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Health Promotion and Risk Reduction in Congregations

Summary and Keywords

A complex web of attitudinal, cultural, economic, and structural variables condition the decision to respond to communications promoting healthy behavior and participation in risk reduction initiatives. A wide array of governmental, corporate, and voluntary sector health-related organizations focus on effective messaging and health care options, increasing the likelihood of choices that generate and sustain wellness. Researchers also recognize the significant and multifaceted ways that religious congregations contribute to awareness and adoption of health-promoting behaviors. These religiously based organizations are credible disseminators of health education information and accessible providers of venues that facilitate wellness among congregants and community members. The religious beliefs, spirituality, and faith practices at the core of congregational cultural life explain the trustworthiness of their messaging, the health of their adherents, and the intention of their care provision.

Considerable inquiry into the impact of religion and spirituality on health reveals substantive correlations with positive psychological factors known to sustain physical and psychological health—optimism, meaning and purpose, hope, well-being, self-esteem, gratefulness, social support, and marital stability. However, the beliefs and practices that create receptivity to health-related communications, care practices, and service provision can also be a deterrent to message impact and participation in healthy behaviors. When a productive relationship between spirituality and health exists, congregational membership offers rituals (e.g., worship, education, mission) and relationships that promote spiritual well-being. Research demonstrates increased life satisfaction and meaning in life, with health risk reduction associated with a sense of belonging, enriched social interactions, and shared experiences.

Congregations communicate their commitment to wellness of congregants and community members alike through offering a variety of congregationally based and collaborative wellness and risk reduction programs. These expressions of investment in individual and community health range across all age, gender, and ethnic demographics and address most of the prominent diagnostic categories. These programs are ordered along three dimensions: primary prevention (health care messaging and education), secondary prevention (risk education), and tertiary prevention (treatment). Applying the dimensions of sponsorship, goal/mission, focus, services, staffing, and intended outcome highlights the similarities and differences among them. Several unique facets of congregational life energize the effectiveness of these programs. Inherent trust and credibility empower adherence, and participation decisions and financial investment provide service availability. These assets serve as attractive contributions in collaborations among congregations and between private and public health care providers.

Current research has not yet documented the best practices associated with program viability. However, practice wisdom in the planning, implementation, and evaluation of congregationally based and collaborative health-related programs suggests guidelines for future investigation. Congregational leaders and health care professionals emphasize well-designed needs assessment. Effective congregational health promotion and risk reduction may be linked to the availability and expertise of professionals and volunteers enacting the roles of planner/program developer, facilitator, convener/mediator, care manager/advocate, health educator, and direct health care service provider.

Keywords: congregations, religion, health promotion, health education, faith communities, spirituality, wellness, health programs, risk reduction, collaboration

Longstanding Community Presence and Trust

Congregations and clergy play a quiet but powerful role in health education and the promotion of community initiatives aimed at wellness and health risk reduction. That congregations have a long-term role in daily life for many people (Levin, 2014) and represent a trusted community presence (Rowland & Isaac-Savage, 2014) provides a significant foundation for their effective engagement in health education and health care provision. Because congregations serve as the “center of life” for many people and as trusted sources of information and guidance, they can integrate and effectively promote health (Kegler, Hall, & Kiser, 2010). They do this informally but also by formally supporting health initiatives (Levin, 2014; Rowland & Isaac-Savage, 2014).

Numerous studies document the nature and extent of the impact of congregations on the physical, relational, and psychological health of congregants as well as persons in the communities they serve (Gunderson & Cochrane, 2012; Krause, 2009; Krause & Wulff, 2005; Oman & Thoresen, 2005; Wilmoth, Adams-Price, Turner, Blaney, & Downey, 2014; Wuthnow, 2004). These findings link the efficacy of congregational health promotion to the relationships among religion, spirituality, and health; identify how congregations activate and sustain their commitment to health and risk reduction; and document the strengths and limitations of their involvement.

Beliefs and Attitudes

For many congregations, health interventions fit into established holist beliefs about the linkage of health and spirituality (Lumpkins, Greiner, Daley, Mabachi, & Neuhaus, 2013). This holism creates cohesion between spiritual belief and physical manifestations, making it very meaningful for congregants to talk about faith and health together (Francis & Liverpool, 2009; National Institutes of Health, 1997). Congregational beliefs, attitudes, and values such as the belief that the body is valuable, mental health problems are unacceptable (Lumpkins et al., 2013), and access to healthcare as a justice concern impact behaviors related to a host of health factors (Kegler et al., 2010; Levin, 2014). Beliefs about personal responsibility and regret over inconsistency between actual behavior and professed values can lead to changes in healthy behaviors (Anshel & Smith, 2014). It is also helpful to see these new behaviors practiced in a variety of settings, e.g., eating healthy foods with others in the congregation or having the opportunity to sign up for a mammogram (Peterson, Atwood, & Yates, 2002). A holistic view of the person that integrates health with spirituality may increase the likelihood that healthy behaviors will be sustained (Sanders, 1997).

Religion, Spirituality, and Health

Relationships among religion, spirituality, and health explain the unique contribution of congregations to community health care initiatives. Over the past few decades, social scientists have identified numerous connections between religion, spirituality, and health (Campbell et al., 2007; Ellison & Levin, 1998; Koenig, King, & Carson, 2012; Lawler-Row & Elliott, 2009; Lee & Newberg, 2005; Levin, 2009; Oman & Thoresen, 2005). Spirituality, defined as a quest for meaning and one’s relationship with the self and the transcendent, is distinguished from religion, a formal organizational structure of persons sharing beliefs and practices based on mutually held perspectives on spirituality (Furman, Benson, & Canda, 2004). Religion as a positive correlate with psychological and physiological well-being is well established. Participation in spiritual activities produces a greater sense of purpose, which positively correlates with subjective well-being (Law & Sbarra, 2009). While some researchers suggest that the correlation with improved well-being is based more on meaning and purpose (spirituality) than religion (Lawler-Row & Elliott, 2009), others suggest that religion has specific aspects that directly improve health. Engagement with religious practices is associated with increased morale, personal adaptation, and improved physical and mental health (Tirrito & Spencer-Amado, 2000). Explanations for the positive correlation between religion and health include the interpersonal support present within congregations (Campbell et al., 2007) and the coping strategies provided in religious teaching (George, Ellison, & Larson, 2002). People who are religious and/or spiritual are less likely to be depressed, suicidal, or anxious or to abuse drugs or alcohol (Koenig, 2011). Healthy behaviors are promoted within a variety of religions and their congregations. For example, the Mormon religion prohibits smoking, alcohol, and sex outside marriage, and it offers guidelines for diet, sleep, and time spent with family (George et al., 2002). These religious prescriptions among active adherents are associated with lower morbidity and mortality, lower blood pressure, and higher immune function, ultimately leading to increased life expectancies (Lee & Newberg, 2005; Townsend, Kladder, Ayele, & Mulligan, 2002).

Positive emotions promoted by religion, such as love and forgiveness, result in healthy physiological responses, and investigators suggest that forgiveness also improves psychological well-being by reducing stress, anger, and anxiety (Ellison & Levin, 1998; Enright & Coyle, 1998; as cited in McCullough, Bono, & Root, 2005). Overall, religion and spirituality positively correlate with numerous benefits including improved optimism, meaning and purpose, hope, well-being, self-esteem, gratefulness, social support, and marital stability (Koenig, 2011).

The connection between religious involvement and health may be theoretically explained by a value-based change in behaviors and thought processes. Individuals who report high levels of religiosity (Benjamins & Brown, 2004) are more likely to use preventive services (e.g., flu shots, cholesterol screening, breast self-exams, mammograms, Pap smears, and prostate screening). In addition, faith in God positively correlates with an improved sense of control and enhanced coping skills (Hood, Hill, & Spilka, 2009; Pargament, 1997). A secure attachment to God correlates with greater life satisfaction and lower levels of anxiety, depression, and loneliness; these, in turn, are related to better physical health. Furthermore, improved psychological states can stem from better coping, meaning derived from religious goals, the experience of forgiveness, helping others, and faith-related expectancy (Oman & Thoresen, 2005).

Negative Congregational Interactions

While most research supports beneficial aspects of congregational interactions, Krause (2008) cites several studies that identify negative aspects of congregational interactions. For example, interpersonal conflict over finances, the format of the service, and moral issues related to gender and sexuality can affect peoples’ willingness to receive health services from a congregation. Furthermore, congregants may be critical, demanding, unwelcoming, or unavailable in times of need. Gossip, cliques, and differences of opinion also affect congregants, undermining their sense of belonging (Krause, 2008).

In a study of congregational health programs, Egbert and Hall (2012) discover that some congregations lack forms of support—such as network, tangible, esteem, and informational supports—that congregants might expect. Furthermore, access to services may be difficult during times of crisis, when it is needed most. Egbert and Hall (2012) uncover difficulties related to getting involved in the congregation’s activities, and this may increase disappointment and frustration.

Such negative interactions within congregations can be detrimental for those seeking congregational health services. Krause (2008) indicates positive correlations between negative interactions within congregations and lower satisfaction in health, increased anxiety and depression, and decreased self-worth. Some people may especially be hurt by negative congregational interactions because they expect the congregation to be a safe place. Therefore, the negative interactions may shock them and leave them more susceptible to physical and mental health problems. Furthermore, distress, hyperarousal, hypervigilance, anger, and doubt may result from negative interactions, leading to adverse health effects and decreased service attendance (Krause, 2008). If people have negative interactions in congregations, they are less likely to go to congregations for health services. Congregations may do their best to uphold religious values in all interactions, but, as in all areas of life, conflicts inevitably arise.

Additionally, stigma associated with moral values may also keep people away from congregational health services, as they may avoid congregations in fear of judgment. Dufour et al. (2013) suggest congregations may miss valuable opportunities (e.g., harm-reduction services) to minister to people when they hold firm to strict morals like abstinence. Without harm-reduction services, many stigmatized groups will likely avoid congregational health care and seek needed services elsewhere. When congregants carry stigma (e.g., related to people with HIV/AIDS), ostracism, punishment, and feelings of guilt may result (Dufour et al., 2013). Congregants also tend to be less educated than clergy about transmission of diseases like HIV/AIDS (Lindley, Coleman, Gaddist, & White, 2010), which may reinforce stigma and maintain gaps in care of stigmatized populations.

In addition to stigma and negative interactions, George et al. (2002) discuss beliefs that may be socially reinforced within congregations and deter involvement in health care. Some religious groups (e.g., Christian Scientists) refuse medical care, possibly leading to shorter life spans. Some religions also encourage negative coping (e.g., feeling as if God punished or abandoned someone or attributing illness to past sin). Positive religious coping (e.g., believing in a loving, caring, and strong God who can manage and cure His people) benefits health, whereas negative religious coping may have the opposite effect (George et al., 2002). Furthermore, religious involvement offers more positive effects in terms of prevention rather than recovery, as religious people may place a greater burden upon themselves for failing in the first place, thus needing to undergo recovery (Oman & Thoresen, 2005). Congregants may also suffer from stigma due to their physical and/or mental conditions. For example, children’s behavioral challenges create marginalization of families (Corrigan, Kerr, & Knudson, 2012; Mukolo & Heflinger, 2011).

While religion and spirituality are often positively associated, religion tends to be more stigmatized than spirituality among health care professionals. Some professionals fear that incorporating religion into their work with clients could result in manipulation or proselytizing (Miller, 2001). Many times, it seems as if health professionals are sympathetic to spirituality but allergic to religion, even though, according to the Pew Research Center (2015), only 23% of Americans do not identify with a specific religion. It is unfortunate when health care professionals overlook the influence of religion and spirituality in the lives of their clients, ignoring the evidence that these factors clearly play a large role in the lives of many of those with whom health care professionals work.

Congregations and Health

Religion is not something abstract but is embodied in the life of a local congregation. Congregations are religious gatherings that: (1) share an identity; (2) meet regularly and long term; (3) unite to worship and accept teachings, rituals, and practices; (4) meet at an established place; (5) worship outside of the purposes and location of work or home; (6) have an appointed religious leader; and (7) identify with a name and formal structure that gives purpose and identity (Boddie, Cnaan, & DiIulio, 2001). Congregations promote spiritual well-being through worship, education, mission, stewardship, and fellowship (Warner, 1994) and are a significant source of social capital (Putnam, 2000). Participation in religious ritual and activities can provide meaning to one’s life, potentially increasing one’s subjective well-being and life satisfaction (Ellison & Levin, 1998; Wilmoth et al., 2014). For example, older adults who demonstrate deep commitment to religion and help others within their religious settings document better health (Krause, 2009). As a result, congregations contribute directly to improved health and health risk reduction through increased social interactions, support, blessings, prayer, and shared experiences.

Organically, congregations exhibit eight strengths that contribute to the health of their members: accompanying, convening, connecting, storying, giving sanctuary, blessing, praying, and enduring (Gunderson & Cochrane, 2012). Because of their long-term relationships, congregants accompany each other through major life events, including many related to health and well-being. For example, congregants come alongside each other to celebrate life passages (births, marriages, deaths), learn how to cope with changing circumstances, and seek guidance for major life decisions. As a result, they develop relationships born out of significant shared experience. Congregants convene together on a regular basis to worship, pray, and discuss difficult topics, and the rhythm of consistent meeting deepens and sustains their relationships. In congregations, congregants connect through sharing resources and knowledge, both of which build social capital. Congregants unify through stories, whether the shared stories of their holy books or the personal stories of fellow congregants. Congregants connect not only through telling their stories but also through listening and participating together in an unfolding story (Gunderson & Cochrane, 2012). Whether telling or listening, they often experience an increased sense of belonging and purpose.

Congregations often give sanctuary, i.e., offer a place for congregants to carry out the work of their faith traditions, learn together, tell their stories, provide psychological and physical shelter, and seek help. Sanctuary provides a special bulwark for people who live as marginalized or minority members of a society. Congregations may provide blessings and affirmations, thus strengthening relationships and encouraging behavior and effort. A positive orientation leads to health benefits in contrast to the pain and sorrow of condemnation. Furthermore, congregations share their hardships as well as their praises so that they can pray together and for the needs of each other. Prayers foster healing and time to meditate. Congregations exhibit endurance as they undergo changes and shifts in thought and practice, adjusting as needed while holding on to their core beliefs, and providing a possible anchor amidst the changes of life. These are the common and often overlooked strengths of congregations that result from life together over time (Gunderson & Cochrane, 2012).

More concretely, congregations foster involvement that promotes healthy relationships and reduces potential risk behaviors. Engagement in congregational ministries and small group activities enhance opportunities for personal and relational meaning (Wuthnow, 2004). Such groups can encourage others to care for the needy, forgive others, and walk with others during emotional crises. In participating in religious activities, social capital inevitably develops, too, forming connections that encourage others in both joyful and somber points of life (Wuthnow, 2004). Generally, social ties are recognized as having a positive impact on health and behaviors (Giger, Appel, Davidhizar, & Davis, 2008). Support from others, such as that provided in congregations, contributes to positive outcomes for individuals involved in health initiatives (Peterson et al., 2002). Because of interpersonal relationships fostered within congregations, congregants sometimes come together to help others concretely but informally by simply praying for others, sending cards and presents, and making phone calls or periodic visits. In addition, congregants can help by offering to transport other congregants who cannot drive (Seeber, 1995). Congregants, acting as surrogate families for isolated persons in the congregation, provide instrumental services such as bringing groceries when the weather is bad or assisting in crises such as injuries, illnesses, fires, or deaths (Steinitz, 1981).

Researchers observe that a sense of belonging to a congregation positively correlates with health satisfaction and note that having increased emotional support from congregants leads to higher levels of physical and mental health (Krause & Wulff, 2005). They refer to Maslow’s theory that belonging is a fundamental human need, demonstrating that congregations offer a sense of belonging through personal investment over the course of a lifetime as well as through hosting important life events such as weddings and funerals. Research suggests that church-based social support, which fosters belonging, is effective in helping congregants cope with stress, live healthier lifestyles, address their immediate needs (e.g., food and clothing), and develop meaning (Ellison & Levin, 1998). A sense of belonging in a congregation can also help congregants feel and express more positive emotions, thus triggering beneficial physiological responses that contribute to health benefits (Krause & Wulff, 2005). In fact, religious affiliation and participation are both protective factors for suicide (Gearing & Lizardi, 2009). However, there is a threshold effect in that frequent attendance at worship services positively correlates with a sense of belonging; without frequent attendance, people do not develop the depth of relationships and support that result in positive health benefits (Krause & Wulff, 2005).

Congregations and Community Health Care

Historically, informal health promotion and risk reduction have existed in congregations, resulting in the associated health benefits. There is growing attention to formal congregation-based health programs (Krause, 2009; Lindner & Welty, 2007; Peterson et al., 2002; Trinitapoli, Ellison, & Boardman, 2009). Religious congregations provide a potentially significant linkage between community resources and other community members (Parker et al., 2003). In general, congregations have established a sense of trust and credibility, and they are likely to have both social and financial capital (Werber, Mendel, & Derose, 2014). Furthermore, congregational leaders tend to know the specific needs of their congregants (Werber et al., 2014), but they may not have the ability to adequately meet each need without additional support. Typically, religious congregations already have many of the foundational resources needed to create and sustain a program, such as buildings with kitchens and meeting areas (Campbell et al., 2007; Djupe & Westberg, 1995). Congregations also have access to large, stable groups of people who already meet weekly and express interest in helping others (Campbell et al., 2007). They also tend to have congregants from a variety of backgrounds, with knowledge of organizational resources, and with concern for their congregants, recognizing they can have influence over those concerns (Djupe & Westberg, 1995). In many cases, congregational leaders already address how congregants can help others through social action and community outreach (Campbell et al., 2007).

Congregations often provide a variety of other formal services related to their religious identity and practice (Seeber, 1995). Clergy make hospital visits and congregations may have formalized nursing home ministries where they perform worship services or hold classes. Most congregations hold funerals and some offer grief counseling related not only to death but also other physical and relational losses. Furthermore, congregations form small groups that help each other navigate through life challenges and celebrate life’s joys, adding love and meaning to congregants’ lives. Luncheons and other occasional activities that promote fellowship are also ways to involve and help congregants (Seeber, 1995). Overall, congregations offer services that keep a person healthy rather than solely help the sick. They challenge the popular opinion that hospitals and medical clinics are “health” agencies because they, in fact, focus on the needs of the sick. On the other hand, homes, schools, workplaces, and congregations are focal points for health promotion and sickness prevention (Djupe & Westberg, 1995).

In addition to the resources present within congregations, many people prefer to receive health promotion services from a congregation rather than a public entity—even those who are not frequent attenders—likely due to their familiarity, accessibility, trustworthiness, and welcoming relationships (Tirrito & Spencer-Amado, 2000). Congregations can bridge the gap for people traditionally disenfranchised from health services. Congregations that use health-related language and encourage the use of health resources make them a part of the congregational culture and thus increase accessibility (Giger et al., 2008). One study indicated that just having services offered through a congregation, at its building, drew congregants’ interest and increased their participation, regardless of what service was being offered (Anshel & Smith, 2014).

Therefore, the services of a congregation can reach beyond its own congregants to assist the whole community. In doing so, the services can stretch beyond improving the health and well-being of congregants by also acting as a form of outreach to the community. In order to holistically address complex health care needs, congregations deliver health-promoting outreach through spiritual resources and support in times of crisis (Seeber, 1995). Because of the nature of congregations, they offer friendly atmospheres that focus more on the person than cost efficiency. As a result, they listen to health concerns and take more time to explain the health care issues than a typical doctor visit allows (Djupe & Westberg, 1995). More formally, congregations can offer health education programs, health screenings, or health services (Krause, 2009). Larger congregations are also more likely to offer more formalized health and social services, supported by congregant donations, paid staff, and specialized programs to meet the needs of the congregation and/or community (Trinitapoli et al., 2009). As a result, they can meet the various health needs in ways that are convenient and comfortable for participants.

Congregational Health Promotion and Risk Reduction Programs

Congregational health and risk management programs may be distinguished by three types of prevention—primary (i.e., patient education), secondary (i.e., risk education), and tertiary (i.e., treatment) (DeHaven, Hunter, Wilder, Walton, & Berry, 2004). In one study, half of all programs consisted of primary prevention, especially related to general health maintenance (24.5%), cardiovascular health (20.7%), and cancer (18.9%). One-fourth of the programs studied consisted of secondary prevention, while 13.2% were tertiary and 9.4% were classified as “other” (DeHaven et al., 2004).

Congregational health programming evaluators, interested in best practices in congregational health provision, document the importance of conducting a health and spiritual needs assessment, identifying leaders for programs, offering training, and remaining intentional and rooted in the underlying goals of the services (Seeber, 1995). Based on the results of the needs assessment, congregations can create congregationally-based health programs that target the distinct needs of the congregation and community. Depending on the needs, these programs (Campbell et al., 2007) can consist of various levels: individual (e.g., motivational interviewing), interpersonal (e.g., support groups, testimonies, family programs), organizational (e.g., bulletin inserts, policy changes, committees, sponsored events), and environmental (e.g., community coalitions, food produce discounts, walking trails).

Needs assessments also equip health programs to account for cultural sensitivity. Researchers (Campbell et al., 2007) observed that a comprehensive assessment along two dimensions yielded data that more accurately reflected holistic variables, such as cultural values and practices, influencing effective congregational health care initiatives. There are two dimensions, including (1) surface structure, which allows leaders to adjust interventions to cater to social and behavioral characteristics of the target population studied in the needs assessment, and (2) deep structure, which assesses the values and factors (e.g., cultural, social, psychological, environmental, and historical) that impact the health care choices of community members. In addressing deep structure, congregations consider how the population views the cause, course, and treatment of illnesses, as well as perceptions of certain health behaviors. By considering both dimensions while creating congregationally based programs, risk reduction initiatives are more likely to be well received and have a greater impact on the population. Five principles guide best practice in this area: (1) build trust and devote great attention to developing partnerships; (2) leave nothing out when trying to recruit participants; (3) perform extensive research to understand the social and cultural contexts of the population; (4) involve the community in implementation of interventions related to the sociocultural environment; and (5) plan for program sustainability (Campbell et al., 2007). Given the inherent opportunities and resources within congregations, health care programs can thrive within congregational settings if health care professionals and congregational leaders collaborate and integrate the aforementioned techniques.

Exemplars of Congregational Health Care Initiatives

Researchers have identified and evaluated a wide range of health-related programs that exist in congregations (Peterson et al., 2002; Trinitapoli et al., 2009). Table 1 provides a sample of the structure and variety of congregational health care programs currently available. These examples are organized along the dimensions of sponsorship, goal/mission, focus, services, staffing, and intended outcome.

Table 1. Exemplars of Congregational Health Programs

Program/Dimension

Celebrate Recovery

Parish Nursing

Bronx Health-Smart Church Program

Cancer Companions

Let’s Move! For Faith Communities

Mental Health Grace Alliance

Sponsor

Congregation

American Nurses Association

Health-Smart Behavior Program

Cancer Companions Organization

Michelle Obama’s Let’s Move! initiative

Mental Health Grace Alliance organization

Goal

Recovery from substance use

Integration of physical and spiritual healing and well-being

Improve health and engagement in health promoting behaviors

Provide cancer patients in the church with peer companions

Fight childhood obesity by educational prevention

Recovery from mental health issues for members of the church community

Focus

Drugs, alcohol, pornography, among other addictions

Physical and spiritual health

Physical health in underserved African American churches

Cancer patients

Healthy weight for youth

Mental health

Services

Group meetings, peer accountability and education

Treats and educates patients; connects patients to spiritual resources

Health care and education

Providing a peer who has been a cancer patient to current cancer patients; therapy groups

Activities to educate and teach healthy choices in wellness for children

Support groups for different age-groups

Staffing

Trained congregation staff

Registered nurses who have completed a Parish Nurse foundations course

Congregation leaders trained by Health Smart Behavior Program staff

Trained volunteers in the congregation

Volunteers in the congregation

Congregation leaders trained by Mental Health Grace Alliance staff

Outcomes

Releasing members from addiction on path to recovery

Increase physical and spiritual health of congregational members

Increase overall health of congregational members

Provide support for cancer patients

Promote healthy youth within church communities

Promote mental wellness and recovery within the church

Website

http://www.celebraterecovery.com/

http://www.parishnurses.org/

http://ufhealthdisparities.med.ufl.edu/research/the-bronx-health-smart-church-program/

http://cancer-companions.org/

http://www.letsmove.gov/faith-communities-toolkit

http://mentalhealthgracealliance.org/

Given the different resources and strengths among varying congregations, partnerships among congregations and between congregations and community health care agencies can be an effective way to promote health in the community (Lasater, Wells, Carleton, & Elder, 1986; Peterson et al., 2002). Community health agencies also have valuable knowledge, expertise, and resources that can benefit congregations looking to implement health interventions.

Collaborations between researchers and faith-based organizations are infrequent (DeHaven et al., 2004), causing a gap in understanding of community needs and how to address them effectively. Program credibility and improvement in program evaluations are the outcomes when congregations collaborate with researchers who can offer targeted knowledge in the area of health care interventions, from both experience and study. On the other hand, researchers receive rich data sources and opportunities for transformational research when they collaborate with congregations to provide health care services.

Participation and Leadership Support

Congregation-based health initiatives benefit from multiple levels of congregational involvement (Rowland & Isaac-Savage, 2014), but especially from public support and approval by congregational leaders (Interfaith Health Program, 2014; Kegler et al., 2010). It does not matter whether leaders are the ones actually providing or connecting congregants to health services. In many congregations, clergy see health care as part of their responsibility as spiritual leaders (Lumpkins et al., 2013). Furthermore, some connect their responsibility for health to promotion of justice and advocacy for their congregants (Rowland & Isaac-Savage, 2014). Better health cultures for congregants are associated with pastors who share personal health experiences from the pulpit (Anshel & Smith, 2014). Leaders in faith communities are often viewed by congregations as an authoritative word on many topics (Kegler et al., 2010). These authorities see themselves as having a role in the health of their congregations and are thus likely to provide health-related information (Lumpkins et al., 2013).

Clergy support is an indispensable factor for success (National Institutes of Health, 1997), but the promoters of health in congregations can be found on multiple levels of a congregation’s hierarchy. Health resources, services, and supports can be formal and informal (Levin, 2014). What they have in common are what can be termed “boundary leaders” (Kegler et al., 2010), i.e., trusted community individuals who bridge or combine the sometimes fragmented worlds of health and spirituality and show them to be a cohesive whole in the life of the congregation. A rabbi sharing experiences (Lumpkins et al., 2013) or adopting new health habits (Anshel & Smith, 2014), a lay person passing on new knowledge (Giger et al., 2008), or a researcher bringing health initiatives into the physical religious building (Anshel & Smith, 2014) are all examples of how congregational life and health can be combined. Participation by numerous stakeholders in the congregation, at all levels of a health initiative, is important (Campbell et al., 2007) for providing congregations with a sense of ownership (Francis & Liverpool, 2009).

Planning and Implementation Roles in Congregational Health Programs

Congregation-based health programs are often organized and implemented by clergy and by health care professionals functioning as staff members (e.g., nurses, social workers, public health professionals) of community health care agencies or as congregants providing volunteer leadership. Nurses, using their training and experience in health settings, have often assumed productive roles in congregationally based health education, risk reduction, and service integration (Rydholm et al., 2008). Most of the efforts by public health professionals in congregations have focused on prevention of health problems through education and activity programs (DeHaven et al., 2004). Non–health professionals, congregational staff, and volunteers also serve in planning and implementation roles.

An absence of research around leadership roles in planning and implementation is a significant gap in understanding effective congregational health involvement. Drawing upon a functional model (Miley, O’Melia, & Dubois, 2001), six roles are projected to be significant in specifying the relationship between leadership and effective congregational health program outcomes.

Planner/Program Developer

The planner can consist of one person or a committee of people who guide the congregation in development, delivery, and continuous improvement of congregationally based health care and risk prevention programs. For example, the planner initiates the needs assessment, researches and implements best practices, formulates the goals of the program, and ensures proper delivery and sustainability of services. As a planner, one might also coordinate collaborative programs and conduct program evaluations with the intention of offering best-practice models that can be replicated and help future congregations develop effective programs.

Facilitator

In this role, the health professional, congregational leader, or volunteer works with community health care providers to make their professional services more accessible to congregants or community members. The facilitator role also includes ensuring that health programs develop from the results of the needs assessment of the congregation and community. It is important to make services affordable and accessible as well, taking into account transportation needs and/or dates and times when congregants could easily attend the health program.

Convener/Mediator

Planning and implementation of congregational health programs may require the involvement of teams and committees staffed by volunteers. Through this process, the leader reinforces the engagement of volunteers and sustains momentum and commitment. In addition, the convener mediates the program’s relationship with the congregation, its ministries, and community health care agencies. When the congregational services are offered in collaboration with other congregations, this role is an essential element in the efficacy of the partnership.

Care Manager/Advocate

In the care manager role, health care professionals, congregational leaders, and/or trained volunteers may provide case management by helping individuals and families assess their needs and assets and by providing referrals to health-related resources and services. The goal is to have an extensive collection of resources to connect individuals and families with people or organizations that will address their specific needs and thus allow them to operate better in daily life. Care managers also act as advocates, using their assertion and negotiation skills to ensure that individuals and families have access to community health services.

Health Educator

The health educator delivers information related to health promotion and risk management. In this role, the health educator may work in individual, family, or group settings. For example, health education may come in the form of brochures, seminars, and one-to-one meetings. Health educators may also take part in outreach in an effort to expand beyond the congregational setting. The health educator may reach a broader audience by offering conferences on health, especially discussing relevant and sometimes controversial health concerns that will grasp the attention of community members during a unique window of opportunity.

Direct Health Care Service Provider

Congregational health care leaders may operate as direct resources to clients (i.e., congregants and community members) as well by providing direct health services within the limits of their professional license. For example, congregational leaders trained in pastoral counseling or clinical social workers could offer counseling services to those in need of mental health healing. Nurses can also use their skills in a similar manner to the Parish Nurse Program highlighted in Table 1, which is an example of direct service provision.

Conclusion

Congregations are an essential element in the fabric of a locality’s health care promotion and risk reduction. The belief systems and religious practices at the core of congregational life are associated with positive health outcomes for congregants, inclining religiously affiliated organizations to provide health-related services. This inclination finds expression in a wide array of health-related programs, and new knowledge development offers guidelines for program development and delivery based on evidence provided by researchers in this area of inquiry. Exemplars of congregation-based health care programs illustrate the scope and focus of these vital initiatives. A wide range of roles highlight the opportunities for researchers to examine the efficacy of community health promotion and risk reduction programs and leadership roles to combat the ever-increasing need for health care by effectively building upon the existing resources within congregations. Future research initiatives can also explain more completely the complex relationship between individual congregant involvement and healthy behaviors as well as offer evidence-based models for effective congregationally based health promotion and risk reduction programs.

Much of the current literature on the topic of congregations and health education focuses primarily on smaller, African American churches (Campbell et al., 2007), but some research is being done on white megachurches with some similar findings regarding leadership involvement and social supports as two of the most important factors for success (Bopp & Webb, 2012, 2013). In many communities, congregations are trusted voices that are central to community life, relationships, and formation of behaviors. They powerfully impact the way that congregants interact with their world and provide opportunities for understanding health information as a whole person. When factors come into play, including trust built over time, ready access to services, potential for ownership and participation on multiple levels, and supportive examples from leaders and laypeople in new health practices, congregations can become places where effective health education and programs are part of daily culture (Chatters, Levin, & Ellison, 1998). An integration of spirituality and physical health topics is also vital for buy-in from congregations and relevance to their experience (Campbell et al., 2007). Wherever faith communities are an established part of community identity, effective health initiatives seek to bring health education onto home turf in a variety of ways. Congregations are uniquely placed to form a sense of cohesion in health education that has real impact in the lives of those in the community.

Historiography

For centuries, religious congregations closely intertwined religion and medicine (Shuman & Meador, 2002) and disseminated health-promoting messages and practices sanctioned by sacred texts, belief systems, and culture of the faith community. Dietary practices, hygiene prescriptions, and abstinence from risk-prone behaviors were inextricably woven into the fabric of congregational life. Sickness was a concern not merely for doctors but also for clergy, and sometimes the two roles were synonymous (Shuman & Meador, 2002; Swartley, 2012). In some contexts, the association between physical healing and religious faith was central to understanding how health could be restored.

In the West, the Christian religion provides an example of this intersection, with sacred texts documenting healing as a central narrative in the story of Jesus. Swartley (2012) refers to Jesus’s ministry in the New Testament of the Bible, noting his teaching intended to correct misconceptions between religion and health and his healing of physical and mental diseases. Prior to the first century ad, people believed that transgressions and illness could be traced back to a personal cause-effect relationship. For example, many people used to look at their sicknesses through the lens of religion, moral issues, and one’s relationship with God (Shuman & Meador, 2002). In Christian theology, sickness emanates from fallen humanity rather than specific sins of individuals. Compassion, unbiased healing, and the importance of faith in the healing process are central themes, important components within current health programs. The Christian church became known for healing through exorcism, which led to many conversions, and health care was offered without regard to social class or religion. The prescription was simple (e.g., faith and prayer), and the services were free. From a societal and public health perspective, faith communities were a trustworthy source and resource for congregant and community health.

In subsequent Christian history, the relationship became more complex (Swartley, 2012). When Constantine institutionalized Christianity, church healing and exorcisms lost popularity due to the increased complexity of health care, and anointing oil became more common through the medieval period. During the Reformation, health care models became even more complex and restrictive as Reformers devalued the Catholic view of health care, and health care began to lose its religious support. The 1800s brought more passivity within Christianity by allowing people to suffer to become more sanctified. The 20th century ushered in the “faith cure” from the Christian holiness movement, followed by the Pentecostal movement’s emphasis on the Holy Spirt and healing. Other church traditions began to formulate new healing practices during the same century. It was not until around 1950 that doctors began to blur the lines between religion and medicine again, with more doctors endorsing a holistic approach (Shuman & Meador, 2002).

The emergence of biological sciences and growing skepticism about religiously based health beliefs and practices further diminished the role of congregations as a primary social institution for communicating and promoting healthy attitudes and behaviors. Doctors became more differentiated, and religious healing received labels such as being superstitious or irrelevant (Shuman & Meador, 2002). Today, healing practices within the Christian church vary tremendously, and the term “healing” has become more politicized and less central to Christian religious practice (Swartley, 2012). Research focused on genetic, biological, psychosocial, and environmental etiologies to the exclusion of religious and spiritual factors in explaining individual and population health. Health care communications and delivery shifted to professionalized medical centers and community health care infrastructure sanctioned and funded through complex networks of legislative, public, and private sector institutions. In this transition, congregational commitment to human wellness and provision found some expression in the birthing of contemporary and highly regarded centers for medical care innovation and treatment.

Subsequently, examination of the relationship between health and spirituality has moved from the margins of medical and health care research to a respected line of inquiry. Rigorous examinations of the impact of spirituality and religious practice on health outcomes are prevalent in scientific and health professions’ annual meeting programs and publications. Positive psychological factors that are correlates of spirituality, such as gratitude, hope, joy, and life satisfaction, help explain the spirituality–health relationship. Other explanations include increased participation in faith practices (e.g., prayer, worship, service), change in behaviors and thought processes, likelihood of using preventive health services, and improved sense of control and enhanced coping skills. Congregational membership and involvement also reinforce adherence to prescriptive health risk reduction communications and behaviors. Examples of how congregational participation improves physiological and psychological health include the availability of interpersonal support and culturally sanctioned health-promoting behaviors. Unhealthy religious beliefs and congregational norms and practices have also been reported.

Researchers have recently turned their attention to congregations as formal providers of health promotion and risk reduction programs, noting a reversal in the trend for intentional programing to be reallocated to the medical and health delivery system. This renewed interest was activated in part by societal and legislative calls for faith-based organizations, mainly congregations, to offer programs addressing the health, social, and economic needs of communities and persons in poverty. Considerable public investments were made in faith-based organizations to build capacity and energize their role in provision of human services. While the initiative did not meet expectations, it helped legitimate the role of congregations as a venue for health care messaging and health promotion programing. It also encouraged research and model development focusing on congregational partnerships with other religiously affiliated and publicly funded organizations. Public health researchers and educators recognized the potential of congregations for health communications, producing robust findings and including the role of congregations in the preparation of public health professionals.

Recent national surveys reveal the extensive involvement of congregations in formalized programs in health care promotion. Comparisons reveal variability across dimensions such as religious affiliation, goal/mission, focus, target population, funding, collaboration, services, staffing, and intended outcome. While the involvement of congregations increases, evidence-based studies that examine best practices and effective delivery modes lag behind. Practice wisdom among congregational leaders and health care professionals offers experience-based prescriptions for the design, implementation, and evaluation of these programs. Unfortunately, systematic investigation aimed at enhancing the role of congregations awaits future study. An analysis of the extant literature also reveals a gap in understanding how changing demographics and innovations in health care impact the capacity of current congregational cultures to reinforce or diminish health-promoting communications and risk reduction initiatives. Researchers need to devote more attention to how congregationally based health communications and services can be more effective, including more attention to critical review of leadership roles in planning and implementation of congregational health programs. Most importantly, health policy and delivery researchers can contribute by designing studies that rigorously test the efficacy of health-related communications and wellness programs in congregations.

Primary Sources

Campbell, M. K., Hudson, M. A., Resnicow, K., Blakeney, N., Paxton, A., & Baskin, M. (2007). Church-based health promotion interventions: Evidence and lessons learned. The Annual Review of Public Health, 28, 213–234.Find this resource:

    DeHaven, M. J., Hunter, I. B., Wilder, L., Walton, J. W., & Berry, J. (2004). Health programs in faith-based organizations: Are they effective? American Journal of Public Health, 94(6), 1030–1036.Find this resource:

      Djupe, A. M., & Westberg, G. (1995). Congregation-based health programs. In M. A. Kimble, S. H. McFadden, J. W. Ellor, & J. J. Seeber (Eds.), Aging, spirituality, and religion (Vol. 1, pp. 325–334). Minneapolis: Fortress Press.Find this resource:

        Ellison, C. G., & Levin, J. S. (1998). The religion–health connection: Evidence, theory, and future directions. Health Education & Behavior, 25, 700–720.Find this resource:

          George, L. K., Ellison, C. G., & Larson, D. B. (2002). Explaining the relationships between religious involvement and health. Psychological Inquiry, 13(3), 190–200.Find this resource:

            Gunderson, G. R., & Cochrane, J. R. (2012). People who congregate: Building on strengths. In Religion and the health of the public: Shifting the paradigm (pp. 99–118). New York: Palgrave Macmillan.Find this resource:

              Koenig, H. G., King, D., & Carson, V. B. (2012). Handbook of religion and health (2d ed.). Oxford: Oxford University Press.Find this resource:

                Krause, N. M., & Wulff, K. M. (2005). Church-based social ties, a sense of belonging in a congregation, and physical health status. International Journal for the Psychology of Religion, 15(1), 73–93.Find this resource:

                  Lindner, E. W., & Welty, M. A. (2007). Congregational health ministry survey report. New York: National Council of Churches USA.Find this resource:

                    Oman, D., & Thoresen, C. E. (2005). Do religion and spirituality influence health? In R. F. Paloutzian & C. L. Park (Eds.), Handbook of the psychology of religion and spirituality (pp. 435–459). New York: Guilford Press.Find this resource:

                      Peterson, J., Atwood, J. R., & Yates, B. (2002). Key elements for church-based health promotion programs: Outcome-based literature review. Public Health Nursing, 19(6), 401–411.Find this resource:

                        Trinitapoli, J., Ellison, C. G., &Boardman, J. D. (2009). US religious congregations and the sponsorship of health-related programs. Social Science & Medicine, 68, 2231–2239.Find this resource:

                          Werber, L., Mendel, P. J., & Derose, K. P. (2014). Social entrepreneurship in religious congregations’ efforts to address health needs. American Journal of Health Promotion, 28(4), 231–238.Find this resource:

                            Wuthnow, R. (2004). Congregations as caring communities. In Saving America? Faith-based services and the future of civil society (pp. 64–98). Princeton, NJ: Princeton University Press.Find this resource:

                              Further Reading

                              Campbell, M. K., Hudson, M. A., Resnicow, K., Blakeney, N., Paxton, A., & Baskin, M. (2007). Church-based health promotion interventions: Evidence and lessons learned. The Annual Review of Public Health, 28, 213–234.Find this resource:

                                Catanzaro, A. M., Meador, K. G., Koenig, H. G., Kuchibhatla, M., & Clipp, E. C. (2006). Congregational health ministries: A national study of pastor’s views. Public Health Nursing,24(1), 6–17.Find this resource:

                                  Croucher, S. M., & Harris, T. M. (Eds.). (2012). Religion and communication: An anthology of extensions in theory, research, and method. Bern, Switzerland: Peter Lang.Find this resource:

                                    DeHaven, M. J., Hunter, I. B., Wilder, L., Walton, J. W., & Berry, J. (2004). Health programs in faith-based organizations: Are they effective? American Journal of Public Health, 94(6), 1030–1036.Find this resource:

                                      Djupe, A. M., & Westberg, G. (1995). Congregation-based health programs. In M. A. Kimble, S. H. McFadden, J. W. Ellor, & J. J. Seeber (Eds.), Aging, spirituality, and religion (Vol. 1, pp. 325–334). Minneapolis: Fortress Press.Find this resource:

                                        Dudley, C. S. (2002). Community ministry: New challenges, proven step to faith-based initiatives. Washington, DC: Alban Institute.Find this resource:

                                          Ellison, C. G., & Levin, J. S. (1998). The religion–health connection: Evidence, theory, and future directions. Health Education & Behavior, 25, 700–720.Find this resource:

                                            Franklin, C., & Fong, R. (Eds.). (2011). The church leader’s counseling resource book: A guide to mental health and social problems. New York: Oxford University Press.Find this resource:

                                              George, L. K., Ellison, C. G., & Larson, D. B. (2002). Explaining the relationships between religious involvement and health. Psychological Inquiry, 13(3), 190–200.Find this resource:

                                                Gunderson, G. R., & Cochrane, J. R. (2012). Religion and the health of the public: Shifting the paradigm. New York: Palgrave Macmillan.Find this resource:

                                                  Hotz, K., & Mathews, M. T. (2012). Dust and breath: Faith, health—and why the church should care about both. Grand Rapids, MI: Wm. B. Eerdmans.Find this resource:

                                                    Idler, E. L. (Ed.). (2014). Religion as a social determinant of public health. New York: Oxford University Press.Find this resource:

                                                      Koenig, H. G. (2008). Medicine, religion, and health: Where science and spirituality meet. West Conshohocken, PA: Templeton Foundation Press.Find this resource:

                                                        Koenig, H. G., King, D., & Carson, V. B. (2012). Handbook of religion and health (2d ed.). New York: Oxford University Press.Find this resource:

                                                          Koenig, H. G., McCullough, M. E., & Larson, D. B. (2001). Handbook of religion and health. New York: Oxford University Press.Find this resource:

                                                            Krause, N. (2004). Religion, aging, and health: Exploring new frontiers in medical care. Southern Medical Journal, 97(12), 1215–1222.Find this resource:

                                                              Krause, N. (2008). Aging in the church: How social relationships affect health. West Coshohocken, PA: Templeton Foundation.Find this resource:

                                                                Krause, N. M., & Wulff, K. M. (2005). Church-based social ties, a sense of belonging in a congregation, and physical health status. International Journal for the Psychology of Religion, 15(1), 73–93.Find this resource:

                                                                  Levin, J. (2013). Engaging the faith community for public health advocacy: An agenda for the surgeon general. Journal of Religion & Health, 52(2), 368–385.Find this resource:

                                                                    Lindner, E. W., & Welty, M. A. (2007). Congregational health ministry survey report. New York: National Council of Churches USA.Find this resource:

                                                                      Marty, M. (Ed.). (1990). Healthy people 2000: A role for America’s religious communities. Chicago: The Park Ridge Center and The Carter Center. Retrieved from http://ihpemory.org/wp-content/uploads/2014/08/Healthy%20People%202000_2.pdf.Find this resource:

                                                                        Miller, A. N., & Rubin, D. L. (Eds.). (2011). Health communication and faith communities. Cresskill, NJ: Hampton Press.Find this resource:

                                                                          Numbers, R. L., & Amundsen, D. W. (Eds.). (1997). Caring and curing: Health and medicine in the Western religious traditions. Baltimore, MD: Johns Hopkins University Press.Find this resource:

                                                                            Oman, D., & Thoresen, C. E. (2005). Do religion and spirituality influence health? In R. F. Paloutzian & C. L. Park (Eds.), Handbook of the psychology of religion and spirituality (pp. 435–459). New York: Guilford Press.Find this resource:

                                                                              Peterson, J., Atwood, J. R., & Yates, B. (2002). Key elements for church-based health promotion programs: Outcome-based literature review. Public Health Nursing, 19(6), 401–411.Find this resource:

                                                                                Steinman, K. J., & Bambakidis, A. (2008). Faith-health collaboration in the United States: Results from a nationally representative study. American Journal of Health Promotion, 22(4), 256–263.Find this resource:

                                                                                  Trinitapoli, J., Ellison, C. G., & Boardman, J. D. (2009). US religious congregations and the sponsorship of health-related programs. Social Science & Medicine, 68, 2231–2239.Find this resource:

                                                                                    Werber, L., Mendel, P. J., & Derose, K. P. (2014). Social entrepreneurship in religious congregations’ efforts to address health needs. American Journal of Health Promotion, 28(4), 231–238.Find this resource:

                                                                                      Wolfer, T. A. (2012). Religion, spirituality, health, and social work. In S. Gehlert & T. Browne (Eds.), Handbook of health social work (2d ed., pp. 263–290). Hoboken, NJ: John Wiley.Find this resource:

                                                                                        Wuthnow, R. (2004). Congregations as caring communities. In Saving America? Faith-based services and the future of civil society (pp. 64–98). Princeton, NJ: Princeton University Press.Find this resource:

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