010). Additionally, some churches were planning on participating but experienced a loss or change in church leadership. The summer months were also difficult for some churches to participate due to scheduling of summer church activities that conflicted with scheduling of program activities.

Contemplation

Churches were more likely to think about participating if they were aware of the project, if they were moved emotionally, and/or already had an existing health team. If the church did not have a health team, the most effective strategy for appointing a team was identifying church members who were leading other activities in the church or who had a background or interest in health (e.g. nurses, social workers). Some churches remained longer in this stage than others, most commonly due to the difficulty of identifying health team members in churches with no existing health ministry.

Self-reevaluation was important in moving churches from the contemplation stage to the preparation stage. However, some churches did not leave the contemplation stage for various reasons and temptations. These included inability to identify and appoint a health team that would participate in the project, uncertainty about the church’s required commitment and involvement in the project, competing church activities, and lack of control and interest in the program they were randomly assigned to, which again echoed findings from prior papers and studies (George et al., 2014; Lancaster et al., 2014). Random assignment was difficult for certain churches, especially for those that preferred to participate in one program over the other. Unfortunately, they were unable to select the program because of the design of the study, which halted them from progressing to the next stage. Churches with older members were more interested in participating in the HWP over the PANP. Older members were not interested in attending weekly meetings at a different location, such as what was required for the PANP arm of the program. Instead, they preferred to meet once a month at their own church, which is what was required for the HWP arm of the program. In addition, some churches did not like the idea of participating in the PANP arm since it was not being held at their church, especially if they had the resources to host it.

Preparation

Churches were more likely to prepare to participate when the church viewed health as an important factor and when the church had a committed health team. In this stage, health team commitment and engagement were critical. Successful planning meetings with health teams played a huge role in moving churches to the next stage. During these meetings, health teams utilized self-liberation which helped move the church to the action stage.

Although self-liberation helped some churches move to action, other churches stayed in preparation. Churches did not leave preparation for a few reasons. These included inability to successfully contact and meet with health teams to plan activities, which was similar to previous studies (Lancaster et al., 2014); scheduling conflicts; and lack of sufficient participant recruitment. Participant recruitment in several churches proved to be difficult for various reasons, including lack of trust in research/academic institutions, burnout from daily stressors (e.g., the Flint Water Crisis) and busy schedules, lack of time and commitment, which were all similar to prior studies (McNeill et al., 2018), and having a small church congregation.

Action

Highly motivated health teams were instrumental in encouraging participants and ensuring project activities were seamlessly completed in the action stage. Most of the research activities were successful because of the planning and coordination by the health team working in concert with the CC team. During this stage, most of the participants enjoyed some research activities (i.e. health program workshops) but did not enjoy other research activities (i.e. data collection).

Helping relationships, one of the processes of change, was an important component in assisting churches to move through the action stage and continue on to the maintenance stage. However, even with helping relationships, some churches did not make it to the maintenance stage. Some reasons included lack of effective research team communication with the health team, internal scheduling conflicts that prevented research activities, and participant drop-out. There were many participants that initially signed up to participate but were not interested in committing to data collection and/or participation in one of the two study arms. In addition, some members would sign-up and drop-off for different reasons, such as bereavement, lack of transportation, lack of time, and conflicting work schedules.

Maintenance

Strong communication and collaboration between the research team and health team helped churches move into the maintenance stage. Establishing good rapport was the driving force for effective collaborations between the research team and the church. Rapport also facilitated participant follow-up, but proved to be difficult and required a lot of time and effort from both the research and health teams.

Discussion

Churches are valuable partners in the effort to reduce blood pressure among African-Americans. However, these efforts rely on a church’s readiness for implementation, especially amidst community-wide traumatic experiences like the Flint Water Crisis. We found that faith-based organizational readiness greatly impacted engagement in CBPR and health programming to reduce blood pressure among congregants. Readiness was an important factor in predicting church participation in the CC. If churches were not ready to participate in the CC, they did not. However, if they were ready, they participated and completed all the CC research activities. The TTM was an appropriate framework to illustrate the relationship between church readiness and engagement in the CC. The model effectively captured the churches’ progress through the stages of change. Several churches progressed through all five stages of change and successfully completed the CC. However, we found that many churches did not progress through the final stages for various reasons, including lack of trust in research/academic institutions, feeling overwhelmed (faith leaders, health teams, and church members), internal scheduling conflicts, and church activities that superseded the research activities.

When working within an African-American community, it is essential to tap into social capital and utilize established trusted relationships. This is especially true for relationships with faith leaders, since they are an integral part of their churches and surrounding communities. Researchers should build rapport and have flexible schedules when working with African-American churches. It may be necessary to meet and hold workshops outside of standard business hours (e.g., evenings and weekends). African-American churches are over-stretched with ongoing church and community activities, especially in vulnerable or marginalized communities such as Flint, making it difficult to restructure schedules to fit into standard business hours. Additionally, it is important, when possible, to host research activities at the home churches where participants feel more comfortable and are closer in proximity.

A novel aspect of the CC was implementing the multilevel intervention in a vulnerable and marginalized community actively dealing with an ongoing water crisis. Several churches, including the leaders, members, and non-member attendees, were overwhelmed with the stress from the ongoing water crisis, which distracted them from focusing on their own health. However, through perseverance and dedication by the research team, faith leaders, health teams, and community partners, the CC was successfully implemented. Another important aspect of this project was that this successful RCT was framed within CBPR approaches, illustrating the success of integrating both approaches. Current literature suggests that incorporating CBPR approaches within components of a RCT helps to improve recruitment and retention (Andrews et al., 2017) and leads to successful RCT implementation (Rink et al., 2020). Additionally, because we had an Academic Primary Investigator (PI) along with a Community PI, we were able to promote equity in leadership and decision-making relative to CBPR processes.

This study is not without its limitations. First, there was no validated tool or instrument used to measure the readiness of the churches. Readiness was measured by evaluating and monitoring church progression through the five stages of change within the TTM. Additionally, we did not examine the preparedness level of church members and leaders to fully assess organizational readiness, nor did we fully capture how the work of church leaders increased and adapted in response to the Flint Water Crisis. If we had, we might have identified and addressed some of the barriers to progression (e.g., lack of support or willingness to travel) earlier on, thereby increasing the number of churches who might have progressed to the maintenance stage and completed the program. We found that individual readiness greatly impacts organizational readiness and should be considered when attempting to promote organizational change.

Conclusion

Although the Transtheoretical Model has traditionally been used at the individual level, we utilized it at the organizational level to assess and monitor church readiness and engagement in community-based participatory research and health programming to improve health in an African-American community. By tapping into previously established social capital, building rapport, having flexible schedules, and hosting research activities at home churches, recruiting and retaining participants from African-American churches within vulnerable communities may be improved, leading to enhanced community engagement and more robust research.

Figure 1.

Church Challenge Research Activities and Stages of Change

Note. Stages of Change adapted from Prochaska & Velicer (1997).

Figure 2.

Processes of Change Used Between Each Stage of Change

Note. Stages of Change adapted from Prochaska & Velicer (1997). Processes of Change adapted from Prochaska et al. (2013).

Table 2.

Research Activities and Strategies Used at Each Stage of Change

Stage	Research Activity	Strategies
Precontemplation	Church Recruitment	Interest meetings with pastor and/or church leaders
		Pastoral/organizational meetings
		Phone calls and in-person meetings
		Word-of-mouth
		Emails with informational materials
		Phone calls to church office
		Community and church events
		Recruitment video
		Local newspaper advertisement
Contemplation	Identify Health Team Member/s	Appoint existing health team
		Appoint church members who are healthcare professionals or interested in improving health within the church
		Appoint members who are leading other church activities
	Memorandum of Understanding (MOU) Presentation	Arrange meeting with research team and faith leader to review MOU
Preparation	MOU Signature	Meet with faith leader to sign MOU
		Deliver MOU to faith leader via health team
	Health Team Engagement	Deliver a handbook with vital information to health team
		Meet with health team
	Participant Recruitment	Announce during Sunday service
		Post recruitment flyers within the church
		Send text messages to church members
		Post recruitment flyers in church bulletins and on bulletin boards
		Use sign-up sheets in the back of the church
Action	Participant Screening	Contact potential participants on the phone to complete screening
		Screen at baseline data collection events
		Screen members after Sunday service or bible study
	Participant Enrollment	Enroll at baseline data collection events
		Enroll eligible church members after Sunday service or bible study
	Physical Activity and Nutrition Program	Hold weekly physical activity and nutrition workshops in the morning and evening at a local community center
	Health and Wellness Program	Hold monthly health workshops after church service and church activities
	Data Collection	Remind church members in bulletins and during Sunday service
		Hold data collection events after church service and church activities
	Health Information Dissemination	Disseminate health information at church on Sunday
Maintenance	Data Collection	Church announcements and bulletin reminders
		Hold data collection events after church service and church activities

Note. Stages of Change adapted from Prochaska & Velicer (1997).

Table 3.

Number of Churches within Each Stage of Change by the End of the Program

Stage of Change	Number of Churches
Precontemplation	35
Contemplation	10
Preparation	3
Action	5
Maintenance	17

Table 4.

Lessons Learned

Stage of Change	Effective Research Activities	Processes of Change	Why Churches Did Not Move to the Next Stage
Precontemplation	The most effective church recruitment strategies included in-person meeting with faith leaders, word-of-mouth, and church/community events.	Consciousness raising and dramatic relief together proved to be the most effective in moving churches from precontemplation to contemplation.	• Lack of trust in research/academic institutions • Involvement in other church activities and/or other research studies. • Inability to contact and reach faith leaders on the phone • Overwhelmed/burnout from ongoing water crisis
Contemplation	Appointing a health team was easier for some churches if they are already had an existing health team.	Self-reevaluation was important in this stage. If faith leaders viewed health as a priority and had a health team then they were likely to move from contemplation to preparation.	• Inability to identify health team to commit to the project. • Uncertainty about the project and their level of commitment • Health teams were not able to commit due to other commitments • Lack of interest in the programs they were randomly assigned to
Preparation	Successful health team engagement and commitment was instrumental in this stage.	If churches did not successfully implement self-liberation they either stayed in stage or moved back to contemplation.	• Health teams were too occupied or unable to meet which resulted in missed meetings. • Lack of participant recruitment • Scheduling conflicts
Action	Highly motivated health teams were helpful in encouraging participants and ensuring research activities (screening, enrollment, data collection, health program workshops) were seamlessly completed.	Helping relationships were necessary and helped churches (health team and participants) continue in action and reach maintenance.	• Participants were not able or willing to participate in research activities • Lack of communication with health team and conflicting church activities and scheduling was an issue.
Maintenance	Strong communication and collaboration between the research team and health team helped maintained church engagement in research activities.	N/A	N/A