Church-Based Lifestyle Intervention Shows Promise for Lowering BP in Hypertensive African-Americans
The study shows that it is possible for laypeople to deliver a lifestyle intervention in churches, with at least a modest impact on BP.
Performing a lifestyle intervention aimed at lowering blood pressure in adults with hypertension at churches with predominantly black memberships appears to have at least some benefit, the cluster-randomized FAITH study shows.
An intervention combining 11 weekly group sessions on lifestyle changes with three monthly “motivational interviewing” sessions delivered by laypeople led to a 5.8-mm Hg greater drop in systolic BP at 6 months compared with a single session on hypertension management followed by a series of presentations on other health topics, according to lead author Antoinette Schoenthaler, EdD (New York University School of Medicine, New York, NY), and colleagues.
The intervention did not, however, lead to greater reductions in diastolic BP or mean arterial pressure, they report in the October issue of Circulation: Cardiovascular Quality and Outcomes.
Senior author Gbenga Ogedegbe, MD (New York University School of Medicine), told TCTMD the FAITH study “demonstrates for the first time that it is quite possible for lay health people to actually deliver a lifestyle intervention in churches. These are interventions that are otherwise delivered in primary care practices.”
He pointed out that even though the between-group difference in systolic BP seems modest, such a drop in BP has been associated with improved clinical outcomes in other studies. The intervention group had a reduction 16.5 mm Hg, Ogedegbe noted, with an unexpectedly large decline of 10.7 mm Hg in the control group (P = 0.029).
If the effect seen in the intervention group “is maintained over time,” Ogedegbe said, “we think that this will be a very, very big game changer.”
Moreover, the study highlights the importance of exploring different ways to deliver care to hard-to-reach populations and “people who traditionally don’t trust the healthcare system,” he said. “We have to figure out alternative models of care, and delivering health interventions in places where people pray, worship, play, and work is very important.”
Tapping Into Church Influence
The FAITH study, conducted at 32 churches in New York City, was designed to explore whether a church’s influence in the community could be used to enhance hypertension management. The cluster-randomized study included 373 adults who self-identified as black, had a diagnosis of hypertension, and had uncontrolled blood pressure (≥ 140/90 mm Hg or, in those with diabetes or chronic kidney disease, ≥ 130/80 mm Hg). Of the churches included in the study, 18 had a predominantly African-American membership, 10 a predominantly Caribbean membership, and four a predominantly African membership. The mean age of the participants was 64, and 76% were women. Average BP at baseline was 153/87 mm Hg.
The intervention involved an intensive phase with 11 weekly group sessions lasting 90 minutes each that covered therapeutic lifestyle changes and incorporated religious elements like prayer, scripture, and faith-based discussion points related to health. Those sessions were followed by three monthly sessions delivered by trained lay health advisors, with the goals of helping participants focus on problem-solving and maintaining the changes adopted in the prior sessions.
We have to figure out alternative models of care, and delivering health interventions in places where people pray, worship, play, and work is very important. Gbenga Ogedegbe
The control group attended one therapeutic lifestyle change session on hypertension management and 10 additional sessions on health topics not related to hypertension that were delivered by local experts. These participants also received a National Institutes of Health booklet on lowering BP.
Average attendance was similar in both groups: 58% in the intervention arm and 56% in the control arm.
The primary outcome of the trial was the reduction in systolic, diastolic, and mean arterial pressure at 6 months. Reductions were seen for all of those endpoints in both trial arms, but the between-group difference for systolic BP (5.79 mm Hg) was the only one that was statistically significant at 6 months (P = 0.029). By 9 months, while a difference of 5.2 mm Hg in systolic BP persisted, it was no longer statistically significant (P = 0.068).
At 9 months, a greater proportion of participants in the intervention arm had their BP controlled, but again the difference between trial arms was not significant (57.0% vs 48.8%; OR 1.43; 95% CI 0.90-2.28).
Churches and Barbershops
In an accompanying editorial, Jeremy Sussman, MD, and Michele Heisler, MD (University of Michigan, Ann Arbor), say it’s worth comparing the FAITH study with another community-based investigation based in Los Angeles barbershops catering mostly to black men. When pharmacists teamed up with barbers, participants’ systolic BP fell by an average of 27 mm Hg over 6 months, greater than the 9-mm Hg reduction in the control group.
There were more dramatic effects in the barbershop study, Sussman and Heisler say, because the FAITH study focused only on a lifestyle intervention delivered by laypeople and not medication management with the assistance of a pharmacist, had a lower level of participant engagement, and targeted a different population (patients with diagnosed hypertension versus those naive to treatment).
“Despite these key differences, both studies significantly advance the field of intervention research targeting access to healthcare of high-risk populations,” they write. “They both showed the effectiveness of using trusted members of the community to deliver care. They reinforce the value of reaching out to communities who have limited access or do not trust the medical community, especially communities who have excellent reason to feel that distrust.
“They also point to the need to include lessons from these and other community-based trials on how to create the necessary links between community and healthcare organizations to engage difficult-to-reach communities,” the editorialists continue. “In this sense, these studies demonstrate how far the US medical system has to go to provide care that is fair to underserved and vulnerable populations.”
For Ogedegbe, the FAITH study addresses the issue of social determinants of health.
“It’s really difficult for folks to come to the clinic every week for this kind of intervention. If you have a job, you just can’t afford to do that,” he told TCTMD. “So if we don’t figure out a way to address that kind of issue then it becomes a problem. This study begins to tell that kind of story, and I think as we build more evidence, it will be very important for the insurance companies to actually consider funding or paying for these kinds of strategies so that the faith-based organizations can engage in health promotion activities in a much more formal way than we did in this study here.”
As for next steps, Ogedegbe said his team will dig into the FAITH data to determine the “sweet spot” in terms of how many sessions are actually needed to achieve an effect, guessing that it is probably four or five.
The researchers are also in the planning stages for another study that will incorporate both elements of the FAITH intervention and the linkage to medical care seen in the barbershop study.
“And we hope with that we’ll not only have a bigger drop, which is important, but what is more important is that we’re going to be engaging more people in care and improving adherence rates,” Ogedegbe said.
Schoenthaler AM, Lancaster KJ, Chaplin W, et al. Cluster randomized clinical trial of FAITH (Faith-Based Approaches in the Treatment of Hypertension) in blacks. Circ Cardiovasc Qual Outcomes. 2018;11:e004691.
Sussman JB, Heisler M. Of barbershops and churches: can community-based interventions improve cardiovascular risk in high-risk patients? Circ Cardiovasc Qual Outcomes. 2018;11:e005149.
- The study was supported by a grant from the National Heart, Lung, and Blood Institute (NHLBI).
- Schoenthaler and Ogedegbe report being supported by grants from the NHLBI.
- Sussman reports being supported by the Department of Veterans Affairs.
- Heisler reports being supported by the Michigan Center for Diabetes Translational Research (through a National Institutes of Health [NIH] grant), the Michigan Claude D. Pepper Older Americans Independence Center (through an NIH grant), and the VA Ann Arbor Center for Clinical Management Research.