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).

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.

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.

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.

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.