Day of Grace - Randy Hurley, MD

“Sometimes I have difficulty walking up small mountains”

Health assessments as part of a “Day of Grace” health, wellness, stress and spirituality seminar for Lutheran Pastors in the Iringa Diocese of Southern Tanzania

“Sometimes I have difficulty walking up small mountains,” replied the 62 year old pastor when asked if he had any concerns about his health.  He was participating in one of 3 day-and-a-half seminars held in January 2012 in Iringa, Tanzania.  These seminars were planned and sponsored by the Iringa Diocese of the Evangelical Lutheran Church of Tanzania in conjunction with the St Paul Area Synod of the Evangelical Lutheran Church of America.  The seminars, entitled “Day of Grace” were conceived and organized in response to the perceived need for support of physical and emotional health and stress management for a group of 185 pastors in the Iringa Diocese.  The seminars included worship and fellowship time, small group discussion, and a lecture on stress management.  Participants were also offered the opportunity to undergo individual physical health assessments.

Data without personal identifying information was reviewed from 155 of 159 pastors (24 female and 131 male) that volunteered to participate in the physical health assessment component of the Day of Grace events.  All were offered screening for hypertension and diabetes and underwent assessment of visual acuity, height and weight.  A health questionnaire was devised with the help of Tanzanian leadership so that only culturally appropriate questions were asked.  Pastors completed the health questionnaire and physical exam with the aid of an interpreter when needed.  Female pastors were interviewed by female medical staff, counseled on breast self-exam and offered pelvic exams.  Volunteer medical staff included physicians, nurses and pharmacists from the Minneapolis-St Paul area and 4^th year medical students and pharmacy students from the University of Minnesota

Pastors in the Iringa Diocese have completed secondary education and theology training at the college level. The age range of pastors participating in the health assessments was 23 to 80 with a median age of 45 years.  Most pastors had never undergone a comprehensive physical exam although most had sough health care for treatment of malaria and a significant minority had been treated for typhoid.  Most pastors live on an income less then $2 per day but many supplement their income with subsistence farming.  Nearly all pastors were married.  The median number of children per married couple was 4 (range 0-10) and a median of 6 persons (range 1-15) lived in each household.  Female pastors had a median of 3 children per married female pastor.  Forty percent had a water source in the home however some pastors had to walk up to 30 minutes to obtain safe drinking water.  The majority of pastors used mosquito bed nets routinely and the prevalence of tobacco and alcohol use was nearly zero.  The most frequent complaints were dental-related and related to presbyopia.  Gastrointestinal/gastritis symptoms and musculoskeletal complaints were the next most frequent.  The musculoskeletal complaints were suggestive of degenerative arthritis or complications of prior accidents.  Few pastors had ever undergone surgery with orthopedic procedures following trauma being the most common.   It as very rare for pastors to be on medications on a daily basis

Visual acuity was strikingly normal with most pastors having distance vision of 20/20.  A significant number, however, were in need of corrective lenses for near vision and reading. Only 12% of the pastors examined had an elevation of blood pressure greater than 140/90 mm Hg however 30% of the pastors above the age of 42 had an elevated blood pressure.  Relatively few abnormal physical exam finding were identified and when present included issues such as soft tissue infections, hydroceles and hernias.  No abnormal breast or pelvic exam findings were noted.  Only 8 of the 155 pastors tested had an elevated fasting blood sugar above 110mg/dl.

For the medical examiners, the physical assessments were an opportunity to understand the health and lifestyle of a relatively homogenous group of Tanzanians.  Moreover, the standardized history and physical exam forms allowed for systematic evaluation of many of the social determinants of health of this population.  The presence of interpreters allowed examiners to enhance their own knowledge of Swahili medical terms

The medical examiners were perhaps surprised at the overall general good health of this cohort of pastors.  Pastors are a relatively highly educated group.  In developed countries, educational level and marital status are both associated with improved health outcomes.  In addition, “healthy worker effect bias” may help explain the relatively good health of this group.  This bias would suggest that those with underlying health problems and disability are unable to remain employed as pastors.  Therefore, only healthy workers remain as part of the cohort examined.

Overall, pastors were highly satisfied with the Day of Grace events and felt the physical assessments were the most important component of the health, wellness, stress and spirituality seminar.  Most indicated they would like to see the Day of Grace concept repeated with the opportunity extended to spouses to also undergo physical health assessments. 

This first attempt at a health, wellness, stress and spirituality retreat for pastors was, in some respects, also a feasibility study.  The co-leaders now have a better understanding of what can be accomplished in a day-and-a-half event.  Evaluation forms and a post-seminar debriefing have generated ideas for improvements and for future events.   Having an understanding of baseline health issues will allow closer tailoring of these assessments to better meet the needs of this underserved population.