emergency preparedness, faith community, infection control, parish nursing, public health, toolkit.



  1. Reilly, Janet Resop
  2. Hovarter, Rebecca
  3. Mrochek, Tracy
  4. Mittelstadt-Lock, Kay
  5. Schmitz, Sue
  6. Nett, Sue
  7. Turner, Mary Jo
  8. Moore, Ellen
  9. Howden, Mary
  10. Laabs, Cheryl
  11. Behm, Linda


A volunteer workgroup of public health personnel and parish nurses in Wisconsin collaborated to develop theInfection Control and Emergency Preparedness Toolkit for the Faith Communityto help prepare congregations for health emergencies and prevent the spread of disease. This article reports a pilot study of the toolkit with 30 parishes/churches, focusing on the infection control portion of the materials.


Article Content

As flu season approaches, are faith communities ready to prevent the spread of infection? Faith communities can play a key role in preventative health practices. Christian faith communities can promote Christ's intention of health, healing, and wholeness for all, as stated by the Apostle John, "I pray that you may enjoy good health and that all may go well with you, even as your soul is getting along well" (3 John 1:2, NIV).

Figure. No caption a... - Click to enlarge in new windowFigure. No caption available.


Before the existence of public health, hospitals, and clinics, the church provided health services to the community during times of disaster or communicable disease outbreak (Evangelical Lutheran Church in America, n.d.). The awareness and commitment of faith communities to help others in times of need remains apparent. Chapell and Bridges (2009) found 95% of churches in their study participated in disaster relief efforts both locally and abroad. Most pastors continue to recognize the need for faith community involvement in the health issues of its members (Catanzaro, Meador, Koenig, Kutchibhatla, & Clipp, 2006).


In this light, faith communities can be key partners in reducing the spread of disease at an organizational level. In response to the influenza A pandemic (H1N1) in New York City and Mexico City in 2009, the Center for Disease Control encouraged the adoption of creative strategies to prevent the spread of infection in faith communities like discouraging the use of the common cup in observing the Lord's Supper, social distancing, and hand hygiene (Bell et al., 2009). Known associated health risks with sharing a common cup include the transmission of diseases such as herpes simplex, herpes zoster, diarrhea, cholera, salmonella, shigella, hepatitis A, influenza A and B, viral encephalitis, bacterial meningitis, streptococcus group A, Staphylococcus aureus, and tuberculosis (Janeke & de Bruin, 2005). Like the common cup, hand hygiene is known to prevent the spread of disease. A study done by Allegranzi, Memish, Donaldson, and Pittet (2009) found that religious faith and culture can greatly influence hand hygiene behaviors in healthcare workers. Thompson (2010) found the most common nursing diagnoses for faith community individuals and aggregates were related to health-seeking behaviors and knowledge deficits. Could access to infection control information affect the knowledge and attitudes of faith communities and influence behaviors related to infection control practices?



In 2008, health departments across the United States were focused on educating the community regarding steps to prepare for the next public health emergency, which was projected to be a novel avian strain of influenza. In closing a presentation to a community group of volunteer drivers, one public health nurse in northeastern Wisconsin suggested alternatives to shaking hands (social distancing) in church as a means to control the spread of infection. A week later, one of the volunteer drivers in attendance contacted his pastor and a church deacon (who unbeknownst to the volunteer happened to be the county director of public health and human services) to explore the process of formalizing infection control practices for local churches.


The northeastern Wisconsin regional public health nurse consultant became involved, and invited any interested parish and public health nurses to collaborate on a workgroup. Collaborative effort is supported by Scripture in Ecclesiastes 4:9-10 (NIV): "Two are better than one, because they have a good reward for their work. If one falls down, his friend can help him up." Work between groups, such as parish and public health nurses, can be enhanced when working toward a common goal. McCabe et al. (2008) found increased openness for collaboration between healthcare organizations and faith communities after a toolkit of psychological first aid materials was introduced. With these concepts in mind, a collaborative workgroup and project took shape.


Endorsed by the Wisconsin Department of Health Services Division of Public Health, six health departments, three parish nurses, a county emergency preparedness coordinator, a regional public health nurse consultant, and a member of nursing academia from the University of Wisconsin, Green Bay came together to develop and gather materials for faith communities about infection control and emergency preparedness. Each workgroup member played an important role in the collaborative process. The public health nurses' and emergency preparedness coordinator's contributions of content and experience with infection control and emergency preparedness practices were valued. The parish nurses offered the congregational viewpoint, in addition to the community health nursing perspective. The regional public health nurse consultant provided ongoing support and state resources to the group members, as well as opportunities to disseminate the toolkit to public health departments and parishes. A public health nursing professor helped the workgroup refine the survey instrument to evaluate the toolkit, complete the Institutional Review Board (IRB) process, and formalize the research pilot study before widespread toolkit distribution.


The workgroup's efforts culminated in the development of the Infection Control and Emergency Preparedness Toolkit for the Faith Community. This article focuses on the toolkit resources and pilot study results related to infection control in faith communities. The emergency preparedness resources and pilot study results will be detailed in a subsequent publication.

Figure. No caption a... - Click to enlarge in new windowFigure. No caption available.


The workgroup decided that the resource materials had to be easy to use, understandable, easy to implement in daily operations, available for free download and use, and previously unknown to the faith community. A literature review produced a scarcity of faith-based materials. Materials for the toolkit were selected from various national and international sources (such as Texas, Missouri, and Canada) and were approved for inclusion in the toolkit by group consensus. One document, Are You Ready for a Health Emergency? (United Church of Canada, 2006), became the foundation for the toolkit resources. Permission was obtained to use resources from all authors before inclusion in the toolkit. When desired educational materials could not be located, the parish nurses developed them, such as simple health messages called "bulletin blurbs" that could be used by any denomination in weekly or regularly published bulletins, newsletters, posters, or mailings.


The final version of the Infection Control and Emergency Preparedness Toolkit for the Faith Community has resources categorized into five areas: (1) Fact Sheets, (2) Posters and Other Resources, (3) Resources for Kids and Schools/Nurseries, (4) Faith-Based Emergency and Pandemic Planning, and (5) Individual and Family Preparedness. Table 1 lists the handouts and content in each of the five areas. Local health departments compiled hard copies of the toolkit in binders, with colored tabs to separate and designate each area. The entire toolkit also was copied electronically onto on a compact disk and included in each binder.

Table 1: Infection C... - Click to enlarge in new windowTable 1: Infection Control and Emergency Preparedness Toolkit for the Faith Community: Table of Contents


A pilot study was undertaken to determine the practicality of the toolkit. The workgroup wanted to determine the effectiveness of the toolkit in changing attitudes and behaviors about infection control and emergency preparedness. These goals reflect Galatians 6:10 (NIV), "As we have opportunity, let us do good to all people, especially to those who belong to the family of believers."


Using Burns and Grove (2005) research text, the literature review, and the Theory of Reasoned Action (TRA) developed by Fishbein and Ajzen (1975) for guidance, the study methodology and a survey instrument were developed over an 8-month period. The TRA mid-range theory was helpful as it suggests that health behaviors can be predicted and understood by the intention to engage in the behavior (Fishbein & Ajzen, 1975; Werner, 2004). Practicing public health and parish nurses in the workgroup reviewed the survey questions, suggesting relevant edits for content, clarity, format, and appropriateness within faith communities.


The resulting survey posed 15 questions about participant demographics; practicality and use of the toolkit; and attitudes, knowledge, and skills related to infection control and emergency preparedness before and after introduction to the toolkit materials. An open-ended section for additional comments was included. Sample survey questions and data relating to infection control can be found in Table 2.

Table 2: Infection C... - Click to enlarge in new windowTable 2: Infection Control and Emergency Preparedness for Faith Communities Survey 2009: Sample Questions Related to Infection Control (N = 28)

After IRB approval was received, each of the co-investigators completed the online course and certification to protect human subjects offered by the National Institute of Health (NIH). Blanket invitations to participate in this pilot study were sent to all faith communities in the six public health departments represented in the workgroup. The first five faith communities from each public health jurisdiction, regardless of denomination, that agreed to participate were surveyed. A standardized script and format was used to schedule appointments with a faith community representative, conduct a 1-hour meeting explaining the toolkit, and offer the survey. Parish, public health, and student nurses presented the toolkit and administered the survey. Surveys were provided to the faith community representative at the end of the 1-hour meeting. Participants were given privacy to complete the survey. The first question of the survey ascertained consent from each participant. Surveys, whether completed or not, were sealed by the participant in an 8.5 by 11 inch envelope and given to the co-investigators. Sealed envelopes were numbered, contained no identifiable information, and were given to the principal investigator to open all at once for data analysis. Data were collected between July and December 2009.



Data were analyzed on 28 of the 30 faith communities that met eligibility criteria, consented, and completed the survey (N = 28). The Statistical Package for the Social Sciences (SPSS) (n.d.) computer software was used to calculate descriptive statistics (means and standard deviations) for relevant questions and paired sample t tests for question items regarding knowledge, attitudes, and skills before and after the toolkit was introduced. Parish representatives in the survey were varied, from parish clergy (48%), other roles-such as parish council member, janitor, and so on (35%), administrative assistants (13%), and parish nurses (4%). In 2008, the religious composition of the population was over 76% Christian according to the United States Census Bureau. Similarly, of the nine denominations that participated in this study, 72% were Catholic, Lutheran, or United Church of Christ (Figure 1). Almost one third of the faith communities had between 501 and 1,000 members (Figure 2). Like the story of the mustard seed (Matthew 13:31-32), this pilot study with 28 faith communities had the potential to spread the word about infection control and emergency preparedness to a minimum of 16,850 faith community members!!

Figure 1: Who comple... - Click to enlarge in new windowFigure 1: Who completed the survey (N = 28).
Figure 2: Number of ... - Click to enlarge in new windowFigure 2: Number of members in faith communities surveyed.

Just under half of the faith communities (46.4%, n = 13) had received and reviewed information on the spread of disease and/or how to prepare for a public health emergency prior to the toolkit presentation. All but one of the parish representatives (n = 27) reported it was important for faith communities to have a plan in place to stop the spread of disease.

Figure. No caption a... - Click to enlarge in new windowFigure. No caption available.

A statistically significant difference (t(26) = -6.63, p < .001) was found between the mean number of resources on infection control and public health emergency planning the faith communities used before (M = 1.62; SD = 1.18) and planned to use after the toolkit was introduced (M = 3.62; SD = 1.78). A second statistically significant difference (t(27) = -6.465, p < .001) was found between the mean number of ways faith communities were prepared to prevent the spread of infection before (M = 4.1; SD = 1.9) and their plans after the toolkit was introduced (M = 6.1; SD = 2.2). In other words, the introduction of the toolkit led to an increase in the number of resources faith communities planned to use to prevent the spread of infection, as well as an increase in the number of practices planned to prevent the spread of infection.


Participants were asked to identify two ways the faith community could reduce the spread of infection after the toolkit was shared. The majority (n = 20) stated that the faith community could educate and make information available via church Web sites, workshops, flyers, newsletters, and bulletins and at coffee hour and in parochial schools to reduce the spread of infection. Seven participants stated hand washing/hygiene/no handshaking or alternate expressive greetings without touch would help, whereas four felt discontinuing the use of the common cup and encouraging members and staff to stay home when sick would be supportive to stop the spread of infection in the faith community.



Participants were asked to evaluate the toolkit materials for things such as ease of use, convenience, and organization, using a Likert-type scale with 1 = strongly disagree; 2 = disagree; 3 = neutral; 4 = agree; and 5 = strongly agree. Participants felt the toolkit was easy to use (M = 4.7, SD = 0.54), organized with its color tabs (M = 4.7, SD = 0.44), and convenient (M = 4.67, SD = 0.55). Participants disagreed that the toolkit was missing information (M = 2.01, SD = 1.05), overwhelming (M = 2.18, SD = 1.00), or confusing (M = 1.48, SD = 0.89). One grammatical edit was suggested.


The workgroup members individually reviewed and identified content themes about the toolkit from comments written by participants. By comparing themes between the 11 workgroup members, validity was established. The four most common themes were (1) acknowledgement of the quality resources for faith communities (eight participants); (2) recognition of the skilled presentation of the toolkit materials by the presenter (seven participants); (3) gratitude for the information and the time saved for the faith community in collecting/sharing the resources (six participants); and (4) increased awareness of the infection control issue in faith communities (five participants). Eight of 10 participants who responded to the question about what would prevent their faith community from using this toolkit stated "not enough time to plan" was a barrier.



A collaborative workgroup from public health and parish nursing formed in 2008 to collect and distribute materials on infection control and emergency preparedness for faith communities as the threat of a pandemic loomed. A pilot study was designed and undertaken with 30 parishes to evaluate the scholarly information in the Infection Control and Emergency Preparedness Toolkit for the Faith Community before further distribution. Almost half of the churches involved in the pilot study had never received materials on infection control or emergency preparedness previously. Statistically significant changes in attitudes and planned behaviors were noted after the toolkit was introduced. However, it is unclear if this change was due to the introduction to the toolkit materials or the face-to-face presentation of the toolkit by a public health, parish, or student nurse to the faith community representative (i.e., Observer's or Hawthorne Effect). Further research could help differentiate between the impact of the toolkit and the impact of the nurse presenter.


To save time for participants and make the meetings shorter, faith community members were surveyed about current use and plans for future use of resources and behaviors only after the toolkit was introduced. A pre- and posttest given to the faith communities at separate times before and after the toolkit introduction may have yielded different results. Chappell and Bridges (2009) found that few faith communities had instituted health recommendations, despite having educational materials provided 3 weeks prior. This suggests that motivation of faith communities to change behaviors is critical to actual behavioral change. In addition, a ground-up "community development" approach-spending time interacting with the faith community, establishing a trusting relationship, determining what it sees as its role in health, discovering perceived health needs-could be a better way to engage commitment and motivate behavior change. If the faith community identified infection control as a need, it could assist in the development of resources and might be more likely to utilize materials.


The emergence of an H1N1 outbreak in 2009 in the midst of this pilot study must be acknowledged. This outbreak and the surrounding media hype may have contributed to a greater sense of urgency about infection control and emergency preparedness and impacted survey answers from faith community representatives. Further research about motivating factors for change in infection control and emergency preparedness practices is indicated.

Figure. No caption a... - Click to enlarge in new windowFigure. No caption available.

This pilot study obtained specific information about current infection control practices and emergency preparedness planning in a small sample of faith communities, while evaluating a toolkit of materials on these topics. The toolkit was favorably received by the faith organization representatives with few suggested changes. It is hoped that the materials in the toolkit will be distributed to faith communities across the country to promote and maintain health, related to infection control and public health emergencies. The complete 224 page Infection Control and Emergency Preparedness Toolkit for the Faith Community can be downloaded for free as supplemental digital content at



The authors want to thank the Waupaca County, Wisconsin volunteer driver, Ron Reynolds; Marg Pollon, author of Bridges of Love Ministry (; the Joplin/Jasper County, Missouri Planning Committee; the Central Texas Conference Toolkit for Disaster Preparedness and Response (; and the United Church of Canada and Bev Oag (


Web Resources


* Infection Control and Emergency Preparedness Toolkit for the Faith Community-


* Center for Infectious Disease Research and Policy (multiple contributors, free resources)-


* Henry the Hand (infection control)-



Allegranzi, B., Memish, Z. A., Donaldson, L., & Pittet, D. (2009). Religion and culture: Potential undercurrents influencing hand hygiene promotion in health care. American Journal of Infection Control, 37(1), 28-34. [Context Link]


Bell, D. M., Weisfuse, I. B., Hernandez-Avilla, M., del Rio, C., Bustamante, X., & Rodier, G. (2009). Policy review: Pandemic influenza as 21st century urban public health crisis. Emerging Infectious Diseases [serial on Internet]. Retrieved from doi:10.3201/edi1512.091232 [Context Link]


Burns, N., & Grove, S. (2005). The practice of nursing research: Conduct, critique and utilization. St. Louis, MO: Elsevier. [Context Link]


Catanzaro, A. M., Meador, K. G., Koenig, H. G., Kutchibhatla, M., & Clipp, E. C. (2006). Congregational health ministries: A national study of pastors' views. Public Health Nursing, 24(1), 6-17. [Context Link]


Chappell, J. R., & Bridges, B. (2009). Are you prepared for pandemic flu? Journal of Christian Nursing, 26(2), 80-85. [Context Link]


Evangelical Lutheran Church in America. (n.d.). Responding faithfully to pandemic flu. Retrieved from


Fishbein, M., & Ajzen, I. (1975). Belief, attitude, intention, and behavior: An introduction to theory and research. Reading, MA: Addison-Wesley. [Context Link]


Janeke, J. B., & de Bruin, G. (2005). Holy Communion-Chalice or challicles? South African Medical Journal = Suid-Afrikaanse tydskrif vir geneeskunde, 95(8), 544. [Context Link]


McCabe, O. L., Mosley, A. M., Gwon, H. S., Everly, G. S., Lating, J. M., Links, J. M., & Kaminsky, M. J. (2008). The tower of ivory meets the house of worship: Psychological first aid training for the faith community. International Journal of Emergency Mental Health, 9(3), 171-180. [Context Link]


Statistical Package for the Social Sciences Version 17 (SPSS). (n.d.). IBM SPSS Statistics. Retrieved from


Thompson, P. (2010). Clergy knowledge and attitudes concerning faith community nursing: Toward a three dimensional scale. Public Health Nursing, 27(1), 71-78. [Context Link]


United Church of Canada. (2006). Are you ready for a health emergency? Congregational Ministry guidelines for worship. Retrieved from[Context Link]


United States Census Bureau. (2008). Self described religious identification of adult populations 1990-2008. Retrieved from


Werner, P. (2004). Reasoned action and planned behavior. In Peterson, S. & Bredow, T., Middle range theories: Application to nursing research (pp. 125-149). Philadelphia, PA: Lippincott. [Context Link]


1Minnesota Department of Public Health


2Wisconsin Division of Public Health Department of Health and Family Services


3United States Dept of Health and Human Services-Centers for Disease Control and Prevention


4FDL County, Wisconsin Health Department


5APIC-Association for the Professionals in Infection Control and Epidemiology


6Washington State Department of Health


7NACCHO-The National Association of County & City Health Officials


8Seattle & King County Advanced Practice Center




10Adapted from the Central Texas Conference Plan


11Building Bridges of Love


12Pandemic Planning-The Faith Based Role: Joplin County, MO