Role of Black Churches in Health Promotion Programs: Lessons From the Los Angeles Mammography Promotion in Churches Program

Abstract

Objectives. This article assesses pastor-level factors that affect the successful recruitment and implementation of community-based health promotion programs in Black churches.

Methods. Semistructured interviews with 16 pastors of Black churches were analyzed for content.

Results. We found that although the involvement of Black pastors in an array of secular activities makes them open to participate in health programs, their overcommitment to other issues can negatively influence their ability to participate. Second, although Black pastors appreciate being included in and benefiting from health research, minorities' history of being underserved and exploited can lead to suspiciousness and reluctance to participate.

Conclusions. Our findings suggest that those interested in developing church-based health programs in the Black community must be attuned to how the same factors can both facilitate and hinder a program's development.

From the time of slavery1,2 through the civil rights movement of the 1950s and 1960s2,3 to civic participation and local organizing of the 1990s,4 the church has been a central institution in the Black community. At the organizational level, the Black church has throughout the 20th century promoted education, business, and political activism within the Black community.2,5 Furthermore, in addition to its contribution through organizational structures and social networks, the Black church has played an important cultural role for the Black community. One study found that both the Black church's collective ethos and its emphasis on God as active in earthly affairs support secular activities within the Black community.4

Given its historical and ongoing roles within the Black community,6 the church is an ideal setting in which to offer health promotion activities for African Americans. Such activities are warranted because Blacks have lower life expectancies, are less likely to have health insurance, make fewer primary care visits, and have lower birthweights and higher infant mortality rates compared with Whites.7,8 In fact, several studies have found that the church can be an important conduit through which to inform racial/ethnic minorities about preventive care and that the Black church, because of its ethic of service to others, is particularly well suited for health promotion.9–19

Despite the potential of Black churches to serve as crucial sites of health promotion to underserved populations, very little research has empirically examined church-level and pastor-level factors that may aid or impede the successful implementation of such programs. For instance, those in minority communities often mistrust outside health programs because of a history of both being underserved and being discriminated against.20,21 Because pastors of Black churches are respected gatekeepers9 and thus play a particularly pivotal role in the implementation and success of community health promotion programs, we investigated lead pastors' responses about their evaluation of their church's involvement in a 3-year health promotion program from 1996 to 1998.

The Los Angeles Mammography Promotion in Churches Program, based at RAND in Santa Monica and funded by the National Cancer Institute, was designed with 2 main objectives: (1) to evaluate the feasibility of using churches as a community resource for delivering health promotion programs and (2) to test the effectiveness of church-based interventions aimed at increasing mammography use among women from diverse racial/ethnic backgrounds. (See Duan et al.22 and Pitkin et al.23 for further discussions of study design and recruitment strategy and methodology.)

In other papers, we discussed the factors that affect the use of mammography screening among women in our study.22–25 In the future, we will explore differences (e.g., race/ethnicity and denomination) between churches. Here, we focus our discussion on factors affecting the participation of Black churches in this church-based health promotion program. In so doing, we hope to contribute to the broader sociological scholarship on the Black church, as well as to the public health research on partnerships between faith and health communities in general and health alliances with Black churches in particular. From our experience with the Los Angeles Mammography Promotion in Churches Program, we identify contradictions facing those interested in implementing health promotion programs in partnership with Black churches—i.e., we identify factors that can simultaneously facilitate and impede such efforts.

METHODS AND DATA

As part of a process evaluation, qualitative interview data were collected to examine how the church as an organization influenced the promotion of long-term health programs. Between June and August 1998, postintervention, pastors from 16 of the 18 Black churches that participated in the Los Angeles Mammography Promotion in Churches Program were interviewed about their participation in the study by 2 of the authors (S. M., a University of California at Los Angeles postdoctoral student, and M. L. G., a RAND employee) who were trained by a medical anthropologist (B. T., a University of California at Los Angeles faculty member) for this specific project. The 2 pastors not interviewed were omitted because they had been at their respective churches for less than a year and were not fully (or at all) participants in the active phase of the project.

The semistructured interviews took place primarily at the churches (a few took place at restaurants or at pastors' homes or places of work), lasted from 45 minutes to 1.5 hours, and included a financial incentive. The interviews included questions on pastor knowledge of, enthusiasm for, assessment of, overall evaluation of, and involvement and role in the program, as well as views on general health issues and job satisfaction (see Table 1 ▶ for interview guide). These topics were chosen to obtain pastors' specific attitudes toward and responses to the Los Angeles Mammography Promotion in Churches Program while learning more broadly about their views, work, and communities.

TABLE 1—

Interview Guide

I. Knowledge of and enthusiasm about the Los Angeles Mammography Promotion in Churches Program

1. Please describe the Los Angeles Mammography Promotion in Churches Program as you know it. How have you come to this opinion/…acquired this information?

2. On a scale of 1–5, with 1 = “not at all enthusiastic” and 5 = “extremely enthusiastic,” how enthusiastic were you about the program when your church was recruited? (Probe)

3. On a scale of 1–5, with 1 = “not at all enthusiastic” and 5 = “extremely enthusiastic,” how enthusiastic are you about the program now? (Probe)

4. If 2 and 3 are different, why?

5. What was the main reason that motivated you to want to participate in the Los Angeles Mammography Promotion in Churches Program?

II. Involvement and role

6. What has been your role with the Los Angeles Mammography Promotion in Churches Program?

7. Who is the person most involved with the program if not you? What is his or her church role?

8. What, if anything, has been satisfying or rewarding for you about participating in the program? For yourself? For your members?

9. What, if anything, has been difficult or disappointing for you about participating in the program?

III. Assessment

10. Has the program created any conflictual situations at your church?

11. In what ways has your role in the program influenced your other work at the church?

12. How has it affected your relationship with others at your church?

13. Has participating in the program encouraged any other health activities or events at your church?

14. On a scale of 1–5, with 1 = “not at all important” and 5 = “extremely important,” how important is this program in meeting the overall goals of your church? (Probe)

15. What suggestions, if any, do you have about how to better implement a program such as this one in the future?

IV. General health issues

16. What do you think are the principal health needs and problems of your membership? Of the surrounding community?

17. How would you describe the priority you give to health issues as a leader of this church?

18. On a scale of 1–5, with 1 = “not at all interested” and 5 = “extremely interested,” how interested are you in establishing a permanent health committee at your church?

19. On a scale of 1–5, with 1 = “not at all interested” and 5 = “extremely interested,” how interested are you in participating in future health projects?

20. If 1 or 2, what would make you more interested in future participation?

21. If 3–5, what would you need to participate in the future?

V. Pastor job

22. What do you like about your job? Can you give me an example?

23. Are there aspects of your job that you dislike? Can you give me an example?

24. Are there aspects of your job that are stressful? Can you give me an example?

25. What brings you the most satisfaction in your job? Can you give me an example?

VI. Closing questions

26. In closing, I'd like to ask you to summarize what the overall effect of the program on your church has been.

27. Are there any questions I have not asked that I should have asked, or is there something else that I should know?

Interviewers tape-recorded and took notes during the interviews for extensive field notes and verbatim transcripts. The transcribed interviews were subjected to a qualitative content analysis from which dominant themes and issues emerged. All authors read through the transcripts, but the first author (a trained qualitative sociologist) was primarily responsible for creating and applying coding categories in consultation with her coauthors. After all the interviews were initially coded, all of the authors discussed and evaluated the coded data, after which the first author read through the transcribed interviews a second time, making slight modifications to the coding as needed. The methodology used was based on grounded theory and inductive approaches to social inquiry,26 in which instead of taking preexisting abstract categories and applying them to the social world, concepts and theories are constructed from the data. Therefore, our questions shaped the overall topics discussed by our informants, yet the particular themes we discuss here are those that emerged as the data were analyzed.

Because our analysis primarily derived from interviews with pastors, we acknowledge 2 issues that raise questions about the limits of these data. First, because lead pastors, for the most part, were not the ones most actively involved in the running of the Los Angeles Mammography Promotion in Churches Program in their respective churches, they may not be the most informed about the exact implementation of the program. However, we believe that the views of the pastors toward the Los Angeles Mammography Promotion in Churches Program specifically and toward health issues in general are quite essential to understanding how best to implement church-based programs, because pastors are important decision makers and supervisors of others who play a pivotal role in the adoption and legitimization of such programs.

Second, we are concerned with the validity of the responses provided to us. We are aware that the pastors were apt to provide generally positive responses about their experience with the Los Angeles Mammography Promotion in Churches Program, perhaps both to be polite and to ensure their church's participation in future programs. Although we found that most pastors were generally very positive and enthusiastic about their church's participation in the Los Angeles Mammography Promotion in Churches Program, we found that many also raised and discussed disappointments with and criticisms of the study. Thus, we believe that our interview data are valid and useful.

RESULTS

Theme I: Commitment to Holism and Community as Both Enhancer of and Barrier to Participation

Not surprisingly, what drew many of the pastors to participate in the Los Angeles Mammography Promotion in Churches Program was their holistic approach to their ministries. Reverend Henry's (all names used are pseudonyms) attitude, for instance, was shared by 12 other pastors of the Black churches:

I try to have a holistic ministry, one that not only deals with the soul but with the body as well… . There are many facets to us that make us whole people, and each one needs to be dealt with and the church can be a focal point in dealing with all the needs of the whole person… . I feel very strongly that the physical well-being of the person is as important as their spiritual well-being.

Some pastors, like Reverend James, in describing how the Los Angeles Mammography Promotion in Churches Program fit in with the holistic goals of his church, linked the secular effect and health focus as relevant to his goals in a Black church in particular:

I think that we find more and more churches in terms of their self-understanding recognizing the influence they can have in the day-to-day lives of people. And more and more of our churches are trying to figure out how do you do that, what efforts can help carry that out. So, this program fit in with that—we want to impact the day-to-day lives of our people… . This program is holistic and tangible [italics added].

Furthermore, while advocating for a holistic approach, several pastors expressed disdain toward the separation of religious devotion from worldly activities and instead explicitly linked spirituality to health promotion. For instance, Reverend Ellington made the following remarks when asked about the priority he gives to health issues:

There are a lot of people because of a spiritual mentality, they believe that the Lord will do everything, and they … really don't have to be really overzealous about doing anything… . So, you have to keep telling them that the doctor is here because God put him here. So then you're supposed to utilize that source. And so that's my kind of emphasis that I place to keep people interested in their total body.

Often, the faith-based motivations for and appreciation of holism and health were tied to very practical ends. For instance, several of the pastors of the Black churches recognized that health was important precisely because the lack of it could affect their spiritual goals. In fact, pragmatism toward health was made very explicit by several other pastors in our study. For instance, Reverend Henry stated, while chuckling, “If you don't help keep people alive, you're not going to have a congregation.” Likewise, Reverend Houser, also chuckling, said, “We try to keep people healthy so they can keep coming to church… . Can't hardly expect people to respond if they don't feel well!” Although accompanied by laughter, these comments suggest that health issues are often taken seriously by pastors of Black churches.

In addition to a range of holistic orientations, many expressed an appreciation of and a desire to be involved with projects that benefited the community at large. As Reverend Hill succinctly explained, “The only reason for the church to be in existence is to better the community … otherwise it's not a church.” Observations made during Sunday church services attended by the Los Angeles Mammography Promotion in Churches Program staff, and in the course of brief visits with Reverend Valentine during his daily running of a soup kitchen out of the back of his church, revealed many of the Black pastors' desires to work with and for their communities.

Pastors and members of the Black churches often used their involvement in the Los Angeles Mammography Promotion in Churches Program as a springboard for implementing and institutionalizing other health activities. For instance, Reverend Hill explained how his church's participation in the Los Angeles Mammography Promotion in Churches Program has encouraged other health activities, including testing members for high blood pressure and diabetes. Other pastors of Black churches responded to the participation in the Los Angeles Mammography Promotion in Churches Program by providing a separate building to house a permanent health committee, by having health fairs, and by organizing Bible aerobics (aerobic exercises combined with Bible lessons).

These holistic and community orientations found among many of the Black churches in the Los Angeles Mammography Promotion in Churches Program are factors that suggest that Black churches can be a promising venue for situating and implementing health programs geared to the underserved. However, further analysis of our pastor interviews suggested a contradiction—these same factors can simultaneously enhance and impede the successful implementation of such programs.

For instance, although generally very enthusiastic about their church's opportunity to participate in the Los Angeles Mammography Promotion in Churches Program, as well as future health programs, a possible barrier to effective participation that came out of the interviews was the overwhelming amount of commitments and responsibilities that their jobs entailed. In fact, a specific theme that was elicited when pastors were asked to talk generally about their jobs was the lack of time available to get everything done that needed to be done and the stress this produced. Reverend Hill summarized his life as a pastor:

Pastoring is one of the most stressful positions in America… . Pastoring is very stressful. Mainly because you're consistently on the go, and consistently on call… . In the electronic age, you have a beeper on either side, a cell phone in your hand. You gotta check your e-mail every day. And every time the phone rings you're concerned… . You're looking at a stressful society.

A view of the specifically demanding job of a Black pastor is expressed by Reverend Hughes: “We're just like a doctor on call. Some pastors in other churches are shielded from this; they have other people who deal with it, but in the Black church, people want to hear the voice of the leader… . Some things just cannot be delegated.” In a similar way, Reverend Lavery stated his view that pastor involvement is particularly important within the Black church: “You're going to get more participation in the African American community if the pastor is involved … [the] pastor is the door-keeper.”

That pastors of Black churches feel taxed to their limits potentially could affect their willingness and ability to participate in specific health promotion programs. For instance, almost half of the pastors of the participating Black churches worked second jobs to support themselves and their families. Furthermore, most of their churches did not have a large membership to draw on for either financial support (a major cause of pastor stress) or volunteer help (a key ingredient for the successful implementation of community programs). The importance of church size should not be overlooked. Lincoln and Mamiya5 found, for example, in their survey of Black churches that larger churches (≥ 600) were more likely to be involved with community outreach programs than were smaller churches (< 100) (see Table 2 ▶ for study church characteristics, including size).

TABLE 2—

Characteristics of Black Churches Participating in Pastor Interview (N = 16), 1997

	%	n
Denomination
Baptist	50	8
Nondenominational or interdenominational	19	3
Methodist	13	2
Catholic	6	1
Lutheran	6	1
Seventh-Day Adventist	6	1
Church size
Median no. of active members		225
Range of active members		35–400
Churches with a health committee	75	12

Ironically, then, the Black church's history of involvement in community and secular activities that makes them ideal sites for health interventions can at the same time possibly affect a pastor's willingness and ability to participate in new health programs. This is just one contradiction that poses a challenge to the involvement of Black churches in health promotion programs. In the next section, we continue our discussion of how the same factor can both help and hinder the implementation of church-based health programs in the Black community.

Theme II: Effects of a Legacy of Neglect and Discrimination

In general, pastors were honored and enthusiastic to be asked to participate in the Los Angeles Mammography Promotion in Churches Program. In particular, a focus of their interest and enthusiasm was the connection of the program with a well-known research institute—RAND. Although the National Cancer Institute funded the project, the program became linked, if not attributed, to RAND, because the Los Angeles Mammography Promotion in Churches Program was housed there. Their comments, therefore, indicate an inaccurate understanding of the funding and research process, but it is still of interest that more than half of the pastors of the Black churches seemed to be particularly drawn to the project precisely because they perceived that a “corporate” entity wanted to work toward the study and betterment of their communities. Many pastors wanted to believe that corporate America cares. For instance, Reverend Martin explained his motivation to participate in the Los Angeles Mammography Promotion in Churches Program by contrasting the program with what he saw as the usual neglect of inner-city neighborhoods:

To realize that corporate America, realizing the needs of the church … one of my contentions has always been … the reason why communities are so devastated … is the lack of involvement of corporations that actually influence communities… . It was quite pleasing to know that this is an area that they are concerned about, they've chosen that area, and that they want to see them well… . That's a different outlook for corporate America… .They talk about a lot of things, but they have yet to really deal with developing communities.

Although perhaps implicit in some comments, at least 1 pastor was explicit that he was particularly motivated and pleased about the Los Angeles Mammography Promotion in Churches Program because of its inclusion of racial/ethnic populations as a key part of the study. For example, when asked what his main motivation was to have his church participate in the program, Reverend Hughes replied, “The main reason I was motivated to participate was, in fact, because of its emphasis on minorities… . We usually come in at the tail-end of progress and this time it was different… . It was good to see us at the preactive stage instead of the reactive stage.”

In addition to appreciation of attention by an established research institute such as RAND, involvement from “outsiders” was welcomed by some pastors precisely as a way of promoting programs associated with their holistic visions and concerns about health discussed previously. For instance, Reverend Hill said, “I'd like to see a permanent committee of coordinators who are doing things on health issues. This is what I'd like to see. But it would have to be someone who is coming in from the outside, stimulating us to do it.”

These sentiments suggest that pastors of Black churches can be both appreciative and welcoming of outside programs that include and assist their community and, in particular, racial/ethnic minority groups. This suggests that church-based health programs will be enthusiastically received by Black communities. However, as we will show, promoting health issues and working with outside groups are not problem free for churches in poor and minority communities—sometimes for the same reasons that make such programs appealing to pastors of Black churches.

First, even when a health promotion program such as the Los Angeles Mammography Promotion in Churches Program is introduced, pastors sometimes believed that it was not taken advantage of as much as they would have liked because of socioeconomic reasons. As Reverend Hill explained:

Economically, we African Americans and Latinos have not in many cases had proper health insurance or proper care… . It's not like we're used to going to doctors all the time… . [We have] improper health care as far as having insurance … [and] we have not been raised going consistently to [the doctor]. Now, you think I'm going to go, … [but] I haven't been there in 5 years, so there must be something wrong… . So now you want me to go down… . I need you to understand, that in our community, we don't just go into the doctors, as if we have plenty of money and everything … plenty of insurance … and just say “give me the works.” … That's not normal for us in this community. Not even those of us who have insurance.

Ironically, then, the very problem of lack of preventive care that is targeted by a health promotion program can be a barrier to increasing health activities.

Second, even when minorities are routinely included in health research, this does not negate a history of abuse and exploitation20,21—a fact that some of the pastors and their members in African American churches raised. This sometimes resulted in wariness about participating in research studies, including the Los Angeles Mammography Promotion in Churches Program. As Reverend Lavery explained, “as Black people, we've been researched and researched and researched. And people just get tired of it. And that's what my folk heard… . We don't need nobody to come in here and research us.” This wariness of being “used” sometimes resulted in suspicion of being researched by an outside organization. Thus, some pastors welcomed the help of an outside organization, but others thought that such outside presence might hinder rather than facilitate member involvement in health studies. For instance, several pastors believed that potential participants in the study were reluctant to provide what was considered private information to unknown fieldworkers. Reverend James commented on this phenomenon: “I think there was a lot of suspicion about why are these people coming in and getting information on us—like income level, education level, people saying what does that have do with breast [cancer] screening … that kind of thing.”

These comments suggest 2 important lessons. First, a disparity can exist between a pastor's commitment for participating in a health study and the enthusiasm of the church's members. Second—and related—pastor endorsement is important, but the recruitment strategies and retention of individual church members should acknowledge their possible reluctance to participate in health studies.

As a result, another paradox exists: on the one hand, many pastors welcome inclusion in health programs and studies, given the low levels of health insurance in their communities and the history of minority underrepresentation in health research; on the other hand, these same factors—lack of access to health care and previous exclusion of minorities—can impede a program's successful implementation and must be addressed. A third contradiction also may exist: on the one hand, studies such as the Los Angeles Mammography Promotion in Churches Program can be important for providing researchers with a better understanding of Black churches and of how best to include them as sites of health promotion; on the other hand, although the Black church stands as a promising venue for the dissemination of health promotion programs to underserved populations, it also may be problematic as a site for needed research.

DISCUSSION

In this paper, we have discussed the factors, from the perspective of lead pastors, that both contributed to and detracted from the successful recruitment for and implementation of a community-based health program in Black churches. We hope the lessons we learned from the Los Angeles Mammography Promotion in Churches Program can be used by others interested in working with Black churches as sites for health promotion to underserved populations. At the same time, our findings send a word of caution to proposals such as President Bush's that call for churches to take a much larger responsibility in filling in gaps in our nation's provision of social services.

Although many of the pastors were very enthusiastic about the Los Angeles Mammography Promotion in Churches Program and open to future health programs taking place in their churches, most of them made clear that if their church's participation rested on their personal active involvement, these programs could not and would not be pursued. We attempted to solve this problem by involving pastors in only the recruitment phase of the study and then recruiting and training church members who served as coordinators between the program and their respective churches. However, because the concern of being overburdened was a dominant theme in the interviews, an important lesson we learned is the need to reduce the burden of projects on pastors even more by working with a pastor delegate.

At the same time, pastors of Black churches often brought up their suspicion of outsiders; thus, church-based community programs must build trusting relationships and make use of volunteers from within the church—2 strategies the Los Angeles Mammography Promotion in Churches Program did use. We also found it important to work in partnership with respected leaders in the community so that our program had legitimacy for the targeted population. Furthermore, to facilitate a sense of partnership as opposed to a one-way relationship in which only researchers benefit, resources—including computers, software, and printers as well as training in their use—were provided to the churches. Finally, our interviews also identified the importance of establishing personal relationships with pastors and members. For instance, the minimum attendance by a fieldworker of at least 1 service at each participating church helped to solidify relationships between pastors, church coordinators, and fieldworkers. However, the positive response and feedback we received from such visits, as well as through the interviews themselves, suggested that the interactions we planned were helpful but were not nearly enough.

Further research should examine the degree to which our findings are unique to Black churches or whether they are applicable to other churches. Additionally, it should be noted that even within our small sample, variation was observed. For instance, even among those pastors who expressed affinity toward holism, the degree to which this was associated with primarily secular or faith concerns varied. Therefore, as with any study of race/ethnicity and health, we highlight a pattern among many of the Black churches in our study that we hope can be useful to others seeking to form health partnerships with Black churches, while cautioning that attention to intraethnic diversity must accompany such efforts.27 Although we could not identify distinct patterns (e.g., denominational) from our small sample, what we observed suggests that church-based health promotion programs should further explore and take account of such differences.

In the end, those interested in developing church-based health programs in the Black community should be attuned to how the same factors can both facilitate and hinder a program's development and devise ways to navigate and overcome these potential barriers by working with the considerable strengths of Black churches.