Description of Study Participants
Eighteen semi-structured interviews were conducted with 22 pastors and staff between April and August 2018 out of 61 churches invited. Differences were not observed between interviews with one participant and those with two participants. Most interviews were conducted in English (n=14) and the remainder in Spanish (n=4). Seventeen of the interviewees were male and 5 were female. Of the 22 stakeholders who participated in the interviews, all held formal positions within their churches: 11 were senior pastors or priests, 5 were associate or assistant pastors, and 6 were paid church staff members (business managers, secretaries, and deacons). One interviewee (assistant pastor) declined to be recorded and was not included in the final analysis.
Barriers and Facilitators to Implementing Faith in Action
The barriers and facilitators identified fell within three of the five CFIR domains (i.e., characteristic of individuals, inner setting, and outer setting). We summarized major findings according to CFIR domains and included seminal quotes as illustrations of each (Table 1).
Characteristics of Individuals
Pastors and staff lack self-efficacy for and knowledge of PA. In general, pastors and staff reported having low self-efficacy for PA and lacked knowledge of PA. While a few mentioned having personal PA habits (e.g., cycling, running), most reported struggling to find time to be active and unsure of how to encourage churchgoers to be active. One pastor described his hesitancy in encouraging PA, “Well probably I’m not the best person to talk about that because I need it badly. I lost already 24 pounds but I need to lose another 40 pounds.” Some pastors mentioned that they would feel like “hypocrites” if preaching about health, given their own challenges in maintaining healthy habits. Pastors shared that their demanding and unpredictable work schedules contribute to unhealthy habits and a lack of priority of their own health. In addition, pastors’ lack of self-efficacy for PA limits their ability to motivate healthy behaviors among churchgoers.
Pastors have influence over churchgoers’ behaviors. Church staff felt that pastors who were roles models for PA and healthy eating had a strong influence on churchgoers. Some pastors said they had opportunities to counsel churchgoers, but while they felt equipped in mental health counseling, they were sure about how to best encourage individuals to be physically active. One pastor described his influence over his congregation in the following way, “If I open my mouth, they’ll hear. They’ll listen.”
Churches can support a culture of overeating and unhealthy behaviors. Pastors and church staff described the important role of food in fellowship in the church. Stakeholders stated that food is often served at churches events, and lacks healthy options. One pastor told us, “There’s a little saying in our Spanish ‘Don’t trust a skinny Pastor’” when describing the gifts of food given him by churchgoers.
Churches implement programs aligned with their mission and values. While many of the pastors and staff we interviewed acknowledged the importance of health and the need for more PA opportunities for their members, many emphasized the need for any program to align with the church’s mission and values. Given that a church’s mission is to build faith and share the message of God, finding a way to frame PA within that mission is essential. Once pastor said, “I think our mission is to help people to have good health physically, mentally, emotionally, and spiritually. So, that is a complement to our mission.” Pastors did see an opportunity in connecting physical health with spiritual and mental health, as one shared, “the church is sometimes too spiritual, but the people do not die due to the spiritual, instead it is physical. They get sick because of physical health.” Finally, pastors had the view that any new program, to be successful, would have to “nestle itself into the homeostasis of the church, so it just becomes natural.”
Church culture and norms are influenced by pastors and staff. A few pastors reported having spoken about physical health from the pulpit, however most reported not having the knowledge or resources to do so. One pastor shared, “that’s what I gotta get my hands on, some of these templates that tie in the scriptures with you know healthy eating and exercise and stuff like that.”
Churches have many competing priorities. While pastors and staff recognized the importance of physical health and acknowledged the potential role of the church in promoting health among churchgoers, they also expressed that churches have many other important priorities. Pastors talked about kids and youth programming, marriage counseling and retreats, spiritual formation, social justice campaigns, and many other ongoing programs. In addition, pastors in more urban and low-resource communities shared about their challenges getting churchgoers to be involved in and committed to church programming given the transitional nature of their communities.
Churches often lack sufficient space and personnel. Many of churches included in this study have small programming budgets, limited space, and few paid personnel. Pastors expressed concern about adding more to already overburdened staff and volunteers, saying, “the people who kind of are the natural leaders are already pretty spread out.” Most were also concerned about the cost of program implementation and said they have little funds to spend on programming outside of faith formation activities. Others were concerned that a new program may have to compete with current programs for space.
Programs typically come from within the church. Particularly among Protestant churches, but to some extent in Catholic churches as well, most programs are implemented from within the church. Pastors described processes in which new programs are suggested by church members and leaders, vetted by the leadership, and implemented if seen as beneficial to members and sufficient resources are available. While no pastors said they would not accept an outside program, many expressed hesitancy in hosting a program from an outside organization and said they would want to hear from other pastors about their experience with Faith in Action before moving forward.
Denominational support is critical for program success. In this study, pastors noted the importance of support from upper denominational leadership. Pastors of Catholic churches mentioned the importance of buy-in from the local diocese. Those in Protestant churches saw denominational support as an opportunity to disseminate the program more widely to other churches.
Promising Implementation Strategies for Faith-Based Health Promotion Programs
The following four organizational-level implementation strategies are recommended to engage pastors and church staff to improve implementation of faith-based health promotion programs. While these strategies are tailored to faith-based settings, each is based on ERIC implementation strategies56 as noted in Table 2. We also identified the proposed mechanism of action to explain how we linked barriers and facilitators to proposed implementation strategies.
- Health Behavior Change Training for Pastors and Staff. Pastors described a lack of self-efficacy for PA and that they would feel like “hypocrites” if preaching about physical health and wellness given their lack of knowledge. They reported not know much about PA recommendations and cited very little if any education or training in health. Pastors shared that their demanding and unpredictable work schedules contribute to unhealthy habits and a lack of priority of their own health, statements that support the findings of Proeschold-Bell and McDevitt.57 The stress and burnout pastors and church staff experience can lead to negative health consequences.58 However, pastors have a strong influence over churchgoers who look to pastors as role models.41,58,59 Some spoke about their role as counselors, particularly with issues related to mental health, but admitted lacking confidence in counseling churchgoers on physical health. Our findings support the literature describing the strong influence pastors have over churchgoers’ behaviors.58,59 Finally, pastors and church staff have a strong influence over the church norms and culture, which can, at times, support a culture of overeating and unhealthy behaviors.60 This is supported in the literature where a number of studies have found higher rates of chronic disease among faith leaders. A national study of various denominations found higher rates of physical inactivity, obesity, poor dietary habits, and chronic disease among faith leaders compared to the general US population.61 Social interactions around food have long been an important part of church culture, and often these foods are high-fat and not nutritious.60,62 While churches can have cultures that are resistant to change and act as barriers to healthy behaviors, there is promising research that churches providing instrumental support for PA through church-based PA programs see increases in PA among members.36 As important decision-makers in the church, pastors and staff have the ability to adopt programs, align them with their vision, and influence the culture and norms of the church.14 Pastors and church staff have the potential to influence church culture and norms in ways that promote health.59 Given these findings, we suggest that faith-based health promotion programs include training and education on health behavior for pastors and influential church staff be included in the intervention, even if the pastors and church staff are not the primary program implementers. We expect that if pastors and church staff are trained in health behavior change methods, they will have increased self-efficacy for PA, will be able to role model healthy behaviors including PA, will encourage churchgoers to be active and healthy, and will influence the norms and culture of the church to shift to include health-promoting policies (e.g., water to replace sugar-sweetened beverages at church events, establishing a health ministry).
- Tailored Messaging. Interviews with pastors highlighted the importance of aligning program messaging with the FBO’s mission and values, which may vary between denominations and churches. In general, pastors in the Protestant churches saw our program as an opportunity for outreach and evangelization while pastors in Catholic churches were interested in how the program could build community among current parishioners. Depending on the church’s denomination and mission, the program messaging could be tailored to either of these objectives and include messages from scripture reinforcing the importance of taking care of one’s health. By tailoring the messaging to each church, the program is more likely to be accepted and perceived as something integrated into the mission of the organization.
- Fostering Community Collaborations. Only a few of the eight churches that participated in Faith in Action sustained the program beyond the study period and for those that did, collaborations with community partners were an important factor that facilitated sustainment. In addition, for those churches with fewer resources and less space to host program activities, partnerships with community organizations, including a local recreation center, facilitated implementation. Developing partnerships with organizations with missions in alignment with the health promotion program, for example, promoting PA, is expected to facilitate improved implementation and program sustainment. These collaborations could help support implementation through sharing of space for PA activities, shared personnel, or join projects to promote PA in their communities.
- Gain Denominational Support. Churches tend to be hierarchical in structure, with the majority of the decision-making left to senior leaders.63 During interviews, pastors highlighted the need for denominational support for the program to have long-term success. For example, buy-in from bishops in the Catholic Diocese or leaders of Protestant denominational groups would validate the program. Given the hierarchical structure of FBOs, support of the program from upper leadership is essential for pastors and staff to implement health promotion programs in their churches.