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Church-Based Health Promotion Program
Impact on Ethnically Diverse Older
Adults' Social Support, Religiosity, and
Spirituality
Holly Pope
a
, Ken W. Watkins
a
, Robert E. McKeown
a
, Daniela B.
Friedman
a
, David B. Simmons
a
& Maggi C. Miller
a
a
University of South Carolina , Columbia , South Carolina , USA
To cite this article: Holly Pope , Ken W. Watkins , Robert E. McKeown , Daniela B. Friedman , David
B. Simmons & Maggi C. Miller (2013): Church-Based Health Promotion Program Impact on Ethnically
Diverse Older Adults' Social Support, Religiosity, and Spirituality, Journal of Religion, Spirituality &
Aging, 25:3, 238-257
To link to this article: http://dx.doi.org/10.1080/15528030.2013.726578
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Journal of Religion, Spirituality & Aging, 25:238–257, 2013
Copyright © Taylor & Francis Group, LLC
ISSN: 1552-8030 print/1552-8049 online
DOI: 10.1080/15528030.2013.726578
Chur ch-Based Health Promotion Program
Impact on Ethnically Diverse Older Adults’
Social Support, Religiosity, and Spirituality
HOLLY POPE, KEN W. WATKINS, ROBERT E. McKEOWN, DANIELA
B. FRIEDMAN, DAVID B. SIMMONS, and MAGGI C. MILLER
University of South Carolina, Columbia, South Carolina, USA
A church-based health promotion program of the United Methodist
Church was implemented to address the holistic health of adults
50 years and older (n = 142). African American congregation
members (n = 65) were paired with white congregation members
(n = 77) for a total of 12 groups. Over a year, biracial groups par-
ticipated in weekly two-hour meetings. A one-group pretest-posttest
design was used to determine impacts on participants’ religios-
ity, spirituality, and social support; and if impacts varied by race.
At follow-up, program components were assessed. Tangible social
support overall improved, and participants experienced meaning-
ful socialization, spiritual opportunities, and improved perceptions
of other race groups.
KEYWORDS ethnogeriatrics, aging, cultural diversity, health pr o -
motion, holistic, social support, qualitative research
INTRODUCTION
Given that the older adult population is increasing at unprecedented rates
(Himes, 2002), remaining in community settings (Federal Interagency Forum
This work was supported by the Caring Communities Program of the Duke Endowment
with Robert E. McKeown serving as Principal Investigator.
We wish to thank the Older Adult Ministry of the South Carolina Conference of the United
Methodist Church for this collaboration opportunity, support, and assistance with the Heart,
Soul, Mind, and Strength Program. We are grateful to all the individuals who volunteered their
time to attend the leadership trainings and for the participants’ commitment to the program.
We are also especially thankful to the pastors who supported the program.
Address correspondence to Holly Pope, University of South Carolina, Department of
Health Promotion, Education, and Behavior, Arnold School of Public Health, 800 Sumter
Street, Columbia, SC 29208, USA. E-mail: hpope@mailbox.sc.edu
238
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Church-Based Health Promotion Program Impact 239
on Age Related Statistics, 2005), and often aging alone (FIFARS, 2006), there
are concerns regarding older adults’ health and quality of life. However,
evidence suggests that religiosity, spirituality, and social support have posi-
tive impacts on physical and mental health (Koenig, 2001a; Koenig, 2001b;
Torosian & Biddle, 2005; Uchino, Holt-Lunstad, Uno, & Flinders, 2001).
Though the constructs of religiosity and spirituality are closely related, and
may yield similar beneficial health effects, authors attempt to distinguish
them. Religiosity has been described as particular beliefs and practices that
occur in social entities or institutions in “search for the sacred” (i.e., God)
(Miller & Thoresen, 2003; Hill & Pargament, 2003). Spirituality refers to the
intrapersonal “search for the sacred” (i.e., God), which may (although not
necessarily) take place in a larger religious context (e.g., church) (Miller &
Thoresen, 2003; Hill & Pargament, 2003). As constructs, religiosity and spiri-
tuality often overlap, as they share some characteristics (i.e., a desire to seek
the sacred), but other characteristics differentiate each construct; religiosity is
characterized by an expression that is formal in nature, and spirituality rep-
resents an expression experienced within the individual and is unsystematic
(Miller & Thoresen, 2003; Hill & Pargament, 2003; Koenig, McCullough, &
Larson, 2001).
It is estimated somewhere between three-fifths to three-fourths of the
American adult population are members of a church (Wald & Calhoun-
Brown, 2007). In 2009, 41.6% of all Americans reported they attended
church at least once a week or almost every week (Newport, 2010). Church
attendance levels varied across the states, with the highest levels generally
occurring in the South and the Midwest (45%-63%) (Newport, 2010). Church
attendance also varies by race: Older African Americans are more likely to
attend church 2–3 times a month, compared with white older adults that
attend about once a month (Krause, 2003). Religion may be an important
source of resilience for older African Americans as a result of historical influ-
ences (Krause, 2004). During periods of social change, the church provided
political unification and cultural resources (Giggie, 2005).
Religious institutions are potential partners with programs working to
improve the health of older adults (Trinitapoli, 2005) because of the faith
community’s common history, values, beliefs, and relationship with a higher
power (Buijs & Olson, 2001), all of which have been associated with health
behavior change (Voorhees et al., 1996). Additionally, leaders in faith com-
munities often view health ministries as one aspect of their mission and
obligation to care for others, that is, as a form of obedience to their
vocation (REM personal communication). Over the past two decades, litera-
ture reviews have shown the relationships between religious variables and
psychosocial and health-related outcomes in gerontological research (Levin
& Chatters, 2011). For instance, a review of church-based health promo-
tion (CBHP) programs by Campbell, Carr, Blackeney, Resnicow, and Baskin
(2007) focused on two review papers by DeHaven, Hunter, Wilder, Walton,
and Berry (2004) and Chatters, Levin, and Ellison (1998). Sixty studies were
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240 H. Pope et al.
initially included in the review, but only 13 studies reported an experimental
or quasi-experimental study design that reported outcomes and statistical
data (Campbell et al., 2007). Further, less than 4% of CBHP programs target
the needs of older adults (Trinitapoli, 2005), even though they are the largest
group of most congregations (Cnaan, Boddie, & Kang, 2005). DeHaven et al.
(2004) reviewed CBHP programs and found only 53 articles (between the
years 1990–2000) discussed an actual program, and out of those, only six
programs targeted older adults. In addition, Knapp (2001) found that the
vast majority of U.S. church programs for older adults are limited to visiting
shut-ins. Therefore, public health practitioners have a continued opportu-
nity to (1) create unique programs to meet the changing needs of older
adults to help off set age-related risks (Cnaan et al., 2005; White, Drechsel,
& Johnson, 2006); and (2) utilize study designs that incorporate evaluation
measures (Campbell et al., 2007).
Conceptual Framework
In a response to the need to create unique CBHP programs for older
adults and evaluate program impacts, the University of South Carolina’s
Arnold School of Public Health, the Duke Endowment, and the South
Carolina Conference of the United Methodist Church (SCCUMC) collabo-
rated to develop the Heart, Soul, Mind, and Strength (HSMS) program from
2004–2007. The program was originally conceived by one of the authors
(REM) at the request of the SCCUMC. The conceptual framework that guided
the rationale of the program is based on several precepts: (1) Religiosity,
spirituality, and social support are associated with positive physical and men-
tal health outcomes, and quality of life (Koenig, 2001b; Koenig, Larson, &
Larson, 2001; Townsend, Kladder, Ayele, & Mulligan, 2002; Uchino et al.,
2001), in addition to being central and valued as ends in themselves.
Further, most religious and spiritual traditions, including Christianity, believe
that people can experience spiritual and religious growth (Ullman, 1989;
Hill & Pargament, 2003), and such growth is “essential to health, broadly
defined” (Hill & Pargament, 2003); (2) John Wesley’s (1703–1791) teachings,
from which the modern Methodist movement was founded, proclaimed that
church members are to care for others, which has mutual spiritual and health
benefits for those receiving the care and those providing the care (Sermon
98); and (3) the opportunity for friendships with individuals of different eth-
nic backgrounds will lead to positive perceptions of one another (Dovidio,
Gaertner, & Kawakami, 2003).
Purpose
The purpose of this study was to examine data at baseline and follow-up to:
(1) determine the extent the program positively impacted the participants’
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Church-Based Health Promotion Program Impact 241
religiosity, spirituality, and social support, and to determine if the program’s
impact varied by participant’s race; and, (2) describe the religious/spiritual
and social program components that made the most difference to HSMS
participants, and to determine if participants’ descriptions varied by race.
Program Design and Setting
The HSMS program emphasized holistic health to address spiritual, men-
tal, physical, and social health of adults 50 years of age and older. African
American congregations were paired with white congregations for partic-
ipation (12 groups). Over the span of a year, up to six adults from an
African American and white congregation participated in weekly two-hour
meetings addressing spiritual, physical, emotional, mental, and social dimen-
sions of health. The first hour of each meeting focused on spiritual, physical,
emotional, and mental dimensions of health. Meetings began with a guided
meditation accompanied by deep breathing and stretching activities, which
emphasized the integration of spiritual, physical, and emotional aspects of
health. These activities provided focus for the physical and mental activities
that followed. The physical activity component combined education, motiva-
tion, and brief exercise routines. The group then engaged in mental exercises
that targeted a range of cognitive functions. The second hour of each meet-
ing included a curriculum designed to facilitate spiritual and social formation
and growth (Indermark, 2004). Participants engaged in scriptural study and
discussions of their spiritual journey. During the span of the program, par-
ticipants were encouraged by their group leaders to develop a customized
method for contact within the group so each member was contacted by at
least one other member on a regular basis, and to identify a need(s) within
their community, and as a group, determine how they would help meet the
need(s) and then follow through.
METHODS
Participants
Participants were 142 attendees or members from 12 United Methodist
churches (n = 117 female, n = 26 male), 50 years of age or older, and from
eight counties in South Carolina. Effective recruitment methods included a
judicatory official’s letter of program support to church ministers. In addition,
a staff member of the Older Adult Ministry of the SCCUMC contacted church
ministers to provide program information.
Training and Participant Recruitment
The spiritual curriculum and training was based on Companions in Christ
(Indermark, 2004), and was led by leaders within SCCUMC. Leaders were
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242 H. Pope et al.
trained to facilitate small groups that promoted respect, trust, confidentiality,
and group bonding. The training also focused on explanation of the program
components, participant recruitment, informed consent forms, and collection
of baseline and follow-up measures. Leaders were asked to recruit up to
six members within their congregation to participate in the program. Thus,
two leaders (an African American leader and white leader) shared group
facilitation responsibilities for a single group (up to 12 members).
Measures and Data Collection
The study was approved by the University’s Institutional Review Board,
and written informed consent was obtained from each participant. Prior
to the start of the study, participants completed a baseline questionnaire
of demographic variables (i.e., age, sex, race, and education level). Other
variables included participants’ frequency of religious service /activity atten-
dance and group participation outside the church. At baseline and follow-up,
measures were completed by participants: (1) Religious Orientation Scale
(ROS) (Allport & Ross, 1967), (2) the Social Support (SS) questionnaire
(modified from the Medical Outcome StudySocial Support Survey) (MOS-
SSS) (Sherbourne & Stewart, 1991), and (3) the Daily Spiritual Experiences
(DSE) questionnaire (Underwood & Teresi, 2002).
ROS. The purpose of the ROS was to identify the types of motiva-
tions (intrinsic and extrinsic) associated with religious belief and practice
(Hoge, 1972). The scale was comprised of three sub-scales: Intrinsic moti-
vation (I) referred to the respondent’s religious commitment (Kirkpatrick &
Hood, 1990), and extrinsic motivation referred to the use of religion for per-
sonal benefits (Ep) and social reward (Es) (Kirkpatrick, 1989). Hood (1970)
suggested that the intrinsically religious motivated person would be more
likely to have a religious experience than the extrinsically motivated person,
whereas the extrinsically motivated person tends to engage in religious activ-
ities for the social integration and support, unlike the intrinsically motivated
individual (Allport & Ross, 1967). Therefore, it was hypothesized in the cur-
rent study that participants that tended to be intrinsically motivated may be
more likely to be impacted by the spiritual program component, indicated
by higher I subscale scores, while participants that tended to be extrinsically
motivated may be more likely to be impacted by the social component of
the program, indicated by higher Ep and Es subscale scores. In an effort
to reduce participant burden in this study, a shorter scale was used (eight
items) based on the highest factor loadings from each subscale in a previ-
ous study (Gorsuch & McPherson, 1989). An example of an I item was “It is
important to me to spend time in private thought and prayer.” An example
of an Ep item was “I pray mainly to gain relief and protection.” An exam-
ple of an Es item was: “I go to religious services mostly to spend time with
my friends.” A Likert-type 5-item response scale was used for all subscales
(1 = Strongly disagree to 5 = Strongly agree). To facilitate interpretation of
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Church-Based Health Promotion Program Impact 243
results in this study, all responses were reverse-coded. The subscale scores
(I, Ep, and Es) were the means of each of the subscale items (Lease, Horne,
& Noffsinger-Frazier, 2005).
DSE. This questionnaire was comprised of 16 items that measured the
understanding of the divine and relationship (interaction or involvement)
with the divine. The goal of this scale was to measure experiences as
opposed to beliefs or behaviors (Underwood, 2006; Underwood & Teresi,
2002), for example: “I feel guided by God in the midst of daily activities.”
Response categories ranged from 1 = Never or almost never to 6 = Many
times a day. The scale score was the mean of individual items; higher num-
bers signified greater spiritual experience. An additional item was examined,
but not scored as part of the DSE scale since the item was not part of the
validated DSE scale: “In general, how close do you feel to God?” Response
options ranged from 1 = Notatallcloseto4= Close as possible.
SS. This questionnaire assessed functional aspects of social support:
tangible, affectionate, emotional/informational, and positive social interac-
tion (Sherbourne & Stewart, 1991). To reduce participant burden in this
study, eight items were selected based on the relevance to the study
population from the original 20 items of the MOS-SSS (two items from
each sub-scale) (Sherbourne & Stewart, 1991). Tangible support referred
to the provision of material aid and behavioral assistance; affectionate
support conveyed love and affection; emotional support was expression
of positive affect, and informational support was the offering of advice,
information, guidance, or feedback; positive social interaction was the avail-
ability of another person to share enjoyed activities (Sherbourne & Stewart,
1991).
An example of a tangible support item was “How often would you have
someone to help you if you were confined to a bed?” An item for affection-
ate support included, “How often would you have someone who shows you
love and affection?” Previous analysis suggested that emotional and infor-
mational support be scored together (Sherbourne & Stewart, 1991). An item
that indicated emotional/informational support was “How often would you
have someone to share your most private worries and fears with?” An item
of positive social interaction was “How often would you have someone
to have a good time with?” The response categories were a Likert-type 5-
item response scale (i.e., 1 = None of the time to 5 = All of the time).
The subscale scores for tangible, affectionate, positive social interaction, and
emotional/informational support were the means of each of the subscale
items.
Evaluation of Program Components. After each group completed the
study, each respondent completed a follow-up questionnaire that included
the following item: “Which emphasis area(s) (social, spiritual, mental, phys-
ical) of HSMS do you think made the biggest difference in your life? Please
provide any details beside each item(s) to explain your choice.”
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244 H. Pope et al.
Data Analysis
Due to scale modifications to the ROS and SS, confirmatory factor analyses
were used to test the dimensional structure of the measures (Stewart,
2001) (i.e., to confirm that the constructs measured by the ROS and the
SS were consistent with their intended use). Inter nal consistency for the
DSE and the sub-scales of the ROS and SS were assessed with Cronbach’s
alpha (Cronbach, 1951). A two-way repeated measures analysis of variance
(ANOVA) was used to calculate between-group mean differences at baseline
and follow-up for the DSE and the sub-scales of the ROS and SS. When the
interaction term between race and time was significant, a paired t-test was
used to calculate within group mean differences from baseline to follow-up.
Qualitative social science research methods allow r esearchers to study
social and cultural phenomena (Myers, 2009). Therefore, qualitative analysis
examined the participants’ descriptions of the beneficial program compo-
nents, and a separate qualitative analysis using the same methods examined
participants’ descriptions by race (i.e., African American and white) to detect
cultural differences. Participants’ written comments from the original data
source were transferred into a Microsoft Excel Spreadsheet by one of the
researchers (HP). A Microsoft Excel spreadsheet was used for data man-
agement (Meyer & Avery, 2009), so the comments could be sorted by race
groups. Each sentence was independently reviewed and analyzed by two
researchers (HP and MC) using an open coding process (Strauss & Corbin,
2008). Labels of codes were determined by each researcher based on sup-
porting quotes, which were discussed and compared. Researchers discussed
inter-rater coding issues until agreement was reached. The list of codes was
compiled into a codebook with definitions (Strauss & Corbin, 2008). At least
two participants had to make a comment about a similar topic for it to be
considered a theme. If one participant made multiple comments about a sin-
gle theme, the theme was counted one time. However, if a participant made
a single comment that represented an overlap in themes, the single comment
was coded in the suggested themes.
RESULTS
Twenty-five pairs of HSMS leaders were identified and completed the train-
ing (each pair represented an African American and white church). Of the
25 pairs of HSMS leaders, 10 pairs of HSMS leaders never started the program
for various reasons within each congregation. Of the remaining 15 pairs of
HSMS leaders, three pairs met as a group, but did not complete the program.
Twelve pairs of African American and white churches met for up to one year.
A total of 11 pairs completed baseline (145 participants) and follow-up ques-
tionnaires (94 participants). At baseline the mean age was 65.33 (SD = 9.89).
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Church-Based Health Promotion Program Impact 245
TABLE 1 HSMS Participant Demographic Characteristics at Baseline and Follow-up
Baseline
N %
Follow-up
N %
Age
50–59 39 28 20 21
60–69 54 38 40 43
70–79 35 25 24 26
80+ 12 9 9 10
Total
a
140 93
Sex
Male 26 18 16 17
Female 117 82 77 83
Total
b
143 93
Race
African Americans 65 46 41 44
White 77 54 52 56
Total
c
142 93
Education
Less Than HS 7 5 3 3
HS Graduate 25 17 13 14
Some College 40 28 32 34
College Graduate 72 50 45 48
Graduate Study 0 0 0 0
Total
d
144 93
Total 144 93
a
Age: Missing baseline data (n = 5); Missing follow-up data (n = 1).
b
Sex: Missing baseline data (n = 2); Missing data (n = 1).
c
Race: Missing baseline data (n = 3); Missing follow-up data (n = 1).
d
Education: Missing baseline data (n = 1); Missing follow-up data (n = 1).
Table 1 highlights participant demographic characteristics at baseline and
follow-up. At baseline, 82 participants (34 African Americans and 48 whites)
reported that they had attended religious services or religious activities at
least once in the past month. Sixty participants (27 African Americans and
33 whites) also participated in non-religious group activities (e.g., clubs,
social groups, and organizations) once a month or more. Seventy- six par-
ticipants (36 African Americans and 40 whites) responded that they felt very
close or as close as possible to God.
Preliminary Results for Measures Used
Confirmatory factor analyses (CFA) of the ROS and SS subscales were per-
formed with MPlus version 4.2 (Muthén & Muthén, 2006). Five indices (and
commonly accepted cut off values) were used to assess model fit: chi-
square(X
2
)/degree freedom (df) ratio (should be < 2.0), p-value (should
be > 0.05), comparative fit index (CFI) (should be > 0.90) and Tucker-Lewis
index (TLI) (should be > 0.90) (Hatcher, 1994) and Root Mean Square Error
of Approximation (RMSEA) (should be close to 0.06 or less) (Hu & Bentler,
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246 H. Pope et al.
1999). Reliability was measured using Cronbach’s alpha (Cronbach, 1951)
(should be > 0.60) (Hatcher, 1994).
Model fit for ROS (X
2
= 9.189; df = 7; p-value = 0.23; CFI = 0.995; TLI =
.992; and RMSEA = 0.048) and SS (X
2
= 12.56; df = 8; p-value = 0.12; CFI =
0.998; TLI = 0.999; and RMSEA = 0.065) met the pre-determined cut-off
values. Measures for this study also had high internal consistency: Cronbach’s
alphas for the scales were .95 for the DSE scale; the ROS subscales were
0.71 for I, 0.70 for Ep, and 0.71 for Es; the SS sub-scales were 0.82 for
tangible, 0.82 for affectionate, 0.85 for positive social interaction, and 0.84 for
emotional/informational.
ROS, SS,
AND DSE MEASURES
See Table 2 for two-way repeated measures ANOVA results for the effects
of race and time on outcome measures. From the ROS, the effects of time
and race on participants’ I, Ep, and Es mean scores were examined using
a two-way ANOVA. Results indicated that there was a significant effect of
race between white (M
W
= 4.33, SD = 0.57) and African American (M
AA
=
4.08, SD = 0.84) participants’ I mean scores [F(1,89) = 18.49, p = < 0.0001];
Ep mean scores (M
W
= 3.08, SD = 0.85; M
AA
= 3.90, SD = 1.08) [F(1,89) =
53.57, p =< 0.0001]; and Es mean scores (M
W
= 1.97, SD = 0.65; M
AA
=
2.49, SD = 0.90) [F(1,89) = 23.65, p = < 0.0001].
For tangible support mean scores, there was a significant effect of time
from baseline (M = 64.32, SD = 25.53) to follow-up (M = 74.72, SD =
22.95) [F(1,88) = 11.22, p = 0.0012]. There was also a significant interaction
between race and time for emotional/infor mational mean scores [F (1,88) =
5.43, p = 0.0222]. For whites, scores increased from baseline (M
W
= 69.50,
SD = 30.00) to follow-up (M
C
= 76.47, SD = 23.67). For African Americans,
scores decreased from baseline (M
AA
= 76.28, SD = 23.61) to follow-up
(M
AA
= 67.31, SD = 23.75). Follow-up paired t-tests, however indicated these
changes in participants’ emotional/informational mean scores were not sig-
nificant for African American [t(38) = 1.74, p = 0.090] and white [t(49) =
−1.52, p = 0.135] participants.
For DSE mean scores there was a significant effect for race among white
(M
W
= 4.59, SD = 0.92) and African American participants (M
AA
= 4.98,
SD = 0.84) [F(1,91) = 13.84, p = 0.0003]. There was a significant interaction
between race and time for baseline (M
AA
= 5.00, SD
AA
= 0.71; M
W
= 4.39,
SD = 1.04) and follow-up DSE mean scores (M
AA
= 4.95, SD
AA
= 0.96; M
W
=
4.78, SD = 0.73) [F(1,91) = 4.67, p = 0.0334]. A paired t-test indicated there
was a significant difference [t(50) = -2.60, p = 0.0123] between baseline and
follow-up mean scores for White participants, but there was no significant
difference [t(40) = 0.49, p = 0.6278] between baseline and follow-up for
African American participants.
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TABLE 2 Results for the Effects of Time and Race on Outcome Measures Using Two-Way Repeated Measures ANOVAs
African American White
N
Baseline
Mean (SD)
Follow-up
Mean (SD)
Baseline
Mean (SD)
Follow-up
Mean (SD) Results
ROS 91
I 4.10 (0.79) 4.07 (0.89) 4.33 (0.55) 4.35 (0.60) p (r) = <0.0001
Ep 3.88 (1.06) 3.93 (1.11) 3.06 (0.83) 3.10 (0.87) p (r) = <0.0001
Es 2.52 (0.97) 2.45 (0.83) 1.94 (0.63) 2.00 (0.68) p (r) = <0.0001
DSE 93 5.00 (0.71)
a
4.95 (0.96)
a
4.39 (1.04)
b
4.78 (0.73)
b
p (r) = 0.0003
p (r × t) = 0.0334
SS 90
T 67.95 (22.90) 77.56 (21.30) 61.50 (27.30) 72.55 (24.11) p (t) = 0.0012
A 85.53 (18.95) 87.82 (17.08) 81.50 (26.64) 83.82 (23.36) NS
E/I 76.28 (23.61)
a
67.31 (23.75)
a
69.50 (30.00)
a
76.47 (23.67)
a
p (r × t) = 0.0222
PSI 73.72 (18.98) 74.36 (21.83) 76.47 (26.18) 78.43 (19.38) NS
Note. p (r) = p-value for race effect; p (t) = p-value for time effect; p (r x t) = p-value for race x time effect; ROS subscales = I (intrinsic motivation), Ep
(extrinsic personal), Es (extrinsic social); SS subscales = T (tangible), A (affectionate), E/I (emotional/ informational), PSI (positive social interaction); NS =
not significant.
a
Paired t-test not significant.
b
Paired t-test significant (at < 0.05).
247
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248 H. Pope et al.
Themes of the Religious/Spiritual Program Component
At follow-up, 62 participants wrote comments about the spiritual component
of the program. The following themes were identified by the participants
(n = number of participants that commented about each theme) in relation
to the spiritual program component. For a summary of the most commonly
reported themes for the religious/spiritual program component see Table 3.
Spirituality (n = 27) or spiritual beliefs referred to the positive effect on
participants’ beliefs or experiences related to their faith, which was the most
common theme reported. Spiritual study (n = 25) was defined as partici-
pants learning about their faith. Spiritual social support (n = 22), based on
a definition from a previous study (Krause, 2008), is assistance from others
that is specifically intended to increase faith, commitment, and beliefs. New
Perspectives (n = 10) was defined as being receptive to a different viewpoint
or learning from others regarding spiritual matters.
Themes of the Social Program Component
At follow-up, 59 participants wrote comments about the social component
of the program. The following themes were identified concerning the ben-
efits from the social aspects of the program. For a summary of the most
commonly reported themes for the social program component see Table 3.
Fellowship (n = 40) referred to the socialization between group members in
the program. Acceptance of others (n = 20) was defined as including oth-
ers within the group of a different race, background, or culture. Emotional
social support (n = 14) referred to the expression of encouragement, com-
fort, and empathetic understanding among group members. Spirituality (n =
6) referred to the participant’s beliefs or experiences related to their faith
TABLE 3 Most Commonly Reported Themes by Program Component and Race
Religious/Spiritual Program Component
a
Rank Overall African American White
1 Spirituality Spirituality Spiritual study
2 Spiritual study Spiritual social support Spirituality
3 Spiritual social support Spiritual study Spiritual social support
4 New perspectives of others New perspectives of others New perspectives of others
Social Program Component
a
Rank Overall African American White
1 Fellowship Fellowship Fellowship
2 Acceptance of others Emotional social support Acceptance of others
3 Emotional social support Spirituality Emotional social support
4 Spirituality Acceptance of others
a
Often in a single quote there was an overlap in themes; therefore, one comment may be coded in more
than one theme.
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Church-Based Health Promotion Program Impact 249
they experienced from their participation in the social components of the
program.
Participants Description of the Religious/Spiritual Program
Component by Race
To determine if there were cultural differences pertaining to the
religious/spiritual program component, participants’ written comments were
stratified by race (African American = 22, white = 40). For a summary of the
most commonly reported themes for the religious/spiritual program compo-
nent and race, see Table 3. Spirituality was the most commonly reported
theme reported by African American ( n = 11) and white participants (n =
16). One African American participant said, “the spirit was always there to
give me what I needed.” One white participant wrote, “We saw the spiri-
tual gifts in each other. The Holy Spirit was there with us.” The benefits of
the spiritual study in the program were also discussed by both by whites
(n = 17) and African Americans (n = 8). One white participant wrote,
“On my constant jour ney to being a better Christian—this course helped
my understanding of scripture and people.” An African American participant
stated, “I spent more time reading and studying scriptures, discussing, [and]
learning from other members.” Spiritual social support was shared among
group members in both race groups, African Americans (n = 9) and whites
(n = 13). One African American participant appreciated the support of group
members by stating the program allowed “others to minister to me.” A white
participant said, “Our spiritual time was very important to all of us, and we
share many experiences that helped us to trust each other more.” African
American ( n = 5) and white participants (n = 5) wrote about positive new
perspectives that were gained. One African American participant wrote “I
understand that we worship the same God who loves us all.” One white
participant realized that “Education has nothing to do with spirituality.”
Participants Description of the Social Program Component by Race
To determine if there were cultural differences pertaining to the social pro-
gram component, participants’ written comments were stratified by race
(African American = 25, white = 34). For a summary of the most commonly
reported themes for the social program component, see Table 3. African
American (n = 14) and white groups (n = 26) most often mentioned that
they enjoyed the fellowship. One African American participant said “The
class also became a social gathering as we became closer.” Similarly, a
white participant noted, “We really enjoyed each other and had lots of fun.
Sometimes we were so loud, I thought we might be thrown out!” White par-
ticipants (n = 15) and African American participants (n = 5) wrote about
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250 H. Pope et al.
acceptance of others. A white participant simply stated that the program
helped, “get past color.” One African American participant wrote, “People
can get along peacefully. People can visit and accept one another into their
homes. I felt that the program is a step toward improving the human con-
dition.” African American participants (n = 7) and white participants (n =
7) wrote about emotional social support among group members. An African
American participant wrote, “I was able to meet new people [and] share
personal experiences. A white participant wrote, “. . . being with others
socially brings helpful decisions.” Only African American participants (n =
6) wrote about spiritual benefits from participating in the social components
of the program. One participant explained, “I got to meet new people, which
helped me improve spiritually.”
DISCUSSION
The goals of this study were to examine the extent to which the HSMS pro-
gram positively impacted the participants’ religiosity, spirituality, social sup-
port, and to determine if the program’s impact varied by participants’ race.
Participants’ descriptions were examined related to the religious/spiritual and
social program components that made the most difference to them, and
further analysis determine if descriptions were associated with race.
For the outcome measures, results were mixed. Overall African
American and white participants had high I mean sub-scale scores, although
white participants had significantly higher I mean sub-scale scores than the
African American participants. African American participants had significantly
higher Ep and Es scores than white participants. This finding may reflect the
multifaceted role the church has had in the lives of African American mem-
bers. Many African Americans carry with them generations of discrimination
and prejudice (Krause, 2004) and churches have historically promoted and
continue to encourage the integration of religion and social reform (Giggie,
2005); therefore, one explanation of the findings from this study is that reli-
gion offers intrinsic commitment for the African American participants, as
well as a common ground to be in community with others that has personal
benefits and social rewards.
For both race groups, DSE mean scores were high at baseline, par-
ticularly among African American participants whose mean scores were
significantly higher than white participants. At baseline, the scores of African
American participants indicated they encountered a spiritual experience
every day. A non-significant decrease at follow-up was most likely due
to a ceiling effect or a program-related realization of new dimensions of
spirituality and recognition of the need for further spiritual growth. White
participants’ DSE scores significantly increased, suggesting the HSMS pro-
gram may have encouraged spiritual formation among whites. Previous
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Church-Based Health Promotion Program Impact 251
studies have shown spirituality to be associated with positive general health
perceptions (Potter & Zauszniewski, 2000), participation in physical rehabil-
itation (Resnick, 2002), and a number of quality of life measures, including
well-being (Kirby, Coleman, & Dailey, 2004) and positive outlook on life
(Ardelt, 2003).
Participants’ overall tangible social support scores significantly
increased, suggesting the HSMS program may have facilitated social net-
works that led to more tangible social support; this form of support has
previously been associated with helpful chronic disease management (Lloyd,
Wing, Orchard, & Becker, 1993; Stanton, 1987; Wilson et al., 1986) lower
risks of depression (Oxman, Berkman, Kasl, Freeman, & Barrett, 1992;
Pirraglia, Peterson, Williams-Russo, Gorkin, & Charlson, 1999), and heart
disease (Seeman & Syme, 1987). Affectionate and positive social interaction
mean scores were high at baseline compared to a previous study with a
similar aged population (Sherbourne & Stewart, 1991). No change in high
affectionate support and positive social interactions mean scores may have
indicated the program had protective effects given that the program lasted
up to a year and there were reports from leaders of personal loss among
participants throughout the program. Similarly, African American and white
participants’ emotional/informational means scores were not significantly dif-
ferent at baseline and follow-up, consistent with the program possibly having
protective effects. It could be that the quantitative measures used in this study
were not sensitive enough to detect the program’s impact on social support.
Leaders reported that participants experienced losses of social support during
the program (e.g., due to the death or illness of a friend). Follow-up mea-
sures would not have been able to detect if the program increased social
support because mean sub-scale scores may appear unchanged, when in
fact without the HSMS program, measures might have indicated a decrease
in social support.
Written responses for the social program component provided fur-
ther evidence that the program may have facilitated emotional support
for both race groups. More research is needed regarding racial composi-
tion of church-based support, but a previous study (Krause, 2004) found
evidence that racially mixed congregations led to more emotional support
than congregations with only one predominant race, which may be due
to mixed congregations’ awareness to include members of various race
groups. Similarly, HSMS participants may have been sensitive to creating an
inclusive culture within the groups, which led to an atmosphere conducive
to emotional social support.
African American and white participants frequently mentioned that
they enjoyed the fellowship opportunities the program provided. Both race
groups also commented that the social component of the program helped
them to accept others of a different race group, noted especially by white
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252 H. Pope et al.
participants. This finding supports that when groups that have different eth-
nic backgrounds (i.e., African Americans and whites) spend time together,
they are more likely to develop favorable attitudes toward one another and
less likely to retain stereotypical beliefs (Dovidio et al., 2003). This aspect
of the study was particularly important to participants given two key points:
(1) the HSMS program took place in a state that has historical problematic
race relation issues (Webster & Leib, 2001), and (2) participants, particularly
African American participants, are from a cohort of older adults that grew
up with stories about slavery, the Civil War, and the Reconstruction period
(Armstrong & Crowther, 2002), and were affected by the Great Migration
(1914–1950) and the Civil Rights Movement (1955–1968), which were often
times of racial division. Interestingly, only African Americans mentioned ben-
efits to their spirituality as a result of social participation, which supports
findings that spirituality is associated with a sense of connectedness to others
among African Americans, which is also associated with well-being (Maton
& Wells, 1995).
There was also indication that the religious/spiritual component pos-
itively impacted African Americans’ and whites’ spirituality, spiritual study,
and spiritual social support. Spirituality is important to older adults because
they invest in its meanings, values, and relationships that cannot be lost
due to the aging process, and because it helps older adults as they seek to
cope with anxieties associated with losses and limitations associated with
aging (Jernigan, 2001). Therefore, the religious/spiritual component of the
HSMS program may facilitate opportunities for spiritual growth and sup-
port, which can have protective benefits during difficult times (Vora & Vora,
2002).
In addition, there was evidence that the religious/spiritual compo-
nent provided common ground for both race groups, particularly among
African Americans, which led participants to gain positive perspectives about
the others of a different race group. This finding supports incorporating
religious/spiritual components and diverse racial composition of participants
into health promotion programs to improve attitudes about other race groups
found previously (Vora & Vora, 2002).
The limitations of this study include a small sample size, specifically low
power in the individual race groups, which may have limited the detection
of program impacts. Also the sample may have been vulnerable to selection
bias given that the vast majority of participants from both race groups were
involved in religious activities and/or social groups and reported feeling
close to God prior to the start of the HSMS program, which may have had
a ceiling effect and led to non-significant findings, especially for social sup-
port measures and African American participants’ DSE scores. The study
population was also overrepresented in the areas of having at least some
college education (83%) and being female (83%). Also because the pro-
gram was one year in length, there was a moderate rate of attrition (36%).
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Church-Based Health Promotion Program Impact 253
Informal reports indicated common reasons for attrition were refusal to com-
plete questionnaires, illness, loss of a spouse/relative, and being a caregiver.
Another study limitation was no comparison group was included. Therefore,
program impacts should be interpreted with caution.
Although the ROS and DSE provided some insight into the participants’
experiences, these measures were limited in that they did not seem to detect
some of the unique experiences from the HSMS program. The historical con-
text in which these measures were developed was dif ferent from the context
in which they were used. The early conceptualization of the ROS was based
on the work of Allport (1950) that grew out of an interest in understanding
the associations between religion and anti-Semitism (Hill & Pargament, 2003).
The authors’ rationalization for using the measures were not in line with
Allport’s original conceptualization of the ROS, as research using the scale
in the past half century does not support all of Allport’s conceptualizations
(Burris, 1999). In addition, the authors do not support Allport’s distinction
between extrinisic motivation, as being ‘immature, bad, or false religion’ or
intrinsic motivation as being ‘mature, good, or true religion’ (Burris, 1999).
Further, although extrinsic and intrinsic items have been found to have a
negative correlation, previous research does not support Allport’s hypothesis
that a person is purely extrinsic or intrinsic (Burris, 1999). The authors real-
ized that the measures did not fully capture the spiritual and social impacts of
the program in light of the qualitative data analysis, which revealed changes
in participants’ experiences that were not adequately reflected in the ROS
and the DSE.
Healing of the whole person requires a multidisciplinary and multicul-
tural approach that is sensitive to the individual’s history of experience and
the history of the community in which the person is formed (Koenig, 2005).
This concept can also be applied to how we define and measure complex
practices and concepts such as religiosity and spirituality. Until the terms
reflect the context of the respondents’ history of experience and history of
community, they will not be sensitive enough to capture the complexity of
each phenomenon. Moving forward, religious and spiritual measures need
to be refined to reflect greater sensitivity to cultural characteristics and issues
(Hill & Pargament, 2003).
A mixed-methods approach, using qualitative methods and quantitative
measures, is recommended when comparing religiosity and spirituality pro-
gram impacts across cultures. Unless culturally sensitive measures are devel-
oped, the consequence of interpretation of findings could be misleading and
cripple the advancement of the study of religiosity, spirituality, and health.
The ethnocentric dangers of adopting universal definitions of these terms
will limit the understanding of these phenomena with regard to individuals
and groups; the analysis and interpretation of data; and the evaluation of the
effectiveness of outcomes (Barnes & Sered, 2005).
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254 H. Pope et al.
Conclusion and Future Research
Despite the study limitations, this study demonstrated that CBHP programs
can provide older adults meaningful socialization and spiritual opportunities.
Incorporating diverse ethnic groups in a health promotion program, such as
HSMS, can lead to social bonding and improved perceptions of other race
groups, when trust and respect are emphasized. Further research is needed
to understand the impact of HSMS among populations that are (1) younger;
(2) predominately male; (3) other race groups besides African Americans
and whites; (4) from other faith traditions, provided the program is tailored
to other faith traditions; and (5) individuals who may be less integrated in
religious and non-religious group activities compared with participants in
this study.
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