Perceptions of Social and Environmental Support for Healthy Eating and Physical Activity in Rural Southern Churches
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- Kegler, M.C., Escoffery, C., Alcantara, I.C. et al. J Relig Health (2012) 51: 799. doi:10.1007/s10943-010-9394-z
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The influence of church environments on healthy eating and physical activity was explored through in-depth interviews with rural adults aged 50-70 (n = 60). Data were analyzed using a constant comparative approach, with an emphasis on noting similarities and differences between African American and predominantly white churches. Findings suggest that church-based nutrition and exercise programs were rare, and existing recreational facilities were geared toward younger members. The majority of church leaders did not talk about nutrition or physical activity, but social support from church friends for healthy eating and physical activity was fairly common. Despite barriers to establishing healthy environments in church settings, churches are rich in social support that could be tapped to promote healthy behavior.
KeywordsNutrition Diet Physical activity Rural Church
Rural residents face many challenges to a healthy lifestyle. As a result, adults living in rural areas are more likely to be obese and less likely to engage in physical activity than urban residents (Jackson et al. 2005; Patterson et al. 2004). Social factors that are more common in rural areas, including poverty and low levels of education, have been linked to obesity and poor diet quality (Darmon and Drewnowski 2008; Drewnowski and Specter 2004). Structural factors contributing to obesity in rural areas include longer distances to supermarkets with healthy foods, fewer exercise facilities, safety concerns like loose dogs and crime, declining town centers, and increased automation of the agricultural and livestock industries (Boehmer et al. 2006; Larson et al. 2009; Liese et al. 2007; National Advisory Committee on Rural Health and Human Services 2005; Sanderson et al. 2002; Sharkey and Horel 2008; Wilcox et al. 2000). Social environments can also impact obesity prevention behaviors. Rural women report seeing other people exercise in their neighborhoods less often and knowing fewer people who exercise than urban women (Sanderson et al. 2003; Wilcox et al. 2000).
Recent ecological models for active living and healthy eating have highlighted a multi-sectoral approach that targets settings such as homes, schools, worksites, and faith-based organizations as important influences on behavior (McLeroy et al. 1988; Sallis et al. 2006; Story et al. 2008). Churches are an especially promising setting for intervention in rural areas because they are one of the major social institutions; 60% of congregations in the United States are located in or near small towns (Roozen 2007). A number of traits common to churches make them logical and potentially valuable settings for behavior change interventions: physical facilities that can allow for scheduled activities or meetings; the church community that can provide social support to members; historical involvement in community outreach, including health-related activities; the role of churches as trusted institutions in communities; and a high degree of respect for church leaders within communities (Chatters 2000; Peterson et al. 2002).
Reviews of church or faith-based health promotion programs report that interventions targeting dietary and physical activity behaviors and weight loss can achieve positive effects (Campbell et al. 2007; DeHaven et al. 2004). A recent review of such interventions by Campbell et al. (2007) noted that formative research to understand the social and environmental context in which church-based health promotion would take place, including pastor support for health promotion, was a key element of successful interventions. However, only a few qualitative and formative studies of church environments have been reported in the literature, and they tend to focus exclusively on African American churches (Atkinson et al. 2009; Bopp et al. 2007; Drayton-Brooks and White 2004; Matthews et al. 2006). To our knowledge, almost no studies have examined white rural churches, despite their important role as a major social institution in rural communities.
This paper reports findings from a community-based participatory research (CBPR) project conducted by the Emory Prevention Research Center (EPRC) in collaboration with the Southwest Georgia Cancer Coalition and the EPRC's Community Advisory Board (CAB). The purpose of this qualitative study was to explore physical and social aspects of church environments and how they may affect healthy eating and physical activity in both African American and predominantly white rural churches. This study provides an opportunity to explore similarities and differences in the environments of African American and white churches. Data are from a larger study that examined how rural church, home, and work environments may influence physical activity, healthy eating, and tobacco use (Kegler et al. 2008). Identifying leverage points and barriers for health promotion in church settings, both African American and white, can be useful for the development and dissemination of church-based health promotion programs, particularly in rural areas that may not be served by a large number of institutions that include health promotion in their missions.
Study participants (n = 60) were long-term residents (≥10 years) of rural Southwest Georgia, African American or white, 50–70 years of age, and lived with at least one other person. Sixty participants were recruited using a purposive sampling approach to obtain 30 African American and 30 white participants, equally divided by gender. One respondent who reported almost never going to church was excluded from analyses reported here. Participants were recruited through a combination of personal contacts and snowball sampling, with local businesses, organizations, and neighborhoods as starting points.
Participants were recruited from two rural counties with large African American populations (≥60%) (U.S. Census Bureau 2000). Calhoun County, designated as a nonmetropolitan county with an urban population less than 2,500 on the ERS/USDA Rural Urban Continuum, had a population of 6,094 in 2000. Terrell County, with a population of 10,657 in 2000, is classified as a county in a metropolitan area of fewer than 250,000 residents. Its largest town has a population of 5,058 and is 20 miles from the regional hub in an adjacent county, giving it a rural feel despite its more urban classification. Churches in these counties are predominantly Baptist, Methodist, and African Methodist Episcopal (AME).
Data Collection Procedures
Interview questions on church environment, healthy eating, and physical activity
Question and Probes
Church activities with food
Does your church have activities with food? If yes, what kinds of activities? Probe on: between or after services, regular church dinners, other types of activities
Steps to serve healthy foods
Has your church taken steps to serve healthy foods at church activities? If yes, tell me about that. If no, how would people react if only healthy foods were available at church functions?
Messages on eating healthy and losing weight from church leaders
Does leadership from the pulpit talk about eating healthy? Does leadership from the pulpit talk about maintaining an ideal body weight or losing weight? If yes, what does s/he say? In sermons or other places? If no, why do you think that is? Same probes.
Social support from church friends for healthy eating and losing weight
Do you and your church friends ever talk about eating healthy? If yes, tell me about one of those conversations. Do you and your church friends ever talk about losing weight? If yes, tell me about one of those conversations.
Church programs for healthy eating and/or weight loss
What programs, if any, does your church have to encourage people to eat healthy or to lose weight?
Current exercise facilities
What kinds of exercise or recreation facilities, such as gymnasiums or outdoor fields, does your church have, if any? Probe on use.
Programs for physical activity
Does your church have any programs to encourage people to be physically active? If yes, what kinds of programs?
Messages on physical activity from church leaders
Does leadership from the pulpit ever talk about being physically active? If yes, what does s/he say? In sermons or other places?
Social support from church friends about exercise
Have you talked to any of your church friends about being physically active? If yes, can you tell me about one of those conversations?
Local residents were hired to recruit participants and conduct qualitative interviews in participants’ homes. Interviewers matched study respondents by gender and race. They attended a 1.5-day training in interview methods and completed several practice interviews with extensive feedback. Additionally, the research team listened to the first five interviews conducted by each interviewer, followed by every fifth interview, and provided detailed written feedback as a quality control measure throughout the data collection phase. The interviews averaged 60 min in length and were tape recorded and transcribed verbatim. The research protocol was approved by the Emory University Institutional Review Board, and all participants provided written informed consent. Participants received a $20 gift card for their participation.
The data analysis strategy was based on the constant comparative approach as described originally by Glaser (1965) and more recently, by Boeije (2002). We used qualitative analysis software QSR-N6 for data storage, retrieval, and analysis (Richards 2002). After reviewing the first several interview transcripts, a comparative approach was used to identify content categories that captured each major topic covered in the interviews, but also allowed for other categories to emerge from the data. After coding several transcripts as a full research team to develop the coding structure and to develop a common understanding of the codes, two coders independently coded each transcript and resolved discrepancies in coding through consensus. Boeije (2002) describes this open coding process as the first step in the constant comparative approach, which focuses on summarizing each interview (comparing text within an interview) and developing a provisional codebook or code tree.
The second analysis step began by generating N6 reports that contained all text associated with particular codes or combinations of codes. This facilitated axial coding and the comparison of interviews within the same group; in our study, these were race and gender-defined groups (Boeije 2002). We identified themes by using matrices organized by gender and race (Miles and Huberman 1994; Patton 2002). For example, one of the matrices for the “reasons pastors do not discuss healthy eating” listed all responses related to content of these conversations by race and gender, with cells displaying cases in which that response was given. These matrices allowed us to list the full range of responses and to identify major themes. Matrices were also used to complete the third step of the comparative process by comparing across race/gender matrices to look for possible patterns by race or gender. The trustworthiness of our findings is enhanced by the availability of an audit trail based on the data matrices. The full range of responses, as well as themes, is reported in the results section, with each theme indicating that multiple participants (≥ 5) discussed it.
Description of Study Participants
Description of study participants
Total2N = 57 N (%)1
African American N = 30 N (%)
White N = 27 N (%)
At least once a week
A few times a month or year
Gender, n (%)
Average age, in years
Education, n (%)
Less than HS
HS graduate or higher
Household Income, n (%)
$25,000 or less
$25,001 or more
Marital Status, n (%)
Married/living with someone
Findings on Healthy Eating
Church Activities with Food
The majority of respondents said their churches had NOT taken any steps to serve healthy foods. When asked to elaborate, participants described that people generally want to eat what they have always eaten at church events. Other comments were that people do not think healthy foods are very good, that people do not want less salt, and that people desire greasy and/or fried food.
“Yes. On the fifth Sundays we have worship services at 8:00 and right after that we have breakfast. And I mean, those guys throw down like grits, sausages, eggs, two kinds of sausage, the patties, and the links.” (African American Male)
Taking concrete steps to serve healthy foods appeared more common in churches attended by African American participants, with African American women offering the largest number of specific actions. Typical steps were serving more fresh vegetables, serving more baked foods, and cutting back on fried foods. Cutting down on salt, sweets, and use of fat back were also mentioned.
“It would be, they’d be shocked. They’d be shocked—tradition. A tradition little kind of the thing that’s inbred, or to change the menu is sort of like defying one of the commandments, I believe, because it’s just the way it’s done.” (African American Male)
“Well mostly everybody that you know, bring the vegetables, it don’t be so much grease and stuff in the food and stuff like that. And the meat, they bake a ham, you know. […] And fried chicken, it don’t be so greasy and stuff like that.” (African American Female)
Messages on Eating Healthy and Losing Weight from Church Leaders
A smaller group of participants, generally African American, reported their church leaders had discussed healthy eating or weight. Significant themes were pastors giving advice about how to eat healthy (e.g., drink plenty of water, eat vegetables, and cut down on fried foods and salt), sharing of the pastor’s own eating habits and efforts to lose weight, and the value of exercising to lose weight. General advice to eat healthy and lose or maintain weight, the importance of weight control to manage health conditions, and biblical references to the body–spirit connection and gluttony as a sin were also mentioned.
Not the Business of the Church: ‘‘Well I guess probably because he’s just not focused on individuals as far as that is, focused more on saving souls.’’ (White Male)
Offensive to Overweight Members: ‘‘Well we are all imperfect and again I think that would be perceived as being a put down, I don’t, I just don’t think it would be well received. You know you go to church to get away from the world not to have your feelings hurt, and I think a lot of people would be, they would have that reaction.’’ (White Female)
Pastor’s Weight a Factor: “…Because the preacher’s chunky. An overweight preacher is not going to get up to talk about eating healthy food.” (White Male)
Appropriateness of Church Leaders Talking about Healthy Eating and/or Weight Loss
Among those who thought it was not appropriate for leadership from the pulpit to talk about healthy eating, major themes included it not being the church’s job and that it might offend people.
One-on-One Only: “I guess under certain circumstances it would be, but I’m not sure from the pulpit, I think that’s something that if they’re maybe addressed individually.” (White Male)
Biblical References: “Because we teach, we teach that a person’s body is God’s temple. And we teach them that God’s spirit does not dwell in a dirty place. So if we are healthy and have a lot of food out of our body that hurts us, certainly they’ll be something for the spirit to dwell in that much longer. […]” (African American Male)
Social Support from Church Friends for Healthy Eating or Losing Weight
Healthy Food Choices: “…Well when we are talking about food, a lot of times we talk about you know, what you need to eat and what you don’t need to eat, and if you have less fried food you have, the better it is…and stop drinking so many sodas and drink more water and juice. You know, it’s just conversation.” (African American Female)
Desire to Lose Weight: “Well me and one lady have a bet…that before July we supposed to be done lost 10 lb…so we have a bet so I’m trying hard to beat her, and I have lost an inch because I have taken up some of my clothes, so I’m hoping to win that bet.” (African American Female)
Eating for Health Reasons: “Oh yeah. I’m friends with lots of people that go to that church. Yeah, it’s [eating healthy] pretty generally a topic of discussion. A lot of them are older, you know, 65 plus, and so diet, health is a major concern for them.” (White Male)
Encouragement: “And I had another one [friend], the one that invited me, she made a comment saying that her daughter at night made those sugar cookies…On, you know, a napkin and it just entices her to eat that. And so I said, oh, no it doesn’t. I said just because she cooking them and they smell good and she brings them and offered them to you, I said, you are the one that chooses to eat it. I said, so you know, so, if you need to let your exercising program work, and your diet work, just stick with it.” (African American Female)
Discuss Exercising: “We just talk a good show about it. We cut up about how thin we used to be and how we aren’t. How thin we’re not now. Just things like that. Just mostly in jest. A lot of the girls now are going to Curves and stuff like that.” (White Female)
Church Programs for Healthy Eating and/or Weight Loss
The vast majority of participants reported no nutrition or weight loss programs at their church. Although no salient themes emerged, they highlighted various reasons for a lack of such programs at their churches, including small church size, discontinued programs, and programs getting planned but never implemented. Among the churches with programs, exercise and weight-loss programs were the most common.
Findings on Physical Activity
Current Exercise Facilities
“Ok we have a playground area for the kids, you know, where they play volleyball and shoot basketball and stuff like that, but that’s just sometimes. And we don’t have a gym.” (African American Female)
Messages on Physical Activity from Church Leaders
Those who reported that their pastor does not normally or ever talk about being physically active gave possible reasons. Themes were similar to those given to explain why church leaders do not talk about healthy eating: it is not a priority issue or concern for the pastor and the pastor does not think it is part of his/her job. Other reasons were that the pastor does not want to make people uncomfortable; there are too many other problems to worry about at the church, and that s/he had simply never thought of discussing physical activity with the congregation.
“Well he talks about, he and his wife they do exercises, they do walking and he tells you about it, it makes you feel better, you know that you need to do your exercise every day, but he’s a kind of older guy but he says he does his exercises.” (African American Female)
Appropriateness of Church Leaders Talking about Physical Activity
The majority of respondents reported that they thought it would be appropriate for church leaders to discuss physical activity with their congregation. Among those who thought it was not appropriate, reasons ranged from it not being the purpose of the church to possibly offending church members. Some thought it would be appropriate one-on-one, but not from the pulpit.
Social Support from Church Friends for Physical Activity
Exercising to Lose Weight: “Yeah I got one lady in particular we always talk about our exercising or whatever.” (African American Female)
Walking in General: “Um, we do talk about walking. I think that’s more of the things than anything. And this Curves thing that they’re going to… just the eating correctly and the weight loss.” (White Female)
Exercise with Friends from Church: “Oh, you just talk about different, different members playing tennis together at the country club or going camping together or just swimming together or walking together or cleaning up the church yard.” (White Male)
Programs for Physical Activity
The vast majority of respondents reported that there were no programs at their church to help adults to be more physically active. The few respondents who did report programs at their churches most often described sports such as basketball for youth. Dance groups, women’s exercise classes, and organized sports such as softball and basketball were mentioned by one or two respondents. A couple of respondents suggested that such programs are not feasible given the small size of the church.
These findings help to portray the environment in rural Southern churches related to the promotion of healthy eating, physical activity, and weight loss. The interviews revealed that certain church activities – especially events with food – are considered traditional and tend toward offering less healthy choices. The offering of more healthful foods at church meals and celebrations appears to be slowly gaining acceptance, at least in African American churches in this study. Although not mentioned by our participants, the limited availability of healthier foods in rural neighborhood environments may also play a role in shaping what is offered at church events. Studies have shown that rural residents have greater access to convenience stores than to supermarkets with lower prices and a greater selection of healthy foods (Hermstad 2007; Sharkey and Horel 2008).
Research consistently shows that rural communities have relatively few recreational facilities (Boehmer et al. 2006; Sanderson et al. 2002). Since churches are a prominent community institution in rural communities, they have the potential to double as recreational facilities. According to our participants, church-based recreational facilities were rare in African American churches, and where they did exist, they were typically the province of children’s playgrounds or sports teams. Given that rural churches are likely to have access to wide-open spaces and/or rural roads for walking, one approach for even very resource-poor churches would be to map local walking routes or build walking trails on church grounds.
Most participants said that their church leaders did not talk about healthy eating, losing weight, or being physically active in their sermons and messages, particularly in white churches. Some thought that this might reflect the pastors’ own situations (e.g., being overweight) and habits (e.g., being inactive). A less-often discussed obstacle might be the limited knowledge of church leaders on these topics. There were mixed reports on the appropriateness of church leaders speaking about these topics from the pulpit: on the one hand, the Bible refers to the body as God’s temple, but on the other hand, public discussion of personal issues might be offensive and better relegated to one-on-one conversations. Generally speaking, however, participants felt that it would be appropriate for pastors to discuss healthy eating and physical activity at church. Indeed, church-based health promotion programs in African American churches often include health messages from church leaders as a key component (Campbell et al. 1999; Resnicow et al. 2005).
A final issue that emerged consistently across healthy eating, weight loss, and physical activity was that churches are a good venue for social support around positive health habits. Although more participants reported conversations about healthy eating and weight than about physical activity with their friends from church, both topics had been discussed by at least half of the participants. This returns to the issue of churches being an important part of people’s lives in their communities, and a gathering place for friends and neighbors (Campbell et al. 2007; Pew Forum on Religion and Public Life 2008). Prior qualitative and intervention research has highlighted the importance of church-based social support for African Americans; our study suggests similar support for white church goers in rural communities (Atkinson et al. 2009; Bopp et al. 2007).
We examined themes by race and gender. As already noted, predominantly white churches were less likely to have taken concrete steps to serve healthier food. Similarly, although atypical in both African American and white churches, our findings suggest white church leaders may be less likely to discuss healthy lifestyles than African American church leaders. One of the more striking differences by race is that white participants described recreational facilities at their churches while African Americans did not. Interestingly, there were surprisingly few gender differences. African American women were most likely to describe specific actions to promote healthy foods, and women, unlike men, shared recipes and discussed cooking techniques. Both men and women reported conversations about wanting to lose weight, diet related to managing health conditions, and exercising to lose weight. Both also mentioned exercising and/or walking with friends from church.
This study has several limitations. Participants were older African American and white adults from rural, low income counties in Georgia, with lower levels of education and income than many communities in the United States. Because of the Southern region and older age, and the low socioeconomic status of most of our participants, our findings may not be transferrable to other types of rural communities. In addition, our CAB suggested that the nutrition and physical activity environments of churches in our study communities may be largely influenced by the size and budget of the church, the location of the church (small town versus countryside), and the frequency of church services. Our study did not collect background information on the churches themselves, so we were not able to examine patterns by church type, beyond race of the members. A related limitation is that we cannot specify which of our findings apply to only rural churches and which may apply to churches in general. Last, the possibility of socially desirable responses exists, with participants potentially overstating the healthy aspects of their church environments.
The findings from our study provide a strong foundation for developing church-based health promotion programs in rural communities, including assets that can be leveraged (e.g., social support) and possible barriers (e.g., tradition, few existing programs) to implementation. Future research could supplement our findings with direct input from church leaders for another perspective on how church environments support or hinder healthy behaviors (Williams et al. 2009). According to our findings, many church leaders were not actively engaged in promoting healthier eating or increased physical activity, either through health messages from the pulpit or through programmatic or environmental support. Barriers identified in our study should be confirmed with church leaders, followed by development of strategies to overcome these barriers. Partners interested in collaborating with churches might consider: giving pastors tips for how to integrate health messages into sermons in a way that does not offend obese members, active engagement of pastors in church-based programs, consistently locating program activities, such as walking clubs or weight loss groups at church sites, offering small grants to churches to build/enhance on-site physical activity resources, and providing sample policies for a healthy church food environment. From a social ecologic perspective, greater alignment of health messages, social milieus, and built environments to support healthy behaviors in churches and other settings in which people live, work, and play would greatly impact the health of community residents. Practitioners in rural communities can draw on our results to identify possible leverage points and obstacles to marshaling churches to participate in health promotion efforts.
The authors wish to thank members of the EPRC's Community Advisory Board for their guidance in the design and implementation of this research and the Southwest Georgia Cancer Coalition for coordinating data collection. We also wish to thank our interviewers and study participants for their valuable contributions to this research.
This publication was supported by Cooperative Agreement Number U48 DP 000043 from the Centers for Disease Control and Prevention. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the Centers for Disease Control and Prevention.