Faith: a project in building community capacity.

Abstract: This planning grant was a unique opportunity to learn how to effectively work with faith communities and increase their capacity for further community development. Faith communities were identified and selected for participation based on their location and characteristics of their populations. Committees were formed, developed a needs assessment tool, and then assessed their congregations to identify health interests or concerns. Upon analysis, the committees determined projects for implementation. Capacity building occurred through participation in the program and the various training sessions as well as surveying congregations, writing grant proposals, determining assets, collaborations, and development of projects. This program focused on systematic change and building capacity, competence and critical awareness. These components provide more impact on health than individual behavior change as they increase skills and resources of groups.

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There goals of Healthy People 2010 (H.P. 2010) are: improved quality of years of life and decreasing health disparities. Decreasing health disparities is long term and challenging, specifically because these disparities are environmental as well as individual. To achieve this goal, varied and numerous programs must be developed, implemented, and evaluated. Diverse partners in health promotion are considered and diverse strategies are attempted, with the aim to reduce these disparities and increase quality years of life.

Faith communities are natural partners for health education. Most function with well being of the individual at their core, and the volunteerism and good will that exist in many faith communities make them viable partners for community health programs. Became many faith communities function also as social centers (Ransdell, 1996), they have the ability to impact large groups of individuals and their families. Additionally, the trust and security that many feel in faith communities increases the credibility of programs offered and the likelihood of participation.

Utilizing faith communities for health education is neither new nor innovative. In fact, many faith communities have implemented their own health education programs to meet the needs of their congregants (Hatch, Moss, Saran, Presley-Cantrell & Mallory, 1993; Hatch & Derthick, 1992) and many specific health programs have been implemented in faith communities (Fox, Stein, Gonzalez, Farrenkope, & Dellinger, 1998; Campbell, et al., 1998; Ransdell, 1996).

Still, health disparities exist and the gap continues to widen. Lives are cut short by chronic diseases that are largely preventable. Increased efforts for education, prevention, early screening and detection are necessary if we are to reach the H.P. 2010 goals. Utilizing faith communities for these efforts is imperative.

REVIEW OF LITERATURE

It is widely recognized that including the target population in the planning, implementing, and evaluation of health programs has increased their effectiveness and perhaps even their success. Using volunteers from the population, designing programs based on the community's needs and interests, and implementing culturally relevant programs have all become methods for increasing participants' awareness and behavior change. Community programs that "start where the people are" in identifying needs and discovering solutions are reported to be more successful than those that are preplanned. Further work has prescribed the use of strength-based assessments and problem identification based on community input (Minkler, 1989; Wallerstein, 1992; Braithwaite et al., 1994; Steckler, 1993; Steuart, 1993; Preston, Baranowski & Higginbotham, 1988; Thompson & Kinney, 1990; Paradis, et al 1995).

Because of the strong support for filling community health needs, churches have been the focus for many health education programs (Wiisst & Flack, 1990). Faith based programs appear to be more successful in reaching marginalized and underserved people because of the perception of trust and security that many find in faith organizations (Davis, et al., 1990). Churches are credible and in many neighborhoods are the oldest established institutions. They offer hope to many in areas that are pervaded by hopelessness, doubt, and materialism (Freudenberg, N., 2000). Churches have space and volunteers and, as helping organizations, reach large numbers of individuals (Ransdell, L. & Rehling, S., 1996). Churches and other religious organizations represent a potentially productive avenue into American racial and ethnic minority communities. They function as social centers and educational facilities, as well as health care resource centers (Sutherland, M., Hale, C.D., & Harris, G.J., 1995; Kong, B.W., 1997; Turner, L.W., Sutherland, M., Harris, G.J., & Barber, M., 1995; Wiist & Flack, 1990).

As with all health education programs implemented in an organization, a program champion is required. Pastoral support is necessary in faith-based programs for sustainability (Haber, D., 1984; Turner, L.W., Sutherland, M., Harris, G.J., Barber, M., 1995).

A problem that has occurred in faith based programs has been the use of faith communities by health educators for short-term programs focused on results for a single behavioral intervention such as number of people quitting smoking, instead of long-term holistic programs. Faith based programs can effect a wide range of behaviors (Cook, 1997). Illness and disease are often related to behavior, to psychological states, and to what is happening in terms of spiritual well-being. Faith-based health education programs must understand how these factors are interrelated and account for them in planning and implementation (Sanders, E.C., 1997). Other barriers found in working with faith based communities is participant's lack of time for program development and participation, lack of volunteers to commit to the program, facility scheduling and conflicts with other program (Ransdell, L. & Rehling, S., 1996). Benefits to participants must be accounted for in initial planning stages (Jackson, R.S. & Reddick, B., 1999). "The best predictor of long-term success is the extent to which broad and informal networks are achieved. Personal interactions build relationships, a foundation for building strong ties and effective collaborations" (Jackson, R.S. & Reddick, B., 1999, p.673).

Derose et al. (2000) found that direct involvement of the outreach team and community advisory committee with those in the religious community was critical to successful program implementation. The importance of relationships and trust developed through those relationships cannot be ignored

Many political figures look to faith communities to assist with those in poverty and many faith communities are actively involved in abetting poverty. "Religious groups can work with homeless people and do whatever they actually need, not just what fits some obtuse guidelines. They can give away resources without self-interest. In the U.S., many positive initiatives, including some done by government, were pioneered by churches: schools, hospitals, help for the disabled, welfare, housing for the poor, etc."(Gunderson, G., May 3, 1996). The ultimate goal of all health promotion projects should be to organize communities in an effort to reduce social/physical disease risk factors and increase quality of life.

Building community capacity is a process that is not quick, easy, or certain. The process requires time. The relationships that are established and nurtured are as important as the complexion of tasks or the implementation of programs. It is on these relationships that trust is formed. Trust is the essence of the relationships that lead individuals to discovering their strengths and developing skills to meet their needs (building capacity). "Like democracy, prevention only makes sense when it includes the whole population. Community is not some sort of equation that needs to be solved. There is not one arrangement or variable that can frame the question and lead to an answer. Nature has found that distributed intelligence is more efficient than any centralized planning process. There will be common themes known by, communicated by, the informal network that pervades a community and we can trust the informal network" (Gunderson, G., November, 26, 1996, p.5).

DESCRIPTION OF CASE

Due to resource limitations and lack of capacity for health promotion among and within regional faith groups, effective Health Ministries are generally not implemented. Yet, for the 32% of adults who lack health coverage identified by the El Paso Health Report (Brown, Wyn & Teleki, 2000), faith groups remain an authoritative source for health information and a model for healthful living. Local studies confirm that 95% of people attending Sunday mass in El Paso think that places of worship are effective contact points for health education. Furthermore, the El Paso "Parish Health Ministries Conference in August of 1999 underscored the complex nature of health ministries and revealed community interest in health ministries (Health, 1999).

In eliminating health disparities, faith communities remain a source of information and access to services for many who have no other means of health education. A planning grant was funded by a philanthropic organization (the foundation), technical assistance provided through a religious organization (the agency), and evaluation performed by the first author, a university faculty member. The grant joined faith communities and community resources in identification of needs and assets for implementation of health ministry programs. Opportunities were provided for capacity building through workshops and group work. Capacity building is one method for strengthening a congregations' ability to minister to the health of their members. One goal of this program was to minister to the whole person in each congregation and the surrounding community. It was not a public health program, but a team approach to improve health through increased capacity, competence and critical awareness. The approach consisted of assessment of congregation's health needs, assessment of resources within the congregation and community, collaboration with area agencies and other congregations to meet the identified needs, provision of technical assistance, enhancement or expansion of existing congregational programs, and development and submission of proposals to the philanthropic organization for program funding. Programs are developed based on the congregations' identified needs and utilization of existing resources within the faith community and the larger community. In this way, faith communities met their health needs and actively pursued resources. Community-based organizations and agency programs were better utilized because they were used where they were needed, not at the whim of the organization or agency.

PROGRAM DEVELOPMENT

In the development of this program, staff first asked, "How should faith groups work together or with other agencies to maximize behavioral or health outcomes within places of worship?" Collaboration was used where it was appropriate, but ownership of the program i.e., implementing specific behavior change programs, remained with the faith groups. Maximizing health outcomes requires education and training, environmental, pastoral, and congregational support, and a desire to succeed. It was decided that facilitation of capacity building was the first step to maximizing health/behavioral outcomes. Training of committee members in grant proposal writing, program development, and evaluation techniques was the foundation for capacity building. Program development was more successful because individuals within the faith communities identified areas for change and implemented their own programs. It was not initiated by anyone from an outside agency. This also aided in participation by the communities because individuals are more likely to participate if the person leading the program is someone they know. As ownership of the program was established and skills were learned, building of capacity commenced. Improving health outcomes was the long-term goal of this program. It was recognized that both behavior change and social change were required to reach this goal.

As the program was developed, it was determined that committed volunteers with proper training could coordinate the program with the faith communities. A director was necessary to facilitate program implementation, lead training sessions and workshops and act as a liaison between other agencies and community-based organizations. The director also served as the fiscal agent and the committees turned in receipts for payment of expenses. In-kind contributions for ongoing or regular expenses were explained and some groups sought both in-kind contributions as well as donations of goods or services for large projects.

Within each faith community, it was determined there was no need for the program to fund a health minister. A sign of institutionalization and sustainability of a program is the dedication of funds by the organization involved for its support. Training was the best way to ensure the program was used appropriately. Committee members were trained by the program director to increase accountability. Technical assistance and support were provided by the program director to facilitate program development and implementation; the support for change was necessary for success and skills were needed in facilitating change. As the faith groups incorporated the program mission as their mission, they developed a program unique to their faith group and maintained the autonomy necessary to fulfill their objectives and still maximize health outcomes. This planning grant also helped the funding agency locate new partners to leverage funds for future initiatives, developed effective relationships with these partners, and identified potential leadership for the promotion of good health.

A requirement of the funding process and participation in the program was that those most in need, underserved or marginalized would be the recipients of the programs as well as those within the faith groups. As the program diffuses, faith communities who are not in poverty areas or who are comprised of those who may not be disenfranchised may chose to participate through partnerships with other faith communities who are. This would be a positive step and could lead to increased capacity and community in both faith communities. It would not be a position of power but one of support and collaboration.

The funding agency and the various faith communities were concerned about proselytizing. The goals of the initiative were held first and foremost and service was the underlying thread, not increases in membership in any one faith group. This helped to minimize proselytizing. Faith communities needed to be very clear in their motivation for participation. The director also monitored activities as well. It was made clear that those desiring to participate would not be barred because they were not members of any one group.

Concise expectations were necessary for accountability and compliance. Clear goals and objectives, explanations of how and why guidelines were to be followed, trust, and respect helped increase accountability. Ultimately, those who chose not to follow the guidelines stir-selected out of the program. Faith groups who choose not to follow the guidelines do not have to participate in the program.

SELECTION OF FAITH COMMUNITIES

Faith communities were identified for participation based on their location and characteristics of their populations. A one-mile radius from the religious organization was used to select potential churches. One requirement for participation was the pastor's commitment and participation on the committee. Another requirement was that the location of the church had to be in an area where at least 20% of the families were living in poverty. This was determined through census tracts. The faith communities involved were selected based on location, population base and income. These were then contacted and asked to participate. One community declined to participate because the pastor felt her congregation was not ready for such a project. Others not selected did not fit the profile as delineated by the planning grant.

The faith communities who agreed to participate were: one Catholic Church, two Lutheran Churches (one Spanish-speaking, one English-speaking), one Pentecostal Church (Spanish-speaking), one Church of Christ Scientist, one Presbyterian, and one Baptist Church. Pastors of the participating communities stated that the program fit their values and missions. Committees, formed by the Pastor, selected and modified a needs assessment tool that reflected congregational values. Committees assessed their congregations to learn about health interests or concerns and assets within their communities. The assessments were analyzed and reports were returned to the committees. Committees then received a Request For Proposal from the philanthropic organization to apply for funds for project implementation.

Grants were offered for initial program implementation and training was provided by the program director in the completion of the applications. Grants of up to $1600.00 were awarded. Communities who had the maximum number of members (10 total) on their committees were eligible for the full amount. Although this figure seems low, the emphasis was on providing funds to get something started and locate other resources for sustainability. The committee members learned how to complete Request For Proposals to solicit future funding from various organizations. The foundation did not plan to be the ultimate funding of the initiative but to provide "seed" money and technical assistance for faith communities to move forward.

Upon funding, each faith community implemented the programs to meet their perceived needs. The programs implemented included exercise and nutrition programs, preparation and the delivery of meals to shut-ins, development of a Praise dance that included all ages, a safety program for children in their after-school program, and the design and construction of a Labyrinth Prayer Walk.

EVALUATION

Providing situations for participants to meet each other, learn from each other, and share experiences helped build trust, increased collaboration and capacity, and led to increasing community competence and leadership development. These were essential in building sustainable programs that lead to healthy communities (Johnston, G. & Gottlieb, N., 2002; Minkler & Wallerstein, 1997). The project coordinator created situations for committee members to get acquainted and work together. The feedback from participants at meetings and workshops was favorable and constructive.

   "Going through the grant writing process
   as a group built trust and understanding
   within our bilingual, bicultural group". "
   The brief time in which to accomplish the
   grant writing process was difficult." "It has
   broadened my vision and appreciation for
   the actions of other congregations." "It has
   been a great learning and growing experience."
   "It has given us the impetus to do
   more than we knew we could do. It helps
   to know there are others working toward
   the same goals."

The concept of building capacity was present through the faith communities' assignments as they assessed their strengths and resources to adequately determine where they could address their needs. As each faith community was different, with different population demographics, belief structures, and locations, generalizability was limited to the scope of the project. Comparison across communities was done based on storytelling and review of the documents involved in their work. The use of Outcome Engineering provided the committees with a method for evaluating themselves and comparison of their work with others in the program. This was another means of building capacity and strengthening or encouraging collaboration. As members charted their progress, they could readily see where they were in the process and where they needed to go. As they examined what others were doing, the opportunity for collaboration was created.

This planning grant was not prone to many pitfalls agencies or organizations encounter when implementing new programs with faith communities. Instead of just doing health programs in the faith communities (giving them fish), the philanthropic and religious organizations sought to not only teach the participants "how to fish" but also showed them "how to build their own fishing poles and give them maps of the area showing the location of the fishable waters" (allowed them to develop their programs using their own resources and based on their belief systems). This method helped to increase ownership, build capacity, increase participation, and improved access to preventive measures for health. The faith communities learned how to meet their own needs and utilize their own resources through assessing their own communities, collaboration, and grant writing.

Evaluation occurred at multiple levels: overall (each group, the foundation and the agency), the coordinator's input and experience plus self-evaluation, and input from the foundation and the agency. The six faith communities completed the original requirements of their participation: they assessed their needs, discovered resources, planned programs to meet their needs and wrote small grant proposals for initial funding. The grants were funded and the faith communities began program implementation. Actual implementation was as varied as the programs themselves. Some began locating additional funds and resources, others recruited participants. At the end of the funding cycle, one church had completed their program and was in the process of locating other resources and collaborating with other organizations, both secular and faith-based. Others were in various stages of implementation.

Process evaluation occurred to keep abreast of what was happening. Outcomes were based 1) on the faith groups' goals and 2) on the Initiative goals. The outcomes for the planning grant were clear. Based on the fulfillment of those goals, the Initiative should have diffused to the larger community. The outcomes were met so plans for diffusion should have continued. Ultimate outcomes for the Initiative were verbalized ("that this initiative becomes the churches' mission"). Methods to evaluate that ultimate outcome were not delineated. The ultimate goal of the program was not determined. The program was not continued.

LESSONS LEARNED

In all programs, challenges exist and the opportunity for growth is present. Lessons learned from this program included the value of listening to each other, allowing participants to work from their own value systems and doctrines of their faith, providing assistance at whatever level was necessary, and the uniqueness of working with volunteers.

The project coordinator stated: "I wish I had known a little better that the relationships were so important. I would have made an even bigger effort to begin nurturing those relationships with the Pastors a lot sooner. It would have made things go a little faster, although I think that things have progressed fast enough. It is a challenge to work with volunteers.

A challenge that was encountered was the different levels that faith communities enter the program. Some individuals/faith communities are very well versed in our society, have high levels of education and literacy and a good command of the English language. Others are at different levels, not having obtained a high level of education or literacy or are not English proficient. Acknowledgement of these differences, but also willingness to assist participants at whatever their level of need was necessary for the success of this program. This was one reason for not comparing across groups, but accounting for change within each group. Individuals with less education or fewer networks may or may not have more difficulty in building capacity. It is important to recognize that those who self-select to participate may be more capable of succeeding or may identify more easily with the scope of this program.

Another challenge remains the differences in culture as well. Clear understanding of how different cultures function is clearly necessary to enable the program to be successful. Part of the process evaluation of this grant was determining how best to work with these various and diverse groups. We learned that ethnicity may be important, but gender and status can have equal impact. Dressing appropriately for meeting with each group, providing translation services (for all participants) at all meetings, and earning the trust instead of expecting it outright are examples. Additionally, having a specific denomination's agency act as fiscal representative may hinder the ability of this program in working with all Religious Organizations as the denomination itself may be a barrier to some who would like to participate. Therefore, it may be more appropriate for a secular agency to act as fiscal agent and provide technical assistance.

Maintaining motivation, participation, and focus was a concern for the committees in the coming year. The participants expressed the following: "The hope that we will remain mutually concerned about each other's projects." "Finding proper implementation personnel." "Keeping the momentum going." "I hope we are able to grow individually, congregation wise and community wise as we develop our project." The first year, participants tend to be very enthusiastic about their commitment and their abilities. As time passes, the realities of bringing programs from paper to implementation can force individuals to withdraw and lead to breakdown in the entire program. It is crucial to expand a program slowly so that those currently involved are not left without the support they need (Johnston, G. & Gottlieb, N., 2000). In building capacity and competence, individuals learn and grow at their respective paces. They may require more or less support in the process. This will not be known until the process is completed. Therefore, it is necessary to maintain whatever support and contact is needed to ensure the process can be completed.

OUTCOME ENGINEERING

Outcome Engineering, a web-based evaluation method (http://www.outcome-engineering.com), was used to assist the committees with their evaluations. This method allows committees to view what others within the program were doing, increasing opportunities for collaboration.

After the participating faith communities were awarded their funds, training sessions were held to teach committee members how to use Outcome Engineering to assist in documenting their accomplishments. Five of the six faith communities had at least one training session. It was recognized that the Outcome Engineering trainings (and subsequent use of Outcome Engineering) would have been more effective if the Faith Communities had been introduced to it from the beginning. That would have enabled continual logging of information and the capture of experiences quickly instead of after-the-fact.

One of the down falls of Outcome Engineering was that unless the person entering the information provided detail, the depth of the information was shallow. The descriptions were too brief to generate much information. If Outcome Engineering is to be used in future programs, training in data entry must be in depth and consistent. It was difficult to see the wealth of the experience in such concise descriptions. Therefore, training needed to emphasize how important this information was to the program staff. Only four churches used Outcome Engineering and of those only one was in-depth.

Another problem with Outcome Engineering was lack of access to computers and the Internet for data input. Many of the participants were not computer literate as well. A possibility not explored would have been having evening and weekend hours at the program office to allow committee members' computer access to input their data. This would have required the program staff's presence for technical assistance. Logistically; it might have been easier for the staff but more difficult for committee members. Committee members' time and lack of transportation may have become barriers.

An alternative to using Outcome Engineering might have been the use of a guided discovery journal. Guided discovery journaling captures the individuals' thoughts, perceptions, etc. as it uses a question format for the user to follow. These questions could have been the same as those used in Outcome Engineering. The journals could then have been entered into Outcome Engineering or any other database for evaluation purposes by program staff.

As has been discovered in the past, each faith community and each individual on the committee had unique strengths and experiences. Instead of forcing each one into a specific form of compliance, perhaps offering different methods would have been more appropriate. If computer skills were necessary for participation, one of the training workshops of the program should have been computer training.

It was recognized that as capacity was built, these groups became more capable of accessing existing programs and services. In one respect, this program was "leveling the playing field" for those who wished to participate in or access services that had been unavailable either through lack of knowledge or lack of access. Therefore, it was a minor expectation that faith groups, once understanding of the processes and resources available, would not need a "special" program. As these six continued in their program implementation and evaluation, they may have found others who needed similar assistance and support and the program may continue through those channels.

In working with these diverse groups, some of the challenges may have been a matter of theology. Catholicism is based on form and ritual, it requires structure. Protestants encourage the freedom of expression and the telling of stories, the substance. The more conservative the Protestant denomination, the more form and ritual play a larger role (Rosten, 1975). Within the scope of these differences, the program could function and be successful. The key is finding the niche that each faith community fills and showing them that this program can compliment and strengthen what they are already doing. The faith community becomes better established within their niche and grows accordingly. This process will become more evident with time and working with the different groups. Over time, and through collaborations, this program may have become more appealing to all groups.

SUMMARY

This planning grant provided a unique opportunity to learn how to effectively work with faith communities. Faith communities provide access for many who are underserved or marginalized to education and skills for improving their quality of life. This grant also provided the opportunity to facilitate growth and change. It was not simply the placing of programs in churches. There were already ample opportunities for that, many agencies and programs exist for individual behavior change. This program was about systematic change, which can provide so much more, more opportunities, more access, more success. The beauty of this program was that each faith community was allowed, and expected, to assess their own needs and strengths, to develop their programs based on what they found, and evaluate their progress in reaching their goals. The grants were small to encourage leverage of funds, in-kind contributions, donations, and collaborations. They were not meant to solely support any program or community. This provides more opportunities for increasing capacity and community competence.

Churches and religious groups, have the foundation of spirituality, the belief in faith, the trust in the Almighty. They can, and do, reach those that government agencies cannot. They can be, and have been, very successful in meeting the needs of many. It is simplistic to think that one program could fit all faith communities. Cookie-cutter approaches of program implementation tend to fail because they do not recognize the strengths or the needs of those for whom they are intended. Working with government agencies to help the homeless, the poor, the disabled are goals of many community-based organizations, both religious and secular. It is hoped that programs such as the one described here can continue by providing support and assistance for that end.

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HEALTH EDUCATION RESPONSIBILITY AND COMPETENCY ADDRESSED

Responsibility II--Planning Effective Health Education Programs

Competency A--Recruit community organizations, resource people, and potential participants for support assistance in program planning.

Sub-competency 4--Incorporate feasible ideas and recommendations into the planning process.

Georgia N. L. Johnston, Ph.D., CHES is an Assistant Professor in the Department of Health and Kinesiology at the University of Texas, San Antonio. Beatriz Benitez, B.S., CHES was a graduate student in the Department of Health and Kinesiology at the University of Texas, San Antonio. Address all correspondence to Georgia N. L. Johnston, Ph.D., CHES, University of Texas, San Antonio, Department of Health and Kinesiology, 6900 N. Loop 1604 W., San Antonio, TX 78249, PHONE: [phone], FAX: [phone], E-MAIL: [e-mail].