Latino Church Leaders' Perspectives on Childhood Obesity Prevention

Latino Church Leaders’ Perspectives on Childhood Obesity Prevention Meizi He, PhD, Summer Wilmoth, MS, David Bustos, MS, Timothy Jones, BS, Jessica Leeds, MA, Zenong Yin, PhD Background: The prevalence of obesity among Latino children is an increasing concern. Churches are settings that a majority of Latino families frequent on a regular basis. In addition to religious worship, churches supply social, emotional, and material support. Therefore, churches may be promising venues for obesity-prevention interventions engaging families and communities.

Purpose: To qualitatively examine Latino church leaders’ perspectives on childhood obesity and insights on obesity-prevention programming in faith-based community settings in South Texas. Methods: In-depth interviews were conducted between 2009 and 2011 with a purposive sample of 35 Latino church leaders from 18 churches in San Antonio, Texas. Interviews were audiotaped and transcribed verbatim. Inductive analysis was performed to identify themes.

Results: The results revealed that participants were knowledgeable about the severity and health consequences of childhood obesity, and the extent to which it was affecting members of their congregations. Participants discussed the interconnection between one’s faith and health (i.e., one’s body as “God’s Temple”). They suggested that churches could serve as a conduit for obesityprevention programs that offer faith-oriented health education, cooking classes, and fun physical activity opportunities for both parents and children. Conclusions: This study reveals the strong potential of faith-based communities to serve as an intervention setting with the needed infrastructure for implementing effective obesity-prevention strategies. (Am J Prev Med 2013;44(3S3):S232–S239) © 2013 Published by Elsevier Inc. on behalf of American Journal of Preventive Medicine

Introduction

I

n the U.S., the prevalence of childhood obesity has dramatically increased over the last 3 decades.1 Recent statistics show that 38% of Mexican-American children are overweight or obese.2 The high prevalence and heavy healthcare burden of childhood obesity highlight the urgent need for effective intervention strategies to reverse this trend among Latino children. Research has shown that Latinos are more likely to live in disadvantaged neighborhoods with limited access to healthy foods and physical activity opportunities, as well as have lower incomes than Caucasians.3,4 These social constraints and economic vulnerabilities are major obstacles to living a

From the Department of Health and Kinesiology (He, Wilmoth, Bustos, Jones, Yin) and Student Health Services (Leeds), University of Texas at San Antonio, San Antonio, Texas Address correspondence to: Meizi He, PhD, Department of Health & Kinesiology, University of Texas at San Antonio, One UTSA Circle, San Antonio TX 78249. E-mail: meizi.he@utsa.edu. 0749-3797/$36.00 http://dx.doi.org/10.1016/j.amepre.2012.11.014

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healthy lifestyle.5,6 Prevention programs for vulnerable populations need to go beyond promotion of healthy lifestyles and address the complex socioeconomic and cultural factors contributing to the childhood obesity problem.7,8 Faith-based communities could be valuable settings for childhood obesity prevention among Latinos. Gittelsohn and Kumar9 suggested that communities, instead of schools, should be the future focus for preventing childhood obesity. Faith-based communities have emerged as important settings for promoting healthy lifestyles.10 Health is viewed as a dynamic process between faith and behavior, with engaging in health behaviors seen as an opportunity to honor God.11 A majority of Latinos are Catholic or Protestant and are associated with faith-based communities.12 Churches, which provide social, emotional, and material support in addition to religious worship, serve as focal points for social networking.13 Studies12,14 –20 have highlighted several faith-based programs that promoted healthy lifestyles and helped prevent obesity and diabetes in high-risk adult populations; most of

© 2013 Published by Elsevier Inc. on behalf of American Journal of Preventive Medicine

He et al / Am J Prev Med 2013;44(3S3):S232–S239

these were conducted with African Americans but a few involved Latinos. Recently, the Faith-Based Coalitions to Combat Childhood Obesity launched by the Robert Wood Johnson Foundation was one of the faith-based childhood obesity-prevention efforts with a focus on community advocacy to increase access to healthy foods and opportunities for physical activity.21 Currently, the willingness of Latino faith communities to address childhood obesity remains unknown. Formative research is crucial to developing effective health promotion programs toward a healthier lifestyle in church settings.22 A qualitative research approach is an effective means to understand a community’s perspectives and perceived needs. To this end, formative research was conducted to explore the willingness of faith-based community leaders to partner with and support intervention initiatives that address ethnic and social economic disparities in childhood obesity among Latino families. The current article reported Latino church leaders’ perspectives on childhood obesity and insights on obesity-prevention programming in faithbased community settings.

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Table 1. Interview guide 1. In your opinion, what is (are) the important health issue(s) currently facing your congregation? 2. How much do you worry about children in your congregation being overweight or obese? What are your concerns? What do you think causes the problem? 3. In your opinion, what role faith (or spirituality) may play in preventing or dealing with illness (e.g., obesity and type 2 diabetes)? 4. How can churches help in preventing obesity in children and youth? 5. What comes to mind if you envision an obesity-prevention program to be implemented in your church? What concerns do you have about your church participating in an obesity-prevention program? What may be some challenges? Who should come to the table for planning and implementing such a program? In what ways would your congregation benefit from such a program?

Methods This qualitative study was conducted between 2009 and 2011. The study was approved by the IRB at the University of Texas at San Antonio. It involved in-depth interviews with Latino church leaders in the Westside of San Antonio, Texas. The target areas were primarily low-income and educationally disadvantaged Latino neighborhoods with a high prevalence of obesity and diabetes.23 A purposive sampling strategy24 was used to recruit a heterogeneous sample of churches based on denomination and congregation size from a list of 138 churches in the targeted area. Invitations were mailed to all congregation leaders requesting participation. Follow-up calls were made by staff to assess church eligibility (i.e., more than two thirds of the congregants were Latinos). Throughout the recruitment process, a total of 32 churches from the list were contacted; 30 were eligible for the study. Among these, 18 (60%) agreed to participate in the study. The offıcial leader of each congregation was fırst interviewed and each leader then recommended one to two individuals in his/her congregation (e.g., youth minister and lay leaders) for subsequent interviews. After giving informed consent, participants completed a brief demographic questionnaire obtaining information on gender, age, and position/ role at church. In-depth face-to-face interviews were conducted by an experienced researcher in either English or Spanish using a semi-structured interview guide. These interviews took place at church and lasted for approximately 30 – 40 minutes. The interview guide was initially developed by the research team and was pilot-tested with two church leaders. Following the pilot interviews, revisions were made to improve clarity and logical sequence of interview questions. The revised interview guide is presented in Table 1. An assistant interviewer was present taking notes throughout and summarizing key ideas at the end of each interview to ensure authenticity of participants’ viewpoints. The team debriefed at the end of each interview to identify emerging themes. Theme saturation occurred after March 2013

completion of the 35th interview. All interviews were audiorecorded and transcribed verbatim by a bilingual professional transcriber, and Spanish transcripts were translated into English. All translated transcripts were edited and proofread by bilingual research assistants based on the audiotapes.

Data Analysis Data collection and analysis took place simultaneously using a combination of the editing and template organizing styles outlined by Miller.25 Two researchers read all interview transcripts to identify key themes and develop a coding template. NVivo 9 software was used to code and categorize themes. The analyses were compared for similarities and differences, and consensus was reached between the two coders, with refınement through multiple iterations. Once coding consistency had been established, the two coders independently continued a more in-depth analysis on each transcript. A summary of the in-depth analysis was prepared and discussed by the research team for interpretation.

Results Thirty-fıve participants from a total of 18 churches took part in the study. The denomination of the participating churches included eight Catholic, two Pentecostal, three Baptist, one Methodist, one Presbyterian, one Seventh Day Adventist, and two nondenominational. Participants’ gender was evenly distributed, and most were aged 30 to ⬎60 years (Table 2). Six main themes pertaining to childhood obesity emerged from the in-depth interviews: (1) perceived health issues facing Latino congregants; (2) perceived causes of overweight and obesity among children;

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Table 2. Participants’ demographic profile n (%) Position/role Priest/pastor/reverend or other official church leader

18 (51)

Youth minister/director

3 (9)

Volunteer leader

2 (6)

Other

12 (34)

Gender Male

17 (49)

Female

18 (51)

Age (years) 19–24

2 (6)

25–29

1 (3)

30–39

7 (20)

40–49

7 (20)

50–59

6 (17)

ⱖ60

12 (34)

Denomination Catholic

19 (54)

Pentecostal

3 (9)

Baptist

9 (26)

Presbyterian

1 (3)

Seventh-Day Adventist

1 (3)

Other

2 (6)

Church size, # of members Small (⬍100) Medium (100–399) Large (⬎400)

13 (37) 9 (26) 13 (37)

(3) beliefs in the interconnection between faith and health; (4) perceived needs for obesity-prevention programs/services; (5) suggested obesity-prevention activities; and (6) suggested practical methods for program implementation. These main themes, along with subthemes and selected quotes, are presented in Table 3.

Theme 1: Perceived Health Issues Facing Latino Congregants Participants indicated that diabetes and hypertension were the common health issues among adult congregants, whereas obesity was common among children. Participants observed that children had started to show signs of chronic illness (e.g., diabetes, heart disease, and hypertension). Additionally, poor academic performance

and low self-esteem were identifıed as consequences of childhood obesity.

Theme 2: Perceived Causes of Overweight and Obesity Among Children Church leaders identifıed lifestyle, culture, society, and the environment as risk factors responsible for childhood obesity in the Latino community. Unhealthy lifestyle. Unhealthy lifestyle, including physical inactivity and poor eating behaviors, were perceived as the major causes of childhood obesity. Participants noted that children were less active than the previous generations and spent a great deal of their time playing video games. They also noted that children consumed sugary beverages and fast foods. Although several participants observed that obesity appears to affect several generations, they believed that genetics did not solely determine a person’s fate, and lifestyle plays a substantial role. The Latino culture. The Latino culture, including its cuisine and emphasis on social gatherings, was blamed for the problem of obesity. Specifıc components associated with the Mexican-American diet (e.g., beans, tortillas, barbacoa, and soda) were identifıed as causing excessive calorie intake. Unhealthy food options were featured at gatherings with family, friends, and other church members. Church leaders identifıed these patterns as part of the social norm in the Latino culture. Low socioeconomic status. Low SES was a perceived barrier to healthy meal access and insurance coverage. This was particularly relevant to undocumented immigrants working low-end jobs to meet their basic needs. A lack of health knowledge and poor parental role models. A lack of health knowledge among congregants and poor parental role models were also perceived as contributing factors to childhood obesity. The built environment. Limited access to healthy food options, parks, playgrounds, and gymnasiums in the surrounding neighborhoods were identifıed as risk factors for obesity.

Theme 3: Beliefs in the Interconnection Between Faith and Health Church leaders perceived the relationship between faith and health as important and benefıcial. Table 3 provides clarifying comments given by interviewees. God’s temple. Church leaders stated that Bible scripture depicts each person’s body as God’s holy temple that must be kept healthy to better serve God. Spirituality was also perceived as being important in strengthening all aspects of life, including health. www.ajpmonline.org


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Table 3. Main themes, subthemes, and selected quotes Theme 1: Perceived health issues facing the congregation Morbidity prevalence in the Latino congregations

Number one is definitely diabetes. Secondly, I think it’s obesity.

Concerns with obesity in children

We have a lot overweight children, and that’s just from a firsthand perception.

Theme 2: Perceived causes of overweight and obesity among children Unhealthy lifestyle

I believe it (what causes obesity) is eating the things that are not appropriate for them. Eating a lot of junk food, eating a lot of chips, a lot of pizza, a lot of sodas.

Latino culture and cuisine

Of course, the Hispanic Mexican Latino diet is very heavy on fats and carbohydrates. I mean tortillas and refried beans are very popular for breakfast, for lunch, for dinner, and those things, you know, are very high in calories.

Low SES

I think one of the things that affect our families, because our families are poor. So poverty also has a lot to do with it (obesity).

Lack of health knowledge and misinformation

Obesity is caused by ignorance. Lack of knowledge, lack of information.

Poor role models

It’s like I said, unfortunately our children are sometimes a reflection of us as adults. They’re sort of a reflection of their mom and dad’s probably eating habits or being overweight.

Built environment

They (children) like to climb, to get out, get the crossbars, run around, but when you have a small area, you go to the Courts right now, there is nothing there. And whoever was the designer, must have his head examined, because when you put family in a court like that, you have to give them a place where they can exercise, move around, and they don’t.

Theme 3: Beliefs in the interconnection between faith and health God’s temple

I mean, it’s not only the spirit and the soul, but the bodies, the temple, the Holy Spirit.

Church’s roles for helping people during illness

I mean, that’s a remedy, you know. People get ill, and then they say, “Please come and pray for us, please pray for me, pray for my family, pray for my son, pray for my daughter.” But there was no prevention done before; there was no prevention.

Church’s roles in keeping people healthy

I truly believe that the church is very, very key—very key in helping families to change their lives.

Theme 4: Perceived needs for obesity-prevention programs/services Obesity-prevention programs

People, they love their children, and they would love to know, what could prevent them from having some kind of disease, it will change their lives. So I think that . . . I would think that it would help a lot in this community because mainly the lack of information.

Faith-oriented programs

I think what would encourage them is just talk about new life and being vital and being healthy and working in the kingdom.

Church as an conduit for obesityprevention programs

If some people come in who have expertise, then . . . the church could be used as a conduit for getting these resources out to the people.

Benefits of obesity-prevention programs/ services

We would be a healthier congregation and I think when we’re healthy we’re more faith filled and just because you become more in tune with each other and as you gather together you start to know each other so bonding takes place.

Theme 5: Suggested obesity-prevention activities Health information and education for parents and children

The only way to prevent it is educating, educating, educating the public, the congregation.

Integration of spiritual and health education

Exercise, food, self-esteem, and a connection to the spiritual.

Hands-on activities and cooking demonstrations

If we are going to teach them how to eat healthy, we need to prepare and give them the meals. (continued on next page)

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Table 3. Main themes, subthemes, and selected quotes (continued) Physical activities

Walking . . . that’s simple and does not take much.

Free health screening

I think that maybe testing diabetes, cholesterol, all those tests, people cannot afford to do those, so those can be provided for families.

Theme 6: Suggested practical methods of program implementation Leadership and engagement

We (leaders) have to be a part of it, and I commend this congregation, both leadership and families that when the staff puts a program together, the staff implements it through the leadership.

Partnership and funding

The congregation would probably be more accepting of more congregation’s members that have been trained by professionals.

Role-modeling

I think it’s gonna start at the top and its gonna start with us (leaders) and when the members see that we’re doing it, that we’re participating, that we’re concerned not only for our health but for their health, that we’re concerned for their kids as well as our kids, guess what, I think that this is going to make an impression in people.

Incentives

You gotta give them a reason for going in in the first place, besides me encouraging them.

Language-sensitive information

I think that information is critical in English and Spanish. English and Spanish is very key for our community.

Family-oriented fun activities

(It will) have a better turnout with the whole family getting educated, maybe changing their habits and their ways.

Time

“The best day I would see that the kids like to hang out is Sunday after mass because they are here already.”

Avoiding stigmatizing obese people

Inviting someone without making them feel like being singled out (like), “Oh he thinks I’m fat. . . .” Trying to make it where we’re like you know, there’s a program that we’re trying to establish that may benefit you and your family.

Church roles for helping people during illness. Many people turn to the church to pray for recovery when they encounter illness. Participants stated that illness would not be cured via miracles, and stressed the importance of prevention efforts in dealing with illness. Church roles for keeping people healthy. Participants suggested that it is benefıcial for the church to engage in efforts to help members stay healthy. Some stated that their churches had engaged in healthy efforts in the past that were not necessarily viewed as “obesity prevention.” Twelve of 18 churches offered activities and programs such as organized sports, exercise classes, nutrition education, peer counseling, and weight-loss competitions. Several parishes had made healthy food substitutions at church events.

Theme 4: Perceived Needs for ObesityPrevention Programs/Services Participants stressed the need for obesity-prevention programs and services. They expressed willingness to engage in the efforts and offered many ideas on what they would like to do in terms of obesity prevention for congregants. Participants articulated that the churches could serve as a conduit for faith-originated obesity programs and services, provided that external expertise and

resources were available. A few voiced concerns that such programs might not be on the priority list for parents juggling multiple jobs.

Theme 5: Suggested Obesity-Prevention Activities Participants suggested a variety of practical obesityprevention activities in faith-based settings. Faith-oriented health education for both parents and children was identifıed as a top priority. Physical activities and hands-on activities, including cooking demonstrations, were perceived as a helpful means to facilitate lifestyle changes. A few participants suggested free health screenings for all congregants.

Theme 6: Suggested Practical Methods of Program Implementation Participants emphasized the importance of leadership and the involvement of volunteers when developing faith-based obesity-prevention programs. Fully engaging congregants was perceived as a prerequisite for program success. Participants also stressed the importance of partnership and collaboration with health professionals. External funding was needed, particularly for churches with limited resources. Positive pastoral and parental role modeling is crucial to promote healthy lifestyle changes www.ajpmonline.org


for children and their families. Participants articulated that program materials should be available in both English and Spanish. Program activities should be fun and implemented at church before or after worship services. Program implementers should be mindful of and avoid embarrassing obese people. For this reason, a few church leaders suggested that such a program not be labeled as “obesity prevention” but rather as a “health program.”

Discussion This study qualitatively explored and documented Latino faith-based community leaders’ perspectives on childhood obesity. Findings from the present study showed that Latino church leaders were aware of the severity and consequences of childhood obesity, as well as of contributing factors in the Latino community. This sample of faith-based community leaders revealed fırm beliefs about the interconnection of spiritual and physical wellbeing. Participants expressed willingness to address the obesity problem and indicated that church could serve as a conduit for such programs and services to be implemented in their congregations. It is encouraging that this sample of faith-based community leaders was aware of and concerned about the severity, consequences, and contributing factors of childhood obesity in the Latino community. In a recent qualitative study26 in Texas, investigators reported that community health workers also recognized obesity as a problem and identifıed healthy eating and physical activity as requisites for controlling the problem in predominantly Latino low-income neighborhoods. Faith-based community leaders’ high awareness level of the childhood obesity problem presents opportunities for health professional to design and implement obesity intervention programs in faith community settings. Church leaders’ perspective about the interconnection between spiritual and physical health is a unique and important revelation that should be taken into account while planning faith-based obesity-prevention programs and services. The dominant theme centered on the scriptural idea that one’s body is God’s temple and on the importance of being a good steward for the temple by living a healthy lifestyle. Such a “religion– health connection” was also expressed by African-American church members.27 On the other hand, research suggested that spiritual ideas about fate and faith may influence people’s perceptions about the causes and treatment of poor health and illness.28 Chong observed that some Latinos may perceive that God determines one’s fate including illness and that nothing can be done to avoid it. Thus, prevention and treatment efforts may not be perceived as relevant to a March 2013

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community holding such a belief. Church leaders in the current study did not hold such views and were able to identify a long list of causes and risk factors for obesity and other chronic diseases. They also stressed the importance of preventive measures, rather than dealing with illnesses in late stages. These church leaders viewed church as a place to care for people during illness through prayers and support, and as a place to offer preventive activities to keep people healthy. Church leaders in the present study were willing to address the obesity problem and said they foresaw many benefıts from future potential obesity-prevention programs/services. They were enthusiastic about the idea of championing and providing leadership for planning and implementing obesity-prevention efforts among their congregations. Their attitudes and inclinations were comparable to those of a national sample of black church leaders who were providing congregational leadership not only for spiritual matters but also for social action and community well-being.29 Given the existing infrastructure (e.g., buildings, kitchens, meeting rooms, and playgrounds), along with a supportive social network and volunteers within a congregation, participants in the current study viewed church as a good conduit for health promotion programs and services. In addition, these leaders indicated it is practical to offer obesity-prevention activities to congregants who are already convening regularly for weekly services and ongoing activities such as Sunday school, Bible study, and family retreat. A recent qualitative study30 with Latino women also showed that church was perceived as a powerful resource to influence Latinas to improve their health, exercise, and nutrition practices. Partnership and collaboration with healthcare professionals and access to external funding were viewed as vital for obesity-prevention programs and services to be implemented in faith-based communities. Church leaders recognized the numerous challenges and social constraints that their congregants were facing, including low SES, high numbers of undocumented and uninsured, and a lack of health knowledge. These leaders identifıed the needs for and expressed their willingness to work with health professionals to facilitate the planning and implementation of obesity-prevention programs to improve the well-being of their congregants. Participants also stressed the need for engaging and involving all congregants in planning and implementing obesity-prevention programs. To this end, the communitybased participatory research (CBPR) approach should be considered to ensure program success.31 CBPR is defıned as a collaborative approach to research that equitably involves all partners in the research process and recognizes the unique strengths that each brings.31 The

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program planning process should involve church leaders and members from the outset to identify the types of program activities and level of church involvement that would be most appropriate. Convening a community advisory committee consisting of church leaders, members, community agency representatives, and other key participants such as local health professionals should be the fırst step for planning obesity-prevention programs in faith-based community settings. This process will also allow customization of intervention strategies to suit the faith-based settings with different congregation denominations, sizes, and available spaces and resources. Research has suggested that using CBPR may increase empowerment and community ownership of the health program and thus lead to greater participation and long-term sustainability.32 Indeed, Reifsnider et al.33 recently used a CBPR approach with faith-based organizations in Texas to develop the “Shaking & Rattling Child Obesity-Prevention Program” for vulnerable Latino families. Such a CBPR approach increased Latino families’ trust and participation in implementing obesity-prevention efforts in their communities.33 Faith-based health education sessions and languageappropriate health information, coupled with hands-on cooking lessons and fun physical activities for both children and families, were preferred obesity program components for these Latino congregation leaders. Adult obesityprevention programs in black churches also have used similar approaches in a number of recent feasibility studies with promising results.15,19,34 –36 For instance, Yeary et al.34 reported that participants enjoyed the spiritual and group-based aspects of a weight-loss program.

Strengths and Limitations The strength of the present study is centered in the qualitative nature of its data collection approach, which acquired rich and in-depth information about faith community insiders’ viewpoints with respect to obesityprevention strategies. Nevertheless, several limitations were introduced. A purposive sampling strategy was used; thus, participants who self-selected to participate in a study may have a keen interest and substantial knowledge in this subject matter. As a result, their opinions may not reflect the general faith-based community leaders’ opinions. Although the current study made every effort to minimize bias by avoiding leading questions, social desirability still may have influenced participant responses. The study was also limited in geographic scope (i.e., research fındings may not be generalized beyond South Texas). Additionally, although transcripts were checked for consistency between raters coders to theme

development, no formal inter-rater reliability score was calculated.

Conclusion and Implications This study reveals the strong potential of a faith-based community as an intervention setting and one that has the needed infrastructure for implementing effective obesity-prevention strategies. Findings from the current study are important for informing public health policy, public funding allocations, and programming/service delivery. Public health and nonprofıt organizations should consider supporting and sustaining obesity-prevention strategies specifıcally for Latinos using existing faithbased community infrastructure and supportive social networks. Further CBPR research is needed on the development of culturally sensitive obesity-prevention programs in faith-based communities and the potential to sustain such efforts. Publication of this article was supported by the Robert Wood Johnson Foundation. This study was funded by the Robert Wood Johnson Foundation through its national program, Salud America! The RWJF Research Network to Prevent Obesity Among Latino Children (www.salud-america.org). Salud America!, led by the Institute for Health Promotion Research at The University of Texas Health Science Center at San Antonio, Texas, unites Latino researchers and advocates seeking environmental and policy solutions to the epidemic. The research team is grateful to Dr. Amelie G. Ramirez, Salud America! Director, and members of the Salud America! National Advisory Committee for their guidance and support throughout the research process. The authors are appreciative of Ms. Arely Perez, Mr. Roger Figueroa, Ms. Lalaine Estella Ricardo, and Ms. Victoria Thompson for their assistance in data collection and verifıcation. Special thanks are extended to participating faith-based community leaders. No fınancial disclosures were reported by the authors of this paper.

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