The United States (US) is experiencing its highest immigration rate since the 1930s. African immigrants (AIs) are a growing yet understudied immigration population in the US. The Migration Policy Institute estimates a 40-fold increase in the size of this population between 1960 and 2007, from 35,555 to 1.4 million.1The existence of hundreds of African-initiated churches signifies the growing demographic importance of AIs in the US. AIs have created their own social, cultural and religious institutions to meet their needs as they face the challenges of integration into the US society. Churches go beyond the fulfillment of spiritual needs and serve as an important avenue to foster their social and cultural identity in AIs. Because a large proportion of AIs attend churches on a regular basis, churches may be a promising venue for understanding the cardiovascular health and health needs of AIs.
Historically, AIs and African Americans have been studied as a homogenous racial group, although health outcomes may differ due to differences in socioeconomic status, culture and genetic admixture.2Given the growing size of AIs, a paradigm shift in approach to research, gathering health information and program planning is required to reflect the diversity of Blacks in the US. Like other immigrant groups, AIs experience many challenges to maintaining ideal cardiovascular health upon migrating to the US. They face challenges with obtaining adequate health care coverage, access to needed healthcare services and navigating the complex US healthcare system.
In this presentation, we will discuss the evidence and lessons learned from the Afro-Cardiac Study3, a cross-sectional epidemiological study of Ghanaian and Nigerian-born AIs residing in the Baltimore-Washington, D.C metropolitan area. We recruited participants from seven churches that serve the AI population in the US to accomplish the study goal of examining the cardiovascular disease risk of AIs and the association with acculturation. The evidence and lessons learned from this study are outlined below.
Churches are feasible settings for engaging AIs in community-based research: Churches and other religious institutions are increasingly popular settings in which to conduct community-based research because they are relatively stable institutions with frequent attendees over many years. Churches provide timely and cost-effective access to a rapidly changing population of new AIs. Several of the churches that participated in our study included health as part of their mission and had existing and robust health ministries which assisted with coordinating the recruitment of participants for the study. Since churches attendees are from diverse socioeconomic backgrounds, in the Afro-Cardiac Study, we were able to recruit a sample that spanned the socioeconomic ladder including homemakers, taxi drivers, lawyers, educators, nurses, technicians and physicians.
Religious leaders play an integral role in recruitment of AIs: Engaging religious leaders in the AI community is an essential step in community engagement. In our experience, leaders of churches that serve the AIs were eager to meet a variety of social and health needs of their congregation and surrounding community. They served as gate-keepers to ensure that the research procedures did not unduly burden the congregation and provided tangible benefits. They believed that assisting with the medical needs of their members was an important aspect of their mission. The leaders were aware of, and described several health needs of their congregations including hypertension management and control as well as healthy weight maintenance. The leaders understood the importance of the dissemination of research findings, and also requested that we give presentations to the congregation on topics related to cardiovascular health.
Partnership development and building trust is critical: Recruitment of participants into community-based research is particularly challenging when working with AIs who traditionally have not been well served by health programs or research. A critical step in recruiting participants from the AI community is establish trust and credibility within the community. The endorsement of the research by the community leaders afforded credibility to our research. Since a number of AIs may not have legal status, it is important to communicate that maintaining confidentiality is an important component of the proposed study and that data will be published and reported on the aggregate level. Methods to ensure confidentiality must be clearly communicated and enforced through-out the research study.
Research procedures should be time- and resource-efficient: It is important that research procedures are efficient and require minimal time commitment by the church and congregation. The principal investigator should ensure that the size of the research team is adequate to ensure that the research procedures are completed within the allotted time for the study. Creating a standardized protocol and providing training opportunities for all the research team members is critical to ensure data integrity and efficiency of procedures. The research team should make every effort to minimize disruptions of the church service unless permission is granted by the church leadership.
Limitations: There are limitations and challenges to consider in using churches as recruitment sites for research. Participants recruited from churches may not be representative of the larger AI population. Participants in our study may have underreported smoking behavior due to social and religious desirability, and health behaviors of church attendees may differ from non-attendees; these aspects may limit the generalizability of our results. Smaller churches may not have adequate space for research procedures. Hence, the research team should meet in advance with the church leadership to determine space needs and strategies for overcoming this challenge.
In summary, churches or religious institutions provide a familiar and reassuring environment for targeting high risk or “hard to-reach” groups such as AIs. Our experience in the Afro-Cardiac Study suggests that churches have a high potential to play an important role in the health of AIs. Hence, health-care providers, researchers and community-based organizations should consider this setting as a viable avenue for engaging AIs in research and delivering and testing culturally-sensitive interventions to improve cardiovascular health and other health conditions.