Identifying the barriers and facilitators to implementation by engaging community stakeholders in an essential component of community-based health promotion. This kind of “co-learning”, in which researchers and community partners learn from each other, can result in more effective program implementation that addresses context-specific influences and factors.18 To our knowledge, our study is the first of its kind to examine barriers and facilitators to implementation of a faith-based PA program through interviews with pastors and church staff. Data supported the value of accounting for the inner and outer context when implementing PA programs in faith-based settings and they may vary by church size and denomination.
Data from the interviews suggest that targeting the health practices of church leaders would be a key strategy that would facilitate implementation and sustainment of health promotion programs in churches. In all religious denominations, pastors are role models and play a critical role in defining the characteristics of church life.64,65 Maton found that church groups with capable leaders reported positive group assessments and well-being and that pastors influence attendees’ commitment and perceived social support.66 Increasing the self-efficacy of leaders to engage in PA and providing education on the benefits of PA could empower leaders to promote PA and create wellness policies in their congregation. Further, church leaders who role model PA may indirectly impact the health practices of their parishioners (e.g., seeing pastors make time for walks). To date, the implementation strategies used to translate EBIs in faith-based settings have primarily focused on ways stakeholders can adopt and implement program activities and less on the health practices of the stakeholders themselves.58,67 The implementation of PA programs may have more impact and be sustained by stakeholders who engage in PA within a supportive organizational climate and culture.
The results highlight the importance of tailoring messages based on church context. Each church has its own culture, norms, and values. Matching the program messages with the culture of the church could lead to improved implementation and sustainment. For example, an important value of the Seventh Day Adventist denomination is healthy living (e.g., members of this denomination practice vegetarianism). Tailored messages for a Seventh Day Adventist Church could connect their value for health with PA programming, perhaps even building health into the mission statement of the church. In addition, churches vary in their style and methods of communication. Some churches communicate programming through printed newsletters and others have sophisticated social media and web platforms. Strategies used to promote the program and invite churchgoers to participate should be tailored to the preferred communication method of each church.
Strengthening the links between churches and health organizations embedded in the larger ecosystem was another proposed strategy noted by stakeholders. Local and national organizations that promote the well-being of community members like parks and recreation, YMCA, Catholic Charities, and health departments may provide resources that would help churches implement and sustain health promotion programs.68,69,70 Most stakeholders reported little connection with outside organizations, but a had a desire to build those connections as important for successful implementation and sustainment. This strategy would involve increasing the capacity of pastors to establish partnerships with outside organizations who could support the implementation and sustainment of PA programs. In this role, church leaders can also connect churchgoers and community members to resources they may not otherwise have and increase the impact of community organizations.
Lastly, participants noted the value of having denominational support when implementing health programs. When considering the Catholic denomination, strong denominational support from the Diocese would support pastors in the implementation of health programs and potentially bring in resources. For instance, the pastors could request time during their monthly meetings at the Diocese to discuss how Faith in Action and other health programming is impacting their church. This would demonstrate to pastors that the Diocese supports health programming in churches and would encourage more pastors to devote time and resources to establishing health ministries and PA programs.
This study contributes to other dissemination and implementation work in faith-based settings.37,38,71 While the potential of health promotion programs in faith-based settings has been recognized,10,14 there is limited evidence on specific barriers and facilitators to program implementation by church leaders and implementers in faith-based settings. Wilcox and colleagues examined the adoption, reach, and effectiveness of a faith-based healthy eating and PA intervention (FAN) in African-American churches in South Carolina by surveying church members of the participating churches.37 Another paper examined the perspectives of church leaders who participated in the FAN intervention.42 Church leaders identified barriers to program implementation including resistance to change, age of churchgoers, lack of participation, lack of time, weather, lack of leadership, and limited budget.42 Facilitators included internal support, communication, leadership, external support, health opportunities, tailoring, and champions.42 While the sample (African-American churches) and methods (survey) vary from our study with church leaders and staff of Latino churches, the barriers and facilitators echo and support our findings. Based on their findings, Bernhart and colleagues recommend providing training and technical assistance directly to church leaders and staff, which supports one of our selected implementation strategies. As noted by Leyva and colleagues, capacity building of church leaders and staff would help support adoption and implementation of health promotion programs in faith-based settings.72
Limitations & Strengths
While the sample size meets evidence-based guidelines,73 the generalizability of the findings could be limited by the relatively small number of interviews. In addition, the findings may not be generalizable to churches that serve other communities and denominations. Of the 53 Protestant churches approached, only 10 participated in interviews. The findings may not represent the opinions of pastors and church staff who did not participate.
The majority of published studies have focused on African-American churches and relied on survey data.23,37,42 Unique to our study is a focus on the perceptions of pastors and staff at Latino churches of a faith-based PA promotion program. Finally, data from multiple sources (pastors and church staff) from various denominations further ensured the credibility and dependability of the findings.