Abstract
Purpose
The purpose of the study was to explore Hispanic adults’ experiences participating in the Building a Healthy Temple diabetes self-management education and support (DSMES) cluster randomized trial and collect their insights on intervention approach, delivery, content, impact, and suggested improvements for future DSMES programs delivered at church.
Methods
Focus groups were conducted with participants from both intervention arms, that is, faith-based (FB) group and faith-placed group. Participating churches were predominantly Hispanic and located in San Antonio, Texas. Focus groups were audiotaped and transcribed verbatim. Inductive content analysis was performed with the assistance of NVivo software to code and categorize emerging themes.
Results
A total of 138 adult participants took part in the current study. Participants in both groups highly valued the church setting for its convenient location and support system and reported positive changes in diabetes-related beliefs, knowledge, skills, behaviors, and health outcomes. FB participants appreciated the incorporation of spiritual teachings and facilitation by lay leaders, which created a sense of empowerment and improved outlook on living with diabetes.
Conclusions
Church holds promise as a setting for DSMES program delivery in Hispanic communities. Church-based DSMES programs using a FB approach may further facilitate program adoption and sustainability.
Type 2 diabetes (T2DM) disproportionally affects Hispanics, the largest minority population in the United States. 1 Ongoing diabetes self-management education and support (DSMES) is crucial for individuals with T2DM to develop and sustain health behaviors needed to effectively reduce risk of severe diabetes-related complications.2 -4 Traditionally, DSMES is offered in outpatient clinical settings. 5 However, Hispanics may have limited access to DSMES services due to a lack of health insurance coverage and a regular source of primary care. 6 Moreover, financial and linguistic obstacles may further impede Hispanic patients’ access to clinic-based DSMES services. 6 Innovative delivery of DSMES programs and services in community settings is needed to address these challenges in reaching underserved Hispanics.
Churches have emerged as a viable setting to reach vulnerable communities, including underserved Hispanic populations. 7 Several DSMES interventions conducted in church settings have shown success in improving various diabetes-related outcomes, including improvements in participants’ ability to read food labels, increased healthy eating behaviors, and increased physical activity.18,29 Given that the majority of Hispanics report a Christian religious affiliation, 8 churches may be a culturally appropriate, cost-effective setting for DSMES program delivery. 9 Health programs offered in a church setting are classified as either faith-placed (FP) or faith-based (FB). FP interventions are delivered by outside health professionals who use the church primarily as a venue for program implementation, whereas FB interventions are delivered by trained church congregants and purposefully incorporate scripture and spirituality into the programming. Currently, there is limited research comparing FP and FB DSMES intervention approaches, particularly regarding participant experiences and insights.
The Building a Healthy Temple (BHT) DSMES study was a cluster randomized trial designed to translate evidence-based DSMES programming into a church setting for Hispanic populations and to compare the impact of FP versus FB DSMES interventions on diabetes outcomes. 10 The BHT DSMES trial embedded a qualitative study within the main trial to explore participants’ perspectives on taking part in either the FP or FB intervention and to solicit their suggestions for future programming. The current article reports findings from this contemporaneous qualitative study. Intervention outcomes of the main BHT DSMES trial were reported in a separate article. 11
Methodology
The BHT DSMES cluster randomized trial took place between 2017 and 2020 in predominantly Hispanic churches affiliated with Christian denominations in San Antonio, Texas. The BHT DSMES main trial was a 14-week intervention conducted in 16 churches allocated to 2 groups, specifically, the FB group (churches = 9, n = 146) or the FP group (churches = 7, n = 125). The FB group, led by trained church lay health leaders (CLHLs), received a “Health Sermon,” 6-session DSMES, and 7-session “Healthy Bible Study.” The FP group, led by outside health professionals, received the 6-session DSMES followed by a 7-session partial attention control curriculum. The BHT DSMES trial measured intervention impacts at baseline and 6, 9, and 12 months on the following diabetes outcomes: A1C, waist circumference, body weight, diabetes distress, diabetes self-care activities, physical activity level, and diabetes self-efficacy. 11 The contemporaneous qualitative study was conducted at the conclusion of the 14-week intervention. All study protocols were approved by the Institutional Review Board at the University of Texas at San Antonio (16-203N). Written informed consent was obtained prior to data collection. The study was registered as “Building a Healthy Temple: A Diabetes Self-Management Support Program in Hispanic Faith Community Settings” (ClinicalTrials.gov identifier: NCT03934593; https://clinicaltrials.gov/ct2/show/NCT03934593). A detailed study protocol was published previously. 10
Focus Group Methodology and Data Collection
Qualitative approaches, aimed at gaining in-depth insights from study participants, are increasingly recommended as an integral part of intervention research but are often absent from traditional outcome-driven randomized control trials. 12 Focus group methodology is widely used in qualitative research. Focus groups bring individuals together to discuss a topic in-depth and share personal experiences, views, and opinions while building on each other’s ideas and contributions. 13 All participants in the BHT DSMES trial (ie, churchgoing Hispanic adults with self-reported T2DM or elevated A1C) were invited to voluntarily participate in a focus group discussion at the conclusion of the 14-week intervention. Only one focus group, with 4 to 12 participants, was conducted at each participating church. Two experienced, bilingual moderators conducted the focus groups, in either English or Spanish, using a semi-structured discussion guide. Table 1 provides a sample of discussion guide topics. Each focus group lasted approximately 60 minutes. The moderators held a peer debriefing meeting to identify key topics and themes emerging from the discussion at the end of each focus group. Focus groups were audiotaped and transcribed verbatim. For Spanish focus groups, Spanish transcripts were translated into English. Another bilingual staff then back-translated the English transcript into Spanish to verify retention of original meaning and concepts. Corrections were made where warranted. Demographic information was collected via questionnaire.
General List of Topics Included in the Focus Group Discussion Guide
Data Analysis
An inductive content analysis method was employed to derive broader conclusions from the focus group transcription data. 14 Working independently, 2 researchers reviewed all transcripts and developed a preliminary coding template. The entire research team then met to develop a merged coding template. Subsequently, 2 researchers pilot-coded the template on 1 transcript using NVivo software (QSR International Pty Ltd, 2020). The team met and resolved coding issues that arose from this initial analysis through consensus. Two researchers independently coded the remaining transcripts. The following strategies were employed to enhance the trustworthiness of data: (a) member checking to ensure participant responses were accurately captured and (b) peer debriefing and detailed discussion notes to summarize key points, note important topics, and identify new lines of inquiry and emerging themes.
Results
A total of 16 focus groups with 138 participants (FB group churches = 9, n = 84; FP group churches = 7, n = 54) were conducted. Participating churches varied by denomination, congregation size, and location. The majority of participants were Hispanic females, over 60 years of age, retired, and with some college education (Table 2). Emerging themes from the focus groups were organized around 4 domains: (1) perceived impact of the BHT DSMES program, (2) DSMES programs in church settings, (3) social support, and (4) suggestions for future DSMES programs.
Focus Group Participants’ Demographic Profile
Domain 1: Perceived Impact of the BHT DSMES Program
Overall, participants spoke favorably about the BHT DSMES program and reported a variety of positive impacts of the program on themselves, their families, and loved ones (Table 3).
Domain 1: Perceived Impact of the Building a Healthy Temple Diabetes Self-Management Education and Support Program
Changing thoughts and attitudes
These included changes in personal thoughts and attitudes regarding managing diabetes, an illness they once felt powerless against. FB participants felt particularly empowered to take care of their body for a higher purpose, to honor God.
Improved knowledge and skills
Examples of improved knowledge and skills ranged from new nutrition knowledge on healthy eating for better glycemic stability to newly acquired skills related to food label reading, portion control, and meal planning.
Improved health behaviors and outcomes
Participants in both groups described new ways of incorporating knowledge and skills into their daily routine to improve eating, physical activity level, and other diabetes self-management habits. A few participants reported positive changes in health outcomes, including weight reduction and improvement in various blood test results.
Positive impact on loved ones
Beyond the identified personal benefits, a frequent theme in both groups was that of helping others through sharing their resources, knowledge, and skills obtained from the BHT DSMES Program.
Domain 2: DSMES Programs in Church Settings
Both FB and FP participants felt comfortable joining a DSMES program at their church and perceived a connection between faith and health (Table 4). FB participants appreciated the integration of scripture into the health program and highly valued their trustworthy and dedicated CLHLs.
Domain 2: Diabetes Self-Management Education and Support Programs in Church Settings
Church is a convenient and comfortable setting
They identified their church as a convenient and comfortable location that they were familiar with through regular worship service attendance. Some participants associated church with sacred ground, and several of these individuals noted that participating in a health program at the church made them feel close to God.
Faith and health connection
Both the FB and FP participants conveyed perceptions of a strong connection between faith and health. FB participants described this connection as taking preventive actions to keep their body, God’s temple, healthy to better serve God. Conversely, FP participants depicted this connection as turning to God via prayer to help cope with illness.
Integration of scripture into DSMES programing
FB participants particularly appreciated the integration of scripture readings with health education. They felt that the BHT Healthy Bible Study sessions helped them incorporate the health information they learned into their existing values and beliefs. Furthermore, FB participants also stated that the BHT Healthy Bible Study sessions enhanced their understanding of God’s instructions, facilitating the adoption of healthy behaviors as a faith practice to care for God’s temple.
Trustworthy and dedicated leaders
FB participants felt that CLHLs were trusted members of the community who understood their disease, culture, religion, and people. Additionally, FB participants were thankful to their CLHLs for their commitment to providing them the 14-week program, and they felt that the leaders’ dedication and lead-by-example approach helped keep them motivated to continue making healthy changes. Of note, FP participants did not have the same feelings toward the health professionals that facilitated their program, and a few expressed desires to have church members be trained as leaders.
Domain 3: Social Support
Social support emerged as a recurring theme during focus group discussions in both the FB and FP Groups (Table 5). The existing support system at church encouraged program participation, and the DSMES sessions strengthened the groups’ social support networks. Subsequently, this strengthened support helped facilitate health behavior changes. Some FB participants further expressed their intent to establish ongoing support groups at their church to sustain this increased social support.
Domain 3: Social Support
Existing support system at church
Both groups were consistent in their approval of the program using the church to leverage their existing sense of community. The existing support system at church made participants feel welcomed and at ease joining the program. Being with a group of “God’s people” who struggled with the same illness created an atmosphere of belonging and support within the DSMES groups.
Strengthening social support
Among both the FB and FP participants, there was the salient acknowledgment that attending the program with members of their church, who had shared experiences and struggles with diabetes, enhanced their sense of community and fostered personal relationships with fellow participants. Of note, participants from both groups mentioned that their relationships with other group members extended beyond the BHT DSMES sessions and contributed to encouraging a greater sense of accountability to one another. FB participants expressed profoundly powerful and meaningful connections with fellow group members and often referred to them as “family.” Additionally, several FB participants referred to the group as their main, or only, source of support and reported they planned to continue meeting and supporting one another once the program ended.
Domain 4: Suggestions for Future Church-Based DSMES Programs
Participants provided suggested strategies for future DSMES program improvements (Table 6). Participants from both the FB and FP groups suggested providing additional flexibility in class options to reach different segments of the congregation with competing obligations, including the addition of an accelerated course to reduce total program duration commitment. FB participants suggested offering an online option for those who could not attend in person. Of note, participants in both groups mentioned establishing ongoing DSMES support groups at churches to support and sustain self-management behaviors. Several also recommended providing a concurrent Spanish-language class, whether it be at their church or nearby. Several participants from both groups also stressed that they wanted exercise activities and music to be incorporated into future DSMES programs.
Domain 4: Suggestions for Future Church-Based Diabetes Self-Management Education And Support Programs
Conclusions
This research employed a community-based qualitative approach to explore participants’ experience of taking part in the BHT DSMES trial and solicit their insights for future DSMES program improvements in church settings. Participants in both groups viewed the DSMES program at their church positively and remarked on improved health outcomes and favorable changes in their personal diabetes management beliefs, knowledge, skills, and behaviors as the result of the program. Many participants acknowledged a connection between their faith and health. They viewed church as a convenient setting for hosting a DSMES program and felt comfortable joining the program through the church’s existing support network. Participants reported that the strong social support dynamic among their groups, magnified by the DSMES sessions, helped facilitate and sustain their positive health behavior changes. FB participants particularly appreciated the incorporation of scripture with the DSMES program led by their trusted CLHLs. They also offered valuable suggestions for improving future church-based DSMES programs.
The DSMES program was well received by both FB and FP participants, who reported several encouraging diabetes-related program impacts. These included changing thoughts and attitudes, improvements in knowledge and skills, improvements in health behaviors and outcomes, and positive impacts on loved ones. Of note, participants perceived an increased sense of control over the management of their diabetes, a chronic illness they have long struggled with. Participants noted that this sense of personal empowerment drove subsequent behavioral changes. Furthermore, participants reported incorporating their newly acquired knowledge and skills (eg, food label reading, portion control, and meal planning) into their daily routine to improve diabetes self-management habits. These perceived impacts were corroborated by objective measures in the main BHT DSMES trial, which showed favorable changes in diabetes self-efficacy, diabetes self-care behaviors, and diabetes distress. 13 The perceived improved health outcomes were also corroborated by the BHT DSMES trial outcomes, which indicated a reduction in waist circumference in both groups and a declined A1C level among the FB participants at 6-month follow-up. 13
Research findings related to improvements in empowerment, knowledge, behavior, and outcomes also are in alignment with a more recent consensus report listing benefits of clinic-based DSMES in adults with T2DM. 15 Of particular note, the program appeared to have an interpersonal impact given that participants frequently reported helping others by sharing resources, knowledge, and skills acquired from the BHT DSMES program. This finding implies that the church-based DSMES program may have indirectly reached others in the participants’ social networks. Although such indirect impacts rarely are documented in randomized control trials, these findings suggest future consideration in assessing program impact. Furthermore, this finding suggests that family members and friends of diabetic patients may benefit from participating in DSMES programs to learn about the disease and provide social support to their affected loved ones.
These findings affirm that churches can provide conducive settings for DSMES programming delivery to reach underserved Hispanic populations. Although churches often have been used as a setting for DSMES programing in Black communities,16,17 few church-based DSMES interventions have been reported among Hispanic communities.9,18 Findings from the current study further understanding of the value of church-based DSMES programs among Hispanic communities. Clearly, a church can provide a convenient and familiar environment for DSMES programing. Participants felt natural partaking in a health program at their church, where they regularly come to worship. Furthermore, the existing social network within church made participants feel at ease joining a DSMES group with their fellow worshipers who struggled with the same illness. Indeed, research has shown that church is a place where congregants may share feelings and hardships, display empathy, and express concern, love, and gratitude.19,20 Such an existing support system is conducive for both FB and FP approaches to DSMES program delivery. In addition, participants in both the FB and FP groups acknowledged the interconnection between faith and health. They considered good physical health as essential to live for God’s purpose and believed God helped keep their physical health in good condition. Similar views about the interconnectedness between health and faith are consistent with research documented among Black churchgoers. 21 Given the familiar church environment and existing social support system coupled with the belief that faith and health are intertwined, churches are conducive settings for DSMES programing. Given the high rate of Hispanics with a religious affiliation, 22 churches serving high-needs communities could play an important role in facilitating access to DSMES programs and services among communities disproportionally affected by T2DM.
This research supports the application of an FB approach, which incorporated scripture and spirituality with a secular DSMES program to foster healthy behavior changes among Hispanics with T2DM. The FB participants particularly valued the BHT Healthy Bible Study sessions’ integration of scripture readings and health education. This approach is in line with congregants’ values and beliefs, which could foster the adoption of healthy behaviors as a faith practice for a higher purpose. 23 It is worth mentioning that although both FB and FP groups acknowledged the interconnection between faith and health, the perceptions between the 2 groups did vary. FB participants tended to view caring for God’s temple as a faith practice and would take preventive actions to keep their body healthy to better serve God. On the other hand, FP participants felt the connection manifested through prayer and God’s healing power in times of sickness. The role of scripture readings in the BHT Healthy Bible Study sessions may have contributed to FB participants’ proactive attitude toward healthy living. Although spirituality is often a natural part of health programs at church, 24 DSMES programs and services could deliberately incorporate scripture readings to further program impact on participants’ health behaviors and outcomes. The addition of health-oriented sermons, Bible study, opening and closing prayers, and scripture readings or religious music integrated with other health activities are relevant ways to add spirituality to DSMES programs. 16 Of note, prior efficacy studies have shown that programs integrating spiritual and physical health education led to lower fasting glucose levels, 25 reduced blood pressure, 26 reduced weight, and improved eating behaviors. 27
Study findings suggest that the social support dynamic, strengthened through the group-based DSMES sessions at church, may have contributed to fostering positive behavioral change. Participants in both the FB and FP groups emphasized that the meaningful relationships formed among group members, through mutual sharing of knowledge and experiences, helped them to hold each other accountable for making healthy choices to reach their goals. Social support has long been recognized as an important aspect of diabetes care. 28 It is also reflected in DSMES programs, which often involve patients with diabetes learning and supporting one another through group-based sessions. 28 The evidence-based DSMES used in this research consists of 6 weekly 2-hour group sessions that foster learning and social support among participants. 29 Prior research has shown that integration of social support into DSMES programing in Black churches led to the adoption of healthy behaviors and resulted in positive health outcomes. 16 In this study, the preexisting support systems and trusted relationships at church may have further strengthened the support dynamics that tend to occur within typical DSMES groups.
These research results reaffirm the value of lay health leaders’ roles as effective intervention agents for DSMES program delivery. The CLHLs in this FB intervention were viewed by participants as trusted members of the community who understood not only their disease but also their culture and religion. Lay leaders are recognized as a culturally appropriate resource for health program delivery in community settings and have been employed successfully to improve various health behaviors. 30 Prior research indicates that lay leaders have the personal bonds, skills, and cultural competence to deliver health promotion programs in church settings while providing support through the existing social network.31 -33 Lay health leaders have long served as intervention agents for DSMES program delivery among Black communities, where they have provided health education and facilitated peer support groups for congregants living with T2DM. 17 Church-based DSMES programs delivered by trained church congregants may offer a low-cost, accessible alternative to traditional DSMES programs.
Another potential advantage of the lay leader approach is the contribution to program sustainability. Trained CLHLs are an integral part of the community and may continue to provide ongoing support to congregants long after program completion. 17 In this study, FB participants expressed they experienced powerful and meaningful connections with fellow group members, were motivated by their CLHLs’ dedication and lead-by-example approach, and were inspired to continue meeting and supporting one another once the program ended. These findings may be explained by the theoretical principles underlying the BHT DSMES program, especially Bandura’s social cognitive theory, which includes constructs of observational learning and reinforcement. 34 The CLHLs offered credible role models of positive health behaviors, and the FB participants acquired new behaviors by observing the outcomes and actions of their leaders. The positive feedback from their CLHLs during each session provided positive reinforcement to continue the healthy behaviors. These behaviors and interactions may have contributed to overall increased participant buy-in and could also be the result of additional social support nurtured by CLHLs in the FB intervention. Furthermore, spiritual support from church members and leaders may have further facilitated sharing of personal faith while seeking spiritual guidance from leaders during the program. This combination of social and spiritual support may foster lasting behavioral changes and contribute to sustainable DSMES programing in church settings.
Understanding participants’ insights for BHT DSMES program improvements could benefit future DSMES program planning. The study investigators identified 3 key findings relevant to future initiatives. First, it is important to examine the participants’ reported desire to shorten or condense the program duration while also expressing a desire for ongoing DSMES programing. It is understandable for some participants to perceive a 14-week program as a significant time commitment given concurrent challenges related to family, job, and church commitments. Similar findings related to lack of time have also been previously reported as a key deterrent to health program implementation in Black churches. 35 On the other hand, participants’ desire for ongoing DSMES programing at church is also understandable. A YMCA-based DSMES program found that alumni of diabetes education programs desired ongoing support for behavior change and considered peer support particularly important for addressing setbacks. 36 To address these dilemmas, health program planners may consider offering flexible, ongoing DSMES groups that meet after worship services. Such options may better accommodate participants’ time constraints while also providing ongoing support at the church. Second, some participants perceived that there may be a language barrier in the delivery of the DSMES program. Although all FB and FP churches were given the option to implement the BHT DSMES program in either English or Spanish, based on the preferences specified by the church, there may be occasions where Spanish-speaking participants only had the option of joining the English group offered at their church. In this scenario, bilingual leaders may often have attempted to provide unplanned translations of program information to ensure Spanish-speaking participants were not turned away. Although bilingual worship services are common practices in the Hispanic faith communities, future DSMES programs in Hispanic faith communities may benefit from providing concurrent English and Spanish sessions as a general practice and to ensure linguistic sensitivity, participant comprehension, and program effectiveness. Third, participants provided further insights for program design through their suggestions to incorporate exercise and music into DSMES programs. Although the Self-Management Resource Center diabetes self-management curriculum included physical activity information, participants expressed the desire for actual exercise (eg, stretching activities) during group sessions. Incorporating structured exercise components in future DSMES programing could provide a practical means for participants to apply the physical activity information they are learning in a safe environment. Additionally, members of the FB group also suggested incorporating gospel music into the DSMES sessions. This notion does have some research support, with 1 study 37 showing that the addition of gospel music into a healthy lifestyle program increased engagement and improved health outcomes in Black churchgoers.
The strength of this study is centered on its qualitative approach, which facilitated gathering rich, in-depth information about participants’ personal experience with taking part in either the FB or FP DSMES program. These qualitative data complement findings from the main BHT DSMES trial. The in-depth insights from FB participants illustrate the underlying processes of the FB approach that may contribute to its success. Nevertheless, there were several limitations associated with this study. First, although all BHT DSMES trial participants were invited to take part in focus groups, the influence of self-selection must be considered with respect to participants’ level of engagement and participation in the group discussions. Therefore, the opinions expressed may not reflect the perspectives of all program participants. Second, participants had preexisting relationships prior to the focus group discussion, which could influence individuals’ participation via known group or power dynamics. For example, known vocal congregants tended to dominate conversations. To reduce the effect of these dynamics had on participants’ contribution, facilitators took care to encourage discussion from all participants. Third, social desirability may have influenced participant responses. The research team made every effort to minimize the potential social desirability bias by using focus group facilitators unknown to participants and avoiding the use of leading questions. Despite these limitations, the rich data generated from this study may be relevant, applicable, and transferable to heath programing with similar settings and characteristics.
In summary, our research findings indicate that church-based DSMES programs for Hispanics can lead to positive changes in participants’ diabetes-related beliefs, knowledge, skills, behaviors, and health outcomes. Of note, these outcomes were similar regardless of who facilitated the DSMES sessions, trained church congregants or outside health professionals. The knowledge and skills gained from the BHT DSMES program coupled with convenient access through a familiar setting and the strong social support dynamics at church provided participants with a sense of empowerment and improved outlook on managing diabetes. Certain program characteristics, including delivery by trusted church congregants and the incorporation of scripture, may have fostered deeper relationships among group members. In turn, this enhanced social support may have encouraged the integration of healthy behaviors into daily practice, which could result in sustainable behavior changes and lasting improvements in diabetes outcomes.
Implications for Practice
Local churches provide promising settings for DSMES programing to reach the underserved Hispanic communities disproportionally affected by T2DM. Expanded implementation of church-based DSMES programs that integrate spirituality and are delivered by local lay leaders could further facilitate program adoption and sustainability.
Footnotes
Acknowledgements
The authors acknowledge Ramon Reyes, MD, of Bandera Family Health Care Research for his role as medical consultant on this study. The authors are grateful to the staff from the Metropolitan Health District of San Antonio, in particular, Ms Kathy Minkley Shields and Ms Ellen Spitsen, for their collaboration on study implementation. The authors also recognize and thank all participating churches and study participants and acknowledge the contributions from undergraduate interns and graduate research assistants supporting this study.
Declaration of Conflicting Interests
The authors declare that there are no conflicts of interest.
Funding
The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the American Diabetes Association (Grant No. 1-17-ICTS-029).
