Early Community Engagement in Rural Hypertension Intervention Development: Perspectives from Faith Leaders in Rural North Carolina

Abstract

Hypertension disproportionately affects rural communities in the United States, where structural barriers and limited institutional resources constrain both prevention and care. Community-engaged interventions have demonstrated potential in rural hypertension settings; however, most interventions engage community partners only after core program structures have been defined. As a result, partners have limited opportunities to assess whether participation is feasible within their existing organizational realities or to shape the intervention to reflect their institutional priorities. This dynamic can weaken partner engagement and undermine the long-term sustainability of the intervention. This thesis argues that early community engagement constitutes a substantive research activity in the development of community-engaged interventions, revealing conditions and constraints of partner engagement that subsequent phases of co-creation cannot identify. This study draws on the PRODUCES co-creation framework to structure this engagement.Using a community café format, the study explored how faith leaders in a high-burden rural county in southeastern North Carolina evaluated potential church involvement in hypertension-related activities and identified the conditions necessary for sustained participation. Thirteen faith leaders representing ten churches participated in structured discussions organized around three activity domains: faith-based health messaging, blood pressure screening and referrals, and healthy lifestyle practices. Discussion notes and audio recordings were analyzed using an inductive-deductive approach, in which the discussion guide’s probe categories provided an initial organizing structure while themes were iteratively refined through close review of transcripts, notes, and recordings. Thematic analysis revealed three cross-cutting themes. First, leaders assessed institutional alignment—whether proposed activities could be embedded within existing church rhythms, schedules, and theological frameworks without creating new organizational burdens. Activities integrated into existing routines, such as sermon-based messaging and fellowship meals, were viewed as feasible, whereas standalone programs and externally imposed curricula were not. Second, leaders deliberated on operational capacity and role boundaries, consistently distinguishing between activities appropriate for pastoral roles and those requiring clinical authority. External healthcare partnerships with trusted clinics or organizations were identified as a necessary condition for any screening or referral activities. Third, leaders described sustainability as the social infrastructure needed to maintain blood pressure awareness and follow-up over time, through peer reinforcement, environmental cues, and integration into the ordinary rhythms of congregational life. These findings demonstrate that early engagement reveals institutional conditions, role boundaries, and capacity constraints that cannot be inferred from the literature or assumed in advance. In rural settings where trust and institutional coordination require deliberate attention, treating this phase as a substantive stage of inquiry ensures that the conditions necessary for sustained co-creation are identified before intervention design, thereby supporting the development of community-engaged health interventions grounded in local realities.