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.

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Table 1. List of topics and presenters as used in training guideline for CHAs.

https://doi.org/10.1371/journal.pone.0285963.t001

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.

Ethics statement.

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.

a) Source.

CHAP emerged as a tailored solution based on the community’s expressed needs during the COVID-19 pandemic. This solution was the result of thoughtful initial deliberations between the research team’s community faculty and AA church/community leaders. Instead of being perceived as an external imposition, it was recognized as a grassroots response tailored to address specific chronic disease management challenges. The integration of CHAP within the AA faith-based framework and its alignment with prior relationships and community values significantly boosted its credibility and trustworthiness. Gathering stakeholder input and assessments throughout the project development process via virtual interviews, focus group discussions, and questionnaires was instrumental in understanding the holistic sentiment of each involved stakeholder.

b) Evidence strength.

The project utilized a CBPR approach, considered a high-quality study design in the field of public health research [42]. The project’s use of faith-based health advisors aligns with evidence supporting this approach’s effectiveness in closing unmet needs gaps and decreasing health disparities for minority communities, including AAs [20, 21, 43–47]. The CDC "scaling up operation" recommends that faith-based organizations (FBOs) establish and maintain communication with local authorities and work closely with health organizations to implement COVID-19 guidelines effectively [22]. Telehealth methods had been suggested as an innovative approach to delivering healthcare services to vulnerable populations, such as AAs, who experience disparities in accessing and maintaining healthcare services [48–50]. AA churches have historically supported their families economically, spiritually, socially, and culturally through programs that are unmatched by other social institutions [20].

c) Relative advantage.

In analyzing CHAP’s integration of virtual technology versus conventional in-person healthcare delivery mechanisms, multiple advantages became evident. CHAs highlighted that the virtual approach offered improved access to primary care providers, diminished barriers to receiving support, and enabled more consistent communication with participants. This virtual approach paved the way for delivering personalized and timely assistance, a noteworthy reduction in in-person health provider and community visits amidst the pandemic, and increased flexibility in scheduling provider appointments. This juxtaposition underscores the potential of the virtual system to address some of the shortcomings inherent in the conventional healthcare delivery model, especially during times of public health crises.

d) Adaptability.

The COVID-19 pandemic greatly impacted chronic disease management for underserved older adults, especially when physical distancing measures significantly limited in-person visits. Initially virtual means of interaction used but it encountered technological barriers and challenges in building rapport. In response, the project team adapted to a hybrid model, model that blended both in-person and virtual check-ins, allowing for personalized care and improved communication.

e) Design quality and packaging.

The research project ensured design quality by providing comprehensive training to FBO leaders and CHAs through a 3-day virtual workshop. FBO leaders received computers, while CHAs were given iPads, resource manuals, and biweekly discussion topics with detailed links to data and resource materials. Continuous feedback and response mechanisms were implemented through weekly meetings with research staff.

f) Complexity.

The program’s nine-month span brought forth intrinsic complexities, including the mandatory bi-weekly meetings and maintaining regular communication between CHAs and older adults. The utilization of multiple communication methods- ranging from videoconferencing and phone calls to direct in-person sessions–added further depth to the complexity, especially in ensuring consistent and effective engagement. Ensuring the reliability of internet access and technology availability posed another set of challenges. However, the team’s approach in providing continuous technical support and troubleshooting helped navigate through these technological intricacies. Managing these overlapping layers of complexity was also essential for further accurately capturing supplemental nutritional, physical activity, and food insecurity data in pre- and post-intervention surveys.

a) Cost.

The CHAP initiative demanded meticulous financial planning. Delving into its cost structure, initial expenditures were directed towards infrastructure: technology pivotal for virtual communication, training modules for FBO leaders and CHAs, and essential materials aiding their roles. While the expert team of workshop resource persons (Table 3) volunteered their training expertise sans compensation, there were indispensable costs. These included compensations for survey and evaluation completions, salaries for three key research team members, and funds earmarked for an end-of-project conference—envisioned as a space for knowledge exchange, results dissemination, and stakeholder dialogue. Despite these significant costs, the potential for long-term savings became apparent with fewer in-person visits and augmented accessibility to primary care via telehealth.

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Table 3. Recruitment and completion rates of CHAs and participants.

https://doi.org/10.1371/journal.pone.0285963.t003

a) Network and communications.

Within each participating FBO, a well-established system of communication became a linchpin for the intervention’s success. The faith-based organizations’ inherent structure facilitated seamless interactions between participants and the research team. The existing rapport and trust within the community, accentuated by the CHAs’ role, ensured that the communication was not just frequent but also meaningful. This robust network, built on shared values and goals, played a pivotal role in surmounting the challenges posed by the complexity of the intervention. It demonstrated the crucial role of internal communication systems in supporting and enhancing the objectives of external interventions like CHAP.

b) Culture.

The use of CHAs from the local churches further ensured that the project was culturally appropriate and responsive to the community’s needs. Several specific examples of the culture construct can be highlighted to demonstrate how it was addressed and integrated throughout this project’s implementation process. Some included:

1. Cultural beliefs about health and illness. The project addressed community preferences for traditional or alternative medicine by training CHAs to incorporate these beliefs into evidence-based self-management strategies.

"As a CHA, I encountered an older adult who relied on herbal remedies to manage their diabetes. I worked with them to ensure these remedies were used alongside conventional treatments, resulting in better blood sugar control."

(FBO#1,CHA#2)

1. Dietary practices and preferences. The research team ensured that culturally relevant nutritional advice was provided, considering specific dietary practices and preferences within the AA community.

"One of my older adults loved soul food, so I helped them find ways to prepare their favorite dishes using healthier ingredients and cooking methods, making their meals both culturally satisfying and beneficial to their health."

(FBO#2,CHA#1)

1. Language and communication. CHAs were selected based on their familiarity with the cultural context and communication styles of AA older adults, and educational materials were modified to be culturally appropriate.

"We made sure our educational materials spoke to our community, using analogies and references that our older adults could easily relate to. This approach made complex health concepts more accessible and understandable."

(FBO#4,CHA#2)

1. Family and community dynamics. CHAs were encouraged to engage with the older adults, their families, and community networks, fostering a supportive environment for self-management strategies.

‘Most of the people I recruited were my family–my husband and sisters. Going through this process, I was able to find out about everyone’s health issues that I never knew they dealt with in the past.’

(FBO#1,CHA#1)

1. Traditional community gatherings. The research team leveraged traditional AA community gatherings as opportunities to raise awareness about CHAP and actively engage with the community, showing respect for the community’s culture and building trust with older adults and their families.

"I used our weekly dinner and bingo sessions to talk with community members about the health ambassador program. We shared stories, addressed concerns, and offered support in a relaxed, familiar environment. It helped us build trust and connect with the community on a deeper level."

(FBO#5,CHA#3)

c) Implementation climate.

Creating the right implementation climate for the CHA intervention required a sense of shared commitment, necessary resources, training, and clear goals. Issues stemming from ambiguity, including confusion about objectives, roles, and expected outcomes, were addressed through additional meetings and workshops. Also by the development of detailed guidelines, the establishment of more explicit performance metrics, and the implementation of regular check-ins with CHAs and community partners. These efforts helped with maintaining clarity, resolve emerging issues, and reinforce the shared commitment to the program’s goals.

1. Tension for change. This awareness of existing health disparities within our target communities created a sense of urgency and motivation for change among the research team, CHAs, and community partners, fostering a conducive environment for implementing the CHA intervention. The lack of support perceived by AA older adults, coupled with heightened concern, misinformation, disinformation, confusion about the messaging and pandemic-related risks increased this tension for change, as stakeholders recognized the need for additional support and resources.
2. As the CHA intervention was implemented, the research team collected success stories from older adults who had benefitted from the support provided by the CHAs. Sharing these success stories with the broader community, including those who were initially resistant to the program, helped demonstrate the intervention’s positive impact and increased the tension for change by showcasing the program’s benefits.
3. Compatibility. To address the specific needs of each participant, the project allowed CHAs to customize the delivery of interventions based on the choices and circumstances of each older adult (Kangovi et al., 2014). Depending on the participant’s comfort level and accessibility, CHAs could choose between selected in-person visits, phone conversations, or virtual meetings. This adaptability boosted the program’s compatibility with the diverse demands of the older adults and contributed to sustaining participation throughout the intervention.
4. Relative priority. Non-participating local church leaders and FBOs collaborated with the project team, actively referring older adults in need of CHA support and participating in the evaluation and improvement of the intervention.

Self-efficacy.

The project equipped CHAs with the knowledge, skills, and resources to provide tailored support, broadly categorizing the approach into training, social support, and peer modeling.

Training: CHAs were trained to employ goal-setting, problem-solving, and self-monitoring techniques/approaches to assist older persons in building confidence in their abilities to manage chronic diseases and stick to treatment programs.

1. Peer modeling. The CHAs, who shared comparable cultural and socioeconomic backgrounds with the older persons they supported, functioned as role models by displaying good self-management skills and highlighting success stories from their communities. Peer modeling played a crucial impact in boosting older individuals’ self-efficacy.
2. Social support. The CHAs also gave older persons with social support, boosting their self-efficacy by establishing a sense of belonging and connection. This assistance comprised emotional encouragement, educational support, and practical solutions in managing their chronic diseases. CHAs provided reassurance, answered concerns, and assisted with chores such as organizing medical visits and navigating the healthcare system.

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 comprehensive assessment of the available resources, including human and technological resources, to support intervention implementation. For instance, we identified local health professionals within the churches who could serve as CHAs and ensured access to necessary technological tools. Following the resource assessment, the project team developed a detailed implementation timeline, which included milestones and deadlines for each phase of the project (Table 4). Lastly, acknowledging the potential for unforeseen challenges, particularly in light of the uncertainties posed by 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.

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Table 4. Project timeline.

https://doi.org/10.1371/journal.pone.0285963.t004

b) Tailoring strategies.

The need for tailored strategies became evident through initial interactions with different FBOs. For instance, while one church had a strong tradition of holding weekly health seminars, another had a robust system of home visits by church elders. Capitalizing on these pre-existing structures, for the former, we integrated our health messages into their weekly seminars, making them more resonant with the congregation’s expectations. For the latter, we incorporated health check-ins during home visits, leveraging the trust and rapport that the elders had built over time. Such customizations ensured that the interventions were not seen as external impositions but seamlessly integrated into the fabric of the FBOs’ practices.

c) Assessing context.

The contextual assessment delved deeply into the dynamics of the community, unearthing some significant barriers to healthcare access. A recurring theme, highlighted by many participants, was a deep-seated medical mistrust, rooted in historical injustices and discriminatory practices experienced by the African American community [30, 51]. By acknowledging this mistrust, we ensured that our strategies were not just about disseminating health information but also about building trust and rapport. Efforts were made to involve trusted FBO figures, like head pastors or respected leaders/elders/administrators, in the intervention. Their involvement acted as a bridge, ameliorating some of the mistrust and facilitating more open conversations about health and disease management.

d) Engaging.

Integral to the project’s success was the proactive engagement of stakeholders at every phase. Beyond the typical participants, a concerted effort was made to involve local health professionals, faith leaders, and community/FBO influencers. Out of the initial 17 FBOs representing the study’s first cohort, 10 actively participated alongside their respective leaders. The participation commenced with each FBO leader receiving an invitation via email containing information regarding the study. Once we received their interest in participating, the research team met with these leaders to discuss expectations and the research plan. FBO leaders were crucial in recruiting potential volunteers as CHAs drawing upon their experience, interest, and capacity to work with older adults in their congregation. FBOs held virtual meetings to convey the project’s goals and objectives to interested volunteers and provided them with eligibility criteria details. They also used various communication channels such as bulletins, newsletters, and announcements during the few in-person services to disseminate information about volunteer opportunities.

1. 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. To address this, the research team implemented strategies such as flexible scheduling, frequent communication, and progress updates. The research team maintained their support and involvement by accommodating the FBO leaders’ busy schedules.
2. Champions. CHAs faced challenges balancing responsibilities and staying updated with relevant information. The research team supported CHAs through refresher training, equipped them with Apple iPads, offering recognition, conducting weekly check-ins, and maintaining ongoing communication. By addressing these challenges and offering flexible scheduling, the team created an environment for CHAs to thrive.

e) Executing.

To enhance CHA recruitment efforts by leaders of various FBOs, the research team used a combination of strategies and procedures to ensure we attracted and retained a dedicated, competent and diverse group of individuals. These strategies and procedures included:

1. 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 serve.
2. 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 with identifying individuals passionate about helping others and had the interpersonal skills necessary to succeed as a CHA.
3. Social media. The research team utilized various advertising channels, such as our FBOs’ social media platforms and radio announcements, to broaden their reach and inform a wider audience about the opportunity to become a CHA. This strategy increased the visibility of the project and attracted a diverse pool of candidates.