Mobilizing faith-based COVID-19 health ambassadors to address COVID-19 health disparities among African American older adults in under-resourced communities: A hybrid, community-based participatory intervention
Department of Family Medicine, Charles R. Drew University of Medicine and Science, Los Angeles, CA, USA
Departments of Psychiatry, Charles R. Drew University of Medicine and Science, Los Angeles, CA, USA
Department of Psychiatry and Biobehavioral Sciences, University of California Los Angeles, CA, USA
Mervyn M. Dymally College of Nursing, Charles R. Drew University of Medicine and Science, Los Angeles, CA, USA
Physician Associate Program, Charles R. Drew University of Medicine and Science, Los Angeles, CA, USA
Department of Internal Medicine, Charles R. Drew University of Medicine and Science, Los Angeles, CA, USA
Office of Research, Charles R. Drew University of Medicine and Science, Los Angeles, CA, USA
Department of Family Medicine, University of California Los Angeles, Los Angeles, CA, USA
*Corresponding author Email: edwardadinkrah1@cdrewu.edu (E.K.A)Abstract
The COVID-19 pandemic disproportionately affected older adults, particularly those with pre-existing chronic health conditions. To address the health disparity gap and challenges faced by under-resourced African American older adults in South Los Angeles during this period, we implemented a hybrid (virtual/in-person), pre-post, community-based participatory intervention research project utilizing a faith-based lay health advisor model (COVID-19 Health Ambassador Program (CHAP)). We recruited COVID-19 Health Ambassadors (CHAs) and African American older adults (participants) from faith-based organizations who partook in CHA-led meetings and follow-ups that educated and supported the participants. This paper seeks to evaluate this intervention’s implementation using the Consolidated Framework for Implementation Research (CFIR) as a reporting tool with an emphasis on fidelity, challenges, and adaptations based on data collected via stakeholder interviews and surveys. Results: CHAP was delivered to 152 participants by 19 CHAs from 17 faith-based organizations. CHAs assisted with chronic disease management, resolved medication-related challenges, encouraged COVID-19 vaccination, reduced psychological stress and addressed healthcare avoidance behaviors such as COVID-19 vaccine hesitancy among the participants. Challenges encountered include ensuring participant engagement and retention in the virtual format and addressing technological barriers for CHAs and participants. Adaptations made to better suit the needs of participants included providing communication tools and additional training to CHAs to improve their proficiency in using virtual platforms in addition to adapting scientific/educational materials to suit our participants’ diverse cultural and linguistic needs. Conclusion: The community-centered hybrid approach in addition to our partnership with faith-based organizations and their respective COVID-19 health ambassadors proved to be essential in assisting underserved African American older adults manage chronic health conditions and address community-wide health disparities during the COVID-19 pandemic. Adaptability, cultural sensitivity, and teamwork are key to implementing health interventions especially in underserved populations.
Article notes
Competing Interest Statement
The authors have declared no competing interest.
Funding Statement
As scholars of the Clinical Research Education and Career Development (CRECD) program at Charles R. Drew University of Medicine and Science (CDU), the research efforts of Drs. Adinkrah, Cobb, and Kibe were supported by the NIMHD/NIH Award number R25 MD007610 (PI: M. Bazargan). In addition, this study was supported by the National Institute of Minority Health and Health Disparities under award number U54MD007598 (PI: J. Vadgama).
Introduction
The COVID-19 pandemic posed significant challenges in managing chronic health conditions, particularly among underserved African American (AA) older adults with underlying health issues (1–3). This under-resourced population, who have historically relied on county-based safety-net facilities for their healthcare needs(4), were forced to adjust their health-seeking behaviors and patterns of necessary medical care to manage their chronic health conditions. Consequently, this may have resulted in delayed, reduced, or halted visits to primary and specialty healthcare providers or pharmacies for medication (3). Moreover, pre-existing health disparities and conditions may have been exacerbated due to limited access with healthcare providers/resources and medication availability and adoption of risky health behaviors, including non-adherence to chronic health condition management guidelines, unhealthy lifestyles, and dietary practices (5). In response to these challenges and the urgent need for timely and health information during the pandemic(6), innovative approaches were necessitated to address health disparities and promote effective self-management of chronic health conditions.
This particular approach capitalizes on the external influence of trusted community organizations and leaders, such as faith-based organizations (FBOs) who have been historically recognized as vital sources of social support and resources for AA communities (7). More importantly, the engagement of Lay Health Advisors (LHAs) (8) from these FBOs are recognized as community liaisons trained to provide health-related support, guidance, and education to their peers (9). By sharing cultural, linguistic, and socioeconomic backgrounds with the populations they serve, LHAs foster trust, rapport, and understanding (10). The integration of LHAs from community churches into health interventions has demonstrated effectiveness in improving health outcomes and addressing the unique needs of AA older adults with chronic health conditions (11–13).
To adapt to the unique challenges of the COVID-19 pandemic, including the necessity for social distancing and reduced face-to-face interactions, a community-based participatory intervention utilizing a hybrid LHA model, the COVID-19 Health Ambassador Program (CHAP), was implemented. This model combined the benefits of in-person and virtual/telephone interactions, leveraging internet-enabled devices/phones and the growing digital literacy among older adults to facilitate remote support and engagement while maintaining the essential personal connection (14, 15). This paper aims to evaluate the successful implementation of CHAP in addressing health disparities among underserved AA older adults during the COVID-19 pandemic using the Consolidated Framework for Implementation Research (CFIR) as a reporting tool.
Methods and materials
This study utilized a mixed-methods, community-based participatory research (CBPR) approach to implement a “one group, pretest–posttest” intervention over a two-year period. All participants provided written, informed consent before participating, and the study protocol was approved by the ethical committee of the Charles R. Drew University of Medicine and Science Institutional Review Board (IRB). Authors had no access to information that could identify individual participants during or after data collection.
Setting
This study took place in 17 predominantly African American FBOs primarily located in urban regions of Los Angeles County Service Planning Area (SPA) 6, which experienced a significant impact from the COVID-19 pandemic. Compared to the rest of Los Angeles County, SPA 6 individuals face increased health challenges at a disproportionate rate.(16) The FBOs, situated within a 10-mile radius of the primary study site, had a well-established membership of older adults who frequently participated in religious services and maintained ongoing relationships with their respective leadership (e.g. pastors, ministers, deacons, etc.).
Recruitment
The study’s lead community faculty (CF), who is also serves as the head pastor of a participating FBOs, initiated contact with other head pastors (HP) and prominent faith-based leaders (FL) to encourage their participation in the research project. Interested FBOs with their respective leaders were conveniently sampled and recruited into the study between 2020 and 2022. No FBO was excluded based on denomination or size of the congregation.
Potential CHAs were conveniently sampled from our 17 partner FBOs. Based on recommendations from individual faith-based leaders, trusted parishioners who voluntarily signed up to become CHAs were chosen based on the following criteria: 1) 18 years and older, 2) AA parishioner from a registered partner FBO, 3) attend a 3-day workshop training, 4) provide at least 3 hours per week for study activities, 5) strongly committed to assisting older adults with chronic illness management and COVID-19 risk reduction, 6) familiar with AA community, and 7) able to communicate effectively in both English and the preferred language of the older adults.
Also, the FBOs provided access to potential participants of the study. These would be members who were 65 years and older or 55 years and older with at least one chronic health condition. Residents in care facilities and those with cognitive deficits (identified by the short version of the mini-mental state examination instrument) were excluded from the intervention.
Data collection
Data on participant and CHA sociodemographic characteristics, chronic health conditions, and health status were gathered through surveys. Participants completed the study surveys using different methods, including Uniform Resource Locator (URL), telephone interview, or CHA-administered interview. Additionally, participants’ acceptance and completion rates throughout the intervention were assessed. Complementing the survey-based approach, in-depth interviews were employed to gain a deeper understanding of the FBO leaders’ and CHAs’ viewpoints regarding the project and its implementation process. As part of the data-gathering process, CHAs and older adult participants identified and prioritized significant barriers and facilitators to implementing the intervention within their church or community setting.
Analysis plan
Data analysis was conducted using descriptive statistics for the quantitative data and thematic analysis for the qualitative data. CFIR, a useful tool for assessing potential barriers and facilitators in implementing healthcare interventions, was utilized to guide the analysis of the implementation process and identify areas for improvement. This tool provides a practical, theory-based guide to tailor implementation strategies and adaptations based on these factors and explain the outcomes of the implementation process(17). The project team also documented any adaptations made to the intervention based on feedback from the CHAs and older adults. The participants’ identified facilitators and barriers were grouped and reviewed before being compiled. The quantitative data were analyzed using SPSS (version 25). To produce a narrative report based on the CFIR domains, qualitative data were organized according to the CFIR constructs and sub-constructs.
Implementation strategies
Our project employed innovative implementation strategies by leveraging the trust and expertise of all stakeholders. These formed the basis of the project’s conceptual model and broadly described below.
Community strategizing
A six-step strategy was developed to forge strong relationships with the FBO leadership and adapt COVID-19 public health guidelines for their respective denominations. This approach involved recruiting leaders, creating a specialized curriculum, and conducting a 3-day virtual training workshop to empower them in addressing COVID-19-related concerns within their communities. FBO leaders were responsible for implementing infection prevention measures, carrying out routine environmental assessments, and ensuring protocol compliance. Additionally, they participated in community outreach through the university’s weekly public radio show that promoted the CHAP’s goals and discussed culturally sensitive topics during the pandemic. These included, 1) ‘Managing COVID-19 Grief in Our Community’, 2) ‘Mental Health and Social Isolation among African Americans’, 3) ‘How to Mitigate Vaccine Barriers in our Communities’, 4) ‘How ‘Your Health Is Connected to Your Faith’, and 5) ‘Addressing Vaccine Hesitancy among the Youth; The Role of the Church’. FBOs supported the project by recruiting lay health advisors, coordinating communication between advisors and participants, and facilitating participant involvement.
Community building and sustainability
The individual-level collaborations established with FBO leadership enabled the development of a tailored CHA curriculum and the dissemination of the CHA workshop/training program. The courses within the workshop covered CHA roles, COVID-19 knowledge, testing and vaccination concerns, risk prevention strategies, social determinants, chronic disease management, available community resources, and specialized care delivery (Table 1). The 3-day virtual workshop was facilitated by FBOs, research/academic staff, healthcare providers, and community faculty, with recorded sessions available to those who missed the live event and for CHAs who needed refresher training. CHAs received iPads and were trained in confidentiality and data security.
Individualized management of care
The project team collaborated to create culturally appropriate intervention materials and trained CHAs to support participants via phone calls and videoconferencing remotely. The three-month intervention included five broad activities: 1) completion of pre-and post-intervention surveys, 2) attendance at six bi-weekly online/hybrid meetings, 3) participation in individualized checkups/visits, 4) project support and feedback, and 5) participation in a post-study conference/gala. The team coordinated with FBOs to align schedules and ensure CHA availability. CHAs helped older adults develop personalized action plans for managing chronic health conditions, addressing medication management, healthy eating, and physical activities.
Results
The intervention engaged 17 AA FBOs in South Los Angeles, with additional churches in Southern California’s Inland Empire, Antelope Valley, and Victorville (n=3). On a daily average, 47 CHAs from these FBOs attended the 3-day workshop, and 19 CHAs actively participated in the recruitment and support of participants. Each CHA aimed to recruit 10 participants, resulting in a 22% rejection rate, as 2 out of 10 parishioners averagely declined the 19 CHAs’ invitations to participate in the study’s baseline data collection. Consequently, out of the 152 participants who enrolled in the study, 110 participants completed the intervention, yielding a 72% completion rate.
The majority of participants (70%) were female, with a mean age of 69 (SD: 9), and 25% were aged ≥75 years. Approximately 14% did not complete high school, 33% lived alone, and 98% had health insurance. Over 35% reported poor or fair physical health, and participants had an average of two chronic health conditions. The most prevalent comorbidities were hypertension (59%), COPD or asthma (24%), diabetes mellitus (22%), and heart disease (11%).
The implementation process was evaluated through a combination of informal interviews with FBO leadership, CHAs and participant survey items. Based on CFIR reporting guidelines, the findings highlighted the intervention characteristics (five constructs), inner setting (three constructs, three subconstructs), and the process (three constructs, two sub-constructs) as the most frequently addressed components of the CFIR, while individual characteristics (one construct) received comparatively less attention in the data. This is likely due to the intervention’s focus on the FBOs and the CHAs collectively rather than individually. The influential components of the CFIR that emerged from the data are illustrated in Fig 2.
CFIR-related process
a)Planning
The project team began by clearly outlining the objectives and goals of the intervention, such as improving chronic disease management among participants and increasing their engagement in health-promoting behaviors. Next, the team conducted a thorough assessment of the available resources, including human and technological resources, to support the implementation of the intervention. For instance, we identified local health professionals within the churches who could serve as CHAs and ensured access to necessary technological tools. After assessing the resources, the project team developed a detailed timeline for the implementation of the intervention, which included milestones and deadlines for each phase of the project (Table 4).
Lastly, recognizing that unforeseen challenges might arise during the implementation of the intervention, particularly given the uncertainty of the COVID-19 pandemic, the project team developed contingency plans to address potential barriers. For instance, we prepared alternative training methods and modes of communication to accommodate potential lockdowns or changes in public health guidelines.
b)Engaging
Ten out of the seventeen FBOs representing the study’s first cohort with their respective leaders actively partook in the study. Each participating FBO leader was sent an invitation notice via email, which contained information regarding the study. Once an expression of interest to participate was received, the research team met with these leaders to deliberate the expectations and research plan. FBO leaders were crucial in recruiting potential volunteers as CHAs based on their experience, interest, and ability to work with older adults in their congregation. FBOs held virtual meetings to discuss the project’s goals and objectives with interested volunteers and provided them with details of the eligibility criteria. They also used various communication channels such as bulletins, newsletters, and announcements during the few in-person services to spread the word about volunteer opportunities.
Opinion leaders (Formally appointed implementation leaders): As internal implementation leaders, FBO leaders faced competing priorities and interests, making it challenging to consistently support the project. The research team implemented strategies such as flexible scheduling, frequent communication, and progress updates to address this. The research team maintained their support and involvement by accommodating the FBO leaders’ busy schedules.
Champions: CHAs faced challenges balancing responsibilities and staying up-to-date with relevant information. The research team supported CHAs through refresher training, providing iPads, offering recognition, weekly check-ins, and maintaining constant communication. By addressing these challenges and offering flexible scheduling, the team created an environment for CHAs to thrive.
c)Executing
To enhance CHA recruitment efforts by leaders of various FBOs, the research team employed a combination of strategies and procedures to ensure we attracted and retained dedicated, competent and diverse group of individuals. These strategies and procedures included:
External Collaborations: The research team partnered with local community organizations, such as African American Community Empowerment Council (AACEC), to identify potential CHAs within their target population. This approach facilitated the recruitment of individuals who were already active in their communities and had established connections with the older adults they would support.
Word-of-mouth referrals: The research team encouraged existing CHAs and other community members involved in the project to refer potential candidates from their personal and professional networks. This strategy helped identify individuals who were passionate about helping others and had the interpersonal skills necessary to succeed as a CHA.
Social Media: The research team utilized various advertising channels, such as our FBOs’ social media platforms and radio announcements, to reach a wider audience and inform them about the opportunity to become a CHA. This strategy increased the visibility of the project and attracted a diverse pool of candidates.
Discussion
Our findings from 17 AA churches in South Los Angeles revealed a high project completion rate (72%) among participants. This success can be attributed to the implementation of a culturally sensitive, contextually relevant, and responsive approach achieved through CBPR. This approach, which involved partnering with community churches, likely increased participants’ trust and engagement with the intervention. (18, 27, 28). These findings align with existing literature on community-based health interventions targeting underserved populations. A study by Kangovi and colleagues (2014) implemented a community health worker intervention in a low-income urban population and observed significant improvements in chronic disease control and mental health outcomes (29). Similarly, Resnicow and colleagues (2006) found that a culturally tailored intervention was more effective in achieving behavior change among AA adults attempting to increase fruit and vegetable consumption (30).
We also observed a considerably higher (70%) number of female participants in this study. In comparison, Kangovi and colleagues (2014) also observed a larger number of female participants (69%) (29). Women, particularly in AA communities, often play a vital role in the social and spiritual life of their communities, with churches traditionally serving as the focal point (7). Additionally, women tend to be more health-conscious and are more likely than men to participate in preventive health initiatives(31). They are also more inclined to seek medical care, adhere to medical advice, and engage in health-promoting behaviors (32). CHAP’s focus on underserved AA older adults with chronic health conditions is consistent with other research highlighting the need for targeted interventions in this population (33, 34). For instance, Lorig and colleagues (2001) found that a self-management program targeting self-efficacy in patients with chronic diseases improved health status, self-management behaviors, and healthcare utilization (33).
This study also highlights the effectiveness of a hybrid approach combining telehealth and in-person visits. Telehealth technology improved access to care, reduced barriers, and offered increased flexibility in scheduling provider appointments, but faced challenges such as technological barriers and maintaining rapport between CHAs and participants (15, 35). Adapting to the hybrid model provided personalized care and improved communication while addressing the limitations of CHAP’s initial approach (36). This approach aligns with findings from several studies that have examined the benefits of hybrid interaction models in various populations and contexts. These studies have found that a hybrid telehealth model improved patient satisfaction, access to care, and health outcomes among older adults with multiple chronic health conditions(37–40). Similarly, Hollander & Carr (2020) reported that telehealth and in-person visits enhanced patient engagement and facilitated timely care, particularly during the pandemic when access to healthcare was limited (36). In another study, Greenhalgh and colleagues (2020) emphasized the importance of adaptability and a hybrid approach to ensure personalized, flexible patient care strategies during the pandemic (41). Furthermore, Smith and colleagues (2020) highlighted the benefits of telehealth in expanding access to healthcare and mitigating barriers faced by underserved populations, including older AA adults (15).
Clear communication and robust relationships were vital for the project’s success, as CHAs offered tailored support to older adults (15, 35). The project’s cultural sensitivity enhanced its acceptability among the AA older adult population. A supportive environment for implementation was crucial, with effective communication addressing health disparities and risks associated with the pandemic such as misinformation and vaccine hesitancy (36, 41). Tailoring the intervention delivery ensured compatibility and maintained participant engagement throughout the intervention (29). The current project’s cooperation with local church leaders and FBOs aligns with Smith and colleagues (2014) (2020), who also found that engaging FBOs was crucial in recruiting community health advisors and ensuring the success of their intervention (15). This collaboration reinforces the significance of community engagement and partnership in promoting the reach and impact of health initiatives.
Limitations
The project took place during the height of the COVID-19 pandemic, which presented unique challenges to managing chronic health conditions for African American older adults, particularly those who were isolated or had limited access to healthcare. Due to the small sample size, statistical comparisons were not feasible.
Conclusions
Overall, the findings from this study offer significant insights into the implementation process and highlight essential factors to be considered when designing interventions for similar contexts. These insights contribute valuable knowledge about the feasibility, acceptability, and impact of a hybrid (virtual/in-person) lay health advisor model during the pandemic. They can guide the development of future interventions in this domain. Our results are also consistent with existing research on the effectiveness of community-based health interventions for underserved populations. The high completion rate and improvements in chronic health condition management underscore the necessity of incorporating culturally sensitive, contextually relevant, and responsive strategies in healthcare interventions aimed at underserved African American older adults.
Data Availability
All relevant data are within the manuscript and its Supporting Information files
Acknowledgements
We would like to extend our sincere appreciation to the following faith-based organizations, all located in South Los Angeles, CA, and their respective leaders for their valuable partnership and support in the completion of this community-centered research project: Beulah Baptist Church (Rev. Dr. Robert L Taylor) Holy Mt. Calvary Missionary Baptist Church (Dr. Leonard White), Mount Salem Missionary Baptist Church (Pastor Patricia Joyce Strong-Fargas), Shiloh Missionary Baptist Church (Dr. Joe Waller), St. Mark Missionary Baptist Church (Dr. Lovely Haynes), and FAME Church (Reverend Judi Wortham). Burning Bush Church (First Lady Lorrie Denson) is in Inland Empire, CA.