Public Health Nursing Vol. 19 No. 6, pp. 401–411 0737-1209/02/$15.00 Ó Blackwell Publishing, Inc. Key Elements for Church-Based Health Promotion Programs: Outcome-Based Literature Review Jane Peterson, Ph.D.(c)., R.N., B.C., ARNP, F.N.P.-C, Jan R. Atwood, Ph.D., M.P.H., R.N., FAAN, and Bernice Yates, Ph.D., R.N. Abstract Although not a new concept, church-based health promotion programs have yet to be widely researched. Few of the initial studies used randomized and controlled designs. Dissemination of study results has been sporadic, with findings often reported in church periodicals. A renewed interest in churchbased health promotion programs (CBHPP) is emerging. The purpose of this article is to propose seven key elements found in a literature review to be beneficial in establishing church-based community health promotion programs that demonstrated desired health promotion outcomes. Based on the outcomes of successful CBHPP, the following key elements have been identified: partnerships, positive health values, availability of services, access to church facilities, community-focused interventions, health behavior change, and supportive social relationships. An example of one program that embodies these elements is presented. The Heart and Soul Program, designed to increase physical activity in midlife women to reduce their risk of cardiovascular disease with advancing age, is discussed within the context of the elements for successful church-based programs. CBHPP have effectively promoted health behaviors within certain communities. To promote health and wellness in light of our diverse society and health needs, health promotion professionals and churches can be dynamic partners. Jane Peterson is a Doctoral candidate in the College of Nursing, Jan R. Atwood is a Professor in the Colleges of Nursing and Medicine, and Bernice Yates is an Associate Professor and the Associate Dean for Research in the College of Nursing, University of Nebraska Medical Center, Omaha, Nebraska. Address correspondence to Jane Peterson, Ph.D.(c), R.N., C.S., ARNP, B.C., F.N.P.-C, Fort Hays State University, 600 Park St., Hays, KS 67601. E-mail: jpeterso@ fhsu.edu Key words: church-based programs, health promotion, physical activity, midlife women. INTRODUCTION The major purpose of this article is to propose seven key elements found in a literature review to be beneficial in establishing church-based community health promotion programs (CBHPP) that demonstrated desired health promotion outcomes. An example of the way these elements can be applied to a health promotion program conducted in churches will be introduced. The example is of a church-based community program designed to increase physical activity in midlife women to reduce the risk of cardiovascular disease (CVD) with advancing age. Health promotion interventions conducted in faith communities provide a promising opportunity to enhance emotional, physical and spiritual health. Early medicine was centered in religious institutions, with physical and spiritual needs being met simultaneously and often by the same provider. Florence Nightingale strongly emphasized the need for nursing to honor the psychological and spiritual aspects of patients to promote health (Nightingale, 1860). In Nightingale’s holistic approach, nurses met the needs of the whole person, including spiritual needs. As scientific knowledge increased, medical care in the 19th and 20th centuries became more concerned with curing illness and nurses provided medically prescribed treatments. Care for the 401 402 Public Health Nursing Volume 19 Number 6 November/December 2002 patient’s spirit and soul became regarded as unscientific and antiquated. More recently, however, in study after study, it has been documented that spirituality and religion are correlated with health and greater longevity (Mullen, 1990). Nurses are, again, finding ways to intertwine the promotion of health into religious institutions. Churches have a strong foundation of caring to positively effect health behavior changes in a safe, supportive environment. Church-based health promotion (CBHP) is a ‘‘large-scale effort by the church community to improve the health of its members through any combination of education, screening, referral, treatment, and group support’’ (Ransdell, 1995). Cardiovascular health is one vital avenue for health promotion. CVD is the leading cause of death and disability in U.S. women, taking the lives of more than half a million women a year. With the life expectancy of women increasing, CVD prevalence in women will increase, posing a serious threat to the health and well-being of aging women. Although men suffer CVD an average of 10 years younger than women (American Heart Association [AHA], 2000), significant increases in CVD are seen in postmenopausal women. By age 75, 79% of women will have some form of CVD, compared to 70% of men who live to age 75 (AHA, 2000). The average life expectancy for women, which will reach 83 years by 2030, is more than 6 years longer than for men. Clearly, interventions are needed to reduce the profound negative impact of CVD on the lives of older women. CVD prevention and treatment in women remains a research priority according to the Task Force of the National Institutes of Health (NIH) Women’s Health Research Agenda in the 21st Century (National Institutes of Health [NIH], 1999a). CVD accounts for 57% of all deaths of American women, killing twice as many American women as all cancers and 11 times as many as breast cancer (AHA, 2000). About 44% of women die within 1 year of a myocardial infarction, compared to 27% of men (AHA, 2000). Although improvements in detection and treatment of CVD in women are currently being explored, further research priorities were established to investigate the modifiable societal and community factors that place women at risk for CVD (NIH, 1999a). Established research priorities specific to perimenopausal women relate to behavioral effects on health, including weight management and interventions to increase physical activity levels (NIH, 1999b). Individuals who are physically inactive are nearly twice as likely to die of CVD as those who engage in regular physical activity (Kaplan, Strawbridge, Cohen, & Hungerford, 1996). Twenty-five percent of all deaths in the United States are directly attributed to physical inactivity (Centers for Disease Control and Prevention, 2000). Despite the profound negative effects of physical inactivity, millions of U.S. adults remain sedentary. Forty percent of U.S. adults report no leisure time physical activity. Only 13% of women, compared to 16% of men, attain physical activity levels sufficient to lower their risk of CVD (United States Department of Health and Human Services [USDHHS], 1999). Women, older adults, persons with lower incomes and less education, and minorities are typically the least active. Promotion of physical activity is particularly important in improving national health as a means to reduce risk of CVD and many other chronic, debilitating diseases, such as diabetes, osteoporosis, hypertension, obesity, and certain cancers. Traditional exercise and fitness programs and individually focused approaches have been inadequate in promoting consistent physical activity in women and minority populations (King et al., 1992). Barriers to adoption and maintenance of exercise differ in various racial/ethnic midlife women, reducing the effectiveness of a universal approach to promoting physical activity (Heesch, Brown, & Blanton, 2000). CBHPP have shown promise in promoting health in individuals and communities. Women are likely to participate in and value church experiences and therefore may be more likely to attend health promotion programs in churches (Wells, DePue, Lasater, & Carelton, 1990). Physical activity programs centered in the church need to be further explored as a successful approach to promote midlife women to attain 30 min of moderate physical activity most days, as recommended by the American Heart Association and Centers for Disease Control and Prevention. LITERATURE-DOCUMENTED KEY ELEMENTS FOR ESTABLISHMENT OF CHURCH-BASED HEALTH PROMOTION PROGRAMS Health promotion programs in schools, health care centers, and work sites are able to target physical activity interventions in specific population groups, while other, perhaps even more sedentary groups, are missed. Community-based health promotion programs ideally should reach an entire population. Places of worship may be particularly important for health promotion initiatives by reaching often neglected, underserved populations (USDHHS, 2000) within a context in which a healthy body, mind, and soul are equally valued. In a holistic approach to health, the mind, body, and spirit are intertwined, and every human experience has mindbody-spirit components. Spirituality is an integral part of a person’s well-being and is important to consider in health promotion or disease prevention interventions. Spiritual health provides a motivational factor in the difficult task of changing health behaviors and meeting Peterson et al.: Key Elements in Church-Based Health Promotion the goals of health promotion programs (Chapman, 1986). When spiritual dimensions are included in establishing new health behaviors and value systems, vital needs of the soul are met. The following literature-based elements are identified in strong church-based programs: partnerships, positive health values, availability of services, access to facilities, community-focused interventions, healthy behavior change, and supportive relationships (see Table 1). Partnerships Establishing collaborative partnerships between the church and health professionals facilitates success in church-based programs. The idea of partnerships between health-related and religious organizations is not new. Churches and health care organizations have cooperated to implement health promotion programs, particularly in vulnerable, underserved populations. Most church-based programs have been administered within the African American community. Churches within these communities have been found to willingly participate in health 403 promotion programs to enhance the health of congregations as illustrated in the following studies. The Health and Religion Project (HARP) was a research study within churches designed to have volunteers deliver behavior change messages on CVD risk factors (Lasater, Wells, Carleton, & Elder, 1986). Receptivity of churches to collaborative implementation of health promotion programs was initially studied. Churches were chosen as the organizational context for this project because of the supportive influence they have on health promotion for individuals, groups, organizations, and entire communities. All churches in Rhode Island were surveyed by mail and phone. Of those churches meeting eligibility criteria, 65% were willing to participate in the health promotion intervention. All 20 churches selected remained in the study for at least 2 1=2 years. Findings from this study indicate that partnerships developed with churches can be highly receptive to health promotion interventions. An example of a partnership in churches is the North Carolina Black Churches 5-A-Day for Better Health Program, discussed later with the behavioral change element. TABLE 1. Key Elements for Church-Based Health Promotion Programs Key elements Partnerships Major literature findings Churches and health care organizations have successfully collaborated to implement health promotion programs, particularly in underserved populations (Lasater et al., 1991; Hatch et al., 1986). Churches are willing to participate in health promotion programs to meet the health needs of their congregation (Lasater et al., 1991; Hatch et al., 1986). Positive health values Churches have a mission of service and caring for others. (Eng et al., 1985). Clergy and other church leaders can endorse health promotion activities to positively influence lifestyle changes in the congregation (Campbell et al., 2000; Cook, 1997). Church leaders support the interrelationship of spiritual, mental, and physical health (Tuggle, 1995). Availability of services Churches are available in almost every community in the United States with approximately 60% of individuals having some association with a church (National Council of Churches, 1996). Minority, low socioeconomic, and other vulnerable or underserved populations have access to church-based health promotion programs (Castro et al., 1995; Hatch et al., 1986). Access to facilities Churches have a base of volunteers that are willing to train as health promotion activity leaders (Hatch et al., 1986; Kong, 1997; Lasater et al., 1986). Churches have facilities appropriate for conducting group meetings and activities (Lasater et al., 1986). Community-focused Church are ‘‘central’’ to some communities, having social, political, and educational functions intervention (Hatch et al., 1986; Kong, 1997; Tuggle, 1995). Health promotion programs based in churches often involve the entire family and may ultimately have a positive impact on health of the community (Castro et al., 1995; Lasater et al., 1986). Health behavior Church-based health promotion programs can facilitate healthy behavior change while incorporating change traditional cultural values (Castro et al., 1995; Hatch et al., 1986). Spiritual-based interventions may be more likely to promote health behavior change than self-help intervention in a church program (Voorhes et al., 1996). Churches provide an inherent social support system, providing an ideal setting for health behavior change (Campbell et al., 1999; Eng et al., 1985; Hatch & Lovelace, 1980; Lasater et al., 1991). Supportive Churches are networked to provide influence in health behavior change through social systems for relationships individuals and communities (Carleton & Lasater, 1987). Church-based health projects rely on educational, and instrumental support for effectiveness (Eng et al., 1985). 404 Public Health Nursing Volume 19 Number 6 November/December 2002 Positive Health Values In some communities, the church promotes physical and mental health for the community, as well as meeting the spiritual needs of the congregation. Historically, the church, African American in particular, has served as an advocate, encourager, and enabler of actions for advancement in the community (Hatch, Cunningham, Woods, & Snipes, 1986). The church has been the center of some communities, social, political, and educational functions (Hatch et al., 1986; Kong, 1997; Tuggle, 1995). CBHPP can provide education, screenings, referrals, and group support for prevention of disease prevalent in the community population. In the ‘‘Fitness Through Churches’’ project funded by the American Heart Association and sponsored by the University of North Carolina, CVD risk reduction and aerobic exercise was the focus of health promotion in African American churches in North Carolina (Hatch et al., 1986). Lay volunteers were trained to provide health education and lead exercise classes. Quantitative measurements of blood pressure, body circumferences, flexibility, and resting heart rate were gathered in a pilot study on 14 female lay volunteers from six participating churches before and after 7 weeks of training in CVD risk reduction education, aerobic exercise, and heart healthy diet information. In evaluation of the pilot project, a 2-in. improvement in flexibility occurred in 85% of the participants and a 5-mmHg reduction in systolic blood pressure was noted in 50% of the participants. Body circumferences showed significant improvements in 90% of participants and resting heart rate showed a 2 beat/ minute reduction in 40% of those participating (Hatch et al., 1986). The findings demonstrate the commitment church leaders and volunteers have for providing health education to the congregation. Although these studies lack experimental design and randomization, the reports emphasize the benefits of a partnership between churches and health care providers in promoting positive health values. Church leaders need to value and demonstrate commitment to health promotion projects in order for the projects to be successful. The CURE (Clergy United for the Renewal of East Baltimore) project supports the interrelationship of spiritual, mental, and physical health (Tuggle, 1995). The CURE organization consists of a group of clergy from 230 inner-city churches involved in CBHP services to the community. Clergy are respected by their congregation and can be an asset to health education and lifestyle changes in church members (Tuggle, 1995). Faith-based centers provide a model of caring in which the clergy can take an active role in assisting health care leaders to promote behavior change that is necessary for health and ‘‘healing’’ of mind, body, and soul (Cook, 1997). Positive health values are also demonstrated in a qualitative pilot study (Maddox, 2000) in which spirituality was assessed to explore the meaning of health in a group of older women, 65–82 years of age, from a large Protestant congregation. The women firmly believed health was a ‘‘gift from God’’ and that their bodies were given to them to be cared for and nurtured. This study supports the positive health values placed on health by members of faith communities. In a study by Weinrich et al. (1998), the impact of previous exposure to prostate cancer was measured by participation in a church-based prostate cancer educational program and free prostate cancer screenings in 442 African American churches in South Carolina. More men attended the educational sessions in churches that had a congregational member diagnosed with prostate cancer within the last year than churches that did not, F(1, 34) ¼ 6.32, p ¼ 0.02. There was no significant difference in participation in free prostate cancer screenings in men who had heard or read about prostate cancer within the past year. The presence of a previous church member having had prostate cancer, however, was a significant cue to action for attendance at educational sessions and promotion of prostate cancer screening. Availability of Services Churches are available in almost every community, and CBHPP can access individuals who typically do not use traditional health promotion resources. Churches are the ‘‘center’’ of many communities, especially for ethnically diverse and minority groups (Lasater, Becker, Hill, & Gans, 1997). Underserved populations may have limited access to traditional health promotion and preventive services located in educational and medical facilities. CBHPP demonstrate sensitivity to language and cultural barriers to health promotion in vulnerable populations. Companeros en la Salud (Partners in Health), a 3-year church-based project funded by the National Cancer Institute (NCI), was designed to reduce risk of breast and cervical cancer in metropolitan Latino/Hispanic women and increase their access to preventive health services (Castro et al., 1995). Fourteen churches were randomly assigned to a cancer control (intervention) or a family mental health (comparison) group. Findings suggested women from the smaller (predominantly Protestant), compared to larger (predominantly Catholic) churches, were less likely to have had health insurance (v2 ¼ 1.2; p < 0.05) and less likely to have had a previous clinical breast examination (v2 ¼ 13.75; p < 0.01). Analysis of variance revealed that the women from the smaller, Peterson et al.: Key Elements in Church-Based Health Promotion Protestant churches were poorer (F ¼ 4.99; p < 0.01) and less acculturated (F ¼ 22.15; p < 0.001). This experimental study suggests that in any community, needs of subgroups may vary depending on individual characteristics, such as lack of health insurance or lower income. Assessment of a specific church population’s health promotion needs is necessary as vulnerability may vary significantly within the same geographical area. The Black Church Family Project was a survey of 635 predominantly African American churches in northern United States to identify church characteristics associated with community health programs (Thomas, Quinn, Billingsley, & Caldwell, 1994). A logistic regression model identified larger church size (medium size, 176–400 members; and large, over 400 members) and ministers with graduate education were the strongest predictors ( p < 0.05) of health promotion community programs associated with the church. Church ownership, in contrast to renting, and larger numbers of paid clergy appeared to be other important factors ( p < 0.05) for engaging in community health programs (Thomas et al., 1994). Study results suggest that the commitment of church leaders to promotion of healthy lifestyles within the congregation is important to the success of CBHPP (Thomas et al., 1994). The availability of church resources may help to sustain and expand health services stemming from a sense of independence and commitment to others within the church. The cost-effectiveness of CBHPP has been minimally studied or reported. Lasater et al. (1997) emphasized the expense of CVD risk reduction within a community and that partnerships with health sectors and religious organizations may be an important resource to contain costs. Weinrich et al. (1998) found in a prostate cancer educational program with predominantly African American men (69%) in work sites and churches that work sites were 50% more cost-effective in program delivery than churches ($9.20 vs. $13.76 per man; p < 0.05). The authors attribute the increased cost relative to the increased time and expenses needed for program coordination in churches and that church costs would still be less than in cancer centers or hospitals. As churches become more accustomed to coordination of health programs, efficiency and costs perhaps would be reduced. Access to Facilities Resources provided by the church facilitate health promotion programs conducted in churches. The church has a direct connection with individuals within the community. Ethnically diverse and minority individuals may feel alienated from traditional health promotion and preventive services, but comfortable in their place of 405 worship. In a qualitative study conducted by interviewing 11 Parish clients from two urban Catholic churches, participants identified that the church was distinctive in promoting feelings of peace and caring. Health care activities connected with the church made the services accessible and user friendly while providing better outcomes (Chase-Ziolek & Gruca, 2000). There are 345,170 reported churches in the United States, providing church availability in almost every community (National Council of Churches, 1996). In a 1994 Gallop survey, 60% of U.S. citizens stated that religious worship is important in their lives and 42% reported church attendance nearly each week. Women and African Americans are more likely to report church attendance as important in their lives, and the importance increases with age in both groups (Roper Starch Worldwide, 1996). In the Pawtucket Heart Health Program, 58% of the persons attending the health events were members of the sponsoring church, 24% were members of another church, and 18% were not members of any church (Lasater, Carleton, & Wells, 1991). The structural facilities of churches make it ideal for holding meetings, educational programs, and in some situations, exercise sessions. Health promotion programs attract individuals from the community in addition to active church members. Community-Focused Intervention Churches are particularly effective in conducting community-focused health promotion programs since churches value ‘‘helping’’ people and a spirit of volunteerism. Individuals who volunteered listed religious activities as the most frequent volunteer pastime (Hodgkinson, Weitzman, & the Gallop Organization, Inc., 1996). The Heart, Body, and Soul Program was designed to test the hypothesis that a community-based program in partnership with a medical center (Johns Hopkins Medical Institute) would result in improving hypertension control in an inner-city African American population ( Levine et al., 1992). Assessment of the ‘‘hard to reach’’ community preceded the intervention to tailor the hypertension and smoking education to be socially and culturally appropriate to the population. Results over a 5-year period demonstrated significant control of hypertension (80% of the population compared to 50% with usual care; p < 0.01), decreased hospitalization (19% of the population compared with 31% with usual care; p < 0.01) and decreased hypertension-related mortality (65% in the intervention group; p < 0.01). Church-based programs can influence entire families and communities (Lasater et al., 1986). The widespread diffusion of health promotion can be effectively conducted in churches. 406 Public Health Nursing Volume 19 Number 6 November/December 2002 Health Behavior Change Health behavior changes have resulted from health promotion interventions conducted in churches. CBHPP have been found to positively influence behavior change in several studies promoting a variety of health behaviors. Four illustrative studies with varying degrees of methodologic rigor demonstrate these changes in health behaviors or the intentions for health behavior change. Three of these studies had randomized controlled designs and one study lacked randomization and a control group, but included pre- and post-test measures. One study was the NCI-funded North Carolina Black Churches United for Better Health (BCUBH) project, one of the 5-A-Day Projects NCI funded to promote implementation of its cancer prevention dietary guideline to eat at least five fruits and vegetables per day. BCUBH was a 4-year intervention trial that successfully increased fruit and vegetable consumption in rural African American adults conducted in 50 churches randomly assigned to a control or delayed intervention condition. The multicomponent intervention used concepts from the Transtheoretical Model, Social Cognitive Theory, social support, and ecological models organized into activities utilizing the PRECEDE-PROCEED model (Campbell et al., 2000). A process evaluation included a 2-year follow-up participant telephone interview, church reports, and a qualitative interview with 22 of the 24 participating church coordinators. Analyses showed that the intervention group consumed 4.45 servings of fruit and vegetables compared with 3.60 servings in the delayed intervention group, a difference of 0.85 (SE ¼ 0.12) servings ( p < 0.0001). The largest increases were seen in women, older individuals, those with more than high school education, and those widowed or divorced. The least change in fruit and vegetable consumption following the intervention was in single individuals and the youngest age group (18–37 years old) (Campbell et al., 2000). In the BCUBH project, psychosocial variables were measured in the 2-year follow-up and the adjusted odds ratio demonstrated that the intervention group was more likely ( p < 0.005) to be in the action or maintenance stage of change, had more self-efficacy, knew that five or more servings were recommended, and perceived that fruits and vegetables were available at church functions (Campbell et al., 1999). Serving fruits and vegetables at church functions was considered to have the highest impact on consumption by over 60% of the participants. Tailored bulletins, pastor’s support of the Project in the sermon, and printed materials were other supportive interventions influencing fruit and vegetable consumption in more than 50% of the participants (Campbell et al., 2000). Although the explicit messages were not described, findings indicated support and social networks of the church provided an effective strategy to implement the five-a-day message (Campbell et al., 1999). Findings from the BCUBH project suggest more frequent church attendance during the study period was strongly related to increased fruit and vegetable consumption. Participants attending church more than once weekly consumed 1.3 more servings/day than participants attending monthly or less who consumed 0.1 more servings/day (Campbell et al., 1999). A randomized controlled trial in a predominantly African American urban population compared the effectiveness of two interventions to move smokers along the Stages of Change (Prochaska & DiClemente, 1983) continuum (Voorhees et al., 1996). The intensive intervention group received ‘‘environmental’’ interventions that were spiritually based messages in the sermon such as Bible passages related to health, smoking-cessation testimony during services, and individual or group support, whereas the minimal (self-help) intervention group received the American Lung Association pamphlet designed for African Americans, ‘‘Don’t Let Your Dreams Go Up In Smoke.’’ Study findings indicated that the intensive intervention group was more likely to make positive progress in the stages of change, compared with the minimal intervention (self-help) group (odds ratio, 1.68; p ¼ 0.04). Findings suggested the spiritual components of an intervention make the church an ideal arena for health promotion and disease prevention strategies. Duan, Fox, Derose, and Carson (2000) assessed the effectiveness of telephone counseling in a church-based mammography promotion intervention trial in ethnically diverse women. Thirty churches were randomly assigned to telephone counseling on mammography promotion or to the control conditions. The intervention included an annual peer-conducted telephone counseling to promote mammograms for two years. The primary outcome measure was an annual mammogram. Data were collected on 1113 underserved women (ages 50–64) in the first year and at 1 year following intervention. To control for women with baseline adherence to annual mammograms, participants were analyzed from baseline-adherence status or conversion-to-adherence status. Findings suggest that at 1 year, peer telephone counseling conducted in the church resulted in 7.5% more mammogram screenings in baseline-adherent participants than in the control group ( p ¼ 0.029). In the control group, the nonadherence rate at the 1-year follow-up was 23.3% of the participants compared to 15.8% in the intervention group. Results show that 32% of year 1 nonadherence in the baseline-adherent group was reduced by the intervention (one-sided p < 0.037). Peterson et al.: Key Elements in Church-Based Health Promotion The Baltimore Church High Blood Pressure Program offered an 8-week behaviorally oriented weight control program consisting of diet and medication counseling and exercise sessions for predominantly African American populations (Kumanyika & Charleston, 1992). The study design lacked randomization and a control group, but did include pre- and postprogram weight and blood pressure measurements for 187 women (only 3 white) (mean age, 51 years). The women were divided into a medication group (47% on medicine for high blood pressure) and a no medication group. Significant within-person weight loss was observed in both the medication and the no medication groups (median weight loss was of 2–3% initial weight; p < 0.005). Almost 90% of the women lost some weight. Seventy-four women participated in the follow-up 6 months later and 65% of the 74 women had maintained or exceeded their weight loss at 8 weeks. Findings suggest that weight control programs in churches result in sustained weight loss. In summary, health behavior change intention or actual behavior change has occurred in church-based intervention studies. The pattern for behavior change has been evident in reported studies using different strengths of research designs, various strategies for interventions and in targeting a variety of behaviors. Health behavior change has been a consistent finding following churchbased health promotion interventions. Social Support Relationships The existence of social networks and social support through churches provides a context for health promotion programming. In the African American church, social support is provided to the congregation and surrounding community to assist overcoming social and political barriers to unequal access to health resources (Eng, Hatch, & Callan, 1985). CBHPP rely on educational, emotional, and instrumental support for effectiveness (Eng et al., 1985). Although social support was not specifically measured in the 3-year HARP, conclusions derived were that individuals belonging to a defined community or organization, such as a church, are networked to provide influence in behavior change through support systems (Carleton & Lasater, 1987). The church and church-based programs within a social influence framework can exert a positive effect on health promotion behaviors (Davis et al., 1994). Although reinforcement of social support in health promotion projects is an inherent strength of church-based programs, few research studies have examined the domains of social support or the outcomes of church-based social support interventions on promotion of health behaviors. Since there are many definitions of social support with a variety of domains, it is unclear which domains of social 407 support are related to effectiveness in church-based interventions. Broadly defined, social support is the helpful resources provided by another person (Cohen & Syme, 1985). Perceived support is the cognitive appraisal of being ‘‘cared for’’ by another person. Social support is a multidimensional construct that refers to three aspects of social relations, quantity, structure, and function, but is most often defined in terms of function. The functional dimensions of social support can be informational (providing information and guidance), emotional (providing acceptance and concern), instrumental (providing goods or services), and self-esteem (promoting selfworth) (Cohen, Mermelstein, Kamarck, & Hoberman, 1985). Social support has been correlated with higher levels of physical activity, particularly in women. The following descriptive studies support these findings. In a crosssectional mailed survey of 2636 ethnically diverse women, ages 20–65 years, Sternfeld, Ainsworth, and Quesenberry (1999) found social support (OR, 2.34; 95% CI, 1.83–2.98) was associated with higher levels of sports/ exercise and active living. Physical activity social support was analyzed in a national sample of middle- and olderaged minority women to determine the relationship between social support and physical activity (Eyler et al., 1999). Participants in the medium and high social support categories were much less likely to be sedentary than those in the no or low support categories (OR, 0.57 and 0.47, respectively). A longitudinal study of men and women in two New England communities found that women were more likely to adopt and maintain physical activity changes if recommended by family, especially children (Eaton, Reynes, Assaf, Feldman, Lasater, & Carleton, 1993). In a qualitative study by Nies, Vollman, and Cook (1998), 35- to 50-year-old European American women identified social support as the major factor that facilitated physical activity. Few studies have included social support interventions to determine the outcomes on physical activity. Although not conducted in churches, social support interventions have been used to promote physical activity in women. In a non-randomly assigned intervention and control group study by Calfas, Sallis, Oldenburg, and Ffrench (1997), activity-specific informational support influenced change in physical activity level in a group of 256 adults counseled on activity by physicians (PACE study). The PACE primary care physician counseling intervention included encouraging subjects to enlist social support for exercise from family and friends and a follow-up telephone call after the physician appointment. Results of this study indicate the intervention group reported more social support for 408 Public Health Nursing Volume 19 Number 6 November/December 2002 physical activity from family (1.9 vs. 1.7), F(1, 210) ¼ 4.20, p < 0.05, than the control group. In the PrimeTime project by Toobert, Glasgow, Nettekoven, and Brown (1998), a randomized clinical trial was designed to determine the effects of lifestyle management on changing behavioral risk factors in postmenopausal women with CVD. The experimental group received enhancement of social support to assist the women in the program in an intensive 1-week group session. Outcome measures of physical activity were frequency and duration of physical activity as measured by the self-report Stanford 7-Day Recall and Summary of Self-Care Activities Questionnaire. Significant improvements were noted in physical activity outcomes at both 4- ( p ¼ 0.001) and 12- ( p ¼ 0.05) month measures in the experimental group. Overall social support was significant ( p ¼ 0.012) at 12 months indicating PrimeTime participants’ increased perception of social support compared to the control group. Steptoe, Rink, and Kerry (2000) found that overweight adults reported increased physical activity following behavioral counseling in a primary care setting. Significant interactions between the behavioral counseled group and support from family ( p ¼ 0.05), friends ( p ¼ 0.03), and partner exercise ( p ¼ 0.006) were present. Although research has shown a link between social support and physical activity, social support is often defined and measured generally and the specific domain of social support provided in an intervention is often unclear. Providing social support to women within the context of a church setting appears an element of CBHPP most amenable to intervention for the promotion of physical activity in women. Programs to facilitate women’s adoption and participation in sufficient, health-enhancing physical activity may be most effective when social support for lifestyle changes is provided. Perhaps an effective method to engage women in regular physical activity is to integrate interventions into community settings that recognize personal health is integrally connected to the physical and social environment (Brown et al., 1995). Conn (1998) found that an existing social environment facilitating socialization with peers enhanced physical activity. Conn (1998) concluded that health-promoting physical activity programs instituted in naturally occurring social groups, such as in churches, would be the most effective. In an analysis of community-based physical activity programs, successful program characteristics included preexisting groups and social support (Yancey, Miles, & Jordan, 1999). The Heart and Soul Program is one example of a health promotion model projected to promote physical activity in midlife women encompassing the established key elements of CBHP programs. FACILITATION OF HEALTH PROMOTION IN CHURCHES Key elements that facilitate CBHPP have been presented, but evidenced-based health promotion interventions in churches remain sporadically implemented. Various reasons exist as to why church-based interventions have been hampered. The research on health promotion in churches has primarily been conducted in African American populations and few studies were conducted with experimental, randomized, and controlled designs. Religious leaders are primarily concerned with integration of mind, body, and spiritual needs of the congregation and may perceive controlled group and randomized research designs as violating an inclusive approach to health (Lasater et al., 1997). The dissemination of findings on CBHPP has been fragmented and often reported in church newsletters or periodicals. Funding for CBHPP has been inadequate in the past related to the distinct separation of church and the government (Lasater et al., 1997). Study designs can and need to address these issues, within the context of the key elements for establishing CBHPP, so clergy can support and facilitate sound research in their own churches. Tuggle (1995) emphasizes the need to provide a service to parishioners while conducting research in a church. In spite of barriers, church-based health promotion programs continue to hold promise in enhancing the health behaviors of diverse populations. The number of CBHPP continues to grow. One factor contributing to the initiation of CBHPP is the establishment of parish nursing. Parish nursing integrates body, mind, and spirit, promoting a promising mechanism for promoting health, healing, and wellness of the individual, their families, and communities (Solari-Twadell, 1999). Flynn (2001) proposed a Christian model of health promotion emphasizing four behaviorally oriented instructive themes for parish nurses. One theme, the provision of care and support for others translated into actions, is conceptualized as health promoting for both the provider and the recipient of support. Although church-based health programs have begun to emerge, few have specifically targeted health promotion in women, and an in-depth program evaluation is rare. One cardiovascular health promotion pilot program in a parish setting designed for midlife women was ‘‘Hearts To God’’ (Ruesch & Gilmore, 1999). The ‘‘Hearts to God’’ educational materials included a holistic foundation based on the stages of change model and a spiritual message to encourage behavior change. Six of the seven female participants stated an increased understanding of heart disease signs in women and three women indicated an increased understanding of risks for Peterson et al.: Key Elements in Church-Based Health Promotion heart disease in women. The Plan, Do, Check, Act (PDCA) Program model was the basis for a mini-CVD health fair conducted at three churches (Wilson, 2000). The evaluation of program effectiveness indicated 80% of participants intended to make lifestyle changes based on information gained at the health fair. Parish nursing is one avenue for implementing health promotion that reaches into the community (Boland, 1998). Other avenues may include health or wellness committees in the church. The Heart and Soul Program has been designed to promote physical activity within the context of existing church groups by utilizing the key elements identified in successful CBHPP (Peterson, 2001). The key elements to promote success in CBHPP are partnerships, positive health values, availability of services, access to facilities, community-focused intervention, health behavior change, and supportive relationships. Applying these key elements to the Heart and Soul Program, partnerships will exist between clergy, church leaders, and community outreach programs. In the Heart and Soul Program, a partnership between the church and the nurse health educator will provide strength and visibility for the program. Through various committees within the church and with pastoral support, positive health values will be promoted in the church. Available facilities within the church will be utilized in the Heart and Soul Program. Volunteers will be recruited and trained to facilitate access to all individuals in the church and ‘‘reaching out’’ into the surrounding community to contact vulnerable and underserved populations. Spiritual messages and endorsements in church bulletins, sermons and newsletters will reflect positive health values and, thus, enhance the health promotion strategies employed. Church facilities can be utilized in the Heart and Soul Program to conduct educational meetings and physical activity sessions. The Heart and Soul Program will be initiated in the church, but will be conducted utilizing a communityfocused approach. The church is often the ‘‘heart’’ of the community with members reaching out to share with others. Increased physical activity would be the health behavior change anticipated following the Heart and Soul Program. Existing social support systems in churches will provide a natural foundation for conducting the Heart and Soul Program. The church as an existing social group provides a promising setting to incorporate a social support intervention to promote physical activity in midlife women. Social support within the church can be strengthened and used to sustain the Heart and Soul Program to involve individuals, families, and the community. The mission of many churches is to provide service to others 409 and may be accomplished by promoting healthy behaviors to the congregation and the community. The Heart and Soul Program has been designed to empower participants to help each other to attain health goals and tailor the program to meet individual and group needs. The church provides an encouraging opportunity for promoting health behavior change. Positive health behavior change is an expected outcome following the Heart and Soul Program. CONCLUSIONS CBHPP have effectively promoted health behaviors within certain communities. 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