COMMUNITY CASE STUDY

Lessons Learned in Community Research Through The Native
Proverbs 31 Health Project

Caroline M. Kimes, BSPH; Shannon L. Golden, MA; Rhonda F.
Maynor; John G. Spangler, MD, MPH; Ronny A. Bell, PhD, MS

Suggested citation for this article:
Kimes CM, Golden SL, Maynor RF, Spangler JG, Bell RA. Lessons
Learned in Community Research Through The Native Proverbs 31 Health
Project. Prev Chronic Dis 2014;11:130256. DOI: http://dx.doi.org/10.5888/pcd11.130256.

PEER REVIEWED

Abstract

Background
American Indian women have high rates of cardiovascular disease
largely because of their high prevalence of hypertension, diabetes,
and obesity. This population has high rates of cardiovascular
disease-related behaviors, including physical inactivity, harmful
tobacco use, and a diet that promotes heart disease. Culturally
appropriate interventions are needed to establish health behavior
change to reduce cardiovascular disease risk.

Community Context
This study was conducted in Robeson County, North Carolina, the
traditional homeland of the Lumbee Indian tribe. The study’s goal
was to develop, deliver, and evaluate a community-based, culturally
appropriate cardiovascular disease program for American Indian
women and girls.

Methods
Formative research, including focus groups, church assessments, and
literature reviews, were conducted for intervention development.
Weekly classes during a 4-month period in 4 Lumbee churches (64
women and 11 girls in 2 primary intervention churches; 82 women and
8 girls in 2 delayed intervention churches) were led by community
lay health educators. Topics included nutrition, physical activity,
and tobacco use cessation and were coupled with messages from the
Proverbs 31 passage, which describes the virtuous, godly woman.
Surveys collected at the beginning and end of the program measured
programmatic effects and change in body mass index.

Outcome
Churches were very receptive to the program. However, limitations
included slow rise in attendance, scheduling conflicts for
individuals and church calendars, and resistance to change in
cultural traditions.

Interpretation
Churches are resources in developing and implementing health
promotion programs in Christian populations. Through church
partnerships, interventions can be tailored to suit the needs of
targeted groups.

Top of Page

Background

American Indians bear an unequal burden of illness and death
from cardiovascular disease compared with whites (1). Moreover,
American Indians have high rates of cardiovascular disease risk
factors, including hypertension, diabetes, obesity, physical
inactivity, a diet that promotes heart disease, and tobacco use
(2). Metabolic syndrome is also higher in this population as
compared with its white counterpart (3). Although cardiovascular
disease affects all US communities, American Indians die from this
condition at younger ages than any other racial/ethnic group (4).
In North Carolina, the 2004 through 2008 American Indian death
rates for heart disease (207.7 per 100,000) and stroke (54.6 per
100,000) were both 10% higher and the diabetes death rate (138.0
per 100,000) was 70% higher than the rates for non-Hispanic whites
(5). Disparities in cardiovascular disease risk factors for
American Indians in North Carolina are similar to those seen
nationally.

American Indian women have high rates of cardiovascular risk
factors, including smoking, obesity, diabetes, physical inactivity,
and unhealthy eating. The Strong Heart Study is a population-based
longitudinal study that examined cardiovascular disease and its
risk factors among American Indians (6). This study demonstrated
that the prevalence of metabolic syndrome, a major risk factor for
cardiovascular disease, was 56.7% for American Indian women
compared with 43.6% for American Indian men enrolled in the study.
Moreover, this 56.7% is much higher than the 23.1% prevalence of
metabolic syndrome among women in the third National Health and
Nutrition Examination Survey (1988–1994). Survey respondents were
non-Hispanic whites, African Americans, and Mexican Americans) (7).
Similarly, the Inter-Tribal Heart Project, a study of
cardiovascular disease in American Indian women in Minnesota and
Wisconsin, showed high rates of cardiovascular disease risk factors
(8).

Community-based interventions, including the tribal programs
participating in the WISEWOMAN (Well-integrated Screening and
Evaluation for Women Across the Nation) initiative of the Centers
for Disease Control and Prevention, are recognized as vital in
addressing the significant cardiovascular disease burden in
American Indian communities (9,10). These studies were conducted
within various community settings, including schools, homes, and
existing tribally operated community organizations (eg, community
centers, health care facilities).

Top of Page

Community Context

According to the US Census, North Carolina has the largest
American Indian population of any state east of the Mississippi
River. In 2012 estimates, American Indians comprise 1.9% of the
state’s population, or about 184,000 individuals (American Indian
alone or in combination with other races). The Lumbee tribe, a
state-recognized, nonreservation tribe with a population of about
55,000, is the largest tribe in the state and is mostly
concentrated in Robeson County (11). This county is rural, has a
high poverty rate, is racially and ethnically diverse, and has a
large population of American Indians (39.0%) and African Americans
(24.7%); 8.2% of all races report Hispanic ethnicity. Disparities
are documented among the Lumbee in diabetes and cardiovascular
disease-related health behaviors (12–14).

The Christian church and Christian faith are important
components of Lumbee culture. The Baptist and Methodist faiths are
the most prominent denominations in the county (15). Many studies
show that the church is important in the delivery of cardiovascular
disease-related health education (16–20). This type of intervention
is understudied among American Indians. Thus, a church-based
approach has the potential to reach a large number of underserved
American Indians at high risk for cardiovascular disease.

Top of Page

Methods

The Native Proverbs 31 Health Project was funded by the National
Institute on Minority Health and Health Disparities as a
feasibility study with the overall goal of developing, delivering,
and conducting a preliminary evaluation of a community-based,
culturally appropriate cardiovascular disease program for American
Indian women and girls. The program was based on the Proverbs 31
“Virtuous Woman” chapter from the Bible and was conducted as a
partnership between Native American Interfaith Ministries (Healing
Lodge) and Wake Forest School of Medicine’s Maya Angelou Center for
Health Equity and the Department of Family and Community Medicine.
One of the co-investigators (R.A.B.) is an enrolled member of the
Lumbee tribe and has led health-related research among the tribe
for 20 years.

The study used a mixed-methods approach to achieve the following
aims: 1) develop a community-based 4-month cardiovascular disease
intervention for American Indian women and girls (aged ≥12 years)
in North Carolina focusing on the themes adapted from Proverbs 31;
2) use a community health and lay health educator model to
implement the intervention in 4 Lumbee Indian churches; 3) evaluate
the intervention using measures including change in diet, physical
activity, and harmful tobacco use. The study was approved by the
Wake Forest Health Sciences Institutional Review Board.

Phase 1, formative research process

In the initial phase of the project, we conducted formative
research designed to inform the development of the intervention and
gain a better understanding of the population in which the
intervention was to be developed. The formative process began with
a review of successful church-based programs and evidence-based
guidelines in the development of the intervention. We then met with
key church leaders from the community to describe study goals and
assess which churches would best serve as sites for the program.
Church leaders suggested several churches that they thought would
be well-suited to our proposed program.

Next, we conducted an assessment of these churches and their
infrastructures pertaining to health issues. The assessment
included the following: 1) availability of exercise equipment and
facilities, including a designated on-site walking trail; 2)
existence of policies focused on health issues, such as on-grounds
smoking bans and provisions for healthy foods at church events, 3)
availability of staff dedicated to health issues (eg, parish nurse,
health educator); 4) past participation in health programs or
activities; and 5) existence of family-based programs and events.
After a review of these factors, we selected churches to
participate that had similar histories, congregation sizes
sufficient to provide an adequate sample of American Indian women,
and geographic distance from each other. We then conducted focus
groups (1 per church, 5 to 9 participants per focus group) with
members and key leaders of the selected churches. The goals of the
focus groups were to 1) assess the level of understanding of
cardiovascular disease risk factors, 2) determine the level of
receptivity of a church-based cardiovascular disease prevention
program, 3) identify the key elements of Lumbee culture that are
important for the development of health messages, 4) test messages
adapted from the Proverbs 31 verses to determine the level of
receptivity of the church members to the relationship between the
verses and health behaviors, and 5) determine the appropriateness
of the design elements and delivery style (eg, artwork, words and
phrases, photography). We were also sensitive in the development of
the intervention messages pertaining to harmful tobacco use, given
the strong cultural and economic ties that the Lumbee have with
tobacco. Focus groups were audio recorded but not transcribed. The
research team took detailed notes and reviewed the recordings to
assess how to modify the intervention for the churches.
Modifications included decreasing the length of the intervention
from 6 to 4 months, reducing the frequency of classes to 1 time per
week, adding more class topics on exercise and nutrition, and
changing the study sample. Originally we hoped to design the
intervention for mothers and their daughters, but focus groups felt
that American Indian adolescents and women aged 12 and older would
be best.

Phase 2, intervention

In the second phase of the study, the research team and
community partners developed the intervention for Lumbee women that
was tailored for Lumbee culture and demonstrated how the verses in
Proverbs 31 translate into healthy behaviors (Table 1). Data were
collected at 2 primary intervention sites and 2 delayed
intervention sites. The churches were selected to participate in
the primary and delayed intervention based on their geographic
distance from each other.

The 4 groups were administered questionnaires at baseline and 4
months. After the 4-month assessment of the primary intervention
sites, the same program was offered at the delayed intervention
sites. Inclusion criteria for participation in the intervention
included being a member of the Lumbee tribe or a Lumbee family,
female aged 12 or older, and able to engage in low-impact physical
activity.

The intervention involved a 4-month, weekly health education
program taught by trained lay health educators from each church.
Lay health educators were identified in the churches through
word-of-mouth and through referral from church leadership. They
completed an application that was reviewed by the study team. The
lay health educators completed the Collaborative Institutional
Training Initiative modules for human subject research, as required
by the Wake Forest Health Sciences Institutional Review Board, and
were trained by the research team and community partners to deliver
the intervention. Training involved a one-half day session in the
study county where the study objectives were discussed, and lesson
plans developed by the study team were reviewed. Teams of lay
health educators and field staff then recruited participants for
the program from their congregations and communities by using
flyers and attending local events like women’s programs and blood
drives. Then lay health educators, in conjunction with church
leaders, decided on the program schedule. Each session of the
program lasted approximately 2 hours and was held in the evening.
Each participant was presented with a notebook at the beginning of
the program and provided with subject matter weekly.

The curriculum included presentations, group discussions,
handouts on 11 topics (Box), and several review sessions. Resources
used to develop the health education messages were drawn from
trusted organizations such as the American Heart Association; the
National Heart, Lung, and Blood Institute; and the North Carolina
Department of Public Health. The team also relied on their personal
research experience in the community and from the insight of the
community partners. The intervention was modeled on the Heart
disease and stroke Education Awareness Rapid response Treatment
adherence Quality Enhancement through Science Translation
(HEARTQUEST) curriculum, developed as part of a project funded by
the National Heart, Lung, and Blood Institute that was part of the
Enhanced Dissemination and Utilization Centers (R.A. Bell,
principal investigator).

Each session had specific elements to be covered by the lay
health educators using lesson plans. The elements included a review
of the Proverbs 31, a “Proverbs 31 Pledge,” a physical activity or
stretching time, a dietary lesson, and a class activity or
worksheet. Some flexibility was given to the lay health educators
in the delivery of these elements. For example, 1 church had a
“walking club” session before the class.

Participants were asked to make weekly “Proverb 31 Pledges”
where they would commit to make 1 change in their lifestyles based
on the lesson from each week. Pledges were reviewed at the next
session and women discussed successes and pitfalls regarding their
pledges during the previous week. Grocery store tours were arranged
with a regional grocery store chain in collaboration with a
registered dietitian. We provided tools and materials to
participants as incentives throughout the program, including
notepads, pens, pedometers, calculators, cookbooks, and tote bags
all bearing the study logo. In addition, church-wide efforts were
made to support and promote the program. Church bulletin inserts
related to the curriculum were distributed congregation-wide, as
were fans printed with information about healthy living.

Lay health educators collected weekly attendance and monthly
evaluations from participants. Additionally, lay health educators
evaluated the success of each session weekly. These processes
allowed the research team to monitor the activities of each church
and provide necessary resources in a timely manner.

Intervention data collection and study measures

After obtaining informed consent and assent from participants,
the study team collected questionnaire data at the churches before
the first scheduled session and again at the conclusion of the
program. Questionnaires took 30 to 45 minutes to complete. Measures
included 1) demographics, including sex, ethnicity, age, marital
status, household size, formal education, and annual household
income (from adults only); 2) perceived health status; 3) dietary
intake including self-efficacy and readiness to adopt healthful
eating behaviors; 4) physical activity, including self-efficacy and
readiness to adopt healthy physical activity behaviors; 5) current
and tobacco use; 6) depressive symptoms; 7) self-esteem; 8)
religiosity. After questionnaire completion, height and weight were
measured and body mass index computed. The primary outcomes were
changes in dietary intake, physical activity, and tobacco use.
Secondary outcomes included changes in body mass index,
self-efficacy, and self-esteem (Tables 2 and 3).

Top of Page

Outcome

Conducting community-based research or developing
community-based programs is an ongoing process, involving constant
communication between all partners and flexibility to accommodate
developing needs in the community. Over time, the process has had
both successes and opportunities for improvement.

Communication was critical for successful implementation of the
elements of our study. Our primary study team is more than 100
miles from the study county where our community partners were. The
study team hired an on-site Lumbee field coordinator whose primary
role was to link the study team with partners at all times and keep
communication flowing to advance the program. She kept the study
team informed on local news and events and attended multiple
community functions to represent the study team and network with
partners. The staff of the Healing Lodge, trained specialists in
health education and community health, were a valuable asset for
the study by connecting the study team with key church leaders in
the community. They reviewed the curriculum and provided critical
feedback on how to format materials for the American Indian
population. Additionally, they were present at each lay health
educator class and helped to facilitate classes as needed.

There were several successes in community engagement. One main
success was that the churches readily welcomed the pairing of
health messages with the Proverbs 31 verses. Because classes were
led by parishioners in the church, the community felt a sense of
ownership of the program, even though attendance was slow to
increase. One church formed a walking group that has continued
postintervention. The churches that participated in the study were
all rural, with limited availability of structured exercise
facilities and safe walking areas, so the church became a safe
venue to support physical activity. Another church drafted a
nonsmoking policy for church grounds. The healthy living idea
spread through many of the churches and entire families became
involved.

Through the process, we faced challenges in initiating and
sustaining enthusiasm to complete participation in all sessions.
Attendance among participants surveyed at baseline averaged 27%
between both primary intervention churches. Interest in the
intervention increased slowly over time as participants invited
others to join them. However, when collecting baseline data, we
could not extend enrollment indefinitely and attendance was tracked
for surveyed participants only. Also, for churches, adding
additional meetings or activities to busy schedules can bring
unexpected delays in curriculum delivery. After session
cancellations from holiday events, funerals, and in the case of 1
church, 4 consecutive weeks of revival services, momentum was
slowed. Many participants had demands on their time requiring high
fast-food and processed-food consumption, or conversely, pressure
from their families to cook extensive meals of “traditional food”
often including high-fat products like whole milk, lard, cured
pork, and deep-fat–fried foods. Adopting low-fat alternatives was
included in the curriculum, but families of participants were often
resistant to this change, and access to or affordability of
high-quality products was not always possible in this rural
setting. Effective change will take more time than a 4-month
intervention can offer.

An additional challenge was that although the churches were
geographically isolated in a large county (921 square miles), it is
unclear how much interaction occurred among study participants from
different churches. This is not something we were able to measure,
and we tried to select churches that were distributed throughout
the county.

We experienced shifting social and political climates at the
time of our intervention. During implementation, there were changes
in tribal leadership, which made it difficult for the study team to
keep the tribe informed of and engaged in our activities. The study
team was persistent in establishing relationships with the tribal
government and maintaining a steady flow of communication about the
project’s activities. We also experienced change in leadership at
one of the intervention sites when a prominent member confessed to
illegal behavior and left the church.

Top of Page

Interpretation

Several community-based issues presented difficulties in
implementing this intervention, including slow start-up, scheduling
problems, and resistance to stray too far from traditional food and
preparation methods. These issues made it difficult for some women
to participate and implement lifestyle changes. However, even with
these struggles, we were able to meet our objectives and engage 4
churches to implement the program. We were able to successfully
determine feasibility, and this model could be adapted for use by
churches in other communities. For this program to be sustained
long-term elsewhere, it will be vital to have community buy-in,
input, and leadership. This program could be adapted for
communities with limited funds. Although it is difficult to
calculate an exact dollar amount, the cost of the program is low,
given that the curriculum has been developed and lay health
educators would volunteer their time. The curriculum could easily
be expanded to other Bible passages, and there are many
biblically-based books that focus on healthy living that could be
resources.

The development of our intervention focused on a biblical theme
was aided by the strong Christian influence in the Lumbee
community. Successful implementation would be more challenging in
communities less receptive to such a focus, particularly in Native
communities that have traumatizing histories with the Christian
church and Christian missionaries.

Churches provide an opportune setting for intervention delivery
because many in the congregation share common values and interests
and the structure of classes is well-received. Curriculum can
easily be promoted with media such as church fans and bulletin
inserts because their use is common practice already. However, when
designing and implementing community-based programs, it is not
possible to anticipate changes in the social or political climate
that might have an effect on the intervention. Community-based
programs should be flexible in their design so that adjustments can
be made as unforeseen circumstances arise. Even with these
limitations, community partners, like churches, are valuable
resources when developing and executing tailored health education
and disease prevention programs in Christian populations.

Top of Page

Acknowledgments

Research reported in this article was supported by the National
Institute on Minority Health and Health Disparities of the National
Institutes of Health under award no. R21MD005995 (R. A. Bell and
John G. Spangler, co-principal investigators). The content is
solely the responsibility of the authors and does not necessarily
represent the official views of the National Institutes of Health.
We thank Charles Adkins, MPH (University of North Carolina at
Greensboro graduate student intern), Cindy Silver, MS, RDN, LDN (A
Market Basket of Nutrition Services, LLC), and the Native American
Interfaith Ministries (Healing Lodge) of Pembroke, North Carolina,
for their help with program implementation.

Portions of this manuscript were presented in poster format at
the 2012 American Public Health Association Meeting, San Francisco,
California, and the 2012 National Institute on Minority Health
Summit on the Science of Eliminating Health Disparities, National
Harbor, Maryland.

Top of Page

Author
Information

Corresponding Author: Ronny A. Bell, PhD, MS, Maya Angelou
Center for Health Equity, Wake Forest School of Medicine, Medical
Center Blvd, Winston-Salem, NC 27157. Telephone: 336-713-7611.
E-mail: rbell@wakehealth.edu.

Author Affiliations: Caroline M. Kimes, Shannon L. Golden,
Rhonda F. Maynor, John G. Spangler, Wake Forest School of Medicine,
Winston-Salem, North Carolina.

Top of Page

References

1. Galloway JM. Cardiovascular health among American Indians and
   Alaska Natives: successes, challenges, and potentials. Am J Prev
   Med 2005;29(5, Suppl 1):11–7. CrossRefPubMed
2. Kurian AK, Cardarelli KM. Racial and ethnic differences in
   cardiovascular disease risk factors: a systematic review. Ethn Dis
   2007;17(1):143–52. PubMed
3. Kaler SN, Ralph-Campbell K, Pohar S, King M, Laboucan CR, Toth
   EL. High rates of the metabolic syndrome in a First Nations
   community in western Canada: prevalence and determinants in adults
   and children. Int J Circumpolar Health 2006;65(5):389–402. CrossRefPubMed
4. Centers for Disease Control and Prevention. Disparities in
   premature deaths from heart disease — 50 states and the District of
   Columbia, 2001. MMWR Morb Mortal Wkly Rep 2004;53(6):121–5. PubMed
5. North Carolina Office of Minority Health and Health Disparities
   and State Center for Health Statistics. Racial and ethnic health
   disparities in North Carolina: report card 2010. Raleigh (NC):
   North Carolina Department of Health and Human Services; 2010.
6. Howard BV, Lee ET, Cowan LD, Devereux RB, Galloway JM, Go OT,
   et al. Rising tide of cardiovascular disease in American Indians:
   the Strong Heart Study. Circulation 1999;99(18):2389–95. CrossRefPubMed
7. Resnick HE; Strong Heart Study Investigators. Metabolic
   syndrome in American Indians. Diabetes Care 2002;25(7):1246–7. CrossRefPubMed
8. Struthers R, Baker M, Savik K. Cardiovascular risk factors
   among Native American women Inter-Tribal Heart Project
   participants. J Obstet Gynecol Neonatal Nurs 2006;35(4):482–90. CrossRefPubMed
9. Jobe JB, Adams AK, Henderson JA, Karanja N, Lee ET, Walters KL.
   Community-responsive interventions to reduce cardiovascular risk in
   American Indians. J Prim Prev 2012;33(4):153–9. CrossRefPubMed
10. Vaid I, Wigington C, Borbely D, Ferry P, Manheim D. WISEWOMAN:
    addressing the needs of women at high risk for cardiovascular
    disease. J Womens Health (Larchmt) 2011;20(7):977–82. CrossRefPubMed
11. Who are the Lumbee? Pembroke (NC): Lumbee Tribe of North
    Carolina; 2012.
    http://lumbeetribe.com/index.php?option=com_content&view=article&id=135&Itemid=115.
    Accessed June 24, 2013.
12. Bell RA, Shaw HA, Dignan MB. Dietary intake of Lumbee Indian
    women in Robeson County, North Carolina. J Am Diet Assoc
    1995;95(12):1426–8. CrossRefPubMed
13. Spangler JG, Bell RA, Knick S, Michielutte R, Dignan MB,
    Summerson JH. Epidemiology of tobacco use among Lumbee Indians in
    North Carolina. J Cancer Educ 1999;14(1):34–40. PubMed
14. Levin S, Welch VL, Bell RA, Casper ML. Geographic variation in
    cardiovascular disease risk factors among American Indians and
    comparisons with the corresponding state populations. Ethn Health
    2002;7(1):57–67. CrossRefPubMed
15. Stilling GES. Lumbee Indians. In: Powell WS, editor.
    Encyclopedia of North Carolina. Chapel Hill (NC): University of
    North Carolina Press; 2006. p. 699–703.
16. Tussing-Humphreys L, Thomson JL, Mayo T, Edmond E. A
    church-based diet and physical activity intervention for rural,
    lower Mississippi Delta African American adults: Delta Body and
    Soul effectiveness study, 2010–2011. Prev Chronic Dis 2013;10:E92.
    http://www.cdc.gov/pcd/issues/2013/12_0286.htm. Accessed June 24,
    2013. CrossRefPubMed
17. DeHaven MJ, Hunter IB, Wilder L, Walton JW, Berry J. Health
    programs in faith-based organizations: are they effective? Am J
    Public Health 2004;94(6):1030–6. CrossRefPubMed
18. Campbell MK, Hudson MA, Resnicow K, Blakeney N, Paxton A,
    Baskin M. Church-based health promotion interventions: evidence and
    lessons learned. Annu Rev Public Health 2007;28:213–34.
    CrossRefPubMed
19. Yanek LR, Becker DM, Moy TF, Gittelsohn J, Koffman DM. Project
    Joy: faith-based cardiovascular health promotion for African
    American women. Public Health Rep 2001;116(Suppl 1):68–81. CrossRefPubMed
20. Resnicow K, Campbell M, Carr C, McCarty F, Wang T, Periasamy S,
    et al. Body and Soul: a dietary intervention conducted through
    African-American churches. Am J Prev Med 2004;27(2):97–105. CrossRefPubMed

Top of Page

Tables

Table 1.
Biblical Passages From Proverbs 31 and Potentially Relevant Health
Implications

Table 2.
Baseline Demographic and Health Characteristics of Adult American
Indian Women Participants by Intervention Group, The Native
Proverbs 31 Health Project, 2011–2012^a

^a Values are expressed as number (%)
unless otherwise indicated.

Table 3.
Baseline Demographic and Health Characteristics of Youth Female
American Indian Participants by Intervention Group, The Native
Proverbs 31 Health Project, 2011–2012^a

^a Values are expressed as number (%)
unless otherwise indicated.

Top of Page

The opinions expressed by authors contributing to this journal do
not necessarily reflect the opinions of the U.S. Department of
Health and Human Services, the Public Health Service, the Centers
for Disease Control and Prevention, or the authors’ affiliated
institutions.