Integrating places of worship (PoWs) into the primary care pathway to prevent and control non-communicable diseases (NCDs) in the Caribbean

The Caribbean has the highest proportion of people suffering from chronic diseases such as diabetes, cancers, stroke and heart disease in the Americas. As in other parts of the world, this is a consequence of ageing populations, urbanisation, lifestyle changes resulting from globalisation such as unhealthy diets, lack of exercise, use of alcohol and cigarettes, and other social influences. The effects of these factors on health are worse in poor communities. Health systems in poorer countries in the Caribbean face challenges in preventing chronic diseases and meeting the needs of those affected. Our approach considers how to enhance health services taking into account the wider social and cultural context in which people live. It will use the strengths and assets of communities to promote health and reach the poorest in a cost effective and sustainable way.
Religion plays an important role in the Caribbean with almost everyone attending a place of worship such as a church, mandir or mosque, at least once a month. Many studies have shown that places of worship can be used successfully to promote healthy lifestyles. However these programmes are often discontinued after the research is completed. In collaboration with national and international agencies including Ministries of Health, Inter-Religious Organizations, the Healthy Caribbean Coalition, the Caribbean Public Health Agency, and the Pan American Health Organization, we will plan and implement an intervention which uses health advocates recruited from places of worship to promote health and lifestyle changes and support the management of chronic diseases. The health advocates will be linked into local primary health care centres and supervised by nurses to ensure that when needed, early referrals are made and patients are followed up in the community. By evaluating the intervention as it is implemented in real time, we will examine whether and how this approach will improve the prevention and early detection of chronic diseases as well as support the care and treatment of those already affected.
The study will take place in three of the less wealthy Caribbean Commonwealth countries which face challenges in providing quality health care: Guyana, Jamaica and Dominica. Each of these have different social and cultural features so we will be able to compare the results and develop solutions that have relevance to the entire region. We will focus on poor rural and urban areas where the need is greatest. We will work with the Ministries of Health, nurses and doctors in regional and local health care centres and hospitals, religious leaders and congregations. The Ministry of Health will train members of the congregations to be health advocates. They will be taught to conduct simple tests such as measuring blood pressure and weight, encourage people to take medications as prescribed and attend clinic appointments, inform people about welfare benefits and help with applications, and support a healthier, more active lifestyle, such as providing exercise or healthy cooking sessions. Health advocates will be supervised and monitored by nurses at local health centres who will be trained in this new role. We will conduct continual evaluation to look at if and how the intervention is working to address the needs of the community, especially the most vulnerable.
If the research is successful, we will develop a tool kit for the Caribbean providing guidelines on how health systems and communities can work together to combat chronic diseases through the engagement of places of worship and other community-based organisations. Changing the health system in this way will reach more people than through traditional health care by providing easily accessible and regular health advice and support in the heart of local communities. It will result in significant social and economic benefits by reducing health care costs for chronic diseases and preventing disability and premature death.

We will evaluate the integration of health advocates in places of worship into the primary care pathway and the potential impact on health literacy, adoption of healthy lifestyles, early detection and referral, and NCD management. The Caribbean has the highest NCD mortality in the Americas placing huge pressure on fragile health systems. Task shifting and collaborative community-based interventions are advocated to reduce inequalities in health and address the burden of NCD, but have seldom been evaluated in LMIC. The intervention will be conducted in 3 of the least affluent CARICOM countries with differing sociocultural contexts to enhance adaptability. We will recruit health advocates from places of worship in poor urban and rural communities to conduct health promotion activities, support treatment adherence, and ensure prompt referral. Our intervention has the features of a complex intervention, i.e. multiple components and outcomes, interactions and feedback loops between intervention and context. Based on the principles of realist evaluation and MRC guidelines for the evaluation of complex interventions, we will evaluate the intervention in real time to observe the interaction between the context of the intervention, the mechanism (how it works), and the outcomes. We will use a mixed methods approach including: 1) concept mapping with stakeholders to gather information on factors influencing implementation, prioritise areas for health system improvement, and foster collaboration; 2) observation and interviews with congregants and health advocates to track the implementation in context over time; 3) quantitative survey of congregants at baseline and endline to examine the influence of the intervention on lifestyle change, health literacy, satisfaction with services, and well-being. If the intervention is successful we will develop a toolkit for up-scaling across the Caribbean through established partnerships with health ministries and regional stakeholders.

We plan to evaluate the integration of places of worship into the care pathway to prevent and control non-communicable diseases (NCDs). Universal health coverage is crucial to reach vulnerable populations. Given the wide reach of places of worship, this innovative model of service delivery will increase health literacy and accelerate access to care among vulnerable communities thus reducing social inequalities in NCD. It will also have societal benefit by improving the health and well being of the entire population. It will reduce care costs and prevent morbidity, mortality and reduced productivity. Arguably it could be seen as poverty reduction strategy given the greater vulnerability of the poor to NCD.
This approach will have significant impact on the organisational culture and effectiveness of primary health care. It helps to bring health care and information as close as possible to where people live, and is embedded in the cultural and social context. The intervention will strengthen collaboration between health services and communities, increase awareness of community needs among health workers, and strengthen the health workforce through the use of health advocates (HAs). Early intervention and prevention in primary care should reduce the need for treatment of NCDs and complications in secondary and tertiary services. Training of primary care workers and HAs will continue after the close of the project, supported by Ministries of Health (MoHs) and the Caribbean Public Health Agency (CARPHA). A network of practitioners and HAs will act as mentors and trainers for other community-based interventions and findings will be relevant to other health domains e.g. mother and child health.
The research will benefit national MoHs and regional health networks, including the Pan American Health Organization (PAHO) and CARPHA, by providing evidence to support NCD Action Plans and commitments to whole system approaches and intersectoral partnerships. If successful the study will provide a model for scale up and on-going evaluation. With support from PAHO/CARPHA/MoHs we will produce a toolkit to guide policy makers on best practice for up-scaling the intervention. The longstanding relationship between the University of the West Indies (UWI), CARPHA and CARICOM provides an effective conduit for research evidence to influence government policy and for Caribbean-wide uptake of the approach with the support of WHO/PAHO. The approach also has international transferable value to resource poor communities with high levels of religious involvement.
We will disseminate findings to stakeholders via professional development events and workshops with professional, patient and civil society organisations (e.g. the Healthy Caribbean Coalition, national Diabetes and Nurses Associations). We will hold seminars at UWI, University of Guyana, Ross University School of Medicine and other higher education institutions to present the findings to students and researchers in the fields of nursing, medicine, and public health. Results will be presented at regional and international conferences, including a symposium hosted by CARPHA at their annual scientific meeting, and in articles in high impact scientific journals. With the support of a communications expert (Co-I PM) we will disseminate findings to communities through local and regional media and through film, drama, and music at places of worship, festivals, and other community events.
This project will strengthen the scientific partnership between UK and UWI research groups and establish a new regional coalition with researchers in Guyana and Dominica. PhD & MPH students, including those in the new Guyana programme directed by Co-I RG, as well as junior researchers will be mentored in topics including social determinants of health and evaluating community-based interventions. We will support local students to complete postgraduate projects based on the research at masters and doctoral level.