Motives Driving Non-healthcare Community Organizations to Engage in Health Promotion Activities

Abstract

While health promotion is not the primary mission of many community organizations (e.g., libraries, religious organizations), it is well documented that many still engage in health promotion activities, even when their resources may be constrained. What is less understood are the driving forces that spur community organizations to divert finite resources to health promotion when it may not directly align with their primary mission. The current study explores the reasons why various community organizations might choose to engage in health promotion, particularly in the context of the COVID-19 pandemic. We conducted interviews with leaders of 22 mosques, public libraries, low-income housing communities, and university-affiliated fraternities/sororities in the state of Maryland and qualitatively analyzed the data using template analysis. Four themes detailing reasons these community organizations engage in health promotion were identified including Organizational perceptions of health, Identifying and addressing issues of accessibility, Organizational responsibility, and Member interest and initiative. Understanding the reasons community organizations outside of the healthcare setting engage in health promotion, especially during a global pandemic, can allow public health researchers and practitioners to develop increasingly relevant and, in turn, effective strategies for recruitment of community organizations and sustainment of partnerships with these organizations. This has implications for population-level health impacts by improving reach to those that may not engage with traditional healthcare providers.

Introduction

Background

Health Promotion in Community Organizations

Great improvements in public and community health have been made in the past several decades, however, disparities in health outcomes persist among populations [1]. Community settings have become important venues for health promotion to reach underserved populations impacted most by disparities [2–4]. Health promotion can be particularly challenging in community settings where health is not the primary mission of the organization. For example, interventionists must understand, adapt to, and work with the (sometimes limited) health resources and priorities in the host setting [5, 6]. However, engaging community organizations in health programs has implications for expanding health promotion to populations that may not otherwise be reached effectively [2–4]. Interventions through community and organizational settings have been designed to tackle a number of health issues in a variety of populations [6]. Interventions have been designed to address mental health in school settings [7], physical activity in workplaces [8], and cancer education in religious organizations [9]. Many community organizations have also engaged in health promotion efforts without a reliance on external interventionists, such as efforts to promote mental health within mosques [10], health screenings in churches [11, 12], dissemination of health information by public libraries [13], and exercise classes in public housing communities [14].

Why Community Organizations Engage in Health Promotion

While health promotion is not the primary mission of many community organizations [15, 16], it is well documented that many community organizations, including those without a primary mission of health, participate in health promotion and seek to improve the health of their members and communities [10–14]. The forces driving non-health-centric community organizations to promote health or their motivations for doing so are not as well researched. Scientists have documented some potential reasons for community organization participation in health promotion without necessarily acknowledging them as such. For example, researchers have described health promotion funding opportunities available for and/or required of some community organizations [17], demand from organization and community membership to address health issues [10, 18–20], and the ability of community organizations to make a positive impact on inadequately addressed community health outcomes [2–4, 20, 21]. While funding, member demand, and the opportunity to make a positive impact can be present within these organizations as described in prior work, the presence or absence of these factors could serve as catalysts for or deterrents to health promotion in that organization. These could be examples of potential reasons that might spur a non-health-centric community organization to engage in health promotion. However, explicit study regarding the reasons why non-health-centric community organizations, which are often limited in resources, choose to promote health is lacking.

The Present Study

The current study explores the reasons why mosques, public libraries, low-income housing communities, and university-affiliated fraternities/sororities engage in community health promotion, particularly in context of the COVID-19 pandemic. It is critical to understand the forces driving community organizations to participate in health promotion, as understanding these reasons will allow public health researchers and practitioners to create and maintain more effective partnerships with community organizations [22]. This work will allow health professionals to be more responsive to the concerns of community organizations and develop increasingly relevant and, in turn, effective strategies for recruitment of community organizations and sustainment of partnerships with these organizations. This work also has implications for the effective implementation of community-based interventions within these settings, as aligning interventions with the goals and motivations of the organization can improve success in intervention implementation [23]. Additionally, by understanding reasons that could motivate community organizations to participate in health promotion, it may be feasible to encourage community organizations to initiate their own health promotion efforts or to expand their existing health promotion efforts into priority health areas they may not already be addressing. During a global pandemic when health promotion and disease prevention are even more relevant, understanding how we can motivate community organizations with access to traditionally hard-to-reach communities to engage in health promotion is all the more critical.

Methods

All study methods and procedures were approved by the Institutional Review Board. This study used semi-structured key informant interviews to understand the reasons community organizations might choose to promote health within their communities, as perceived and reported by leaders of various community organizations. Eligible organizations: (1) were mosques, public libraries, low-income housing communities, and university-affiliated fraternities/sororities, (2) had between 15 and 2000 regular members or attendees, (3) held at least one monthly, organization-wide meeting or event, and (4) were based in Maryland. Mosques, public libraries, low-income housing communities, and university-affiliated fraternities/sororities were identified as the focal organizations for the current project because health promotion is not necessarily the primary mission of these organizations like it is in a community clinic or other healthcare setting. However, each of these organizations still have intimate ties with community members and have been identified as community settings for health promotion in prior research [10, 13, 14, 24]. One individual from each participating organization was eligible to complete an interview on behalf of the organization if they: (1) were at least 18 years of age, (2) were a self-identified leader of that organization; and (3) indicated that they were willing and able to understand and respond to questions about health within their organization in English. Pseudonyms are used in all reporting to protect participant confidentiality.

Recruitment via email, phone, and word of mouth began by leveraging existing relationships with community organizations in Maryland. We then conducted targeted outreach via contact information available online to reach additional potentially eligible community organizations. The study team also employed purposive snowball sampling to identify additional organizations and leaders meeting the study eligibility criteria.

Interviews were conducted in person or over Zoom in the summer and fall of 2021 and generally lasted 30–60 min. Each interview was led, audio recorded, and transcribed by trained members of the research team. Participants were provided with a $10 incentive for the interview. A semi-structured interview guide for the study was developed based on an extensive literature review and was revised at each step following expert review and pilot-testing with three community leaders before finalization. The interview guide consisted of 12 questions covering the leader’s experience with health promotion in their organization, why their organization participates in health promotion, how health promotion has changed at their organization in context of the COVID-19 pandemic, and their perceptions regarding the future of health promotion at their organization. Interview questions were supplemented by a list of probes interviewers could use following each question and interviewers were encouraged to generate additional probes in response to specific participant responses during the interview.

Data collection continued until a minimum of five organizations representing each organization type (mosque, public library, low-income housing community, or fraternity/sorority at a college or university) was included and data saturation was achieved within each organization type. The research team met following the fifth interview in each organization type to discuss data saturation or the need for additional interviews within an organization type, if applicable. A total of 22 individuals were interviewed, including five leaders of mosques, seven leaders of public libraries, five leaders within low-income housing communities, and five leaders of fraternities or sororities at a college or university (see Table 1). Additional leaders of public libraries were recruited, as the team suspected that data saturation had not been reached by the fifth or sixth interview.

Table 1.

Participating non-healthcare community organizations by type (N = 22)

Mosques	5 (22.7%)
Public libraries	7 (31.8%)
Low-income housing communities	5 (22.7%)
Fraternities/sororities	5 (22.7%)

Analysis

Template analysis, a specific form of thematic analysis, was used for this qualitative study [25]. Each member of the research team independently familiarized themselves with the transcribed interview data and noted initial ideas for potential codes reflecting the qualitative data. The team then met to compare the initial individual impressions of the data and through consensus, initial codes and a template codebook were developed. Two team members independently applied this template codebook to the data using the Nvivo software, coding the interviews in line with the established codes and noting additional data of interest not reflected among the established codes. The team met regularly to discuss the coding process and findings, including revisions to the template in which codes and subcodes were added, deleted, and moved to iteratively refine the template codebook. Once all the data were coded, additional meetings were conducted to collectively reflect on the iteratively revised codebook and develop a finalized list of themes and subthemes.

Results

Four themes with corresponding subthemes on the reasons behind health promotion among these community organizations were identified from the interview data with the 22 community organization leaders. Organizational perceptions of health indicates the importance an organization places on health. Identifying and addressing issues of accessibility describes when an organization is able to recognize a particular resource, service, or health concern that is not being addressed adequately in the community and works to respond to and improve community health. Organizational responsibility describes a requirement of or pressure on the organization to promote health. These forces may often be external to the community organization itself, such as an overseeing body (e.g., a government funding agency, university administration, social expectation/responsibility), a religious deity, or a tradition/expectation inherent among that organization to promote health. Member interest and initiative reflects the input from individuals who are a part of the community organization that spur that organization to promote health. Each of these themes was identified across all types of organizations interviewed. However, in some cases, these themes were more common among select organization types or were expressed differently among one organization type, as described below.

Theme One: Organizational Perceptions of Health

Significance of Health

Participating organization leaders frequently reported the view that health and helping others to improve their health are critically important. Frequently used phrases included the “importance” and the “impact” of “helping people live longer,” “helping them to be healthy,” and “helping them achieve their health goals.” Cindy, a leader from a low-income housing community, shared, “We participate in health promotion because it is important […],” adding, “A very rich man said, he had all the money in the world, but he could not get his health back, no matter what he did. So, if you can promote prevention and intervention as early as possible, you can help people live longer, or at least give them the information and the tools that they need to live to live longer and healthier.” Anecdotally, some participants suggested the $10 incentive provided for participation in the project was not sufficient to compensate them for their time at the point of recruitment; however, these same participants were quick to add that they were still willing to participate because of the project implications for health promotion and the perceived significance of their community’s health.

Passion for Helping Others

Many organization leaders expressed their passion for helping others and for health promotion driven by the importance they place on the community and the health of that community. They described themselves as passionate individuals wanting to help the community and wanting to improve health. Even in interviews where participants did not specifically mention their passion, the value and pride they associate with their health promotion efforts could often be felt in the way they spoke about them. Tiffany, the leader of a housing community, said, “I do it [promote health in the organization] because I'm a very passionate person. I just love helping people. I love helping my community.”

Importance of Health Equity

Beyond the broad significance of health, some leaders spoke specifically to the importance of health equity and addressing health disparities. Natalya, a leader of a public library, said, “(Our) system has a mission statement centered on equity. Health care is an equity issue. Racism is a health care issue. […] We are a site where people can pick up food. [During the pandemic] we saw a lot of people picking up food for the first time. First-time SNAP recipients. First time needing community health care.” This leader added, “One component of our current focus is LGBTQ-centered healthcare. We work with some nonprofits on legal and emotional needs of LGBTQ populations. Awareness of trans and [gender] nonbinary challenges finding healthcare. Establishing ourselves as a safe place for them.” Many of the leaders who participated indicated that the health promotion efforts at their community organizations often serve underrepresented and minoritized communities.

Health as a Resource

Some leaders alluded to the importance of member health in sustaining active membership and member contributions to the organization. Terry, leader of a housing community, said, “We help families to be more sustainable and residents will stay with us a long time if they get the support they need.”

Theme Two: Identifying and Addressing Issues of Accessibility

Need for Accessible and Reliable Health Information

Leaders often pointed to a need for more reliable and accessible health education in their communities. Organization leaders shared that without accessible health information, one cannot expect members of the community to be healthy. One of the most frequently reported informational needs was education regarding COVID-19 in the context of the pandemic. Many community members were unable to or unsure about how to access information on the virus, the COVID-19 vaccines, where to get vaccinated, etc. To address this limited accessibility of health information, the promotion of health education via distribution of information (e.g., pamphlets, community presentations, trainings) was one of the most frequently reported types of health promotion among the participating community organizations. Cindy, from a housing community, said, “Sometimes people aren’t eating correctly, or exercising, or preserving their health because they don’t have the information that can help them to do that. And so that's why it’s important that we get that information out to the members of our community.” Leaders of libraries were also more likely to address the reliability of health information. Carson, leader of a public library, said, “Part of the library’s role is to provide vetted professional resources and information. We’re seen as information experts. To be able to bring quality info[rmation] about any subject—the community trusts us to do that.”

Need for Health Resources and Healthcare

Participating organization leaders often indicated that members of their community would struggle to access healthy foods, to access COVID-19 vaccinations during the COVID-19 pandemic, and to access other health and healthcare services. Recognizing these needs, many community organizations were spurred to fill the gap in care. Sandy, a leader of a mosque that established an internal health clinic staffed by health professionals from their membership, said,

There was a need for health services for those uninsured and being from an immigrant family. We were seeing lots of our community members who didn’t have access to health insurance, who didn’t have access to proper care. So, it [the health clinic] was really to initially create a mechanism to ensure that community members who didn’t have access to care were getting seen by a doctor and were getting the care they needed.

Subpopulation Needs

Some leaders spoke to the specific needs of subpopulations that they have seen struggle with gaps in access to health information, services, or programs. Families, youth and children, senior populations, and individuals with an audio or visual impairment were some of the subpopulations mentioned that could require specific or tailored resources and services. Ari, a library leader, said,

There’s so much info out there, but there are so many people unaware of blind/low vision/print-disabled groups needing access to this info. Many of these people […] just need info in a format they can access, not somebody to hold their hand. […] What we do is with the intent of giving people access to something that should have already been accessible.

Theme Three: Organizational Responsibility

Organizational responsibility was a common theme across all organization types, however, that sense of responsibility was not always derived from the same source. Libraries, for instance, mentioned their traditional duty and expectations as an institution that serves to educate the public, including educating them on matters pertaining to health. Mosques referred to a religious duty imparted by God to help others, to live a healthy life, and to help others live a healthy life. Some organizations may be required to take certain actions to maintain good standing or to receive funding from an overseeing body. These actions could manifest in a contribution to health promotion, in some cases. For instance, fraternity and sorority chapters were often bound by their overseeing national bodies and/or university policies to “give back” in some way. Among participating fraternities and sororities, examples included supporting local health-centric non-profit organizations or community service events helping to provide food for those in need.

Across organization types, many organization leaders reported that it was their duty as a “community” organization to serve and support their community in endeavors that might include health. Some leaders even suggested that their organization has a responsibility not just to support the community, but an inherent duty specifically to promote health. Charles, leader of a low-income housing community, said, “It’s important for my organization to promote health because we are held responsible or accountable for the lives of so many individuals, so many families in Baltimore City.” Expressing the duty of his organization to set a health promotion example for other housing organizations to follow, Charles added, “In terms of public housing, we lead the way, we are example makers for others to see.”

Theme Four: Community Interest and Initiative

Requests from Community Members

Participating leaders described the central role of their members in helping to decide which programs and activities the organization would offer. Participating organizations suggested that they are sometimes called on by their members to address community concerns, including health. While health is often not the primary mission or objective of these community organizations as it is in a healthcare setting, community members are turning to these organizations to address health concerns. Brittney, a leader from a university sorority, said, “We have open spaces, such as texting the group, and coming to me. The executive board, as well as me, carefully listen to what is needed in the chapter. We have a health and wellness chair and we work with them to plan events. […] Typically, they send out surveys asking about what topics and activities they [the organization members] want.” Community member input also becomes central in deciding which health promotion efforts to continue offering. Leaders cited member event attendance, word-of-mouth feedback, and evaluations in the form of surveys as key contributors to the decision-making process about whether or not to offer a particular health program or event again.

Community Member Initiative to Champion a Cause

Though health promotion efforts in some community organizations were frequently implemented by paid or volunteer members of the organization, some leaders described health promotion efforts that were entirely driven by a member or a small group of members who approached organization leadership to champion a health cause. In these instances, the member(s) would approach organization leadership not to ask that they address a health concern, but rather to gain leader approval and support in their own effort as a member to address the concern. L, a sorority leader, recounted an instance of a community member starting a health promotion effort to address cancer due to her own experience with cancer. Tiffany, a leader of a housing community, spoke about a resident who organized a mental health cookout for their community after residents had been isolating indoors during the COVID-19 pandemic. She said,

One of my residents said, ‘Miss Tiffany, our Memorial Day was so whack. Can we please have a cookout for Fourth of July? And we want it on the Fourth.’ […] The resident who put it all together, she's an older lady, she had all her ducks in a row. Everything went so smoothly, there was no foolishness. All the residents that were coming, they social distanced, they all listened.

Partner Organization Initiatives

Organization leaders frequently referenced partnering organizations (e.g., health clinics, health-oriented non-profits, local universities) that would offer a health program to their community members. Community organizations were sometimes approached by other organizations offering partnerships in health promotion, while at other times the community organization would actively seek out health promotion partnerships with other organizations. Partnering organizations and community organizations would collaborate to offer health events for the community led by the partner but often hosted within the community organization. Depending on the success of the event, community organization leaders could recontact their partners should they want to offer that same program in the future. Though these inter-organization partnerships were not exclusive to any community organization type, they were especially emphasized among participating libraries and housing communities, two sites where the membership may generally be less active in the implementation and execution of health programming as compared to mosques and fraternities and sororities.

Discussion

The purpose of this study was to identify the reasons why community organizations engage in health promotion. While community organizations are often approached by outside entities (e.g., researchers, healthcare organizations), study of why a community organization would choose to engage in health promotion efforts for their members is limited. This study makes a novel contribution to the public health literature by identifying common themes and reasons why community organizations choose to promote health. This study presents four themes contributing to community organization decisions to engage in health promotion efforts as reflected by interviews with leaders of mosques, public libraries, low-income housing communities, and university-affiliated fraternities/sororities.

The current findings suggest that although health is not the primary mission of most community organizations, these organizations are interested in and regularly engage in health promotion efforts. Each of the participating community organizations had engaged in some form of health promotion previously and expressed why they felt it was important for their organization to continue to do so in the future. Organizations were spurred to promote health in their communities based on the value they placed on the health of their community members, the recognition of health issues and recognition of contributions they could make to address them, and a sense of duty or responsibility imparted to the organization, as well as interests and initiatives driven by their communities. The reasons identified in these interviews largely overlap with those implied in previous research. The impact community organizations can make on the health of their communities [2–4, 20, 21], responsibilities and requirements for securing and maintaining funding [17], and demand from membership [10, 18–20] have been implied as reasons that might spur health promotion in community organizations. However, subthemes such as the perceived value of promoting health equity, the religious duty to promote health in some faith-based organizations, such as mosques, and offers extended by partnering health organizations are less frequently reported. The perceived value that an organization and its members place on health was also the most reported theme throughout the interviews. And while the perceived value of health among community organizations and leaders may not be explicitly reported widely in the health promotion literature, it should not be overlooked as a key reason spurring many community organizations to engage in health promotion.

Notably, these reasons do not appear to act independently. No organization was driven solely by any one of these themes. Rather, leaders who were interviewed suggested that these organizations were driven by two, three, or often all four of the themes presented. It is likely that some unique combination of these themes plays into each organization’s decision to engage in health promotion. It is also feasible that each of these themes could influence the others. The health interests that community members bring to organization leadership could raise the organization’s perceived value of health, for instance.

It is critical to note that interest and motivation to promote health can start with just a few organization leaders or members in some cases. Some organization leaders indicated that just a few people can be sufficient to initiate a health promotion effort. Leadership is a driving factor in community health promotion [26–28], so while the entirety of the organization may not need to exhibit all these reasons for health promotion, it is critical that at least one individual willing to take a lead in the health promotion efforts is spurred by one or more of these reasons driving engagement in health promotion.

Limitations

This study should be interpreted in the context of its limitations. First, our sample represented only community organizations that have previously conducted some form of health promotion. While prior conduct of health promotion was not a requirement to participate in the study, many types of community organizations [10–14] have performed some form of health promotion before (e.g., distribution of health pamphlets, posting health-related content on their website or social media, offering food assistance or exercise classes). There was also likely a self-selection bias among the organizations that chose to participate. Those that agreed to participate in the current interview on health promotion in their organizational setting may highly value the health of their communities. Valuing community health could make that leader and that organization more likely to support and conduct health promotion. The leaders and organizations that participated in this study may not be reflective of their respective organization types and are not reflective of other types of community organizations.

This study did not assess the “weight” of these reasons in health promotion decision-making among community organizations. That is, based on the interview data, it is difficult to discern which reasons contribute the most to community organization engagement in health promotion. For instance, while organizational perceptions of health was represented most among the four themes in terms of frequency, frequency does not necessarily indicate that the perceived value of health contributes more to the organization’s decision to promote health than the “responsibilities” of that organization to promote health. Understanding the most impactful reasons for health promotion among community organizations would allow for improved tailoring of messaging when seeking to engage community organizations in health promotion.

In addition, the interviews conducted for this study took place in 2021 during the COVID-19 pandemic, when prioritization of health and health concerns undoubtedly shifted for all people, as compared to 2 years prior. Based on the insight provided by the leaders in the interviews, the reasons for promoting health generally seemed to be amplified due to the COVID-19 pandemic (e.g., greater perceived community need for health information and access expressed by leaders, greater perceived member interest in health promotion efforts). Leaders focused less on their organizational responsibilities to promote health during the interviews, but this reason may be more readily reported by leaders outside of a pandemic context.

This study focused on the reasons driving community organizations to participate in health promotion efforts. This study did not evaluate the capacity of these organizations to conduct health promotion efforts. While the rationale for and interest in health promotion may be present, many community organizations may not have the capacity to implement health promotion efforts or to implement all the health promotion efforts they would like to. Similarly, members may not have the capacity to participate in these programs even if they would like to. Many organizations are stretched thin in terms of the services they can provide, particularly given the COVID-19 pandemic. Many organizations have lost members, have had to deal with budget reductions, are balancing competing priorities, etc. Similarly, for members, competing priorities could make it difficult to participate in health promotion efforts.

Future research could further apply these themes and assess the relative importance of reasons driving health promotion across community organizations. For example, what themes carry the most weight in making decisions about health promotion? Is it largely the demand from members that spurs health promotion? Or are opportunities for funding particularly persuasive for community organizations?

Implications

Leveraging the reach of community organizations has the potential to fill critical gaps in public health and health promotion efforts. Understanding the reasons driving community organizations to promote health is imperative for developing successful public health partnerships in these settings. Understanding is the first step in responding to organizational concerns and priorities, which will allow researchers and practitioners to recruit and retain community organizations as partners in health promotion, as well as tailor interventions to the interests of the organization to bolster intervention adoption and implementation. During a global pandemic, understanding how we can best motivate community organizations to partner with health professionals or engage in health promotion for underserved populations is even more essential.

Authors Contributions

All authors contributed to the study conception and design, material preparation, and data collection. Coding and analysis were performed by NW, DB, and AH. The first draft of the manuscript was written by NW and all authors provided suggestions to improve the manuscript. All authors read and approved the final manuscript.

Funding

This work was supported by a Faculty-Student Research Award from the University.

Data Availability

The datasets analyzed during the current study are not publicly available due the fact that they constitute an excerpt of research in progress but are available from the corresponding author on reasonable request.

Code Availability

The Nvivo software used to for the current analysis is made available by QSR International.

Declarations

Conflict of interest

The Authors declare that there is no conflict of interest.

Ethical Approval

This study was approved by the Institutional Review Board [1548447-11].

Consent to Participate

All participants provided their informed consent to participate in the study.

Consent for Publication

All participants provided their informed consent for their de-identified data to be published.