Rural Religious Leaders’ Perspectives on their Communities’ Health Priorities and Health

Abstract

Objectives

In traditionally underserved communities, faith-based interventions have been shown to be effective for health promotion. Religious leaders—generally the major partner in such interventions—however, are seldom are consulted about community health priorities and health promotion preferences. These insights are critical to ensure productive partnerships, effective programming, and sustainability.

Methods

Mixed-methods surveys were administered in one of the nation’s most under-resourced regions: rural Appalachia. A sample of 60 religious leaders, representing the main denominations in central Appalachia, participated. Measures included closed- and open-ended survey questions on health priorities and recommendations for health promotion. Descriptive statistics were used for closed-ended survey items and conventional qualitative content analysis was used for open-ended responses.

Results

Substance abuse, diabetes mellitus, suboptimal dietary intake and obesity/overweight, and cardiovascular and respiratory illnesses constitute major health concerns. Addressing these challenging conditions requires realistically acknowledging sparse community resources (particularly healthcare provider shortages); building in accountability; and leveraging local assets and traditions such as testimonials, intergenerational support, and witnessing.

Conclusions

With their extensive reach within the community and their accurate understanding of community health threats, practitioners and researchers may find religious leaders to be natural allies in health-promotion and disease-prevention activities.

Addressing health inequities requires focusing on multiple levels of determinants, including the appropriate provision of medical care, policies that influence access to such care, and public health initiatives that target community health concerns.¹ Although upstream population health interventions, including health equity transformation in policy, systems, and structures, offer wide-reaching potential for improving the health of the most underserved populations, community-based interventions also have the potential to decrease inequities in health care.² Among these community-based intervention opportunities, faith communities often have been important partners in community-based participatory research) projects, with faith-based programming demonstrating success for efforts in health promotion.^3,4

Faith-based institutions can serve as key partners in the development, implementation, and analysis of health-promotion programming. They bring key strengths to a research partnership: faith-based institutions (henceforth denoted here as “churches,” because, to our knowledge, few other religious institutions exist in Appalachian Kentucky) involve close social relationships, have an existing infrastructure, and play pivotal roles in the community. As community-owned institutions particularly among marginalized groups, churches have established trust and legitimacy, making them an ideal, trusted setting for providing and sustaining health programming.^5,6 Most Americans (85% nationally, 90% in the South) claim religious affiliations, thereby offering excellent potential for participant recruitment and access to underrepresented populations.⁷ Research demonstrates that many faith-based programs improve health.^8–10

Research into the role of faith communities in the health of their congregations and communities has begun to illustrate how and why faith-based health interventions may promote health. Catanzaro and colleagues¹¹ engaged nearly 350 ministers from across the United States to assess whether their congregations maintained a health ministry and why, offering insights into the content and approach of these ministries’ operations and functions. Results suggest that most congregations aspire to engage in health-promotion and disease-prevention support services. Ministers whose congregations maintain a health ministry tend to be actively involved in such efforts. Congregations lacking such a ministry implicate inadequate resources rather than lack of enthusiasm. Carter-Edwards and colleagues administered a survey to church leaders to determine which programmatic attributes of health ministries are perceived as important.¹² Church leaders indicated that displaying health information and incorporating health messaging in sermons, hosting health fairs and foundation support, and providing church-based Internet access to health information were important aspects of health ministries.¹² This potential role of information transmission constitutes a theme in faith-based settings and health promotion.¹³

Although these efforts have provided critical insights into how congregations integrate health-promotion programming into their ministries, they do not necessarily address an issue of fundamental importance to academic–faith partnerships: ministers’ perceptions of community health priorities and health-promotion preferences. Without such critical insights, researchers often develop topical foci and approaches before engaging faith communities in health-promotion activities.¹⁴ This orientation not only precludes a true academic–community partnership but also misses a valuable opportunity to call on an expert, a key community thought leader capable of identifying needed and promising and sustainable health-promotion approaches.

This omission represents a limitation of the literature for several reasons: in general, ministers maintain a solid, grounded understanding of their communities; they often hear from a diverse array of community members; because they are “natural helpers,” they know what social and health services are available in their communities and may contribute to these resources through their health ministries; and they tend to be influential in implementing programming. For all of these reasons, assessing their perceived community health priorities represents an opportunity to enhance partnerships for interventions and gain access to well-informed community members’ perceptions.

In this article, we attempt to address this gap by identifying priorities and approaches using a mixed-methods model among rural religious leaders. Such information provides researchers with a starting point to address health concerns prioritized by key community spokespeople.

Methods

Study Population

The population studied included rural, faith-based representatives from Appalachian Kentucky. As part of the US region that is traditionally known as the “Bible Belt,” Appalachia places particular importance on their religious institutions. In Kentucky’s Appalachian counties, 78% of religious congregations are Evangelical Protestant (in the Appalachian context, this includes several Baptist sects), 17% are mainline Protestant, 2% are Catholic, 1% is black Protestant, and 2% are “other.”¹⁵

In addition to this strong faith tradition, socioeconomic and health inequities constitute other characterizing features of Appalachia. Compared with the United States as a whole, Appalachian Kentucky county residents have twice the rate of poverty (28% vs 14.5%); more than twice the premature death rate (12,028 vs 5317); and nearly twice the obesity and physical inactivity rate (39% vs 21% and 37% vs 21%, respectively) of people living elsewhere in the United States. Approximately 17% of this population has been diagnosed as having diabetes mellitus (compared with 10% nationally), increasing to 44% when undiagnosed people with diabetes mellitus are included.^16,17 In recent years the region has experienced a rapid increase in substance abuse and associated mortality.¹⁸ Compounding this high burden of disease, healthcare provider (HCP) shortages are pervasive in Appalachian Kentucky, with nearly 80% of the 54 Appalachian Kentucky counties considered HCP shortage areas.^19–21 To address these health and resource inequities, our academic–community team has undertaken community-engaged interventions for >13 years, focusing predominantly on faith-based partnerships.²²

Study Design

We used a mixed-methods approach, including administering a survey with closed- and open-ended questions, with a convenience sample of 60 religious congregational representatives. The qualitative component was a descriptive study using conventional content data analysis, an approach that is particularly useful in the absence of other research.²³ Data were collected from May 2015 to February 2016. After completing informed consent processes, participants completed a 2-page survey and either returned the survey by e-mail, fax, mail, or handed it to our local project office (54 participants, 90%), or requested an in-person interview with local project staff (6 participants, 10%). We followed up after 2 weeks if we had not received the completed survey (7 participants, 12%). No church representatives refused to complete the survey.

Measures

The survey (Table 1) was developed in conjunction with our community advisory board, which provided lists of potential health priorities and approaches to address these concerns. The survey also included demographic questions and space for responses to open-ended questions.²⁴ Local staff field tested the survey.

Table 1.

Survey questions on health priorities and approaches

1. What are the biggest health problems in the community?

Close-ended checklist: drugs, diabetes [mellitus], obesity/overweight, cancer, high blood pressure, heart disease, respiratory disease, lack of exercise, mental health issues, drinking, poverty, teen pregnancy, others (list)

2. Of these, which would you consider the most pressing problem?

3. If we excluded drugs, which would you consider the most pressing problem?

4. Why?

5. What are some approaches to address these problems?

Close-ended checklist: overall health education, healthy-eating classes, exercise including facility access (free), classes, clubs, groups, walking groups, wellness clinics, gardening, group prevention/wellness sessions, transportation to doctor’s office, classes/information on cancer prevention, smoking cessation, home hygiene, free clinics, others (list)

6. What would be most inspiring to your parishioners?

Close-ended checklist: group support sessions, motivational interviewing, testimonials, advertising, weekly e-mail or telephone reminders, online programming, others (list)

7. What are some characteristics/attributes of good health-promotion programs?

8. What else do we need to know about promoting good health in your community?

Analysis

We used standard descriptive statistics for the structured instruments and conventional qualitative content analysis for the open-ended questions.²³ We selected a conventional content analysis approach because we aimed to describe perspectives on community health priorities from the views of respected community leaders, a research area that has not received extensive attention. Briefly, we read the narratives multiple times to devise codes, took notes on impressions, developed an initial coding scheme, and then abstracted these codes to a broader context. We then categorized these codes and clustered them into more encompassing and meaningful categories.²³

Results

Consistent with the region, most congregations were Baptist (n = 34, 57%), followed by nondenominational (n = 7, 12%), Pentecostal (n = 6, 10%), Methodist (n = 4, 7%), Church of God (n = 4, 7%), Presbyterian (n = 3, 5%), Catholic (n = 1, 2%), and Church of Jesus Christ of Latter-Day Saints (n = 1; 2%). All of the congregations were located in four rural Appalachian Kentucky counties, selected 13 years earlier to participate in community-based research based on their suboptimal health profiles.

Most of the respondents (85%) were ministers or associate ministers, with the remaining 15% describing themselves as lay leaders, including those directing health ministries or women’s groups. Most respondents (82%) were between the ages of 42 and 61 years; married (90%); and, reflecting the demographic of the region, white (92%). Educational attainment ranged from eighth grade to ≥16 years, and most participants indicated that their financial status was sufficient.

Nearly all of the 60 ministers or designees indicated that substance abuse, specifically drugs, constitutes the major community health problem, with nearly two-thirds identifying substance abuse as the primary threat to health. Church representatives also identified diabetes mellitus, suboptimal diet, overweight/obesity, cancer, hypertension and heart disease, respiratory conditions, and inadequate amounts of exercise as major health priorities (Table 2).

Table 2.

Appalachian religious leaders’ perceptions of community health priorities (N = 60)

Health priorities	Mentioned n (%)	Most popular selection n (%)
Drugs	55 (91.7)	38 (63.3)
“If we excluded drugs, what would be the biggest health problems in the community?”
Diabetes mellitus	34 (56.7)	14 (23.3)
Poor diet	35 (58.3)	8 (13.3)
Obesity/overweight	33 (55)	8 (13.3)
Cancer	28 (46.7)	10 (16.7)
Hypertension and cardiovascular disease	28 (46.7)	5 (8.3)
Respiratory disease, including lung cancer, COPD, asthma, allergies	26 (43.3)	7 (11.7)
Lack of exercise	25(41.7)	2 (3.3)
Mental health issues, including depression, anxiety, anger	14 (23.3)	2 (3.3)
Alcohol abuse	13 (21.7)	1 (1.7)
Poverty, lack of economic opportunity	14 (23.3)	2 (3.3)
Teen pregnancy	4 (6.7)	1 (1.7)

COPD, chronic obstructive pulmonary disease.

Table 3 highlights approaches that religious leaders mentioned as being potentially helpful in addressing these health concerns. Health education classes were suggested frequently. Participants also recommended enhanced access to fitness facilities, fitness clubs, walking groups, and gardening. More than one-third of participants recommended a holistic medical approach to improve health, specifying wellness clinics or wellness group sessions. When asked specifically about five approaches frequently used in health-promotion interventions, group sessions and testimonials (through storytelling or witnessing) were endorsed strongly. Motivational interviewing, an approach we have used in our previous projects, also was deemed promising. Conversely, most church representatives did not endorse public service announcements or advertising. Technologically oriented approaches, including online programming and text/e-mail/telephone reminders received the least amount of support.Repeated narrative comments included the need to focus on accountability (eg, buddy systems, social support), ensure program affordability (eg, walking groups), and ensure intergenerational engagement (eg, parent/child cooking classes), all in the context of a constrained environment.

Table 3.

Appalachian religious leaders’ approaches to address community health priorities (N = 60)

Approach	n (%)
Health education overall	42 (70)
Healthy-eating classes	38 (63.3)
Exercise, including facility access (free), classes, clubs, groups	43 (71.7)
Walking groups	24 (40)
Wellness clinics	24 (40)
Gardening	19 (31.7)
Group prevention/wellness sessions	19 (31.7)
Transportation to healthcare professional’s office	12 (20)
Classes/information on cancer prevention	12 (20)
Smoking cessation	10 (16.7)
Home hygiene	8 (13.3)
Free clinics	10 (16.7)

Discussion

Improving health equity requires a broad, concerted effort that addresses engagement at policy, system, community, and individual levels.¹ As one of the most trusted and sustainable community resources, religious institutions have been involved in health-promotion efforts, engaging their members at the individual, community, and organizational levels of influence, and often demonstrating positive effects.³ The support of such community partners is enhanced if their leadership prioritizes a health condition and endorses a strategy.^25,26 Faith institutions are conducive to health promotion because of the values placed on health, established social connections and community engagement, infrastructural support, and role modeling.²⁷

This article demonstrates consistency between religious leaders’ perception of community health priorities and epidemiologic research. Although many more Appalachian residents have been diagnosed as having chronic physical diseases than substance abuse,²⁸ there is strong consensus that drug abuse constitutes communities’ most serious health problem. The rapid rise in drug abuse, media attention, the young age of those most afflicted by addiction, and the devastation entire families and communities experience as a result of substance abuse may shape perceptions about its elevated threat.²⁹

Several recommendations were provided by religious leaders, also converging with standard health-promotion approaches. Reflecting local culture, social support and testimonials (through storytelling or witnessing) were strongly endorsed. More passive forms of social interaction (advertising, technology-oriented communications) were seen as less promising strategies. Although practitioners and researchers often maintain interest in using technology-mediated outreach strategies, religious leaders should be consulted before investing significant resources in such approaches. For these rural Appalachian communities, more intense interpersonal communication appears to hold more promise.

These results have important implications for both researchers and HCPs. For researchers, engaging religious leaders early in the process can lead to a better understanding of which health challenges are community priorities and gaining active buy-in and participation of these community leaders. Understanding these priorities and preferences can lead to more acceptable interventions, enhancing the likelihood of success. For medical professionals, the expectation of fostering a personal relationship with patients, although ideal, is challenging in the current healthcare environment. Sparse medical resources present an extreme challenge to Appalachian Kentucky. As a consequence, education and prevention activities that are suitable for implementation by laypeople (eg, advocacy for cancer screenings, public health interventions to reduce obesity) may find a good home in religious settings and may alleviate the high demand for medical expertise. Collaboration between providers and ministers, particularly those with health ministries (53% of churches in one survey), may alleviate some of the burdens of routine disease prevention education and advocacy.¹¹ Unfortunately, there are far fewer congregational health ministries in rural and poorer communities, a situation made worse by the greater needs of the population.

Conclusions

Although this study was limited by involving a geographically distinct convenience sample, the main findings are transferable to most underserved groups. Researchers must determine community health priorities and the optimal ways to address them, building communities of support through stakeholder engagement. Religious institutions often offer such support and engagement and may alleviate the challenge of providing routine health education and disease prevention support programming, which is best implemented through authentic partnerships.

Key Points.

• In rural communities, particularly in the US South, religious leaders may offer grounded insights into community health priorities and may be particularly helpful in facilitating health-promotion programming.

• A survey of 60 Appalachian religious leaders from diverse rural populations suggested the following as community health priorities: substance abuse, diabetes mellitus, dietary issues, and cardiovascular and respiratory illnesses because they constitute major health concerns.

• The faith leaders surveyed suggested programming that acknowledges sparse community resources, builds in accountability, and uses traditions such as testimonials and intergenerational support.