A nurse is planning a health promotion presentation for a group of African American

Journal Article

Michael W. Parker, DSW, LTCR, BCD, LCSW, ACSW,

Michael W. Parker, DSW, LTCR, BCD, LCSW, ACSW

Michael W. Parker, DSW, LTCR, BCD, LCSW, ACSW, LTCR, BCD, LCSW, ACSW, School of Social Work, University of Alabama, Little Hall, Box 870314, Tuscaloosa, AL 35487-0314. E-mail: .

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16 November 2001

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  Michael W. Parker, DSW, LTCR, BCD, LCSW, ACSW, Jeffrey M. Bellis, PhD, Phillip Bishop, EdD, Mary Harper, PhD, RN, FAAN, Richard M. Allman, MD, Cynthia Moore, MS, RD, LD, Paula Thompson, PharmD, A Multidisciplinary Model of Health Promotion Incorporating Spirituality Into a Successful Aging Intervention With African American and White Elderly Groups, The Gerontologist, Volume 42, Issue 3, 1 June 2002, Pages 406–415, https://doi.org/10.1093/geront/42.3.406

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Abstract

Decision Editor: Eleanor S. McConnell, RN, PhD

Our aging population underscores the importance of developing effective strategies for meeting the needs of our elderly population, particularly those of underserved groups (American Association for World Health 1999; Department of Health and Human Services 1991; Marin and Burhansstipanov 1995; Stoller and Gibson 2000). Yet, much of what is known about how people age successfully is not being applied effectively (Antonucci 2000). The old public health model, which focused primarily on the prevention of acute, life- threatening communicable diseases, provided a strong context for community-based initiatives; however, more recent public health efforts with the elderly population have lacked a community-based context (Wallace 2000; Yee and Weaver 1994). Instead, noncommunicable, individualized risk factors (e.g., smoking, lack of exercise, high fat diet) have been emphasized because of their clear association with chronic conditions (e.g., coronary heart disease, cancer, diabetes) of late life (Dychtwald 1999; Haber 1999). The health promotional model advocated in this study combines individualized and community-based approaches using a faith-based intervention paradigm that relies on a collaborative synergy among religious, medical, and academic institutions.

This study has three primary purposes. First, we highlight the value of implementing a spiritually based, community model of health promotion that helps key community groups unaccustomed to working together forge partnerships that affirm seniors. Second, we emphasize during the formative stages the importance of maintaining an ecumenical spirit and a focus on the aging church in facing some of the community tensions brought about by racial, socioeconomic, and religious diversity. Finally, we describe how an expanded version of Rowe and Kahn's model of successful aging (Rowe and Kahn 1987, Rowe and Kahn 1997) that incorporates spirituality helps maximize the potential contributions and collaborations of churches, health care providers, and academic institutions in meeting the challenges of an aging society at the community level.

Historically, community health promotion efforts and health care focused on predominately White, economically privileged populations (Bengtson & Parrot, 1994; Rosenberg and Smith-Rosenberg 1968; Stoller and Gibson 2000; Turner 1987). As researchers and practitioners in the field have since recognized, generally these populations were already among the most healthy and health conscious (Turner 1987). In more recent years, health promotion efforts targeted toward less affluent and historically underserved groups have been developed and evaluated, and have tended to rely on communication channels, networks, and leaders internal to the underserved communities (e.g., Eng and Hatch 1992; Hatch and Lovelace 1980; Jackson and Parks 1997; Levin 1986; Taylor and Chatters 1986). Many initiatives have focused exclusively on ethnically relevant and sensitive health promotion initiatives (e.g., Kong 1997; Kumanyika and Charleston 1992; Okwumabua and Martin 1997; Smith and Merritt 1997). Although responsiveness to special health needs and concerns of minority populations had its benefits, a result of the ensuing "ethnically targeted" approaches is an implied emphasis on the differences between various groups and communities.

It is not our intent to be critical of these approaches or their successes. Rather, we present an alternative, and perhaps more collaborative approach, that capitalizes on the common bonds of spiritual devotion and practice among different cultural groups. Using this approach, our successful health promotion intervention has united different cultural and denominational groups of elderly people by focusing on health and successful aging, and by fostering inclusive and collaborative relationships among historically separate cultural and spiritual communities.

Professional groups have been slow to recognize the important role of religious organizations in providing support for aging members in communities and health care settings (Koenig 1997, Koenig 1999). Religious-based health promotion has been criticized historically for emphasizing moralistic, individual responsibility for successful aging (Wallace 2000). Yet, for more than two millennia, religious groups in society have provided care and support to the poor and elderly persons (Koenig 2000; Koenig, McCullough, and Larson 2001).

It is well established that churches and religious organizations strengthen personal networks; empower older persons by providing opportunities for leadership, participation, and intergenerational exchange (Hooyman and Kiyak 1999; Koenig et al. 2001); provide significant help with day-to-day tasks (Blasi 1999; Ramsey and Blieszner 1999); and provide other forms of instrumental and emotional support for older persons (Blazer, 1991; Koenig et al. 1999; Koenig et al. 2001). Formal religious involvement is related to general measures of personal adjustment and subjective health and life satisfaction (Koenig 1999; Matthews et al. 1998). Outreach to elderly people is part of the primary mission of many religious organizations, particularly African American churches (Koenig 1999).

The socially supportive role of African American churches is well documented (e.g., Jackson and Reddick 1999; Levin 1986; National Heart, Lung, and Blood Institute, 1992; Taylor and Chatters 1986), and a growing body of research focuses on the health promotional, preventive role of the African American religious community (Chatters, Taylor, and Jackson 1985; Marin and Burhansstipanov 1995). Smith and Merritt 1997 have examined the impact of education and support provided by African American churches in encouraging health promotion activities for blood pressure management and report efficacious outcomes. Jackson and Parks 1997 have reviewed the expanding lay health advisor movement that has grown over the past 20 years. They recommend that professional educators rely on the collective wisdom of the community to identify, recruit, select, and train lay health advisors. A number of additional studies confirm the value of incorporating the collective wisdom of the African American religious community into health promotional outreach programs (Chatters et al. 1985; Eng and Hatch 1992; Kumanyika and Charleston 1992; Stillman, Bone, Rand, Levine, and Becker 1993).

Methods

Our model of health promotion leading to a successful aging intervention with faith-based communities is portrayed in Fig. 1 and described in the sections that follow.

Interdisciplinary, Multiinstitutional Collaborative Synergy

The underlying foundation for our model is partnering medical and academic institutions with faith-based communities. Faith-based communities bring the most important resource—people—with a common focus on spiritual practice and devotion in their lives. A powerful synergy can be realized when church leaders partner with individuals from the local medical community, who contribute clinical knowledge and expertise, and individuals from local academic institutions, who provide a focus on evidence-based approaches to prevention and health promotion. Our model provides a community and faith-based focus analogous to the sanitary movement that received moral legitimacy during the 20th century (Condran, Williams, and Cheney 1984; Rosenberg and Smith-Rosenberg 1968), but addresses health promotion within an individualized, spiritual context. The spirituality of an aging person, a professional, a family, a church, and a community represents a tremendous source of tenacious motivation and commitment. Examples of this synergy are discussed in the Results section.

Target Population

Our model targeted seniors and their adult children affiliated with Christian faith-based organizations. Although other religious groups were not included in the planning process, no effort was made to limit attendance at the conference based on religious affiliation or belief. However, conference organizers decided to plan their interventions under a Christian ecumenical umbrella, because the primary impetus for unity across the varied academic, religious, and medical organizers was their shared religious beliefs. The decision to target Christian faith-based organizations came out of a recognition that even these organizations—which share many common values and orthodoxy of beliefs—seldom engage in joint ventures such as these conferences, and need to partner and share church resources to better cope with the growing number of elderly church members.

Planning Process

The objectives of the conference were in keeping with the broad goals of Healthy People 2000 and 2010: to increase of the span of healthy life; to reduce health disparities among Americans; and to improve access to preventive services (Department of Health and Human Services 2000). The community-based objectives of our conference were to present state-of-the-art expertise on how to age successfully in a manner that acknowledged the important role of spirituality; to affirm and encourage elder leadership, work, and volunteerism in all spheres of society; and to promote discussions between elderly people and their adult children on how to prepare for the next season of life. In addition, we hoped to foster ongoing, ecumenical partnerships among academic, medical, and religious communities that bridged racial, ethnic, class, and educational barriers.

With these guiding principles setting the agenda, our model recognizes the critical importance of key aspects of the planning process. The process began when one individual asked one church to invite other church leaders to attend a meeting where the vision for the conference could be shared. In the meetings that followed, an effort was made to include as many churches as possible, irrespective of denomination. Once officers were elected, minutes were taken, and key decisions were made democratically. Committee leaders either volunteered or were nominated and elected during the early stages of the planning process, and care was taken to ensure that leadership positions (e.g., committee chairs and so forth) were equitably distributed across all ethnic and denominational groups. Votes were taken in key matters of decision. For example, although the decision to work with the Continuing Education Department of a public university was unanimous, it was initially controversial and was made only after much study, debate, and discussion.

Organizational meetings were held in a nondenominational setting so that no particular church, denomination, or religious organization could be viewed as the primary proponent for the conference. Likewise, the conference setting was a public university conference center and not a church-related one, although future conferences may be held in a large church facility for cost containment purposes. Cost of attendance—which included meals, free screenings, and selected presentations—was minimal and based on the economic needs of the individual attendee. Costs associated with the conference were defrayed by profit and nonprofit sponsors, most of which were providers of programs and services for elderly people. Registration costs were kept low through church subsidies, and scholarships were offered to those unable to pay. Transportation was organized and provided by sponsoring churches and religious organizations.

Representatives from more than 30 local churches participated regularly in monthly and sometimes biweekly organizational meetings over a 9-month period. During the initial phases, three leaders were elected to oversee the planning process. Two of these leaders represented predominately White religious organizations, and one leader represented an African American church. Each representative of a religious organization also supported the intervention by promoting the conference in his or her local organization, and each active member of the planning group served on one of the seven subcommittees. Table 1 describes the primary contributions of each partnering institution.

The College of Continuing Studies of a local public university provided substantial budgetary and conference planning consultation, managed the registration process, assisted with the publicity, and provided oversight the day of the conference, at reduced cost. University involvement generated some "town and gown" contentions. The University Chancellor's Office voiced initial suspicions about the Christian tenor of the conference, and representatives from the religious community expressed concerns about freedom of religious expression. University officials were assured that official university involvement was limited to continuing educational support and to the provision of health promotional information, and church representatives were assured of their rights to freedom of religious expression during identified workshops and presentations at the conference. Representatives from the Office of Continuing Education indicated that, before the conference, local pastors rarely took advantage of continuing education opportunities offered by the university and that this conference represented the first successful bridge to the religious community.

African Americans and Whites in this local community had never previously collaborated in planning and/or sponsoring programs for the elderly population . In recognition of these concerns, a primary aim among the conference planners was to have strong participation by members of both racial groups. African American members of the grass roots planning committee were instrumental in helping their White colleagues present culturally important, sensitive, and relevant information and perspectives. For example, they pointed out the tendency of "well meaning" White professionals to take their own cultural message and approach about wellness and successful aging to the African American community with little consideration for cultural, lifestyle, and status differences. Their counsel was important in educating many of the White leaders and presenters about an inclusive approach. If issues of diversity had not been addressed, diversity of participation by all groups in the conference would have been compromised.

The planning process brought together diverse groups, including a multidisciplinary group of professionals, economically and educationally advantaged and disadvantaged individuals, Whites and African Americans, and religious "liberals" and "conservatives" from a variety of religious organizations. Focusing on issues related to aging minimized differences in the orthodoxy of beliefs across denominations. During the planning process, "town and gown," racial and denominational barriers and suspicions were voiced, discussed, and addressed. The importance of including African American and White, Protestant, and Catholic faculty among the plenary and workshop presenters was emphasized as an important strategy in securing diversity of attendance at the conference. Feelings of accomplishment and unity were greatly facilitated by opening and closing prayers at each meeting. Although the idea of sharing leadership among diverse constituencies is neither novel nor unique, it is extremely important to report that this process was successful in forging partnerships that were previously not thought possible, and that these community groups coalesced around issues related to the needs of seniors.

In summary, African American and White religious leaders of different orthodoxy shared key leadership roles on the various committees and the executive leadership team. Religiously diverse input from representatives of different religious communities strongly influenced the development of promotional strategies, faculty selection, and funding. Meetings were managed to maximize a democratic process of participation. African American and White faculty members were prominent as plenary speakers and workshop leaders, and were represented in all public promotional initiatives (TV, radio, newspaper, and brochures). When African American faculty saw the conference brochure, which featured an African American couple, many said Whites would not attend. One African American faculty asked if it was a "Black conference." It was gratifying for all when conference participation rates corresponded to the racial demography of the community.

Conference Content

The conference was conceptualized as a comprehensive opportunity for seniors and their adult children to obtain relevant health promotion and elder-affirming messages in a "one-stop-shopping" environment. Parameters for conference content were managed using the expanded Rowe and Kahn model. Professional input and expressions of need from lay conference planners provided the Faculty Committee chairman with balanced input. Ultimately, the topics and faculty selected were reviewed and sanctioned by the entire conference-planning group. Academic and medical professionals were more actively represented on the Faculty committee, and lay members were more involved in logistical committee planning.

Analogous to the concept of dining at a "smorgasbord," where the individual diner has many options from which to choose, we envisioned providing a range of activities and topics from which conference participants would select those sessions and workshops of individual interest. The specific content provided was conceptualized within the context of a Life Course perspective, which suggests that the aging process is affected by individual attributes and experiences. These, in turn, are influenced by sociohistorical times, membership in a birth cohort, and by a person's position in systems of inequality based on gender, race, and economic status (Parker et al. 2000; Thomas and Quinn 2000).

An enhanced version of Rowe and Kahn's model of successful aging, which includes positive spirituality as a core construct, provided overall foci for the conference (Parker et al. 2001; Ramsey and Blieszner 1999; Rowe and Kahn 1997). We took generativity as a general theme by clearly affirming the critical role of older people in society. During the planning process, many seniors expressed frustration with ageist attitudes and policies of their churches (age-graded Sunday school classes rather than the "old" teaching the "young" admonitions of the Scriptures). Many participants expressed appreciation for the affirming nature of the positive role seniors play in the community. For example, conference attendees were repeatedly told that "they were needed as leaders" in their families, their churches, and their communities. Many involved with the planning process maintained that the organized church needs to be more actively and proactively involved in facing America's demographic imperative and in enhancing the quality of life for the elderly population.

Conference presenters were suggested by and recruited from varied medical practices, academia, public health services, and faith-based communities. The range of topic areas covered was broad, including interventions promoting behaviors related to positive health outcomes, information about resources and services, presentation of opportunities for active engagement, legal and financial strategies for older adults and their adult children, and spiritual practice. The format consisted of plenary sessions, seminars, and a variety of free, health-risk assessments offered by local hospitals and state agencies. Themes promoted included the importance of elder leadership; spiritual growth; avoidance of disease and disability; active engagement with life; maintenance of high cognitive and physical fitness; intergenerational transfers of wisdom; awareness of services and programs for seniors; and late-life legal, health, and financial planning. Table 2 includes a list of presentations made by a multidisciplinary team of experts arranged by each of four successful aging themes promoted at the conference. The most requested, highly attended workshop for the conference is identified, and presentations are listed within each theme based on demand at preregistration. The "enhancing your memory" workshop was the most highly requested topic for the conference as a whole. In addressing this request pattern, the workshop was repeated to meet the demand that organizers felt was related to fear of dementia. The session addressing palliative care and death and dying issues was the most poorly attended; however, all who attended were enthusiastic advocates of its efficacy.

Topics that are needed, but perhaps avoided because of the unpleasing subject matter, may need to be integrated into plenary sessions at future conferences. All professionals provided their services gratis, motivated largely by their religious beliefs and the opportunity to speak on issues in an applied, preventive setting to a group of older people on a subject of professional interest and relevancy.

Results

Although conference evaluations were provided to all who attended, 27% (n = 135/500) of those attending completed and returned program evaluations at the end of the conference. Registration information was used to determine that the racial composition of those attending was approximately 74% White, 23% African American, and 3% other races, mirroring the overall racial composition of the community.

Based on postconference survey data (N = 135), African American and White participants were comparably distributed with respect to level of educational attainment. On average, the conference audience was fairly well educated, with 50% of survey respondents having at least a 2-year college degree. Eighty-eight percent of African American and 95% of White survey respondents reported attending religious services at least one time per week. The most frequently endorsed reason for choosing to attend the conference, across the entire sample, was "to learn more about aging successfully" (79%). Conference attendance appeared to motivate African American and White individuals to make changes in their lives, although the influence seemed to be stronger on African American survey respondents. Ninety-seven percent of African Americans reported an intention to make changes as a result of the conference, in contrast to 80% of White participants (χ2 = 6.13, df = 2, p = .047). Both ethnic groups rated the conference highly, with 98% rating their experience as either "excellent" (African American—67%; White—77%) or "good" (African American—33%; White—24%). Ratings of the instructors were nearly identical.

Examples of interdisciplinary, multiinstitutional collaborative synergy are represented by the willingness of academic experts in aging, health care providers, and other professionals from a variety of disciplines to offer their services gratis. Further illustrations are the capacity of volunteers from diverse religious groups to persevere through months of planning to organize a conference; and for these same representatives from three key community groups to develop ongoing associations, partnerships, and activities that advance the welfare of seniors. Another critical measure of success was the achievement of high rates of participation and satisfaction among White and African American participants.

Many spiritually motivated elderly individuals suspicious of traditional health promotional messages received for the first time accurate information about healthy lifestyles and participated in health screenings. After the conference, one pastor requested help in developing and evaluating a falls prevention program that included a balance-related exercise program not previously offered in the community. One adult child who attended the conference with his widowed father described its impact: "After the conference, my father was a different person. He began a daily exercise program, attended church again, and became involved with my children in a special way." Local pastors who attended the session designed specifically for them stated that it was the first time they received answers to difficult questions, and several volunteered resources for communitywide use.

Recommendations from postconference meetings by the organizers included the need for more focused interventions linked with follow-up programs between the annual or biannual conferences, and for increased community-based ecumenical support and coordination of ongoing health promotional interventions that would facilitate the sharing of resources and support sustained lifestyle change with elders. In planning for future conferences, an effort will be made to document hypothesized conference effects.

Discussion

Desired sequelae emerging from the conference were the establishment of continuing health promotion and the formation of life-affirming activities focused on older adults within these newly established faith-based coalitions. We found that ongoing relationships among the denominational and racial groups arose spontaneously, resulting in functional, proactive, ongoing coalitions that have planned and implemented further health promotion activities within the community.

In what we viewed as a particularly positive and gratifying sequela of the conference, lay leaders and pastors to the elderly people representing the participating churches and religious organizations agreed to meet monthly to discuss opportunities for sharing resources, developing ongoing and innovative programs, and planning future events for the elderly people in the community. Budgetary funding for a community senior ministry association was explored by individual churches, and with two denominations at the state and national level. Community representatives advocated for inclusion in church annual budgets the costs of part-time staff who would assist in the development of grant opportunities, coordination of ecumenical partnerships with medical and university experts (e.g., survey the religious community to determine existing programs and to identify needs), and the provision of an ongoing, monthly newsletter to enhance communication to seniors across denominational lines of affiliation.

Because the principal author has shared this model and these ideas at various professional forums across the country, a number of large churches, national denominations, and other faith-based organizations have expressed interest in developing similar conferences that foster academic–medical–religious partnerships that cut across racial, educational, and class boundaries (Parker et al. 2000). This outcome is perhaps the most important in that it provides evidence that the proposed model supports the initiation of a sustainable, inclusive process that can activate communities to take advantage of existing resources and organizational structures. We maintain that ecumenical conferences can help communities jump-start needed health promotional activities, improve communication across denominational and racial barriers, and result in ongoing creative partnerships between religious, academic, and medical communities.

Keys to African American participation in the conference were African American leadership in organization and planning; African American faculty involvement; African American ministerial support for the conference; African American representation in promotional efforts; and, most important, African American and White expressions of spiritual unity through shared beliefs, prayer, costs, and responsibilities for implementation.

The preliminary success of this model symbolizes the positive potential of reversing the trend toward separation of spirituality, religion, and medicine that has historically occurred particularly in the south. Furthermore, the success of this endeavor promotes the idea that by focusing on a common commitment to spiritual growth and physical health across often separated ethnic and religious denominations, a community can bring groups together within a successful aging health promotion forum.

Future research using a longitudinal research design with a comparative control group would provide information about the effectiveness of such conferences in generating ongoing programs within the religious community and the effectiveness of the conference in assisting attendees in sustained lifestyle change. We know, however, that the expanded Rowe and Kahn model used to guide our intervention in the community has the capacity to generate interest and collaborations across denominational, racial, and class barriers. Most important, this model has the potential of helping to unify the religious community around the important task of promoting successful aging.

As our aging society faces the growing costs of health care, it will be forced to look with the religious community and the health care industry for creative methods to address the coming health crisis. How will the aging church (and other religious organizations) respond? This century will bring a growing realization within the health care industry and among religious organizations that the spiritual dimension of people can help bridge the gap between our medical discoveries and how we live.

Table 1.

Primary Contributions of Each Partnering Community by Key Conference Elements

Table 1.

Primary Contributions of Each Partnering Community by Key Conference Elements

Table 2.

Presentations Made by a Multidisciplinary Team of Experts Arranged by Each of Four Successful Aging Themes Arising Out of the Expanded Rowe and Kahn Model

a

Indicates most highly attended session within conference.

Table 2.

Presentations Made by a Multidisciplinary Team of Experts Arranged by Each of Four Successful Aging Themes Arising Out of the Expanded Rowe and Kahn Model

a

Indicates most highly attended session within conference.

Figure 1.

Proposed model for development, implementation, and sustainability of community-level health promotion intervention targeting faith-based communities.

Special appreciation is offered to Ms. Sandra Flynn, Research Assistant, and to the 30 area churches of all denominations who helped fund and organize the Conference on Successful Aging; and to the faculty representatives from the University of Alabama, Samford University, University of Alabama in Birmingham, and the University of Montevallo, who provided their services gratis. Although the views expressed in this article are the exclusive opinions of its authors, the authors gratefully acknowledge the assistance of The Gerontological Society of America and The John A. Hartford Foundation's Geriatric Social Work Faculty Scholars Program.

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