INTRODUCTION

Churches are promising partners for behavioral interventions, as they are located across the United States, oftentimes in locations where other health-promoting services may be lacking [1,2]. Churches also have tremendous reach; about 45% of the United States. adults attend religious services at least monthly, while 62% of Christians report at least monthly church attendance [3]. Health promotion efforts, specifically physical activity (PA) and healthy eating (HE) interventions, have been successful in faith-based settings, and multiple reviews have found that faith-based interventions can increase church member PA and improve HE behaviors [4,5]. Clergy and church leaders play an important role in the success of faith-based health promotion interventions by influencing the types of intervention activities that are offered in the church and by serving as role models of healthy behavior [6–8].

Some evidence suggests that clergy are at greater risk for chronic disease than their congregants [9,10]. The few studies that have examined the physical health of pastors suggest a high prevalence of obesity and obesity-related chronic disease [11,12]. While this trend could be related to the potentially stressful and time-intensive nature of pastoral work, more research on pastor health behaviors is warranted. Church leaders’ health and health-related quality of life are also integral to the success of an intervention [13], yet few studies have examined church leader health behavior longitudinally, and it remains unclear whether church leaders’ health behaviors are associated with implementing health promotion programs. Examining adherence to health behavior guidelines among church leaders may offer perspectives on how to broaden the reach of interventions among church members, as many pastors view themselves as influential role models for their members, and they are often key decisionmakers in church-level program adoption [13,14].

The Faith, Activity, and Nutrition (FAN) program promotes PA and HE among church members by targeting policy, systems, and environmental change in churches [15–17]. As a part of FAN, a key church leader serves as the FAN program coordinator. The support of church pastors is also an instrumental part of the program’s success. In 2014, a two-phase dissemination and implementation (D&I) study of the FAN program was launched to assess program adoption, implementation, and maintenance in countywide (phase one) [15] and statewide [18] settings. This study is a secondary analysis of the FAN D&I study and aims to: (1) to describe the health and health behaviors of church leaders who participated in the statewide (second) phase of the FAN D&I study, (2) to analyze whether these behaviors differed by socio-demographic characteristics, (3) to examine whether church leaders’ health and health-related behaviors changed during the 12 month implementation of the FAN program, and (4) to examine whether changes in health behaviors were associated with church-level implementation of the FAN HE and PA components.

METHODS

Study Design and Sample

Data for this study were drawn from the second phase of the FAN D&I study, which has been described in detail elsewhere [19]. Briefly, this phase was a partnership between the University of South Carolina Prevention Research Center and the South Carolina Conference of the United Methodist Church (SCCUMC). All 985 member churches across 12 districts of the SCCUMC were invited to participate. Interested church leaders completed a telephone screening; eligible churches had ≥20 regular attendees and both a pastor and a designated program coordinator for the FAN program (FAN coordinator) who were willing to complete evaluations at baseline, 12 months, and 24 months. In total, 115 churches enrolled in the study. When a pastor served multiple churches, one of his/her churches was randomly selected to be included in evaluation activities. For a given pastor, the biostatistician was provided with all of his/her churches and used a random number generator to select one of the churches to participate in the evaluation. This process resulted in the inclusion of 93 distinct churches in the evaluation. Baseline and 12-month data are reported in this study.

Baseline telephone surveys with 92 FAN coordinators and 93 pastors were completed from February 2017 to May 2017. Twelve-month surveys with 84 FAN coordinators and 78 pastors were completed between April 2018 and July of 2018. However, between the baseline and 12-month surveys, there were 6 FAN coordinators and 6 pastor changes (12 different churches). Thus, for analyses that examined health behavior changes, the sample was 78 for FAN coordinators and 72 for pastors. Surveys administered by telephone were conducted by interviewers at the University of South Carolina Survey Research Laboratory (SRL), using the SRL’s computer-aided telephone interviewing system. The SRL has a long history of conducting surveys for diverse groups, including the Centers for Disease Control and Prevention, and has experienced staff that were trained and supervised for this project. Furthermore, many of the interviews were monitored to ensure that instructions were being followed.

A small number of 12-month surveys were completed via online survey (1 FAN coordinator, 2 pastors) or by paper and pencil (3 FAN coordinators, 2 pastors). All participants received a $20 gift card for completing each interview.

Measures

Church leader characteristics and health status

At baseline (before receiving training) and at 12 months, pastors and FAN coordinators answered identical questions regarding their socio-demographic characteristics (including age, gender, race, and education level), health, and health behaviors. Health indicators included self-rated health (5-point scale; poor [1] to excellent [5]) as well as self-reported height and weight. Body mass index (BMI) was calculated as weight in kilogram/height in squared meter. A BMI <18.5 kg/m² was categorized as “underweight,” a BMI between 18.5–24.9 kg/m² was categorized as “normal weight,” a BMI of 25.0–29.9 kg/m² was “overweight,” and a BMI ≥30.0 kg/m² was “obese.”

Church leaders’ F&V

Fruit and vegetable consumption (F&V) was measured in cups per day; 1-cup F&V portion examples were provided to assist participants in making estimations. This measure has been previously used and validated in faith-based studies [20,21]. Following the Dietary Guidelines for Americans (recommending 2 cup/day of fruit and 3 cup/day of vegetables) [22], pastors and FAN coordinators were dichotomized as either meeting or not meeting F&V guidelines.

Church leaders’ PA

PA was measured using 4 of the 6 items from the 2009 Behavioral Risk Factor Surveillance System PA module [23]. Participants reported whether they took part in combined moderate and vigorous physical activity (MVPA) for at least 10 min/day and if so, on how many days per week and for how much time per day. Minutes of MVPA per week were calculated for each participant. Pastors and FAN coordinators were categorized as meeting the 2018 National PA Guidelines [24] if they reported ≥150 min/wk of MVPA

Program implementation

FAN coordinators answered the same questions regarding implementation of the 4 FAN components (providing PA and HE opportunities, sharing messages about PA and HE, creating PA and HE policies, and increasing pastor support) at baseline and at 12 months. The development of this instrument has been described elsewhere [25]; in brief, it was based on the model of Cohen et al. [26] and adapted from the instrument used in an earlier FAN effectiveness trial [15]. The survey included questions for 10 PA components and 9 HE components; each was measured on a 4-point Likert scale that described how frequently a church conducted each activity (1=“rarely or never”; 4=“about weekly” or “almost all of the time”). Continuous mean subscale scores were calculated for each component (range, 1–4). Church-level PA and HE composite scores were then calculated as the average of the 4 subscale scores for church implementation of the core FAN components.

Statistical Analysis

All analyses were performed in SAS version 9.4 (SAS Institute Inc., Cary, NC, USA). Baseline means and frequencies were calculated for self-rated health, BMI, F&V, and MVPA for pastors and FAN coordinators separately. Chi-square analyses examined differences in self-rated health, weight status, meeting F&V dietary guidelines, and meeting PA guidelines by gender (pastors only, because most FAN coordinators were women), race (Black/African American, White), education (FAN coordinators only because most pastors were college-educated; college-educated vs. not college-educated), and age (<65 vs. ≥65). Changes in self-rated health, BMI, F&V, and MVPA between baseline and 12 months were assessed using paired t-tests or McNemar’s test.

To examine if changes in health and health behaviors were associated with church-level implementation of FAN, individual multiple linear or multiple logistic regression models were conducted for both pastors and FAN coordinators using residualized change scores. For continuous outcomes, we tested whether each 12-month residualized health behavior change score (adjusted 12-month BMI, adjusted 12-month self-rated health) or change in meeting F&V or PA guidelines was associated with baseline practices and 12-month implementation scores for the HE and PA components of FAN. Due to a high correlation between HE and PA implementation scores, separate models were conducted for HE and PA. We chose to use residualized change scores in these models to account for the strong correlation between baseline and 12-month scores for both BMI and self-rated health as well as for church-level PA and HE implementation scores. This enabled the inclusion of both baseline scores and residualized 12-month scores in the same model. All linear models were checked for independence, homoscedasticity, and normality. Effect sizes (Cohen’s d) for BMI and self-rated health were computed as (12-month mean–baseline mean)/(baseline standard deviation [SD]).

For dichotomous outcomes (F&V and PA), we examined whether participants met guidelines at baseline and at 12 months for each behavior separately. We then categorized participants into 2 groups for each behavior (F&V and PA): (1) those who met guidelines at baseline and at 12 months AND those who did not meet guidelines at baseline but met them at 12 months, or (2) those who did not meet guidelines at baseline and at 12 months AND those who met guidelines at baseline but not at 12 months.

Ethics Statement

The study was reviewed and granted exempt status by the University of South Carolina Institutional Review Board. Informed consent was obtained from all individual participants included in the study.

RESULTS

Baseline Socio-demographic and Health-related Characteristics

A total of 93 pastors and 92 FAN coordinators completed baseline surveys. The pastors averaged 55.2 years of age (SD, 10.3), 59.1% were men, 57.0% were White, and most were college graduates (95.7%) (Table 1). At baseline, 45.2% of pastors met the PA guidelines while 23.7% met the F&V dietary guidelines. Pastors had a mean BMI of 30.0 kg/m² (SD, 5.8), and most rated their health as “good” (53.8%) or “very good” (32.2%). FAN coordinators averaged 56.2 years of age (SD, 13.1), and the majority were women (94.6%), White (55.4%), and college graduates (64.1%). While 62.0% of FAN coordinators met the PA guidelines at baseline, only 27.2% met the F&V dietary guidelines. FAN coordinators had a mean BMI of 27.8 kg/m² (SD, 5.4), and most rated their health as either “good” (31.5%) or “very good” (39.1%).

Associations Between Baseline Health Behaviors and Socio-demographic Characteristics

Black/African American pastors were less likely to report “very good” or “excellent” health than White pastors (p=0.03) (Table 2). Women pastors were more likely to be underweight or normal weight than their men counterparts (p=0.001). For F&V intake, women pastors were more likely to meet F&V dietary guidelines (p=0.04) than men pastors, as were White pastors compared to Black pastors (p=0.04). There were no significant associations between pastor PA and gender, race, or age.

Black/African American FAN coordinators were less likely to report “very good” or “excellent” health than their White counterparts (p=0.03; Table 3). Black/African American FAN coordinators were more likely to have obesity than White FAN coordinators (p=0.001), and FAN coordinators aged 65 and older were less likely to be underweight or normal weight than those aged 65 and under (p=0.05). There were no significant associations between FAN coordinator race, education, or age and either F&V intake or PA.

Changes in Pastor and Faith, Activity, and Nutrition Coordinator Health Behaviors

Between baseline and 12 months, there were no significant changes in pastor BMI, self-rated health, or F&V (Table 4). However, the percentage of pastors meeting the PA guidelines increased significantly from 41.4% to 50.7% after 12-month of FAN program implementation (p=0.03). Among FAN coordinators, the percentage meeting F&V dietary guidelines increased from 27.1% to 43.4% (p=0.05). No significant changes were observed between baseline and 12 months for BMI, self-rated health, and meeting PA guidelines (Table 4).

Health Behaviors and Church-level Implementation of Faith, Activity, and Nutrition

No significant associations were found between changes in any pastor health-related variables and church-level implementation of the FAN program (Table 5). Among FAN coordinators, those who reported greater 12-month church-level implementation of the FAN HE components had significantly higher self-rated health scores (F=15.86, p<0.01) (Table 5), as did those who reported greater baseline (F=4.34, p=0.04) and 12-month church-level implementation of the FAN PA components (F=5.43, p=0.02). No other associations existed between FAN coordinator health or health behaviors and church-level implementation of the FAN program.

DISCUSSION

Church leaders are influential role models in the lives of their congregants, and the engagement of church leaders may influence the success of faith-based interventions [12]. This paper addresses gaps in the literature by describing the health and health behaviors of church leaders who participated in a church-based HE and PA promotion program and examining whether these variables were associated with socio-demographic characteristics and whether behaviors changed over time. This paper also examined whether program implementation was associated with changes in the health and health behaviors of pastors and FAN coordinators.

Church Leader Health and Health Behaviors

We found that most pastors and FAN coordinators who participated in the study had overweight or obesity and did not meet F&V intake guidelines. This corroborates previous research indicating that clergy may be at an increased risk of chronic disease due to their high rates of overweight or obesity compared to other church leaders or members. A study of United Methodist Church clergy in North Carolina found that the prevalence of obesity among clergy was more than 10% higher than in the general population of the state [11]. Another study of African American pastors found that 93% were overweight or had obesity, and that the majority did not meet F&V intake guidelines [12]. In our study, over 80% of pastors reported a BMI within the overweight or obese range, and fewer than half of pastors reported meeting F&V and PA guidelines at baseline. Similarly, roughly 70% of FAN coordinators reported BMIs within the overweight or obese range, and fewer than half reported meeting F&V guidelines at baseline. As the national prevalence of overweight and obesity among adults is roughly 69% [11], clergy in these earlier studies and in our own study appear to be more affected by overweight and obesity than adults in the general population.

Disparities in Church Leader Health Behaviors

There were disparities in the health and health behaviors of both Black/African American pastors and FAN coordinators compared to the “White or other” racial group. Black/African American clergy were less likely than White/other pastors to meet the F&V dietary guidelines at baseline, and more likely to report lower self-rated health. Additionally, Black/African American FAN coordinators had higher BMIs and lower self-rated health at baseline than their White/other counterparts. Although studies of racial health disparities among church leaders are rare, these results are reflective of persistent health disparities and health inequities found between racially minoritized and White populations, particularly in chronic disease prevalence [27–29]. While there has been a groundswell of public health partnerships with the black church to address these inequities among congregants, there may also be a need for interventions among African American clergy specifically [1,2,30].

Additional disparities were observed for pastors according to gender: women were more likely to meet the F&V dietary guidelines and less likely to have overweight or obesity than men. These results are similar to previous research indicating that women are more likely than men to meet F&V intake guidelines [31], although they differ from national data indicating that there tends to be a greater prevalence of overweight and obesity among women [32]. Nonetheless, as men represent a greater proportion of clergy [33], there is opportunity to focus on obesity prevention efforts among men pastors.

Health Behavior Changes and Faith, Activity, and Nutrition Implementation

Few changes were observed in health or health behaviors between baseline and 12 months for pastors and FAN coordinators. Among pastors, the only significant change observed was an increase in the number of pastors meeting the PA guidelines; the proportion of FAN coordinators meeting F&V dietary guidelines also increased significantly. These findings are meaningful because the proportion meeting the guidelines was low at baseline, the increase was substantial, and the health behaviors of these leaders were not the direct targets of the FAN intervention. In the FAN coordinator models that included residualized 12-month implementation change scores, there was a significant positive association between FAN coordinator self-rated health and the residualized 12-month implementation score for the FAN HE and PA components. There was also a significant positive association between FAN coordinator self-rated health and baseline composite church PA practices. Further, although we hypothesized that leaders in churches with higher levels of implementation of the FAN program would have greater improvements in health behaviors, it may not be surprising that these individual outcomes among church leaders were largely unaffected by FAN program implementation given that FAN is an organizational-level intervention.

Limitations and Strengths

Our sample was limited to churches within the SCCUMC, and the results may not be generalizable to other denominations and/or geographic areas. Additionally, although the total sample of churches (n=93) was large for faith-based research, it is relatively small for statistical analyses, and we may have been underpowered to detect small changes over time. Finally, we used self-reported measures of health and health behaviors: our BMI, and F&V, and PA measures were all self-reported, and therefore may underestimate actual BMI, F&V, and/or PA. Despite these limitations, the study was strengthened by several factors. Although the sample was limited to United Methodist Churches in South Carolina, we were able to recruit a racially diverse and representative sample from within this population. Another strength of this study is that it focused specifically on church leaders’ health behaviors and included longitudinal measures. Previous cross-sectional research has described church leader health behaviors, but there is a need to examine church leader health behaviors over the course of program implementation. Finally, most studies in this literature have only included clergy samples. We also studied lay leaders (i.e., FAN coordinators) who are likely to also be very influential in church life.

Conclusions and Implications

This study filled gaps in the literature by examining church leaders’ health behaviors as well as the relationship between the implementation of an organizational, faith-based health promotion program and church leader health behaviors. We found that most pastors and FAN coordinators who participated in the study had overweight or obesity and did not meet F&V intake guidelines. As our findings align with previous evidence that pastors are more affected by obesity and chronic diseases related to obesity than their congregants, faith-based interventions that include content tailored to pastors are warranted. We also found that pastor PA and FAN coordinator F&V intake improved between pre-FAN and post-FAN program implementation, and that the 12-month church-level implementation of the HE and PA components of FAN were positively associated with FAN coordinator self-rated health, as was the baseline church-level implementation of the FAN PA components. These results may reflect the impact of one of the FAN core components—namely, enlisting pastor support in the intervention—and imply that church leaders can tangentially benefit from the implementation of faith-based interventions in their church. Future studies should build upon this work by prioritizing church leaders in health promotion interventions, either through content that is specifically tailored to pastors or by engaging church leaders throughout the development and implementation of the intervention As our study also identified differential health indicators between African American and White church pastors and leaders, including self-rated health, F&V, and obesity prevalence, future research should also seek to address these disparities by focusing on health promotion among African American church leaders specifically.

Notes

Conflict of Interest

The authors have no conflicts of interest associated with the material presented in this paper.

Funding

This study was supported during the preparation of this article by cooperative agreements from the Centers for Disease Control and Prevention (U48DP005000 and U48DP006401).

Acknowledgements

We wish to thank the pastors and FAN coordinators for their participation in the study.

Contents of this publication are solely the responsibility of the authors and do not necessarily represent the official views of the Centers for Disease Control and Prevention, NIGMS, or NIH.

Author Contributions

Conceptualization: Day KR, Decker L, Bernhart J, Wilcox S. Data curation: Wilcox S. Formal analysis: Day KR, Wilcox S, Decker L. Funding acquisition: Wilcox S, Kaczynski AT. Methodology: Day KR, Decker L. Project administration: Wilcox S. Visualization: Day KR, Baruth M, Pellegrini CA. Writing – original draft: Day KR, Wilcox S. Writing – review & editing: Wilcox S, Decker L, Bernhart J, Pellegrini CA, Kaczynski AT, Baruth M.

REFERENCES

• 1. Levin J. Faith-based partnerships for population health: challenges, initiatives, and prospects. Public Health Rep 2014;129(2):127-131. https://doi.org/10.1177/003335491412900205ArticlePubMedPMC
• 2. Campbell MK, Hudson MA, Resnicow K, Blakeney N, Paxton A, Baskin M. Church-based health promotion interventions: evidence and lessons learned. Annu Rev Public Health 2007;28: 213-234. https://doi.org/10.1146/annurev.publhealth.28.021406.144016ArticlePubMed
• 3. Pew Research Center. U.S., decline of Christianity continues at rapid pace; an update on America’s changing religious landscape; 2019 [cited 2021 Sep 22]. Available from: https://www.pewforum.org/2019/10/17/in-u-s-decline-of-christianity-continues-at-rapid-pace/
• 4. Bopp M, Peterson JA, Webb BL. A comprehensive review of faith-based physical activity interventions. Am J Lifestyle Med 2012;6(6):460-478. https://doi.org/10.1177/1559827612439285Article
• 5. Tristão Parra M, Porfírio GJ, Arredondo EM, Atallah ÁN. Physical activity interventions in faith-based organizations: a systematic review. Am J Health Promot 2018;32(3):677-690. https://doi.org/10.1177/0890117116688107ArticlePubMed
• 6. Baruth M, Wilcox S, Saunders RP. The role of pastor support in a faith-based health promotion intervention. Fam Community Health 2013;36(3):204-214. https://doi.org/10.1097/FCH.0b013e31828e6733ArticlePMC
• 7. Ammerman A, Corbie-Smith G, St George DM, Washington C, Weathers B, Jackson-Christian B. Research expectations among African American church leaders in the PRAISE! Project: a randomized trial guided by community-based participatory research. Am J Public Health 2003;93(10):1720-1727. https://doi.org/10.2105/ajph.93.10.1720ArticlePubMedPMC
• 8. Bopp M, Fallon EA. Individual and institutional influences on faith-based health and wellness programming. Health Educ Res 2011;26(6):1107-1119. https://doi.org/10.1093/her/cyr096ArticlePubMed
• 9. Wells CR, Probst J, McKeown R, Mitchem S, Whiejong H. The relationship between work-related stress and boundary-related stress within the clerical profession. J Relig Health 2012;51(1):215-230. https://doi.org/10.1007/s10943-011-9501-9ArticlePubMed
• 10. Proeschold-Bell RJ, Legrand S, James J, Wallace A, Adams C, Toole D. A theoretical model of the holistic health of United Methodist clergy. J Relig Health 2011;50(3):700-720. https://doi.org/10.1007/s10943-009-9250-1ArticlePubMed
• 11. Proeschold-Bell RJ, LeGrand SH. High rates of obesity and chronic disease among United Methodist clergy. Obesity (Silver Spring) 2010;18(9):1867-1870. https://doi.org/10.1038/oby.2010.102ArticlePubMed
• 12. Baruth M, Wilcox S, Evans R. The health and health behaviors of a sample of African American pastors. J Health Care Poor Underserved 2014;25(1):229-241. https://doi.org/10.1353/hpu.2014.0041ArticlePubMedPMC
• 13. Bopp M, Baruth M, Peterson JA, Webb BL. Leading their flocks to health? Clergy health and the role of clergy in faith-based health promotion interventions. Fam Community Health 2013;36(3):182-192. https://doi.org/10.1097/FCH.0b013e31828e671cArticlePubMed
• 14. Baruth M, Bopp M, Webb BL, Peterson JA. The role and influence of faith leaders on health-related issues and programs in their congregation. J Relig Health 2015;54(5):1747-1759. https://doi.org/10.1007/s10943-014-9924-1ArticlePubMed
• 15. Wilcox S, Saunders RP, Kaczynski AT, Forthofer M, Sharpe PA, Goodwin C, et al. Faith, Activity, and Nutrition randomized dissemination and implementation study: countywide adoption, reach, and effectiveness. Am J Prev Med 2018;54(6):776-785. https://doi.org/10.1016/j.amepre.2018.02.018ArticlePubMedPMC
• 16. Wilcox S, Parrott A, Baruth M, Laken M, Condrasky M, Saunders R, et al. The Faith, Activity, and Nutrition program: a randomized controlled trial in African-American churches. Am J Prev Med 2013;44(2):122-131. https://doi.org/10.1016/j.amepre.2012.09.062ArticlePubMed
• 17. Wilcox S, Saunders RP, Jake-Schoffman D, Hutto B. The Faith, Activity, and Nutrition (FAN) dissemination and implementation study: 24-month organizational maintenance in a countywide initiative. Front Public Health 2020;8: 171. https://doi.org/10.3389/fpubh.2020.00171ArticlePubMedPMC
• 18. Wilcox S, Day KR, Saunders RP, Jake-Schoffman DE, Kaczynski AT, Stucker J, et al. The Faith, Activity, and Nutrition (FAN) dissemination and implementation study: changes in and maintenance of organizational practices over 24 months in a statewide initiative. Int J Behav Nutr Phys Act 2022;19(1):23. https://doi.org/10.1186/s12966-022-01253-9ArticlePubMedPMC
• 19. Wilcox S, Jake-Schoffman DE, Saunders RP, Kinnard D, Kaczynski AT, Hutto B, et al. Predictors of implementation in the Faith, Activity, and Nutrition dissemination and implementation study: application of the Consolidated Framework for Implementation Research (CFIR) in a statewide initiative. Transl Behav Med 2021;11(2):419-429. https://doi.org/10.1093/tbm/ibaa025ArticlePubMed
• 20. Resnicow K, Campbell M, Carr C, McCarty F, Wang T, Periasamy S, et al. Body and soul. A dietary intervention conducted through African-American churches. Am J Prev Med 2004;27(2):97-105. https://doi.org/10.1016/j.amepre.2004.04.009ArticlePubMed
• 21. Resnicow K, Jackson A, Blissett D, Wang T, McCarty F, Rahotep S, et al. Results of the healthy body healthy spirit trial. Health Psychol 2005;24(4):339-348. https://doi.org/10.1037/0278-6133.24.4.339ArticlePubMed
• 22. DeSalvo KB, Olson R, Casavale KO. Dietary guidelines for Americans. JAMA 2016;315(5):457-458. https://doi.org/10.1001/jama.2015.18396ArticlePubMed
• 23. Centers for Disease Control and Prevention. 2009 Behavioral Risk Factor Surveillance System survey questionnaire; 2008 [cited 2024 Apr 15]. Available from: https://www.cdc.gov/brfss/questionnaires/pdf-ques/2009brfss.pdf
• 24. Piercy KL, Troiano RP, Ballard RM, Carlson SA, Fulton JE, Galuska DA, et al. The physical activity guidelines for Americans. JAMA 2018;320(19):2020-2028. https://doi.org/10.1001/jama.2018.14854ArticlePubMedPMC
• 25. Saunders RP, Wilcox S, Jake-Schoffman DE, Kinnard D, Hutto B, Forthofer M, et al. The Faith, Activity, and Nutrition (FAN) dissemination and implementation study, phase 1: implementation monitoring methods and results. Health Educ Behav 2019;46(3):388-397. https://doi.org/10.1177/1090198118818235ArticlePubMed
• 26. Cohen DA, Scribner RA, Farley TA. A structural model of health behavior: a pragmatic approach to explain and influence health behaviors at the population level. Prev Med 2000;30(2):146-154. https://doi.org/10.1006/pmed.1999.0609ArticlePubMed
• 27. Cunningham TJ, Croft JB, Liu Y, Lu H, Eke PI, Giles WH. Vital signs: racial disparities in age-specific mortality among Blacks or African Americans - United States, 1999–2015. MMWR Morb Mortal Wkly Rep 2017;66(17):444-456. https://doi.org/10.15585/mmwr.mm6617e1ArticlePubMedPMC
• 28. Zimmerman FJ, Anderson NW. Trends in health equity in the United States by race/ethnicity, sex, and income, 1993–2017. JAMA Netw Open 2019;2(6):e196386. https://doi.org/10.1001/jamanetworkopen.2019.6386ArticlePubMedPMC
• 29. Brown AF, Liang LJ, Vassar SD, Escarce JJ, Merkin SS, Cheng E, et al. Trends in racial/ethnic and nativity disparities in cardiovascular health among adults without prevalent cardiovascular disease in the United States, 1988 to 2014. Ann Intern Med 2018;168(8):541-549. https://doi.org/10.7326/M17-0996ArticlePubMedPMC
• 30. Berkley-Patton J, Thompson CB, Bradley-Ewing A, Berman M, Bauer A, Catley D, et al. Identifying health conditions, priorities, and relevant multilevel health promotion intervention strategies in African American churches: a faith community health needs assessment. Eval Program Plann 2018;67: 19-28. https://doi.org/10.1016/j.evalprogplan.2017.10.012ArticlePubMed
• 31. Emanuel AS, McCully SN, Gallagher KM, Updegraff JA. Theory of planned behavior explains gender difference in fruit and vegetable consumption. Appetite 2012;59(3):693-697. https://doi.org/10.1016/j.appet.2012.08.007ArticlePubMedPMC
• 32. Cooper AJ, Gupta SR, Moustafa AF, Chao AM. Sex/gender differences in obesity prevalence, comorbidities, and treatment. Curr Obes Rep 2021;10(4):458-466. https://doi.org/10.1007/s13679-021-00453-xArticlePubMed
• 33. Masci D. The divide over ordaining women; 2014 [cited 2024 May 6]. Available from: https://www.pewresearch.org/short-reads/2014/09/09/the-divide-over-ordaining-women/

Figure & Data

References

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