National Heart, Lung, and Blood Institute

Stroke Belt Initiative

Contents

Overview

Principal Investigators and Other Key Staff

Features of the Stroke Belt Initiative Projects

Alabama

Arkansas

Georgia

Indiana

Kentucky

Louisiana

Mississippi

North Carolina

South Carolina

Tennessee

Virginia

Summary:  Lessons Learned

CHES Continuing Education Quiz

Project Accomplishments and Lessons Learned

OVERVIEW

Cerebrovascular disease or stroke is the third leading

cause of death in the United States.  About 500,000 strokes

occur each year, and about 150,000 result in death.  Age-

adjusted stroke deaths are higher in African Americans and

men.  High blood pressure has long been established as the

major risk factor for stroke.  More recently, cigarette

smoking and obesity also have been found to be significant

risk factors for stroke.

Stroke mortality rates differ substantially by State.  In

the 1950s, epidemiologists documented the higher than

average death rate from stroke among people living in the

southeastern United States compared to those living in

other regions of the country.

The National Heart, Lung, and Blood Institute (NHLBI)

examined the 1980 age-adjusted stroke mortality rates by

State.  Eleven States had stroke death rates that were more

than 10 percent higher than the U.S. average:  Alabama,

Arkansas, Georgia, Indiana, Kentucky, Louisiana,

Mississippi, North Carolina, South Carolina, Tennessee, and

Virginia.  Ten of these States are in a contiguous cluster

in the Southeast.  Indiana, the remaining State, is located

on the northern border of the Southeast cluster.  The NHLBI

designated these 11 States as the Stroke Belt.

Similar to the national pattern, African American men and

women in the Stroke Belt have higher death rates than white

men and women.  White men and women in the Stroke Belt also

have a higher stroke death rate than their counterparts in

other regions of the country.  Thus, the higher death rates

in the Stroke Belt cannot be attributed solely to the

higher proportion of African Americans in these States.

In fiscal year (FY) 1991, the NHLBI funded 11 pilot

projects through State health departments to reduce the

risk of stroke in the Stroke Belt.  These 1-year projects

demonstrated the capacity of the health departments to

design and implement approaches to reduce risk factors in

the community. In FY 1994, the NHLBI funded the State

health departments to deliver effective health education

interventions, using the methods and materials from the

pilot projects, to reduce the overall risk of stroke in the

Stroke Belt.

These projects, which lasted 2 to 3 years, fell in one of

four general education/intervention categories:  (1)

interventions in health department clinics and outreach

services, (2) church-based risk factor intervention

programs, (3) community education and intervention

programs, and (4) public education campaigns using the mass

media.

On May 9-10, 1996, the principal investigators and other

key staff members of the Stroke Belt Initiative projects

convened at Morgan State University in Baltimore, Maryland,

to present their accomplishments and lessons learned.  This

document describes the accomplishments of the 11 projects

of the Stroke Belt Initiative.

PRINCIPAL INVESTIGATORS AND OTHER KEY STAFF

Alabama

Robert R. Hafner, III, M.H.A., J.D.

Director, Hypertension Division

Alabama Department of Public Health

434 Monroe Street

Montgomery, AL  36130-3017

Susan Bland

Special Projects Coordinator

Hypertension Division

Alabama Department of Public Health

434 Monroe Street

Montgomery, AL  36130-3017

Arkansas

Barbara Hager, M.P.H.

Director, Division of Health Education and Promotion

Arkansas Department of Health

4815 West Markham Street

Little Rock, AR  72205-3867

Dwight Flanagan

SOS Coordinator

Arkansas Department of Health

4815 West Markham Street

Little Rock, AR  72205-3867

Georgia

Jerry Brown

Program Manager

Georgia Department of Human Resources

2 Peachtree Street, N.E., Room 6-515

Atlanta, GA  30303

Shirley Thomas

Physical Therapy Program Advisor

Stroke and Heart Attack Prevention Program

Georgia Department of Human Resources

2 Peachtree Street, N.E., Room 6-500

Atlanta, GA 30303

Indiana

Roger McClain, M.P.H. (Retired)

Director

Division of Health Education

Indiana State Board of Health

1330 West Michigan Street

P.O. Box 1964

Indianapolis, IN  56206-1964

Teri Sinise, M.P.H.

Chronic Disease

Marion County Health Department

3838 North Rural Street

Indianapolis, IN  46205

Kentucky

Carol Forbes

Administrator

Kentucky Department of Health

275 East Main Street

Frankfort, KY  40621

Louisiana

Shirley Kirkconnell, M.P.H.

Administrator, Adult Services

Louisiana Department of Health and Hospitals

P.O. Box 60630

325 Loyola Avenue

New Orleans, LA  70160

Janice Burchell, R.N., B.S.N.

Nursing Services

Louisiana Department of Health and Hospitals

P.O. Box 60630

325 Loyola Avenue, Room 605

New Orleans, LA  70160

Mississippi

Robert Travnicek, M.D.

District Health Officer

Mississippi State Department of Health

Coastal Plains Public Health District IX

P.O. Box 3749

Gulfport, MS  39505

Patrysha Smith, R.N., B.S.N.

District Hypertension Nurse

Mississippi State Department of Health

Coastal Plains Public Health District IX

P.O. Box 3749

Gulfport, MS  39505

North Carolina

Brenda Motsinger, M.S.

Chief, Disease Prevention Section

Division of Adult Health

North Carolina Department of Health

P.O. Box 27687

Raleigh, NC  27611-7687

South Carolina

Frances Wheeler, Ph.D.

Director

Center for Health Promotion

South Carolina Department of Health and Environmental

  Control

Robert Mills Complex, Box 101106

Columbia, SC  29211

Sally Temple, M.S., R.D.

Director

Division of Cardiovascular Health

Center for Health Promotion

South Carolina Department of Health and Environmental

  Control

2600 Bull Street

Columbia, SC  29201

Tennessee

Connie Pearson, R.N., M.N.

Director, Tobacco Prevention and Control

Tennessee Department of Health

426 5th Avenue, North, 6th Floor

Nashville, TN  37247-5210

Virginia

Ramona Schaeffer, M.S.Ed.

Director

Division of Chronic Disease Control

Virginia Department of Health

Main Street Station

P.O. Box 2448, Room 242

Richmond, VA  23218

Jody Stones, M.Ed.

Health Education Coordinator

Virginia Department of Health

Main Street Station

P.O. Box 2448, Room 242

Richmond, VA  23218

FEATURES OF THE STROKE BELT INITIATIVE PROJECTS

Below is a quick summary of activities of the 11 Stroke

Belt Initiative projects.

--   Automated blood pressure measurement--Georgia and

     Mississippi

--   Coalition building--Arkansas, Georgia, and Tennessee

--   Community health centers--Indiana

--   Contests--Georgia and North Carolina

--   Health care ministries or church teams--Louisiana,

     Tennessee, and Virginia

--   Health fairs--Arkansas and Mississippi

--   Heart-healthy cooking demonstrations--Louisiana,

     Tennessee, and Virginia

--   Hypertension screening or education--Alabama,

     Arkansas, Georgia, Indiana, Kentucky, Louisiana,

     Mississippi, North Carolina, South Carolina,

     Tennessee, and Virginia

--   Nutrition education--Arkansas, Louisiana, North

     Carolina, Tennessee, and Virginia

--   Poster contests--North Carolina

--   Public service announcements--Georgia, North Carolina,

     South Carolina, and Tennessee

--   Quality assurance audits--Alabama

--   Recipes--Louisiana

--   Smoking cessation programs--Indiana, Kentucky,

     Louisiana, Tennessee, and Virginia

--   Training manual development--South Carolina,

     Tennessee, and Virginia

--   Video production--Georgia, Mississippi, Tennessee, and

     Virginia

--   Weight loss programs--Louisiana, Tennessee, and

     Virginia

--   Youth mentors--Tennessee

ALABAMA

The Alabama Department of Public Health (ADPH) used the

Stroke Belt Initiative funding to improve and expand

existing blood pressure detection, treatment, and followup

interventions in health department clinics.  Sixty-three

out of 67 local health departments offered hypertension

management services, including blood pressure monitoring,

free or low-cost medication, and patient counseling and

education.  The health departments offered these services

to Alabama's medically indigent population.  To qualify for

services, patients had to be in a low income category and

have a prescription from a physician that needed to be

renewed every 6 months.  This ensured a joint relationship

between the physicians and the county health departments.

The ADPH employed two strategies to achieve its goal. 

During the pilot phase (phase I), the State began a program

of quality assurance audits to improve the level of care

provided to patients with hypertension in local clinics. 

The quality assurance audits continued during phase II. 

The second strategy, patient recruitment and coordination,

targeted county health departments with low patient loads

to increase patient enrollment.  Thus, more patients

received an improved level of care.

The quality assurance audits were the first line of the

two-pronged strategy.  The State established 17 clinical

standards and 10 administrative/environmental standards for

the care of hypertension.  Quality assurance teams visited

the clinics and reviewed patient charts for compliance with

the 27 standards.  The audit focused on deficiencies, or

the failure to meet standards.  The audit team reviewed 10

randomly selected patient charts for compliance with the 17

clinical standards and then rated the clinic on the 10

administrative/environmental standards.  Therefore, the

maximum number of deficiencies that a clinic could have was

180 (i.e., 10 times 17 clinical standards plus 10

administrative standards).

The county health departments were required to develop a

plan of action to correct any standard that was more than

10 percent deficient (2 or more records out of 10). 

Counties with excessive deficiencies (40 or more) received

followup audits to determine if they had implemented their

corrective plan of action.

The team audited 42 counties during the pilot phase and 41

counties in the first 2 years of phase II.  (Sixty-three

out of 67 counties in the State participated.)  Twenty-two

of the original 42 counties received a second audit during

the first year of phase II.  A comparison of the 22

counties with two audits provided an early indication of

the effect of the project.  In the first audit (FY 1991),

the 22 counties had a total of 547 deficiencies and

averaged 24.9 per county.  The number of deficiencies for

each county ranged from 9 (5 percent) to 52 (24.9 percent).

The 22 counties had a total of 482 deficiencies for an

average of 22 (12.2 percent) deficiencies per county on the

second audit (FY 1994) with deficiencies ranging between 5

(2.8 percent) and 42 (23.3 percent).  Thus, the total

number of deficiencies declined by 65 (11.9 percent).  The

decline in the number of deficiencies did not reach

statistical significance (p=.15) but showed a trend in the

right direction and is possibly of public health

importance.

A review of the deficiencies related to the 17 clinical

standards showed that deficiencies declined by 7.1 percent,

from 510 to 474.  The data showed that two standards

accounted for more than 45 percent of the deficiencies on

both audits.  The two standards were:

--   the patient's blood pressure was below 140/90 mm Hg at

     the last clinic visit; and

--   the patient was scheduled to return to the clinic

     within 2 weeks following the last uncontrolled blood

     pressure reading (140/90 mm Hg or greater).

This information showed the ADPH where to focus its

training and monitoring efforts.  After a midcourse review,

the State health department made some changes to improve

the quality assurance program.  The ADPH lowered the

benchmark for counties needing additional followup, from

greater than 40 deficiencies to greater than 30

deficiencies.

Three counties had excessive deficiencies on the first

audit, and that declined to only one on the second audit. 

However, with a benchmark of greater than 30 deficiencies,

the numbers would have increased to 6 on the first audit

and 7 on the second.  The ADPH made the change because the

purpose of the audits is to improve the level of care and

not endorse the status quo.

Patient recruitment and outreach activities were the second

approach in ADPH's two-tiered strategy.  The project

employed a patient coordinator/recruiter to work with the

targeted county health departments with low patient loads. 

Each year, the project targeted four new counties while

continuing to work with those from previous years.  Annual

data on the results of this effort are available for the

counties targeted during the first 2 years.

To evaluate the effectiveness of the effort, the ADPH

compared the number of new patients registered in the

clinic during the project with the number of new patients

registered in the year before entry in the project.  This

comparison was deemed valid because the trend of new

patients had been stagnant or declining since 1991.

The four counties recruited during the first year of the

project had data for 2 years (FY 1994 and FY 1995) of

recruitment efforts.  A comparison with the number of new

patients in FY 1993 showed that the number of new patients

increased by 46.3 percent in FY 1994 and by 89.4 percent in

FY 1995.  The number of new patients increased each year in

each county.  The overall increase was statistically

significant (p=.05).  The increase from 1993 to 1994 was

not significant (p=.08) whereas the increase from 1993 to

1995 was highly significant (p=.006).

The four counties with only 1 year of recruitment (FY 1995)

used new patients in FY 1994 as the baseline.  The number

of new patients increased by 12.3 percent, which was

statistically significant (p=.02).  As in the above

counties, recruitment increased in each county.  The rate

of increase ranged from 0.7 percent to 59 percent.

The above evidence showed that the number of deficiencies

related to standards for the treatment of high blood

pressure in health departments declined based on the

quality assurance audit.  Decreasing deficiencies should

indicate that patients with high blood pressure are getting

better care in health department clinics.  The patient

recruitment activities brought in more patients to the

hypertension clinics.

ARKANSAS

The Stroke Belt Initiative project in Arkansas was an

expansion of the work started in the pilot phase (phase I). 

During phase I, the Arkansas Department of Health (ADH)

conducted extensive data analysis and surveys to document

the characteristics of the 10 counties with the highest

stroke mortality.  These 10 counties are located in the

Mississippi Delta Region.

The ADH designed the Strike Out Stroke (SOS) project to

form planning groups or coalitions in each of the 10

counties to plan and carry out activities to reduce stroke

risk.  The purpose of the coalition-building strategy was

to involve each community in the decisionmaking process and

to build a long-term commitment to continue the project. 

Each coalition selected the risk factors to reduce or

control and the program's strategies for their communities.

The ADH hired a project coordinator to organize each

county.  This individual met with the health department

administrators in each county to compile a list of

potential coalition members and key community

organizations.  They subsequently convened meetings of the

targeted community leaders to form the planning groups.

The project was successful in forming planning groups in

each of the targeted counties.  Many of the groups were

initially enthusiastic about the SOS project.  The groups

held monthly or quarterly meetings.  However, the planning

groups generally saw the project as the project

coordinator's program and failed to "take ownership" of the

project.  To keep activities going, the project coordinator

joined with established community groups and in some cases

worked with a committed individual.

By far, health fairs were the predominant program activity

sponsored in the targeted counties.  About 9,000 residents

participated in these events, and nurses from the local

health departments and hospitals screened about 700 people

for high blood pressure.  The project coordinator played an

active role in organizing many of the health fairs.  Many

counties also directed activities toward middle school

students.  Teachers taught special lessons on stroke and

its risk factors.  Stroke survivors spoke in some classes

and answered questions from students.  Other activities

included church-based blood pressure screening, a nutrition

workshop, and an interactive television program on stroke.

The project staff believes that the project was successful

in educating people in these high-risk counties about the

risks of stroke.  However, it may have been more prudent to

target fewer counties to ensure penetration and adoption of

the risk reduction activities.  It is well known that

coalitions take time to develop.  Thus, by working with one

or two counties, the project coordinator may have been able

to spend more time developing the planning groups more

fully and facilitating a shared commitment to the goals of

the project.

GEORGIA

The Georgia Department of Human Resources conducted a mass

media campaign to encourage persons who were aware of their

hypertension to stay on their treatments.  The centerpiece

of the campaign was the successful Strike Out Stroke (SOS)

campaign, which began with the Atlanta Braves professional

baseball team during phase I of the Stroke Belt Initiative.

The campaign included public service announcements (PSAs)

and live coverage on WTBS-TV as well as hypertension

screening and other activities at the stadium during

selected games.  The project also placed a major emphasis

on developing a working relationship with smaller

television stations outside Atlanta and with the network of

African American gospel and talk radio stations.  The print

campaign, which targeted small town newspapers, included

feature articles, health reports, human interest stories,

and letters to the editor related to stroke.

In phase II, the SOS campaign with the Atlanta Braves faced

an immediate challenge to its implementation.  The players'

labor strike at the beginning of the 1994 season made it

impossible to start the campaign.  Following the strike,

the Braves' management focused on baseball-related issues

for the remainder of the shortened season.  They also were

not interested in rekindling the campaign during the 1995

and 1996 seasons.  Thus, the strike of 1994 ended this

highly visible campaign that served the greater Atlanta

area during the three previous seasons.

With the SOS campaign on hold, the project focused on the

other parts of the mass media campaign.  The project hired

a communications firm to help develop and promote the

campaign.  The firm conducted a training and motivational

meeting for local health department staff and

representatives from the targeted local media outlets. 

Following the meeting, the staff and media representatives

initiated the campaign.  The purpose of this activity was

to develop a core group of media representatives from

different areas of the State who would rely on the health

department to provide them with educational messages on

heart disease and stroke.

The project installed automated equipment in State office

buildings to monitor blood pressure, pulse rate, and

weight.  In the first 18 months, the automated machines

recorded 10,457 blood pressures, an average of nearly 20

measurements per day including weekends.  The machines also

made 16,408 weight measurements during this period.

The project joined the Georgia Stroke Belt Consortium, a

coalition of health and medical organizations formed to

promote interventions to reduce the risk of stroke in

Georgia.  Other members include the Association of Black

Cardiologists, the Medical College of Georgia, the Centers

for Disease Control and Prevention, the local affiliate of

the American Heart Association, the Morehouse School of

Medicine, and Stop Stroke.  By participating in this

coalition, the Georgia Stroke Belt project became involved

in the development of easy-to-read materials and in

screenings at churches, community centers, and State office

buildings.

The project also held SOS contests in churches throughout

the State.  Each church had to present a skit, sing a song,

or perform another activity.  The activity had to present a

stroke prevention message, to be intergenerational, and to

last 3 to 5 minutes.  The top three winners performed at

the 1995 Southeastern Regional High Blood Pressure

Conference.  The project produced a video of the winning

skit, which is being used in senior center nutrition sites

and church groups throughout Georgia.

INDIANA

The Indiana State Department of Health expanded its

emphasis in the pilot phase of the Stroke Belt Initiative

project from hypertension control alone to include smoking

cessation.  This 2-year project targeted the low-income

populations of two health centers and their adjacent

housing projects in Indianapolis.

Both the Citizen's Health Center and the People's Health

Center serve low-income populations.  Patients at Citizen's

are predominantly African American, whereas 80 percent of

those at People's are white.  Each health center hired a

health educator to conduct the program.  The interventions

focused on community awareness and education and individual

counseling by a health educator.

The health educators frequently made presentations and

conducted risk factor screenings for the residents of the

targeted housing projects and the community.  The

presentations provided information on risk factors for

heart disease and stroke and the services available at the

health centers to prevent or control risk factors.  The

screenings identified potential patients for the

intervention programs at the centers.

Some patients who entered the counseling and followup

program were referred by a doctor or other health care

provider; others were self-referred.  At the initial

contact, the health educator explained the program and

asked the patient to agree to stop smoking or to make

lifestyle changes to help control their high blood

pressure.  Patients who agreed to participate completed a

health risk appraisal and intake form.  The health educator

also provided basic education about the risk factors for

stroke and asked the patient to set a behavior change goal.

Most interventions lasted 3 months and consisted of a

combination of personal sessions with the health educator

and followup and counseling on the telephone.  Followup

interviews were conducted at 6, 9, and 12 months after the

intervention was completed (i.e., made significant progress

toward the goal they selected or decided not to see the

health educator any more) to measure progress and to

evaluate the services provided.

The health educators received 1,125 referrals--575 at the

Citizen's Health Center and 550 at the People's Health

Center.  At Citizen's, 210 patients (36.5 percent) enrolled

in the program; 235 (42.7 percent) enrolled at People's. 

Most of the enrollees (306, or 68.8 percent) were smokers--

143 (68.1 percent) at Citizen's and 163 (69.4 percent) at

People's.

The smoking cessation component provided a nicotine

replacement patch and behavior modification counseling to

participants who wanted to quit smoking.  The patches were

provided free of charge.  A physician referral and

prescription were needed to get the patches.  Patients

completed a preassessment and were asked to monitor their

smoking behavior before starting the patches so they could

develop a plan to handle the psychological challenges of

smoking cessation.  Patients were asked to return either

once or twice a month to get their next supply of patches

and to meet with the health educator.

The health educators conducted the 1-, 3-, and 6-month

postintervention surveys to identify the quitters and

nonquitters.  By the end of the project, only 107 (35

percent) of the enrolled smokers had been in the program

long enough for a 6-month followup.  Of the 107 eligible

participants, 13 (12.1 percent) were not smoking.  The quit

rates were similar at both the People's Health Center (11.1

percent) and the Citizen's Health Center (12.9 percent).

The health educators found a marked difference in the

number of patches used by quitters and nonquitters. 

Quitters used 90 patches (the full course of treatment)

whereas the mean number of patches used by nonquitters was

21 (less than 1 month's worth of patches).  Most of the

respondents (88 percent) said that the sessions with the

health educator were extremely helpful.

Health educators also worked with patients with

hypertension to set goals for lifestyle changes.  They met

with the patients during regular office visits with their

primary care provider.  They also followed up on missed

office visits and worked with the patients to solve

adherence problems.

The project developed an electronic database for patient

tracking and evaluation.  The database contained baseline

information from the intake form and the health risk

appraisal, data from sessions with the health educators,

and periodic measures of risk factor control status.

Although the project provided a valuable service to low-

income populations in community health center settings, two

problems limited the full impact.  First, 2 years were not

enough time to organize, conduct, and evaluate the program. 

It took time to get the project started.  Securing and

maintaining staff was difficult.  Once the hiring and

orientation of staff were completed, it took more time to

educate the health center clinicians about the program and

build enough confidence for them to refer patients. 

Indeed, referrals started slowly and increased steadily to

peak near the end of the project.  Thus, many patients were

not in the program long enough to complete the intervention

and reach the appropriate followup intervals.

Second, data collection was a major problem.  Although the

project included an adequate data collection system, two

factors limited the actual data recording.  Many of the

patients refused to complete the intake form and the health

risk appraisal.  The health educators, when pressed for

time, frequently chose not to collect the necessary data in

favor of providing education at a teachable moment to meet

the immediate needs of the patient.  These factors severely

limited the number of completed and "matched" records for

analysis.  Fewer than half the participants had matching

baseline data and risk factor status data at the

appropriate intervals.

Despite these problems, if programs like this can gain

sufficient support from center administrators and

clinicians, they can be integrated into the basic services

of the center and are likely to be sustained.  One year

after the cessation of funding from the Stroke Belt

Initiative, the project at the Citizen's Health Center

remains in place.  The project and the health educator are

supported through the Center's operating budget.

KENTUCKY

The Stroke Belt Initiative project of the Kentucky

Department of Health Services (KDHS) included three

components:

--   an inservice training program on the role of community

     health nurses in cardiovascular disease;

--   a smoking cessation program for local health

     department staff, especially nurses; and

--   extended followup to smokers who agreed to quit and

     received a prescription for nicotine patches from the

     health department.

The State health department employs more than 800 nurses at

153 delivery sites.  The training program--developed during

phase I of the Stroke Belt Initiative project--targeted

public health nurses who did not receive training during

the pilot phase.  This self-study package consists of four

modules--two on hypertension, one on smoking cessation, and

one on obesity.  The University of Kentucky College of

Nursing approved the course for continuing education

credits.  The nurses also attended a 6-hour course on how

to give effective smoking cessation advice to patients.

The project also conducted smoking cessation classes in

local health departments to reduce the number of staff who

smoke.  The purpose was to increase the number of nurses

and other staff who would routinely interact with clinic

patients who smoke.  Staff members who smoked were less

likely to interact with smoking patients.

The health department received a free allotment of nicotine

transdermal patches for use in an organized smoking

cessation program for low-income smokers.  The project

devised a program of counseling and followup using public

health nurses.  To participate in the free nicotine patch

program, smokers had to attend a support group.

Public health nurses conducted smoking cessation classes

and support groups at local health departments.  They also

followed up these smokers beginning on the date that the

patch prescription expired and at the 2-week, 1-month, and

3-month intervals.  The purpose of the followup was to

determine their smoking status and to encourage those who

resumed smoking to quit again.  Of the 828 participants,

340 (41.1 percent) completed the nicotine patch therapy. 

Records indicate that 248 participants (30 percent) quit

smoking for at least 1 day.  At the 3-month followup, 132

(15.9 percent) of the total number of participants were

still not smoking.

LOUISIANA

The Louisiana Department of Health and Hospitals (LDHH) has

worked with churches for a number of years.  During phase I

of the Stroke Belt Initiative project, the LDHH established

high blood pressure prevention and control programs in 26

churches in the New Orleans area.  The interventions

consisted primarily of awareness and education activities,

blood pressure screenings and followup, and heart-healthy

cooking demonstrations.  Some churches also conducted

weight loss and smoking cessation sessions.

The phase II project was a 2-year effort to expand the

program to churches in other areas of the State.  The LDHH

subcontracted with the National Kidney Foundation of

Louisiana and the Natchitoches Outpatient Clinic to achieve

this goal.  The latter subcontractor concentrated its

efforts in northern Louisiana.  The subcontractors hired

consultants from the targeted communities to recruit

churches and help them organize and establish programs.

The consultants followed the procedure established in phase

I for recruiting churches.  In phase I, the project tried

unsuccessfully to recruit churches through the State

affiliates of national organization of churches. While the

organization was supportive of the project, this did not 

result in the recruitment of any churches.  Therefore, the

project had to recruit churches individually through their

clergy.

Thus, in phase II, the first official contact with the

church was always made through the clergy because they

usually determined whether the church would participate or

not.  However, the consultants frequently used other

contacts within a church to get an introduction and initial

meeting with the clergy.  At the meeting with the clergy,

the consultants explained the purpose and nature of the

project, the benefits to the church, the support that the

project would provide, and the responsibilities of the

church.  After the overview, they asked the clergy to

commit the church to participate in the program.

Once a church agreed to participate, the first step was to

establish a health care ministry (HCM), an organization of

the church responsible for organizing and implementing the

health programs in the church.  The clergy appointed the

coordinator of the HCM.  The clergy also introduced the

program to the congregation during regular services and

asked for volunteers to serve on the HCM.  In some

churches, the consultant was allowed to address the

congregations to promote the program.

The consultant trained the members of the HCM.  The 4-hour

training session consisted of an orientation to the

programs, risk factors for heart disease and stroke,

referral and followup techniques, and medical record

systems.  The members also attended a course to become

certified in blood pressure measurement.

The HCMs planned and carried out program activities in

their churches.  The consultant assisted the HCMs in

planning and provided equipment for program events.  The

consultant was generally onsite for these events to answer

questions and solve any problems.  They also recruited

health professionals to conduct educational sessions on

nutrition, smoking cessation, exercise, and other topics.

Thirty churches agreed to participate in the program and

established HCMs.  The HCMs from 22 churches (156 members)

attended the 4-hour training workshop and completed the

blood pressure measurement course.  Scheduling the training

sessions was often a challenge.  There were many

cancellations, often on the night before the scheduled

event.  The consultants had to maintain flexibility and

work with the HCM to reschedule the training.  Still, eight

of the churches that agreed to participate did not attend a

training workshop.

The HCMs at 16 churches conducted blood pressure screenings

and other program events.  The consultant supervised the

initial blood pressure screening event at each church. 

Many of the churches reported a large attendance at their

first screening and educational seminars.  The remaining

six churches with trained HCMs did not conduct a program

event.  Two churches decided not to conduct a screening

because of the fear of liability issues.  Another church

decided that it was too much work.  The three other

churches did not schedule an event but indicated that they

planned to do so.

The project contracted with a nutritionist to teach church

members to prepare heart-healthy meals.  Several churches

identified the members whom their congregations considered

to be the best cooks.  The nutritionist worked with these

people to modify their favorite foods into heart-healthy

dishes.  They served these heart-healthy selections to the

congregations at food events held by the churches.  Church

members were always eager to try foods prepared by their

best cooks.  The members were not told that the food was

heart-healthy until after they tried the food and said they

liked it.

The nutritionist also prepared recipes of all the heart-

healthy dishes served in the churches.  The LDHH reproduced

the recipes in a cookbook, Soul Food Cooking--The Heart-

Healthy Way.  The consultants distributed the cookbook to

the churches so that all members would have access to the

recipes.

The consultants kept a log of the dates of their initial

visits with the clergy, when the clergy committed the

church to participate, the training of the members of the

HCM, and each program event.  Analysis of these logs showed

that it took an average of 46.4 weeks (10.8 months) from

the initial visit with the clergy to the first program

event.  The times ranged from 2.6 weeks to almost 2 years

(22.2 months).  However, eliminating the last three

churches that took 18.8, 19.0, and 22.2 months reduced the

average time to 8.3 months.  The patience and persistence

of the consultants in getting all the churches to

participate was responsible for the longer time periods. 

Thus, the process of recruiting churches and moving them

into action takes time.  The consultants continue to work

with three other churches to implement programs.

The consultants reported that keeping the HCM members

motivated and committed to the screenings and other

activities was difficult in many of the churches.  They

attributed the problem primarily to the leadership of the

coordinator.  HCMs with strong coordinators tended to

maintain a consistent flow of program activities whereas

those with weak leaders held activities much less

frequently.  Thus, it is very important to select a strong

coordinator in the beginning because the clergy is

generally unwilling to replace an ineffective coordinator.

The coordinators met with other key HCM members to discuss

their experiences and share information between the

churches.  Difficulties in getting HCM members to

participate actively in planning and carrying out program

activities were a common theme.  Some coordinators stated

that sometimes they had to conduct screenings by

themselves.

The churches agreed to submit monthly tally sheets

summarizing their screenings and other activities.  Some

churches submitted these reports, but most did not, even

after followup telephone calls and letters from the

consultant.

Finally, after the conclusion of the project, many of the

churches continue to hold screenings and other program

activities.  Three churches that did not hold an event

during the project period indicate that they still plan to

conduct screenings.  This shows that the benefits of

programs to prevent heart disease and stroke are evident to

the leadership of many churches.  Projects like the Stroke

Belt Initiative provide the stimulus for them to get

started.

MISSISSIPPI

The Mississippi State Department of Health (MSDH) proposed

a new initiative for phase II of the Stroke Belt Initiative

project.  A hypertension education and intervention program

targeted high-risk populations--those with high blood

pressure and those at risk of getting high blood pressure--

in the State's six most southern counties.  These counties

have a total population of 378,505, of which 68,367 (18

percent) are African American.  The poverty rate among

African Americans in these counties is especially high--41

percent compared to 16 percent among whites.  The counties

are also classified as medically underserved.

To reach the high-risk population in the targeted counties,

the MSDH developed its program around automated blood

pressure measurement (ABPM) machines.  The machines

provided the targeted communities with a free method of

checking blood pressure.  Along with each machine was a

toll-free telephone number for counseling and referrals. 

Two machines were initially placed in March 1994 in each

county--one in the county courthouse and the other in the

local public health department, two areas used by the high-

risk populations.

The ABPM machines displayed a message instructing persons

with elevated blood pressure readings to see a doctor.  It

further instructed those without a source of care or

resources to pay for care to call a toll-free number.  The

project nurse answered the toll-free calls and helped

patients find a source of care.  The nurse also arranged

for drugs, nutrition counseling, and social services as

needed.

The initial 12 automated machines recorded about 200,000

blood pressure readings from April 1994 through June 1996. 

The monthly total ranged from 4,150 to 10,608.  Machine

usage was greatest during May through September each year. 

The lowest usage occurred during December, January, and

April.

Although the communities responded immediately to the

automated machines, usage of the toll-free telephone number

was less dramatic.  After several months of operation, the

number of calls remained at 1 or 2 per month. The project

nurse, who also had experience in marketing, visited

several of the sites to observe the usage and talk with

some of the users.  She discovered that many users did not

see the instructions to call the hotline and others thought

that they would have to pay for the services.

To correct this, the staff designed a new sticker and

scorecard (for users to record their blood pressure

reading).  The new sticker included the following caption,

"Free Call, Free Help . . . A Registered Nurse Is at Your

Fingertips!"  The sticker was printed with red letters on a

yellow background to make it more noticeable.  The new

scorecard contained the same message and design.  The new

stickers and scorecards were placed on all the machines. 

The number of calls to the hotline increased to 44 after 3

months and continued to increase thereafter.

The automated machines also attracted the attention of

private health care facilities.  A regional medical center

purchased three machines for the project.  They placed one

machine in the emergency department and the other two in

the community.  In 9 months of operation, these three

machines recorded an additional 54,208 blood pressures. 

Thus, the new machines combined with the initial 12

machines recorded a total of 249,644 readings.  This

positive experience persuaded several other medical centers

and businesses to make a commitment to purchase additional

machines and link them to the project.  At the end of the

project, 20 machines were operating in the six counties.

To complement the automated screening, the project

maintains an aggressive traditional blood pressure

screening, counseling, and referral program.  Trained teams

conduct screenings in churches, community centers, civic

organizations, health fairs, schools, banks and other

businesses, and other community gatherings.  Participants

with elevated readings receive counseling and referrals. 

Those without a source of care or the ability to pay for

their health care are given the toll-free telephone number

and instructed to call it.

Since fall 1994, the onsite screening program has reached

more than 5,000 people.  Data analyzed on the first 1,594

participants in the onsite screenings showed that 35.9

percent had blood pressure readings greater than 140/90 mm

Hg.  The rate for men was 41.2 percent compared to 32.6

percent for women.  As expected, the proportion of elevated

readings was directly related to age and range from 13

percent in persons age 18 to 34 to 64.3 percent in those

age 65 and older.  Of the 572 persons with high readings,

227 (39.7 percent) knew they had high blood pressure and

were taking medication.  Conversely, 345 (60.3 percent)

represented potentially new cases of high blood pressure.

In addition, the MSDH hypertension program promoted primary

prevention and targeted elementary school children.  The

staff wrote a one-act play, The Angry Heart, to promote

healthy lifestyles.  The characters of the play represent

body organs and tissue--Heart, Lung, Brain, Muscle, and

Stomach.  The play is usually delivered in the auditorium

before the entire student body.  Teachers serve as

impromptu actors, which makes the play entertaining as well

as informative.  Following the play, the students complete

a healthy heart crossword puzzle based on the information

presented in the play.  During the 1995-96 school year,

9,268 children viewed a live enactment of the play.  A

videotape of the play is also available to the schools, and

the play was selected for presentation at the Prevention

'96 conference in Dallas.

NORTH CAROLINA

The North Carolina Department of Environment, Health, and

Natural Resources continued to focus its Stroke Belt

Initiative project on high blood pressure in African

Americans.  The project combined a mass media campaign with

community outreach activities and professional education.

The mass media campaign was a statewide effort.  Although

it included the major television and newspaper outlets in

North Carolina, the primary targets were radio stations and

newspapers that served predominantly or large African

American audiences.  A major emphasis was placed on

reaching the network of African American gospel radio

stations.

The project formed core groups of media representatives and

local community leaders to develop culturally appropriate

educational messages.  Staff members, along with health

care professionals and other volunteers, were trained to

give interviews on hypertension to local television, radio,

and print media in the promotion of the media campaign. 

Accordingly, the campaign has received wide and continuous

coverage in the major and targeted media.

The community outreach activities included the

dissemination of easy-to-read educational materials, blood

pressure screenings, poster and letter-writing contests,

activities with churches, and risk factor reduction classes

in community centers.  They compiled the educational

materials into a resource guide, which was distributed to

health agencies across the State.  The agencies could order

the materials in the guide from the project.

A poster contest among high school students was a major

success.  The theme of the contest was "High Blood Pressure

Control Is a Family Affair."  The contest involved ninth-

and tenth-grade students in the Raleigh area.  The staff

promoted the contest throughout local school districts, but

only three schools agreed to participate.  Project staff

worked with the teachers in these schools to provide

students with the background information to prepare fact-

based posters related to the theme.  A lesson plan focusing

on hypertension was taught to 727 students in ninth- and

tenth-grade health education and art classes.

The students designed and submitted 500 posters.  The

projects established a seven-person committee to judge the

posters.  The committee included teachers and staff members

from the county and State health departments.  The posters

were judged on the following criteria:  appropriateness,

originality, creativity, and neatness.  The winners were

determined by the highest scores.  The judges chose first-,

second-, and third-place winners as well as four honorable

mentions.  Most of the posters (350, or 70 percent) came

from one school as did the three winners.

The project held an award ceremony to honor the winners and

all students who participated in the poster contest.  The

top three winners were awarded plaques and gift

certificates ($75 for first place, $50 for second place,

and $25 for third place).  The honorable mentions received

plaques.  Local businesses donated gifts to supplement

these prizes.  Jonathan B. Howes, secretary of health

for the State of North Carolina, presided over the

ceremony, and Dr. Claude Lenfant, NHLBI director, presented

the awards.  All participating students, teachers, and

schools received certificates.

The winning posters were displayed across the State in

public buildings and as PSAs on television and in local

newspapers.  Some radio stations used the wording for short

PSAs as well.  In another positive development, teachers

from the two schools that submitted fewer posters and did

not have a winner promised to do a better job next time to

make their schools more competitive.  Principals and

teachers from nonparticipating schools also vowed to

participate in the next contest.

The project collaborated with African American ministers to

select appropriate educational materials for distribution

to churches during the month of May for High Blood Pressure

Sunday activities.  The most popular item was a fan--

developed during phase I of the project--with a health

message printed on one side.  Local health departments

worked with local morticians to get the fans produced at no

cost.  The project compiled the selected materials into a

High Blood Pressure Sunday kit, which was distributed to

African American churches across North Carolina.

The project also worked with African American churches to

sponsor letter-writing contests for elementary school

children.  The children wrote letters to parents or other

significant adults asking them to control their blood

pressure or change a high-risk behavior, such as smoking

cigarettes or eating high-fat foods.

Local health departments conducted high blood pressure

screenings in local convenience stores and fast food

restaurants between 5 a.m. and 8 a.m.  These screenings

targeted African American men who were waiting for

transportation to their jobs.  At first, many were

reluctant to participate, but they became more responsive

to screening after the staff returned to follow up on them. 

The staff also was able to obtain additional information on

diet and lifestyle behaviors.  Based on this limited

experience, convenience stores and fast food restaurants

have potential as screening sites for young African

American males and others who do not use local health

department services and do not have a regular source of

care.

Other county health departments set up nine weekly

educational sessions in four community centers and housing

developments that included classes on stress management,

exercise, and nutrition.  These sites were chosen to

improve access to these educational opportunities for low-

income individuals who ordinarily would not be able to take

advantage of such classes in other settings.

SOUTH CAROLINA

South Carolina has the highest age-adjusted stroke

mortality rate in the United States.  In 1994, the stroke

mortality rate in South Carolina was 31.8 per 100,000 for

whites and 65.4 per 100,000 for African Americans.  Because

of this disparity, the Center for Health Promotion of the

South Carolina Department of Health and Environmental

Control chose to focus its efforts in the African American

community.

The goal for the South Carolina Strike Out Stroke (SC SOS)

project was to improve hypertension awareness, treatment,

and control among African Americans in the State.  The

project sought to increase the number of community-based

programs to control high blood pressure among African

Americans.

The Center for Health Promotion chose to work through three

channels within the African American community:  churches,

the media, and beauty shops and barbershops.  This

capacity-building project included the development of

training manuals for health professionals and lay

volunteers to develop stroke prevention initiatives within

each channel.

The church-based training manual, Guidelines for Working

With Black Churches, was developed to train professionals

to work with the faith community to implement stroke

prevention initiatives.  This manual includes many of the

do's and don'ts for different denominations within a

community.  Training for professionals on the concepts

presented in the manual was completed in a variety of

settings including the Minority Health Issues Conference,

which draws a variety of professionals statewide who are

interested in making a difference in the health status of

African Americans in South Carolina.

Using the training manual developed for lay volunteers,

Guidelines for African American Church-Based Health

Promotion, the process of identifying and training local

lay volunteers began.  This how-to manual employs a step-

by-step approach to developing health activities within the

church, using trained area health professionals as

resources.  These volunteers were trained to start or

expand health promotion efforts in the church.  Although

these health promotion efforts included stroke prevention,

the manual included a generic process on how to initiate

health promotion efforts, which was useful in implementing

a variety of health-related issues.

Reaching African Americans Through Media Channels stresses

the importance of the African American media as an avenue

to get positive cues and messages out to the community. 

This manual was designed for professionals either who do

not know how to access this useful channel within their

communities or who are unfamiliar with the availability of

specific media resources for African Americans.  Training

using this manual was offered to health professionals

through conferences that attract professionals statewide.

Health promotion staff members were trained statewide to

use this important communication avenue.  This activity 

continues beyond the contracted period of performance.  The

manual provides specific information on stroke and

cardiovascular health, including camera-ready articles,

PSAs, and additional resources.  One media component

addresses radio stations and newspapers owned and operated

by African Americans.  The media were encouraged to use the

materials as they are or in developing health education

segments.  Linking local African American media personnel

with local health professionals is under way.

The project developed two manuals on the use of beauty

shops and barbershops as a resource for spreading the word

about stroke prevention.  One is a how-to booklet for shop

owners; the other is a manual for health professionals. 

Information is included on State and local representatives

of beauty shop and barbershop associations and hair care

professionals as contact persons in every region in South

Carolina.

To introduce the concept of SOS activities, the staff

continues to make presentations to statewide organizations

about the availability of training for health advocates. 

To maximize the number of people who can take ideas back to

their communities, the SOS coordinator has given

presentations at State conventions, conferences, and

special group meetings.  The most recent presentations were

made to organizations such as the Palmetto State Barbers

Association, the South Carolina African Methodist Church

Youth Convention, and the State Baptist Conference.

SOS has worked to maximize the impact of the project by

coordinating with other projects that are working on risk

factors for stroke, such as diabetes and smoking.  SOS is

working with the African American Initiative on Diabetes

through the efforts of the Diabetes Control Program within

the center.  The project also is working with the American

Cancer Society on the Beauty Shop Health Advocate Project.

The framework of the project was capacity-building of the

community--among both health professionals and lay

volunteers.  This framework has provided opportunities to

link with a variety of organizations statewide that are

interested in reducing disease risks among African

Americans.  The most critical outcome of this project has

been that, because it was based on building capacity, the

life and impact of the project will live well beyond the

funding.

TENNESSEE

The Tennessee Department of Health (TDH) continued the

efforts started in phase I of the Stroke Belt Initiative

project with the metropolitan counties with the largest

African American populations.  Nearly 70 percent of all

African Americans in the State live in these three

counties--Shelby (Memphis), Davidson (Nashville), and

Hamilton (Chattanooga).

The TDH coordinated services of three independent but

related projects managed by the Chattanooga-Hamilton County

Health Department, the Metropolitan-Davidson County Health

Department, and the Preventing African American Strokes

From the Use of Tobacco (PAAST, Inc.) Coalition.  The goal

of the project was to organize and enable African American

communities in Tennessee to develop and carry out

prevention and control programs targeted at the risk

factors of heart disease and stroke.

In Memphis, the PAAST Coalition, formed during phase I,

continued to provide leadership and community involvement

to the project.  A coalition-building workshop offered

coalition members an opportunity to learn about

collaboration strategies and issues regarding working with

others in the community.  The members wrote two training

manuals--Eating Healthy for Spiritual Well-Being and Stop

Smoking With Spiritual Power--for use in church-based

programs.

The PAAST Coalition also recruited and worked with five

African American churches to develop and carry out programs

for smoking cessation as well as nutrition education and

weight management for their congregations.  The coalition

worked with the clergy and other church members to

establish a health promotion team in each participating

church.  The teams were responsible for planning,

conducting, and monitoring program activities.  The

coalition also arranged a training program for each of the

health promotion teams.  The training included a team-

building workshop for skills development in smoking

cessation, healthy eating, and weight reduction

interventions.

Memphis also formed a youth mentor program to carry out

smoking education, prevention, and cessation activities for

adults and youths.  Twenty teenagers age 15 to 18 were

recruited and trained as youth mentors.  The top three

reasons given for joining the youth mentor team were

helping others, informing people of the dangers of smoking,

and helping friends and other people stop smoking.

The youth mentors received intensive training to prepare

them as smoking cessation facilitators.  The training

focused on group facilitation, resistance skills, health

behaviors and addiction, and the role of the African

American family in health promotion and disease prevention.

The youth mentors produced a series of videos including a

play called "It's a Killer," a PSA called "Is It Worth It?"

and a document on the hazards of tobacco use.  The Memphis

City Schools reviewed these videos and decided to include

them in their video library.  They also conducted smoking

cessation classes for adults and teenagers and made

presentations on tobacco use to youth groups and adult

organizations.

In Nashville, the local health department recruited and

worked with African American churches to set up programs

for smoking cessation, hypertension control, and weight

reduction.  During the first year, the staff targeted five

churches to implement the project.  Two other churches were

added in the second year.  In each church, the clergy

appointed health promotion teams to plan and implement

project activities.  Each team included a coordinator, also

appointed by the clergy.

The project staff trained the church teams and worked

closely with the church teams, especially during the early

stages, to plan project activities.  This included

assisting with the needs surveys of church members and

providing ideas for kickoff or initial projects.  The

project staff also attended team meetings when possible and

provided encouragement to the coordinators and the members.

The church teams demonstrated that they could maintain an

ongoing program within their congregations.  They readily

used existing education and risk factor reduction programs

from voluntary health and other community agencies.  The

teams also were very creative in devising other ways to

communicate health messages to their congregations.

Innovative activities developed by the teams included a

children's letter-writing campaign, production of a play

about risk factors, and food-tasting demonstrations.  The

letter-writing campaign was both a contest and a health

intervention.  Children from the churches wrote letters

asking a significant adult in their life to quit smoking. 

Each child followed up at 3, 6, and 12 months to see if the

significant adult was still smoking.  The planners used the

contest format to encourage maximum participation by the

children and cooperation from the significant adults. A

panel of church members and health department staff judged

each of the letters and selected a winner for each age (age

6 to 11).  The contest winners each received $50 and a

certificate at a special awards ceremony.

One team decided to use drama to communicate health

messages to its congregation.  They asked a local

playwright to write a play depicting what a typical African

American family might experience when confronted with the

need to lower its risk of heart disease and stroke.  High

school and college students performed the play during

church services, and it was videotaped for future use when

the actors were not available.

Food-tasting events played a major role in building support

for and sustaining the program.  At a meeting of the clergy

from participating churches, the team from the host church

prepared and served a heart-healthy meal.  The clergy

learned how the food was prepared only after they finished

eating and acknowledged how good the food tasted.  The

taste of the food so impressed the clergy that most

included messages about heart-healthy eating and the

program in their Sunday sermons.  Many of the teams also

conducted food-tasting events for their congregations,

using the same strategy.

The Nashville project succeeded in recruiting churches,

training teams among the congregations to carry out program

activities, moving the teams to action, and sustaining

their actions over time.  The staff kept logs with the

dates of the completion of each milestone in each church. 

Analysis of these data showed that it took an average of

11.6 weeks (or 2.7 months) from the initial contact with

the church to the point when the pastor commits the church

to participate.  It took another 20.4 weeks (or 4.8 months)

from the commitment to participate to the appointment and

training of the church team.  The first program event took

place, on average, 10 weeks (or 2.3 months) after training

the church team.  Thus, it takes about 42 weeks (or 10

months) from the initial contact with the church to the

first program event.

The project in Chattanooga also attempted to work with

churches, but initial efforts did not meet with much

success.  The project staff sought the counsel of the

Nashville staff.  After several discussions,

representatives from Nashville visited Chattanooga to meet

with local church leaders.  The delegation from Nashville

consisted of clergy members, members of the church teams,

and staff.  Following the meeting, churches in Chattanooga

began implementing the program.  Overall, activities in

these churches continue beyond the official end of the

project.

VIRGINIA

The Stroke Belt project in Virginia is a unique

collaboration between the Virginia Department of Health

(VDH) and the Baptist General Convention (BGC) of Virginia

to promote stroke risk reduction programs in African

American churches.  This 2-year project expanded the

activities of the Virginia Cardiovascular Risk Reduction

(VCRR) project to work with the BGC.  The VCRR project

conducts statewide hypertension detection and control

programs.

The BGC is an association of more than 1,000 independent

African American churches located throughout the

Commonwealth of Virginia.  These churches have more than

200,000 members.  The BGC health care ministry (HCM) has a

full-time director who is an ordained member of the clergy. 

The BGC-HCM has a history of working with health agencies

to implement programs in member churches.

The VDH and the BGC-HCM agreed to focus on three risk

factors--high blood pressure, smoking, and obesity.  For

more than 10 years, the VDH and the BGC-HCM have

collaborated to conduct blood pressure screening in BGC

member churches.

The director of the BGC-HCM recruited the churches, trained

the volunteers, and supported their efforts.  However, the

expanded project required more than one person to

coordinate and support the activities of local churches. 

Thus, the VDH and the BGC-HCM established a system where

regional coordinators worked with the churches in their

area.  The BGC-HCM director recruited 10 volunteer

coordinators from area churches.

The clergy at the regional coordinators' home churches

pledged to support the efforts of the coordinator and to

make their church the model for the region.  The

responsibilities of the regional coordinators were to

recruit churches, assist the churches in organizing to

carry out the program, train church team members, and

deliver the programs and materials selected for

implementation.

To facilitate the high blood pressure component, a group

consisting of VDH staff, the BGC-HCM director, three

regional coordinators, four blood pressure measurement

(BPM) specialists, and one clergy member developed two

training manuals and a brochure.  They designed one manual

to train trainers and the other to certify BPM specialists

(students).  A brochure called Stroke Busters was an

educational piece for the congregation.

Next, the VDH staff and the BGC-HCM director trained the 10

regional coordinators.  While supporting the churches

already involved in hypertension detection, the regional

coordinators also recruited new churches and helped them

set up HCMs.  This increased the number of participating

churches to 100.  The coordinators certified 100 new

specialists and recertified 50 specialists.  Seventy-nine

additional BPM specialists did not require recertification.

The certified specialists measured the blood pressures of

3,723 church members in FY 1995.  Elevated readings were

found in 265 people who were not under the care of a

physician for high blood pressure.  Referrals were made for

282 individuals with elevated readings who were already

under treatment for hypertension.

The VDH and the BGC-HCM selected the smoking cessation

program from Clergy United for the Redemption of East

Baltimore (CURE)--an NHLBI-funded study.  The American Lung

Association (the local sponsor of the CURE Program) trained

the regional coordinators to implement the CURE smoking

cessation program.  The BGC-HCM director and the regional

coordinators revised the CURE materials to be more suitable

to the BGC and renamed the program "Thank God I'm Free"

(TGIF).  The materials included a TGIF trainer's manual, a

guide for church group leaders, a devotional for group

participants, a program tracking form, an intake form for

participants, an information form for group leaders, T-

shirts, and coffee mugs.

The regional coordinators conducted TGIF training for group

leaders in seven regions.  Although it was not difficult to

get volunteers to participate in the group leader

trainings, it was hard to get church members to attend the

classes.  The volunteers attributed the problem to the

employment of many church members in the tobacco industry. 

Because these persons perceived the program as a threat to

their livelihood, many pastors were resistant to the

program.  However, the group leaders conducted 16 courses

for 115 participants.  Sixty-eight of these smokers

completed the course, and 26 (22.6 percent) were not

smoking at the end of the course.  To increase

participation, local health department clinics offered

classes away from the church, which provided greater

confidentiality.  The group leaders also offered self-help

information as an alternative to group classes.

The BGC-HCM director convened a group consisting of

regional coordinators, a member of the clergy, church

volunteers, and VDH staff to select suitable nutrition and

weight loss management programs for the project.  The group

reviewed existing programs and selected a locally developed

program called TRIM.  The group revised the TRIM materials

and gave the program a new name because the old title was

not an acronym for anything.  The project staff felt that

the program would have more meaning if the letters

represented a relevant message--i.e., Taking Responsibility

in Meal Management (TRIMM).  The working group also

selected an appropriate exercise video to complement TRIMM.

The BGC-HCM director and the VDH nutrition education

coordinator conducted the first TRIMM training session for

regional coordinators and assistants.  Shortly before the

end of the project, regional coordinators began training

local volunteers to lead TRIMM classes.  So far, the

volunteer leaders have conducted three TRIMM classes with

100 participants.  Twenty-two of the 100 participants lost

weight.

The VDH and the BGC-HCM continue to implement all phases of

the project since the conclusion of their Stroke Belt

Initiative funding in September 1995.

SUMMARY:  LESSONS LEARNED

The Stroke Belt Initiative projects demonstrated the

capability of State health departments to plan and carry

out health education interventions to prevent and control

risk factors for stroke and heart disease.  They also

provided some valuable lessons that others can use in

planning intervention programs for use in the Stroke Belt

and elsewhere.

Several of the projects worked with churches, and the many

lessons learned from their experiences will add to the

knowledge base on how to work with churches to implement

health education programs to prevent and control risk

factors for stroke.  They succeeded in recruiting churches,

training teams among the congregations to implement program

activities, moving the teams to action, and sustaining

their actions over time.  Some lessons learned are

described below.

--   It takes time to organize and carry out health

     programs in churches, but patience is rewarded.  In

     some churches, it can take 10 months or more from the

     first contact with the church to the time of the first

     program event.  Analysis of the combined data from 21

     churches in Louisiana and Tennessee showed that it

     took an average of 44.9 weeks (10.5 months) from the

     first contact with the church to the time of the first

     program event.  It took an average of 6.4 weeks (1.5

     months) from the initial contact with the church to

     the point when the pastor committed the church to

     participate.  It took another 15.6 weeks (3.6 months)

     from the commitment to participate to the appointment

     and training of the church team.  The first program

     event took place, on average, 20.7 weeks (4.8 months)

     after training the church team.  Health professionals

     must realize that this is normal and not give up.

--   There is no single best way to recruit churches and

     sustain their participation.  Each church-based

     project used different approaches.

--   Support from the clergy is essential.  The clergy

     usually decides whether the church will participate or

     not.  The level of support for the project by the

     clergy also determines the priority that it receives

     in the church.

--   The appointment of the right person as coordinator of

     the health care ministry or team is critical to

     keeping the members motivated and committed to the

     screenings and other activities in the churches.  HCMs

     with strong coordinators tended to maintain a

     consistent flow of program activities whereas those

     with weak leaders held activities much less

     frequently.  Thus, it is very important to select a

     strong coordinator in the beginning because the clergy

     is generally unwilling to replace an ineffective

     coordinator.

--   Church teams or HCMs can be very creative in devising

     ways to communicate health messages to their

     congregations.  Examples seen by the Stroke Belt

     Initiative projects included plays during services,

     healthful cooking demonstrations, "Gospelsize"

     (exercising to church music), and letters from young

     people urging significant adults to quit smoking. 

     Project staff should encourage this creativity.

--   Scheduling training sessions for church teams or HCMs

     is often a challenge.  Cancellations are frequent. 

     The project staff must maintain patience and

     flexibility and work with the HCM to reschedule the

     training.

Other major lessons learned:

--   It takes time to build coalitions that will plan and 

     carry out programs to prevent and control risk factors 

     in their communities.

--   Smoking intervention by nurses and health educators 

     with low-income smokers in health department clinics

     produces respectable quit rates.  

--   Automated blood pressure measurement machines can make 

     a valuable contribution to the hypertension detection 

     and control efforts in rural and low-income communities.

It is hoped that the life and impact of many of these

projects will live well beyond the funding.

CHES CONTINUING EDUCATION QUIZ

The National Heart, Lung, and Blood Institute (NHLBI) has

reviewed and approved this report on the Stroke Belt

Initiative for continuing education credits in health

education.

A certified health education specialist (CHES) may receive

2 credit hours in category 1.  To receive credit, answer

all of the following questions after reading this special

issue.  Circle the appropriate letter for each question on

the answer sheet following the questions.  Mail the

completed answer sheet to:

     Glen Bennett, MPH, CHES

     National Heart, Lung, and Blood Instutute

     31 Center Drive, MSC 2480
     
     Building 31, Room 4A03

     Bethesda, MD 20824-2480

If at least eight of your answers are correct, you will

receive a certificate indicating 2 credit hours in category

1.

1.   Which Stroke Belt State used quality assurance audits

     to improve the quality of care given to low-income

     patients with hypertension in health department

     clinics?

     a.   Alabama

     b.   Georgia

     c.   Indiana

     d.   Kentucky

     e.   North Carolina

2.   Churches affiliated with the Baptist General

     Convention were the focus in which Stroke Belt State?

     a.   Louisiana

     b.   North Carolina

     c.   South Carolina

     d.   Tennessee

     e.   Virginia

3.   The Stroke Belt Initiative project in Mississippi used

     automated blood pressure measuring machines to record

     more than ________ blood pressures in six counties.

     a.   10,000

     b.   50,000

     c.   100,000

     d.   150,000

     e.   200,000

4.   Which State has the highest age-adjusted stroke death

     rate?

     a.   Florida

     b.   Georgia

     c.   Indiana

     d.   North Carolina

     e.   South Carolina

5.   Which one of the following Stroke Belt States did NOT

     target any of its activities to churches?

     a.   Kentucky

     b.   Louisiana

     c.   South Carolina

     d.   Tennessee

     e.   Virginia

6.   Health educators working with low-income smokers in

     two Indianapolis health centers achieved a 6-month

     quit rate of:

     a.   3 percent

     b.   5 percent

     c.   12 percent

     d.   15 percent

     e.   20 percent

7.   On average, about how long did it take from the time

     the clergy committed the church to participate until

     the first program activity in the church?

     a.   1 month

     b.   3 months

     c.   6 months

     d.   9 months

     e.   1 year

8.   When did epidemiologists first document the higher

     stroke death rate in the southeastern United States?

     a.   1940s

     b.   1950s

     c.   1960s

     d.   1970s

     e.   1980s

9.   Which Stroke Belt State organized a poster contest

     among high school students and used the winning

     posters in public service announcements?

     a.   Arkansas

     b.   Georgia

     c.   Indiana

     d.   North Carolina

     e.   Tennessee

10.  Which Stroke Belt State attempted to set up planning

     groups or a coalition in each of the 10 counties to

     plan and carry out stroke risk reduction activities?

     a.   Arkansas

     b.   Georgia

     c.   Indiana

     d.   North Carolina

     e.   Tennessee

 NHLBI Stroke Belt Initiative

CHES Continuing Education Self-Study Answer Sheet

NCHEC Provider No.:  MD0013                   Event No.:  01015

Circle the correct answer to each question and mail this answer

sheet to:

     Glen Bennett, MPH, CHES

     National Heart, Lung, and Blood Instutute

     31 Center Drive, MSC 2480
     
     Building 31, Room 4A03

     Bethesda, MD 20824-2480

(Please print or type)

Name:  ___________________________________  Degree(s):  ________

Title:  ______________________________________  CHES No:  ______

Agency:  _______________________________________________________

Address:  ______________________________________________________

City:  ________________________  State:  ____  Zip:  ___________

Telephone: ______________________  Fax: _________________________ 

Internet:  ___________________________________

Please circle the letter of the correct answer for each question.

1.  a  b  c  d  e         6.  a  b  c  d  e

2.  a  b  c  d  e         7.  a  b  c  d  e 

3.  a  b  c  d  e         8.  a  b  c  d  e

4.  a  b  c  d  e         9.  a  b  c  d  e

5.  a  b  c  d  e        10.  a  b  c  d  e

Does the information in this Special Issue on the Stroke Belt

Projects:

                                                  Agree Disagree

1.  Show evidence of competence in carrying out 

    planned educational program?                   1  2  3  4  5

2.  Show evidence that program planners selected 

    methods and media best suited to implement 

    program plans for specific learners?           1  2  3  4  5

3.  Interpret results of program evaluation?       1  2  3  4  5

4.  Infer implication from findings for future

    program planning?                              1  2  3  4  5

Date:  ________________  Signature:  ___________________________

CHES No.:  ________