Church leaders' barriers and facilitators before and after implementing a physical activity and nutrition intervention

Facilitators and barriers to implementing the Diabetes Prevention Program in rural church settings: A qualitative study using the Consolidated Framework for Implementation Research

PURPOSE

The CDC's Diabetes Prevention Program (DPP) is an effective lifestyle intervention to prevent type 2 diabetes (T2D). However, DPP implementation in rural areas is limited. This study sought to address this gap by implementing DPP in rural church settings through a community-academic partnership and identifying implementation facilitators and barriers.

METHODS

This was a cross-sectional qualitative study. Semistructured interviews guided by the Consolidated Framework for Implementation Research (CFIR) assessed church leaders' and lifestyle coaches' perceptions of implementing DPP in rural churches. Thematic analysis was used to identify key themes through an inductive approach; then, these emergent themes were deductively linked to CFIR constructs. COREQ guidelines were used to report study findings.

FINDINGS

Twenty-five stakeholders participated. Facilitators to implementing DPP included its evidence-based effectiveness in preventing T2D, as well as support from the academic partner in terms of funding, training, and communication. Additionally, DPP's alignment with community needs, along with the active engagement of pastors in participant recruitment, supported implementation. Several barriers hindered DPP implementation, including transportation and childcare issues, as well as program participants' medical conditions/disabilities limiting their participation. Furthermore, rural residents' reluctance to adopt lifestyle changes and loyalty to family churches posed challenges to their engagement in DPP.

CONCLUSIONS

This study identified contextual factors influencing DPP implementation in rural communities. Findings highlight the importance of tailored strategies that leverage facilitators while proactively addressing barriers, including rural residents' reluctance to attend programs outside their church, resistance to lifestyle changes, and transportation issues to ensure successful DPP implementation in rural areas.

Constructs from the Consolidated Framework for Implementation Research associated with church enrollment and intervention adoption in a national implementation study of a faith-based organizational change intervention

BACKGROUND

Organizational adoption is a key but understudied step in translating evidence-based interventions into practice. The purpose of this study was to report recruitment strategies and factors associated with church enrollment and intervention adoption in a national implementation study of the Faith, Activity, and Nutrition (FAN) program.

METHODS

We worked with partners using multiple strategies to disseminate intervention availability. Interested churches completed an online form. To enroll, the church coordinator (FAN coordinator) and pastor completed baseline surveys and then received intervention online training access. We compared enrolled vs. non-enrolled churches on how they heard about the study and church characteristics. We compared intervention-adopting vs. non-adopting churches on Consolidated Framework for Implementation Research (CFIR) constructs using Fisher's exact tests, χ2, or independent sample t-tests and reported differences where p < 0.10, d≥|0.35|, or the difference in percentage points was ≥ 10.

RESULTS

We received 226 interest forms; 107 churches enrolled, and 85 churches adopted the intervention. Faith-based sources were the most, and paid media the least, effective in reaching churches, which were largely from the southeast with a Methodist or Baptist tradition (no differences by enrollment status). Enrolled churches were less likely to have 500 + worshipers and more likely to have attended a study information session than non-enrolled churches. Church (CFIR inner setting) and FAN coordinator characteristics, but not intervention characteristics, were related to intervention adoption.

CONCLUSION

Partnerships, relationships, and "face time" are important for enrolling churches in evidence-based interventions. Church and church coordinator characteristics are related to intervention adoption. Further work on adoption conceptualization and operationalization is needed.

Barriers and Facilitators to 24-Month Maintenance of the Faith, Activity, and Nutrition Program in the U.S

Little is known about the barriers and facilitators to organizational maintenance of faith-based health promotion programs. This study used qualitative data (collected from 2016-2019) from pastors (n = 81) and program coordinators (n = 103) to identify barriers and facilitators to 24-month maintenance of a faith-based physical activity (PA) and healthy eating (HE) intervention in South Carolina. Barriers differed for PA versus HE: resistance to change impeded HE while church characteristics tended to impede PA. Similar themes emerged for PA and HE facilitators: healthy opportunities, church communication, and consistency. Future research should build upon this study to tailor faith-based health promotion programs for long-term sustainability.

Using the consolidated framework for implementation research to identify church leaders' perspectives on contextual determinants of community-based colorectal cancer screening for Black Kentuckians

BACKGROUND

Black Kentuckians experience more deleterious colorectal cancer (CRC) outcomes than their White counterparts, a disparity that could be reduced by increased screening in Black communities. Previous research has shown that Black Kentuckians may not be equitably informed of different CRC screening options by health care providers, making community-based screening a potentially effective option among this disparate population. We used the Consolidated Framework for Implementation Research (CFIR) to identify church leaders' perspectives of contextual factors that might influence community-based screening and explore the feasibility of using church-based screening outreach.

METHODS

Six participants were selected, based on leadership roles and interest in CRC screening, from five established Louisville-area church partners that had previously participated in community health initiatives. Data were collected, both virtually and in-person, in Summer 2021 using semi-structured interview guides developed with guidance from the CFIR Guide that focused on domains most relevant to community-based interventions. Data were transcribed verbatim, coded by two independent researchers, and member checked for accuracy.

RESULTS

Data were aligned primarily with six CFIR constructs: key stakeholders, champions, opinion leaders, tension for change, compatibility, and culture. Participants noted a strong tension for change in their community due to perceptions of inadequacy with clinical approaches to CRC screening. Additionally, they stressed the importance of identifying individuals both within the church who could champion CRC screening and help implement program activities, as well as those outside the church who could collaborate with other local organizations to increase participant reach. Finally, participants agreed that faith-based CRC screening aligned with church culture and would also likely be compatible with overall community values.

CONCLUSIONS

Overall, our church partners strongly endorsed the need for, and importance of, community-based CRC screening. Given a history of successful implementation of health promotion programs within our partner churches, it is highly likely that a CRC screening intervention would also be effective. Findings from this study will be used to identify implementation strategies that might positively impact a future faith-based CRC screening intervention, as well as CFIR constructs that are most positively associated with CRC screening completion.

Barriers and Facilitators to Improving Cardiovascular Health in Churches with Predominantly Black Congregations

Objective

Black communities bear a disproportionate burden of cardiovascular disease (CVD). Barriers and facilitators for improving cardiovascular health (CVH) in churches with predominantly black congregations were explored through a qualitative needs assessment.

Methods

Four focus groups with church members (n=21), 1 with wellness coordinators (n=5), and 1 with primary care providers (n=4) and 7 individual interviews with church leaders were completed in New Orleans and Bogalusa, Louisiana. Virtual, semistructured interviews and focus groups were held between October 2021 and April 2022. The Theorical Domains Framework (TDF) guided a framework analysis of transcribed data based on inductive and deductive coding to identify themes related to determinants of CVH.

Results

The following four domains according to the TDF were identified as the most relevant for improving CVH: knowledge, professional role, environmental context, and emotions. Within these domains, barriers expressed by church leadership and members were a lack of knowledge of CVD, provider distrust, and little time and resources for lifestyle changes; facilitators included existing church wellness programs and social support, community resources, and willingness to improve patient-provider relationships. Primary care providers recognized a lack of effective communication and busy schedules as obstacles and the need to strengthen communication through increased patient autonomy and trust. Potential strategies to improve CVH informed by the Expert Recommendation for Implementing Change compilation of implementation strategies include education and training, task shifting, dissemination of information, culturally tailored counselling, and linkage to existing resources.

Conclusions

These findings can inform the implementation of interventions for improving cardiovascular health and reducing disparities in black church communities.

NEW Soul in the neighborhood-reach and effectiveness of a dissemination and implementation feasibility study

Dissemination and implementation (D&I) studies of dietary interventions for African Americans are limited. Restaurants may be an innovative setting to deliver dietary interventions. Purpose: Assess weight loss, self-efficacy for healthy eating, diet quality, and quality of life in African Americans in two groups: virtual synchronous and virtual asynchronous. Guided by RE-AIM, the Nutritious Eating with Soul @ Rare Variety Café Feasibility study included nutrition education, accountability partners for support, and cooking demonstrations led by a community health worker and was delivered across two cohorts in a non-randomized design. The intervention was conducted over 12 consecutive weekly classes. Due to the COVID-19 pandemic, intervention delivery was online. African Americans between 18-65 years old with overweight/obesity, not currently following a plant-based diet or taking medications to control diabetes, and living in a southeastern city were recruited. Participants completed in-person weight assessments and online surveys at baseline and post-intervention. Linear mixed models analyzed changes in outcomes and differences in 3-month outcomes between groups. All models controlled for age and sex. Regarding Reach, 199 participants expressed interest, and 60 enrolled. Among the full sample, participants decreased body weight -2.6 ± 0.5 kg (p < .0001) and increased self-efficacy 1.6 ± 0.7 points (p = .03). No differences in 3-month outcomes between groups were observed. This D&I feasibility study successfully recruited participants during the COVID-19 pandemic and produced significant results. The successful online intervention delivery compared to in-person suggests the potential for greater D&I in vegan soul food restaurants. As restrictions are loosened, future studies will test in-person delivery.

Application of the consolidated framework for implementation research to understand implementation context of a cardiovascular disease risk-reduction intervention in rural churches

Rural populations in the USA face higher rates of cardiovascular disease (CVD) incidence and mortality relative to non-rural and often lack access to health-promoting evidence-based interventions (EBIs) to support CVD prevention and management. Partnerships with faith organizations offer promise for translating preventative EBIs in rural communities; however, studies demonstrating effective translation of EBIs in these settings are limited. We used the Consolidated Framework for Implementation Research (CFIR) and a multiple case study approach to understand the role of internal organizational context within 12 rural churches in the implementation of a 12-week CVD risk-reduction intervention followed by a 24-month maintenance program implemented in southernmost Illinois. The study involved qualitative analysis of key informant interviews collected before (n = 26) and after (n = 15) the intervention and monthly implementation reports (n = 238) from participating churches using a deductive analysis approach based on the CFIR. Internal context across participating churches varied around organizational climate and culture in four thematic areas: (i) religious basis for health promotion, (ii) history of health activities within the church, (iii) perceived need for the intervention, and (iv) church leader engagement. Faith organizations may be ideal partners in rural health promotion research but may vary in their interest and capacity to collaborate. Identifying contextual factors within community organizations is a first step to facilitating rural, community-based EBI implementation and outcomes.

The FAN program plan: Creating a healthy church environment for physical activity and healthy eating

Background

Faith, Activity, & Nutrition (FAN) helps churches create a healthier environment for physical activity (PA) and healthy eating (HE) through policy, systems, and environmental changes.

Objective

The purpose of this paper is to describe the implementation, evaluation, and revision of the FAN Program Plan across a two-phase study to help churches create guidelines and policies for PA and HE.

Methods

In Phase 1, church committees attended trainings led by Community Health Advisors (CHA) where they assessed current practices to PA and HE. Committees used the FAN Program Plan to outline an implementation plan to increase opportunities, programs, messages, pastor support, and guidelines/practices for PA and HE. FAN Program Plans were submitted to the research team for review. Findings from Phase 1 plans directed revisions in program materials for Phase 2, where the submission and review processes were repeated.

Results

Review of Phase 1 FAN Program Plans (53/54 churches submitted a Program Plan) revealed that church committees confused guidelines/practices with programs and had trouble differentiating programs for PA and HE from providing opportunities (i.e., building PA/HE into existing events). The CHA training, FAN church committee training, FAN Program Plan, and other documents were revised to use the term "guidelines (policies)" instead of "guidelines/practices." In addition, CHAs facilitated a training section on guidelines (policies) to committees, and a guidelines (policies) section was added in the FAN Program Plan and other program documents. These changes in Phase 2 were helpful for differentiating policies from programs and programs from opportunities in FAN Program Plans (53/115 churches submitted a Program Plan), although some confusion remained.

Conclusions

This study underscored challenges churches may have in setting policies for PA and HE and discusses strategies to address these challenges in future faith-based initiatives.

Two-year outcomes of Faith in Action/Fe en Acción: a randomized controlled trial of physical activity promotion in Latinas

Background

Latina women are less likely to report engaging in leisure-time physical activity (PA) than non-Latina white women. This study evaluated the 24-month impact of a faith-based PA intervention targeting Latinas.

Methods

The study is a cluster randomized controlled trial of a PA intervention or cancer screening comparison condition, with churches as the randomization unit. A total of 436 Latinas (aged 18-65 years) from 16 churches who engaged in low levels of self-report and accelerometer-based PA were enrolled. The experimental condition was a 24-month PA intervention, with in-person classes, social support, and environmental changes, led by community health workers (i.e., promotoras). At baseline, 12-, and 24 months, we assessed changes in accelerometer-based and self-reported moderate to vigorous physical activity (MVPA; primary outcomes). Secondary outcomes were light intensity activity, sedentary time, body mass index (BMI), and waist circumference.

Results

After adjusting for sociodemographic factors, a mixed effects analysis found significant increases in self-reported leisure time MVPA (p < 0.005) and marginal increases in accelerometer-assessed MVPA (p < 0.08) 24 months post-baseline in the intervention compared to the attention-control condition. Data showed significant associations between PA class attendance and engaging in MVPA as assessed by self-report and accelerometry. No significant changes were found for light activity, sedentary time, BMI, or waist circumference.

Conclusions

Participants who attended the PA classes at least once a month engaged in significantly higher MVPA compared to those who did not. Maximizing engagement and maintenance strategies to enhance PA maintenance could contribute to important long-term health benefits.

Trial registration

NCT01776632, Registered March 18, 2011.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12966-022-01329-6.

Identifying barriers, facilitators, and implementation strategies for a faith-based physical activity program

Background

Community engagement is critical to the acceleration of evidence-based interventions into community settings. Harnessing the knowledge and opinions of community leaders increases the likelihood of successful implementation, scale-up, and sustainment of evidence-based interventions. Faith in Action (Fe en Acción) is an evidence-based promotora-led physical activity program designed to increase moderate-to-vigorous physical activity among churchgoing Latina women.

Methods

We conducted in-depth interviews using a semi-structured interview guide based on the Consolidated Framework for Implementation Research (CFIR) at various Catholic and Protestant churches with large Latino membership in San Diego County, California to explore barriers and facilitators to implementation of Faith in Action and identify promising implementation strategies for program scale-up and dissemination. We interviewed 22 pastors and church staff and analyzed transcripts using an iterative-deductive team approach.

Results

Pastors and church staff described barriers and facilitators to implementation within three domains of CFIR: characteristics of individuals (lack of self-efficacy for and knowledge of physical activity; influence on churchgoers' behaviors), inner setting (church culture and norms, alignment with mission and values, competing priorities, lack of resources), and outer setting (need for buy-in from senior leadership). From the interviews, we identified four promising implementation strategies for the scale-up of faith-based health promotion programs: (1) health behavior change training for pastors and staff, (2) tailored messaging, (3) developing community collaborations, and (4) gaining denominational support.

Conclusions

While churches can serve as valuable partners in health promotion, specific barriers and facilitators to implementation must be recognized and understood. Addressing these barriers through targeted implementation strategies at the adopter and organizational level can facilitate improved program implementation and lead the way for scale-up and dissemination.

The Faith, Activity, and Nutrition (FAN) Dissemination and Implementation Study: 24-Month Organizational Maintenance in a Countywide Initiative

Introduction: Despite the important role that faith-based organizations can play in eliminating health disparities, few studies have focused on organizational change and maintenance of interventions in this setting, making their long-term impact unknown. This study reports 24-month maintenance of the Faith, Activity, and Nutrition (FAN) program in a southeastern county. Previously reported findings of reach, adoption, implementation, and effectiveness are also summarized.

Methods: Church coordinators from 35 intervention churches (97% predominantly African American) located in a rural, medically underserved county in South Carolina were interviewed at baseline (2015), and 12- and 24-months post-training regarding implementation of physical activity (PA) and healthy eating (HE) components of the FAN program. Guided by the RE-AIM framework, organizational maintenance was defined as church coordinator-reported 24-month implementation of the four FAN components (providing opportunities, setting guidelines/policies, sharing messages, engaging pastor). Repeated measures analyses (mixed models) examined change in implementation over time. Churches were also classified as maintainers, non-sustained implementers, and low implementers for each FAN component. Statistical analyses were conducted in 2019.

Results: Church coordinators reported significantly greater implementation of both PA and HE FAN components at 12 and 24 months compared to baseline (medium to large effects). The percentage of churches classified as maintainers ranged from 21 to 42 and 27 to 94% across PA and HE components, respectively. Most churches (58% for PA, 97% for HE) were maintaining at least one FAN component at 24 months.

Conclusions: These promising findings position FAN well for the national implementation study now underway.

Trial Registration: This study is registered at www.clinicaltrials.gov NCT02868866.