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Journal of Community Health Nursing

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Empowering Community Health: An Educational Approach

Cynthia Lewis-Washingtona; Lygia Holcomba
University of Alabama at Birmingham, Birmingham, Alabama

Online publication date: 06 November 2010

To cite this Article Lewis-Washington, Cynthia and Holcomb, Lygia(2010) 'Empowering Community Health: An
Educational Approach', Journal of Community Health Nursing, 27: 4, 197 — 206
To link to this Article: DOI: 10.1080/07370016.2010.515454


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Journal of Community Health Nursing, 27:197–206, 2010
Copyright © Taylor & Francis Group, LLC
ISSN: 0737-0016 print/1532-7655 online
DOI: 10.1080/07370016.2010.515454

Empowering Community Health:

An Educational Approach

Cynthia Lewis-Washington and Lygia Holcomb

University of Alabama at Birmingham, Birmingham, Alabama

Collaborative efforts among community members, health care professionals, and faith-based insti-
tutions can prove valuable in efforts to improve community health. This study used data obtained
from before and after health risk assessment surveys to assess participant’s knowledge of risk fac-
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tors leading to chronic diseases among African Americans in an underserved community of Ala-
bama. Data obtained from activity logs and health screening sessions was used to assess effect of
knowledge gained on lifestyle practices. The study findings support the need for ongoing popula-
tion-specific education program development in religious institutions located inside underserved

According to the Centers for Disease Control and Prevention (CDC), chronic illnesses present
major health problems in the state of Alabama. Three chronic illnesses affecting individuals be-
tween the ages of 35 to 85 leading to disability and death in Mobile County are cardiovascular dis-
ease, stroke, and diabetes. Factors such as age, race, gender, family history, and genetic predispo-
sition are considered nonmodifiable risk factors leading to these illnesses. However, modifiable
risk factors have been identified as smoking, hypertension, obesity, high cholesterol, physical in-
activity, and unhealthy eating habits (CDC, 2006).
Thirty-two percent of adults residing in Alabama reported having high blood pressure, 9% re-
ported that they had diabetes; 5% reported having a heart attack; 3% reported a history of having a
stroke, and 7% reported history of heart disease (Alabama Department of Public Health [ADPH],
2005). According to this study, populations affected by these illnesses have experienced an in-
crease in rate of occurrence. African Americans and other minority populations are dis-
portionately affected by such illnesses and experience a high rate of death and disability as an end
result (ADPH, 2005).
The death rate for Mobile County ranked in the top two, totaling 3, 986 in 2006, according to
the county health profile report. In 2002, the mortality rates from chronic diseases such as heart
disease, diabetes, and strokes were higher in the African American population of Alabama than in
the United States (ADPH, 2005). Evidence supports the need for implementing strategies to help

Address correspondence to Dr. Cynthia Lewis-Washington, DNP, FNP-BC, 6629 Red Maple Drive, Mobile, AL
36618. E-mail:

reduce the burden of heart disease, stroke, and diabetes at the individual and community level
(Gold, Doreian, & Taylor, 2008). The importance of strategies geared toward prevention through
risk reduction, early detection, and disease management are imperative to reduce the occurrence
of diseases resulting in disability and death among African American populations (Williamson,
Mobile County had 18.5% of its population living below poverty level. There were high rates
of prevalence of chronic illness affecting the population. The prevalence of diabetes was 8.4 %,
hypertension was 31.9%, tobacco use was 24.4%, obesity was 24.5% and prevalence of heart dis-
ease was 5.1% (ADPH, 2005). As a result of the high rate of occurrence of risk factors leading to
chronic illnesses, Mobile ranked fifth in the overall burden of chronic diseases in the state of Ala-
bama. This evidence supports the need for a comprehensive multidisciplinary approach to reduc-
ing risk factors leading to illnesses affecting the African American population of Mobile County
(Meeto, 2008).
In an effort to have the greatest impact on risk reduction behaviors among this population, strat-
egies must be implemented to target chronic illnesses that often coexist and share similar risk fac-
tors. According to recent literature, some chronic illnesses coexist such as heart disease and diabe-
tes. Also, strokes often result from uncontrolled hypertension and diabetes (Frank & Grubbs,
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2008). Therefore, an education program focusing on only one chronic disease affecting the Afri-
can American population of Mobile County may not result in a reduction of occurrence, disability,
or death rate.
New interventions are needed to decrease barriers to health care among vulnerable populations
leading to chronic illnesses and death. To be effective, interventions must involve individuals,
families, local stakeholders, and community resources in an effort to improve the overall health of
community residents (Cooper, Hill, & Powe, 2002).
Recent literature suggests that low socio-economic populations tend to have low response to
traditional health education programs. However, health education programs held in religious insti-
tutions have resulted in improved health among African American populations (Frank & Grubbs,
2008). Implementation of an educational program in a church environment can improve overall
quality of life by promoting modification of risk factors leading to chronic illnesses. Interventions
based on best practices can lead to healthy living habits preventing occurrence and/or worsening
of chronic diseases and death among African American communities of Mobile County (Graham,
Kim, James, Reynolds, Buggs, & Hunter, 2006).
Religious institutions have provided outreach programs targeting lower socio-economic popu-
lations in surrounding communities’ worldwide (Oexmann, Thomas, Taylor, O’Neil, Garvey, &
Lackland, 2000). Religious organizations are major sources for health screenings and social sup-
port systems in most communities. Some African American cultures tend to believe that there is a
connection between spiritual and physical health and are more receptive to health promotion and
disease prevention programs held in religious institutions. Familiarity and trust play a major role
in this belief among this population (DeHaven, Hunter, Wilder, Walton, & Berry, 2004).
The purposes of this study were to increase knowledge of risk factors to heart disease, diabetes
and strokes among African Americans in an Alabama community; and to empower community
members to take control of their health by modification of living habits through a health education
program held in a community church setting.
The foundation of this study was based upon promoting community empowerment to take con-
trol of health through healthy living habits and knowledge gained through an education program

(Hildebrandt, 1996). The global goal is to reduce risk factors for heart disease, diabetes, and
strokes among African Americans, thereby decreasing occurrence of chronic diseases, disability,
and death.


The study was completed using a qualitative design with a convenience sample of 17 African
American adults. Participants were 19 years of age and older. As shown in Table 1, there were two
male participants age 40 and 45. There were 15 female participants whose ages ranged from 25 to
72. The participants lived in an underserved community of Alabama. The sample critieria for in-
clusion in this study included any member in the community aged 19 years and older without any
observable or reported mental disability. Church administrators gave permission to conduct the
study at the facility. Participants were provided with written correspondence that explained the
purpose of the study. Participants were informed that participation was voluntary and that confi-
dentiality would be maintained throughout the study. Consent was obtained during the focus
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group meeting held prior to the study.

Activities included in the education sessions were: discussion of modifiable and nonmodifiable
risk factors; health screenings of weight, blood pressure, and blood sugar readings; self-assess-
ment survey of daily eating and living habits, self-care strategies to control health; healthy food
choices by a dietician; sessions to discuss diabetes, stroke, and heart disease; exercise regimen dis-
cussions with handouts provided; medication review with Q & A session; lab test discussions to
encourage “knowing your numbers and taking control of your health;” and a session to discuss
“what to report and questions to ask when I go to the doctor.”
An attendance log was recorded and entered into the database. Education hand-outs obtained
from the American Heart Association and Stroke Foundation and the American Diabetic Associa-

Demographics of Participants

Gender Age

Male 40
Male 55
Female 25
Female 28
Female 32
Female 36
Female 45
Female 47
Female 54
Female 56
Female 60 (2 participants)
Female 61
Female 63
Female 70
Female 71
Female 72

tion were distributed to participants to aid in education sessions. All data collected was coded,
computerized and password protected.
Healthy snacks and water were provided at each education session. Incentives were awarded to
participants in the form of t-shirts, bags, pedometers, mugs, healthy living cookbooks, and $10.00
gift cards.


Data was collected through a pre- and post-health-risk assessment survey to obtain health history,
current and potential risk factors leading to heart disease, diabetes, and stroke (see Appendix A).
Surveys were administered by the investigator. Participant’s weight, blood pressure, and blood
sugar levels were measured and recorded on an activity log. A weekly log of activities, food diary,
and blood sugar (for diabetics only) checks was submitted by each participant. Data obtained from
weekly logs, pre- and postassessment surveys were used to track progress throughout the 6-week
education program.
The surveys were developed by the investigator from risk factors identified by the American
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Heart and Stroke Foundation and the American Diabetic Association. Content validity of the sur-
veys was validated by four clinical experts in the field of nursing and research.


The survey’s results were assessed for risk reduction through lowering of blood pressure and
blood sugar. Also, weight loss; reports of increased exercise; dietary changes to include healthy
food choices; and report of increased knowledge of diabetes, stroke, and heart disease risk factors
were assessed.


As shown in Table 2, forty-two percent of the participants had existing hypertension, 30% had dia-
betes, 12% had elevated blood pressure, 12% had heart disease, and 6 % were without known
health problems. However, 36% of the participants had hypertension and diabetes, with 83% re-

Presence of Illnesses Among Participants

Illness Percent

Hypertension (HTN) 42
Diabetes (DM) 30
Heart disease 12
HTN and DM 36
Elevated blood pressure 12
Without known health problems 6
Family history of DM, HTN, or stroke 83

ported having family members with diabetes, hypertension, and a history of strokes. Less than
10% were aware of non-modifiable and modifiable risk factors to heart disease, diabetes, and
Knowledge of nonmodifiable risk factors to heart disease, diabetes, and stroke varied greatly
among participants. Family history and race was identified the most frequently. As shown in Table 3,
participants lacked knowledge of age, gender, and genetic predisposition as being risk factors to
heart disease, diabetes, and strokes. Sixty-five percent of the participants were aware of high blood
pressure and smoking as risk factors to strokes, but were unaware of these risk factors leading to
heart disease. Heart disease has been identified as the number one cause of death among African
American populations in Alabama (ADPH, 2005). Eighteen percent were unaware of obesity, high
cholesterol, physical inactivity, and unhealthy eating habits as risk factors to diabetes, heart disease,
and strokes. It is clear that continued preventive health education is needed to address this difference
in knowledge.
As shown in Table 4, twenty-four percent of participants experienced a reduction in blood pres-
sure during the study. A reduction of 18% (3 of 17 participants) in blood sugars was experienced
among participants, with only 6% (1 of 17 participants) experiencing a reduction in weight. How-
ever, as shown in Table 5, 60% reported increased exercise with 77% reporting changes in eating
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habits that included healthy food choices. Overall, 95% of participants reported increased knowl-
edge of risk factors to heart disease, diabetes, and strokes as a result of the education program.
Participants reported that the education program was valuable and of excellent quality, and rec-
ommended that it be offered on a continuing basis. The church setting was a great venue for the ed-
ucation program according to participant’s evaluation report. Strengths identified by the partici-
pants were the investigator’s knowledge of diseases and ability to answer disease specific

Percentage of Participants Unaware of Modifiable Risk Factors to Illnesses Prior to Study

Tobacco Elevated Physical Eating
Risk Factors Use HTN Obesity Cholesterol Inactivity Habits

Diabetes NR NR 18 18 18 18
Heart Disease 65 65 18 18 18 18
Strokes 0 0 18 18 18 18

Note. HTN = hypertension; NR = no risk.

Post Study Results: Percentage of Participants
Whom Experienced a Reduction in Readings

Item Measured Percent Decrease

Blood pressure 24
Blood sugar 18
Weight loss 6

Percentage of Participants Whom Reported
an Improvement in Healthy Lifestyle Practices

Health Practice Percent Increase

Exercise 60
Healthy food choices 77
Increased knowledge of risk factors to DM, HTN and strokes 95

Note. DM = diabetes; HTN = hypertension.

questions with supportive data. A weakness identified by participants was the timing of education
sessions occurring during church meetings and activities.


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The findings indicate that African Americans have some knowledge of risk factors to heart dis-
ease, diabetes, and strokes. However, knowledge of particular risk factors to heart disease was low
among participants. The finding that 65% of participants lacked knowledge of high blood pressure
and smoking as risk factors to heart disease is significant. Results support the use of population
specific education programs held in religious institutions located in underserved communities to
empower community health.
It is worthwhile to note that population-specific education programs held in religious institu-
tions in underserved communities produced a substantial effect on knowledge of risk factors to ill-
nesses among participants. As a result, healthy lifestyle practices increased with reduction in
blood pressure, blood sugar, and weight loss among a percentage of participants. Therefore, the
effects of the educational program have statistical significance.
Interventions to increase knowledge among this population can prove valuable in preventing
illnesses leading to disability and early death. Consideration should be given by health educators,
religious organizations, community organizations, and multidisciplinary healthcare members to
address risk factors identified less frequently. Population-specific education provided in nontradi-
tional settings, such as religious institutions located in the community, can prove valuable in ad-
dressing this issue. Knowledge is the key to early intervention and prevention of illnesses.
As a result of this study, ongoing educational sessions are held at the community church on a
monthly basis. Health screenings of blood pressure, blood sugars and weights are held on a
weekly basis. Community outreach collaboration efforts are in play with plans to hold ongoing
collaborative relationships with Healthy Communities Organization to address growing health
needs of vulnerable communities through outreach programs.
Limitations of the study were the small sample size and short duration of the study. The 6-week
education program was well received. However, it is evident that ongoing, active involvement by
healthcare professionals of multidisciplinary members, church members, and community organi-
zations are needed to increase knowledge and decrease risks to heart disease, diabetes, and
strokes. Implementation of weekly health education sessions would promote knowledge and pro-
vide opportunity for reinforcement of healthy living habits. A larger sample size would yield most

reliable results, leading to a major impact among African American’s knowledge of health risks to
chronic diseases. Strengths of the study were the use of a church environment that promoted trust
and population-specific education material provided and taught by a health care provider at partic-
ipant’s level of understanding.


Alabama Department of Public Health. (2005). Mobile county health profiles 2006. Retrieved January 25, 2009 from http://
Centers for Disease Control and Prevention. (2006). About minority health. Retrieved January 26, 2009 from http://
Cooper, L. A., Hill, M. N., & Powe, N. R. (2002). Designing and evaluation interventions to eliminate racial and ethnic dis-
parities in health care. Journal General Internal Medicine, 17, 477–486.
DeHaven, M. J., Hunter, I. B., Wilder, L., Walton, J. W., & Berry, J. (2004). Health programs in faith-based organizations:
Are they effective? American Journal of Public Health, 94, 1030–1036.
Frank, D., & Grubbs, L. (2008). A faith-based screening/education program for diabetes, CVD, and stroke in rural African
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Americans. The Association of Black Nursing Faculty Journal, 19, 96–101.

Gold, M., Doreian, P., & Taylor, E. F. (2008). Understanding a collaborative effort to reduce racial and ethnic disparities in
health care: Contributions from social network analysis. Social Science & Medicine, 67, 1018–1027
Graham, G., Kim, S., James, B., Reynolds, G., Buggs, G., & Hunter, M. (2006). Benefits of standardized diabetes and hy-
pertension screening forms at community screening events. Health Promotion Practice, 7, 26–33.
Hildebrandt, E. (1996). Building community participation in health care: An example from South Africa. IMAGE, 28,
Meetoo, D. (2008). Chronic diseases: The silent global epidemic. British Journal of Nursing, 17, 1320–1324.
Oexmann, M. J., Thomas, J. C., Taylor, K. B., O’Neil, P. M., Garvey, W. T., & Lackland, D. T. (2000). Short-term impact of
a church-based approach to lifestyle change on cardiovascular risk in African Americans. Ethnicity & Disease, 10,
Williamson, D. E. (2004). Chronic disease in Alabama, past, present and future trends. Retrieved December 1, 2008 from
Center of Health Statistics Alabama County Health Profiles, Statistical Analysis Division.



Please circle your response to the following statements. All information is confidential.
1. I consider myself healthy.
Strongly agree Agree Disagree Strongly disagree
2. I have good eating habits and exercise regularly (at least 3 times a week).
Strongly agree Agree Disagree Strongly disagree
3. My diet consists of 5 servings of fruits and veggies daily.
Strongly agree Agree Disagree Strongly disagree
4. I drink 8 glasses of water daily.
Strongly agree Agree Disagree Strongly disagree

5. My diet consists of 6 or more servings of bread and cereals daily.

Strongly agree Agree Disagree Strongly disagree

6. Black Americans have a high rate of heart disease, diabetes and strokes.
Strongly agree Agree Disagree Strongly disagree

7. Major risk factors leading to heart disease and stroke that can be controlled are high
blood pressure and high cholesterol.
Strongly agree Agree Disagree Strongly disagree

8. Major risk factors for Diabetes are family history and overweight.
Strongly agree Agree Disagree Strongly disagree

9. Individuals who smoke have increased risk of experiencing complications of heart

disease and stroke.
Strongly agree Agree Disagree Strongly disagree
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10. Black Americans have a high rate of disability and death from diabetes, stroke and
heart disease.
Strongly agree Agree Disagree Strongly disagree



Age___ Gender ___ Height____ Weight____ Do you have insurance coverage __Y __N

Please check all that apply to your health and/or your relative health.

Self Family Medical History

Previous stroke
Temporary loss of vision, numbness, weakness, dizziness, confusion or headache
Heart disease
High blood pressure
Previous heart attack
Surgery, if so what kind
Swelling in hands, feet or any other part of body
Experience shortness of breath
Consume diet high in fat or have high cholesterol
History of or current smoker, if so how many packs per day_____
Alcohol use, if so how many drinks per day____ week_____ month___
Over weight
Physical inactivity

Please answer the following questions

1. How many days a week do you engage in exercise? ________________
2. Do you take medications for diabetes, high blood pressure, or heart disease? ____
(Please circle which illness you have)
3. Do you take medications for heart problems, stroke prevention or high cholesterol?
_______ (Please circle which illness you have)
4. Have you had a physical exam in the past year? ________
5. Have you had a colonoscopy in the past 10 years? ______
6. Have you had a mammogram in the last year? ________ or Not applicable _____
7. Have you had labs to check your prostate? _________ or Not applicable______
8. Have you had a pap smear in the last year? _______ or Not Applicable _______
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We would like to know how this educational program has influenced your health habits and
knowledge of diseases affecting your health. Please circle your response to the following state-
ments. All information is confidential.
1. This program has helped me to start taking better care of myself and enjoy a healthy
Strongly agree Agree Disagree Strongly disagree
2. Have you increased your exercise pattern to at least 3 times a week as a result of this
Strongly agree Agree Disagree Strongly disagree
3. I have changed my diet to include healthy food choices.
Strongly agree Agree Disagree Strongly disagree
4. The educational sessions were very useful to me and increased my knowledge about
risk factors and how to reduce them.
Strongly agree Agree Disagree Strongly disagree
5. The Faith-Based Health Promotion program is valuable to the community and should
be offered on a continuum basis.
Strongly agree Agree Disagree Strongly disagree
6. The overall quality of the program was …….
Excellent Good Fair Poor

7. The church was a good place to conduct this educational program.

Strongly agree Agree Disagree Strongly disagree
8. Program strengths/weaknesses and/or further recommendations:
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