Description of participants
Of the 107 church leaders to whom the survey was sent, 52 consented and attempted the survey and 40 (39%) responses contained sufficient data for analysis. The median and interquartile ranges for the AIM, IAM and FIM scales were 16 (15–20), 16 (16–20) and 16 (15–17) (out of 20), respectively. On examining individual items, highest percentage of pastors agreed with the item- “Chronic Disease Self-management program in church seems possible” (97%) and the lowest percentage was found for the item where leaders responded to the statement: “Chronic Disease Self-management program in church seems easy to use” (60%). Given that this was the first use of the AIM, IAM and FIM questionnaires in this population, we assessed the internal consistency of the scales using Cronbach’s alpha and the scores were as follows: 80% - AIM; 96% - IAM; 82% - FIM.
For the semi-structured interviews, we conducted thirteen in-depth interviews with church leaders from five denominations- New Testament Church of God, Wesleyan, Anglican, Nazarene, and Independent Pentecostal. There were nine males and four females interviewed ranging in age groups from 35 to 75 years old.
Acceptability
The quantitative survey showed high levels of acceptability, between 77 and 92% of respondents indicating that the self-management program as described to them would be acceptable within the church (Table 2). This assessment was in alignment with the overall findings from the semi-structured interviews. Church leaders generally indicated that it would be acceptable to them but held mixed views around how acceptable the program might be to their members.
Table 2
Mean and proportional scores for each item on the Acceptability of Intervention Measure scale
Survey items
|
Mean (95% CI)
|
Percentage who agree/strongly agree%, (95% CI)
|
Acceptability of Intervention Measure
|
Chronic Disease Self-management program in church meets my approval.
|
4.0 (3.7,4.3)
|
82 (69, 95)
|
Chronic Disease Self-management program in church is appealing to me.
|
3.9 (3.6, 4.3)
|
77 (63, 91)
|
I like Chronic Disease Self-management program in church.
|
4.0 (3.7, 4.3)
|
82 (69, 95)
|
I welcome Chronic Disease Self-management program in church.
|
4.3 (4.0, 4.5)
|
92 (83, 100)
|
Acceptability: church leaders describe palatability of health programs
Mirroring the quantitative findings, church leaders were very positive about acceptability of self-management programs within the church. Church leaders consistently referred to the role the church needed to play in promoting healthy lifestyles.
Some leaders highlighted their acceptance of the integration of healthy lifestyle programs within the church by providing examples of those that already existed:
“We have many presentations for health. We look at different areas of the Women's Health, men's health and the total man. We had an exercise program but because of COVID that has stopped a little bit.” (EA, Female, 50–60 yrs)
“We had a chef who is one of our members and he started teaching about healthy living and healthy cooking… how to do your chicken and so on without frying and trying to do your vegetables and you know steaming and so on.” (TS, Female 60–70 yrs)
Many leaders also saw the church as having a health promotion role through making education/advice and diagnostic checks more readily accessible to members:
“ Some persons have an aversion to going to a doctor um…or don’t have a lot of patience going to the clinic, um… Whatever the reason might be so here’s an opportunity to come and get some of those things checked without having to pay any money without any hassle whatever the care maybe and then you get back the results and then you can you know be given guidance as to what to do from there.” (IR, Male, 40–50 yrs)
Acceptability: Pastors perception of members’ acceptability of health programs
While church leaders were confident in their own acceptance of health programs, they held mixed views on the likely acceptability to members. Only 63% (95% CI: 48%, 79%) felt that members were determined to implement healthy lifestyle changes in their own lives and 63% felt that their members feel confident that they can keep track of progress made in creating a supportive healthy environment. During interviews, leaders revealed that in their attempts to change the content of their sermons to include more health-related content, they may experience some “backlash”.
“So like half, not half, like about a third of the service, every Sunday is going to be about health… So I know, um how some persons may say to me that they prefer to have the entire service on about God and Jesus…And less doing with seems spiritual, so I know I may get some backlash there in terms of that, but I know it may be a challenge.” (WL, Male, 35–40 yrs)
While church members welcomed health education and screening activities there was resistance to programs that tried to introduce individual level care as some saw this as a replacement of their personal health care provider.
“Because in their mind this is a medical situation. I already trust this particular doctor. I don’t need to back talk to the pastor about this. I will go to the doctor. We find that mainly that is what would happen.” (IR, Male, 40–50 yrs)
Finally, as it relates to perceived members’ acceptance, church leaders felt that even those members who might be amenable to such a program might have difficulty in maintaining healthy lifestyle recommendations. These barriers identified within acceptance may affect the feasibility of implementation.
Appropriateness: Healthy lifestyle programs are aligned with doctrine
The levels of appropriateness were high in both quantitative and qualitative assessments. Approximately 90% of church leaders believed these programs are appropriate (Table 3). In the interviews, they explained that health was a priority for the church as it deals with the whole man. Interestingly, some were keen to highlight that the church’s priority is spiritual health and thus that must take precedence over all else.
Table 3
Mean and proportional scores for each item on the Intervention Appropriateness Measure
Survey items
|
Mean (95% CI)
|
Percentage who agree/strongly agree%, (95% CI)
|
Chronic Disease Self-management program in church seems fitting.
|
4.3 (4.0, 4.6)
|
90 (80, 100)
|
Chronic Disease Self-management program in church seems suitable.
|
4.2 (3.9, 4.5)
|
88 (77, 98)
|
Chronic Disease Self-management program in church seems applicable.
|
4.3 (4.0, 4.6)
|
90 (80, 100)
|
Chronic Disease Self-management program in church seems like a good match.
|
4.3 (4.0, 4.5)
|
90 (80, 100)
|
Church leaders consistently aligned healthy lifestyle programs with the tenets/doctrines of their faith irrespective of denomination. Leaders frequently quoted from various passages of scripture. Most commonly, pastors mentioned the concept that the body is the “temple” of God which should be treated with care. They also quoted from their own doctrinal commitments for example the Marks of Mission which express the Anglican community’s common commitment to, and understanding of, God’s holistic and integral mission.
“Well the churches role should be to promote the healthy eating and physical activity um from a biblical standpoint, if I may use that because the body is the temple and we have been commissioned to take care of the temple.” (OE, Male, 30–40 yrs)
“The body was created by God. It's good. and Part of our responsibility as the Psalmist tells us he made us a little lower than the angels to take care of god's created order and part of what was created is the body. from managing illnesses, managing ourselves is part of that role.” (GF, Male, 40–50 yrs)
Appropriateness: Health programs appropriate but spiritual health is the priority
Similar to what was described when addressing the acceptability of chronic disease self-management programs in churches, the issue of spirituality being seen as the priority of the church was discussed:
“The primary health concern is the spiritual health, of course we must also be concerned with our physical health, our mental health, or emotional health .... The major challenge that I see… when we would do it. Do we sacrifice ….…like our bible study time or pray time, (IR, Male 40–50 yrs)
Feasibility: pandemic effects on health programs in churches
For three of the four quantitative items, more than 85% of church leaders indicated that chronic disease self-management programs in churches seem implementable, possible and doable (Table 4). Only 60% thought that such a program would be easy to use/follow. In semi-structured interviews, church leaders shared their ideas on the feasibility of the programs in churches by drawing on experiences they had had previously with health programs in churches. Based on these experiences, they were able to share potential barriers and provide advice on possible facilitators. They spoke about the pursuit of health and wellness activities such as hiking and health fairs; however, the Covid-19 pandemic hindered many of these health-related activities” creating a barrier to positive health practices such as physical activity and social interaction.
Table 4
Mean and proportional scores for each item on the Feasibility Intervention Measure
Survey items
|
Mean (95% CI)
|
Percentage who agree/strongly agree%, (95% CI)
|
Chronic Disease Self-management program in church seems implementable.
|
4.1 (3.9, 4.3)
|
88 (77, 98)
|
Chronic Disease Self-management program in church seems possible.
|
4.3 (4.1,4.5)
|
97 (92, 100)
|
Chronic Disease Self-management program in church seems doable.
|
4.2 (4.0, 4.4)
|
92 (84, 100)
|
Chronic Disease Self-management program in church seems easy to use.
|
3.6 (3.4, 3.9)
|
60 (44, 76)
|
Some church leaders felt that the economic impact of the pandemic, specifically the loss of income due to COVID-19 contributed to poor dietary habits in people, because of the lack of affordability of nutritious foods considered to be more expensive.
“Due to COVID etc, a lot of persons are no longer working. Finances have become a problem, and healthy eating is expensive unfortunately.” (OE, Male, 30–40 yrs)
This COVID-19 impact is likely to continue beyond the pandemic for both the individual and the church as an organization.
Feasibility: the relationships between food, culture, and church fundraising events
As is culturally typical in Barbados and the wider Caribbean, big events such as church fundraisers are food-centered events. Many foods high in salt, fat and sugar are also culturally accepted foods that are expected to be sold at these events to attract patrons. Anecdotally, the relationship between these foods (e.g. coconut sweetened bread, macaroni pie-a cheese filled pasta dish, and fish cakes) and fundraising is strong; healthy items have less selling power. Yet having such items at church events would undermine chronic disease self-management programs.
“At church events we sell a variety of things ……we do healthy foods we have those people who would promote healthy foods, but you know the Barbadians still like them fishcake (fried fish and flour)… and them souse (pickled pork) and those kind of things so we cater to them. We have fruit, we have vegetables we have fruit drinks, we prefer not to use the… bottle drinks and you know the drinks like the sodas.” (AL, Female, 70–80 yrs)
There is a fear that removing unhealthy items for sale would challenge the financial success of such events and the church financial bottom line.
Feasibility: church leaders not equipped to deliver health-related topics
Despite acknowledging the appropriateness of health programming within the church, some leaders expressed that they felt ill equipped to address health-related topics themselves.
“I know how to preach the word but I don't know how to ask people about how they are feeling regards with regards to disease and diabetes and hypertension so putting someone in place like that to be able to communicate with them is important”, (OL, Male, 40–50 yrs)
Many indicated the need for a focal point/health champion within the church with the knowledge on how to communicate these issues appropriately, to assist in this regard.
Feasibility: facilitators to health programs in churches
Church leaders shared ways that programs can be shared to make health programs in churches more effective:
1. Use a Biblical perspective: Our respondents felt that using biblical verses and examples would enhance the adoption of the program within churches and increase its success.
“And I find when you are dealing with um Christians, you have to bring a biblical perspective. Why they should not do this and shouldn’t do that and, you understand?.......... Especially when you are dealing with the older folks” (AR, Female, 60–70 yrs)
2. Build and maintain trust: There was a sense that persons were generally skeptical of some health information and of taking medications. Leaders therefore suggest that before health information is shared, collected and used, researchers and health educators should work on building the trust of congregants.
“So I think um… the challenges is to gain people’s confidences that you are not going to be um… the information you get will be used confidentially.” (AE, Male, 60–70 yrs)
3. Keep materials and questionnaires simple and avoid jargon: This was an important theme for the church leaders who felt that some of the information presented was not always at a level that members and the community could understand. Thought must therefore be given to the health literacy of the society being served.
”Where possible you have a simple questionnaire and probably make it easier …for people to respond. That’s why I said simplicity in the questionnaire. So that’s another thing, the language that … is used … I know you can’t really adulterate the terms but if it can be simplified it would help.” (AE, Male, 60–70 yrs)
“So in other words being able to use less jargon but not water down the facts of what you are sharing.” (IR, Male, 40–50 yrs)
4. Individual and committee champions needed: As seen in other organizations, pastors here felt that health champions should be identified to lead if the effort is to be successful, but some felt that they may experience challenges in finding persons interested in taking up this role.
“We would have to put some person in charge of it, yes, we have church clerk and we have you know the normal church structure, ……you would have to put somebody in charge of it to be responsible for it and make sure that everything is recorded and given to the Church. Cause to go and put this on um on the system now, it will be too much.” (GF, Male 40–50 yrs)
“Finding the person might be the hardest part now to want to take up that role.” (RE, Male, 40–50 yrs)
5. Programs should offer practical solutions
They encouraged doctors and other healthcare providers to provide practical solutions to the health problems they identify since simply outlining the problem with no solution can be “depressing”.
“Just you know practical ways in which the particular cause I know sometimes from sessions not at our church but I’ve been to sessions before that people literally left depressed cause it was like okay so I am dead. There is nothing. I just heard about a million things that are probably wrong with me and …there was no solution given right?” (IR, Male, 40–50 yrs)
6. Create family programs: There was the recognition by some of our leaders that these conditions can occur and may be caused by behaviors that occur at various stages of life. Thus, they called for an approach to healthy lifestyle programs that considers integration of the whole family.
“Put a spin on it so that it is family oriented,……. So get the whole family involved. Because these matters...these issues. I do believe there, there are some children some teenagers, who are afflicted with these illnesses as well.” (GF, Male, 40–50 yrs)
“We’ve done a lot on families as well. Because strong families for me builds strong communities and strong churches” (TS, Female, 60–70 yrs)
Feasibility: Churches need health professional support to deliver programs
Even though church leaders believe that churches can create a facilitative environment for behavior change through supporting of health programs within the church delivering health messages from the pulpit, some did not feel equipped enough to deliver the messages themselves. They described that they have invited health professionals to deliver these messages and indicated ways in which the professionals can improve their delivery and the appeal of the health message. While they have used professionals of different faiths/beliefs their preference was for persons of the same faith who understood the culture of the faith. One pastor indicated that he prefers to use the doctors from his own congregation because they “know the people” and the congregation “has confidence in them”- indicating the value of relationship, trust and the power of knowing the culture of specific faith.
Reaching the wider community through churches
In the quantitative survey we asked pastors about their perceptions of the church’s readiness to be a community hub for healthy lifestyle programs. The majority of church leaders (90%, 95% CI 81, 99) felt that people who attend their church wanted to promote healthy living and 83% (95% CI, 72%, 95%) felt confident that the church could serve as a community hub for healthy lifestyle programs; From our inductive coding, a strong theme emerged around the impetus of the church organization to reach out to their neighboring communities for special projects and events. Church leaders freely discussed their activities in the communities explaining the extent to which the church could be used not simply as a mode to improve members’ health but as a vehicle by which the wider community around the church can be reached. Leaders viewed community involvement and outreach as part of their mission as churches and described it as aspects of their “compassionate” ministry.
“Well sometimes when we have activities we don’t only restrict it church members. We would have suppose… there is a seminar we would encourage persons to invite their family and friends um… who are obviously not members of the church as well, so in a way you are helping them in reaching out in evangelism but at the same time we also reacting to a need that they would have so that…cause I don’t think as I said that the church is there just to preach at people…” (AE, Male, 60–70 yrs)
The communities are more likely to attend outdoor church events like community fairs which involve but are not exclusive to health activities.
“As part of our evangelistic effort um… every summer we had a major outreach in the (Community name) and we would setup tents and up jumping tents you know all these things and we would have a tent where you would get the same um… health checks being done, blood pressure checks, checking of heart rate, these different things happening there. So in that instance that would be an annual exercise.” (IR, Male, 40–50 yrs)
In addition to community fairs, leaders mentioned other health-related community activities that included creation of kitchen gardens with children, exercise/gym activities on the church premises and line dancing.
Churches have engaged the communities via a variety of mechanisms from individual level family to family invitations, knocking on doors of houses within the communities to more public communication using flyers placed in mini-marts and local gas stations and social media platforms like WhatsApp, Facebook, and Instagram. The use of virtual platforms has increased access to those who did not previously attend. On the virtual platforms, church leaders have noticed more community/ non-member attendees.