Incorporating religion and spirituality into the design of community-based physical activity programs for African American women: a qualitative inquiry

Objective Limited research has examined how aspects of religion and spirituality can be incorporated into community-based physical activity programs delivered outside of religious institutions. The purpose of this study was to qualitatively explore how spirituality and religion can be leveraged in the design of community-based physical activity programs for African American women delivered outside of faith-based or faith-placed settings. Results Three focus groups were conducted were conducted with 23 African American women (M age = 37.8 years, M BMI = 39.6 kg m2). Results showed that incorporating aspects of spirituality (i.e., words encouraging connectedness to a higher power, meditation, mind–body activities) into a physical activity program was universally accepted among participants, regardless of religious affiliation. In contrast, including concepts of religion (i.e., bible verses and/or quotes from religious leaders) was controversial and not recommended among women who did not identify with a religious faith. Findings indicate that when developing community-based physical activity interventions that will not be delivered through faith-based or faith-placed settings, researchers should avoid references to specific religious beliefs. Instead, interventions should focus on spirituality and emphasize the mind–body relationship between physical activity and an African American women’s inner-being and her connectedness with a higher power. Trial Registration ClinicalTrials.gov NCT02823379. Registered July 1, 2016


Introduction
African American (AA) women exhibit low physical activity (PA) levels [1] and are disproportionally burdened by associated cardiometabolic disease conditions [2][3][4], emphasizing the need for effective interventions to promote PA in this population. Religion and spirituality have an extensive history in AA culture [5,6] and have been the focus of many interventions designed to promote PA [7,8]. Programs that incorporate religion and spirituality are viewed as advantageous because they acknowledge the deep-rooted religious beliefs and social networks of AA women and leverage them to promote PA [9,10]. Such programs are generally known as either faith-based or faith-placed. Faith-based programs formally incorporate aspects of religion (i.e., scripture/biblical stories) into PA promotion efforts. Faith-placed programs are delivered through religious institutions (e.g., churches), but do not necessarily incorporate aspects of religion into formal intervention activities. However, as others have noted [11], faith-placed programs are often augmented by congregation members during delivery to include religious references; which makes them very similar to faithbased programs.
Despite the large body of research on faith-based and faith-placed PA interventions, few studies have examined Open Access BMC Research Notes *Correspondence: Rodney.Joseph@asu.edu 1 Center for Health Promotion and Disease Prevention, College of Nursing and Health Innovation, Arizona State University, 550 N 3rd Street, Phoenix, AZ 85004, USA Full list of author information is available at the end of the article how religion and spirituality can be incorporated into PA interventions delivered outside of religious institutions. The purpose of this report is to describe how spirituality and religion can be incorporated into PA programs for AA women delivered outside of faith-placed or faithbased settings. Data for this report were collected as part of a larger on-going study that focused on: (1) collecting empirically-driven qualitative data on perceptions, manifestations, and determinants of PA among AA women to improve and refine the cultural relevance of a an established PA program for AA women, and (2) testing the refined intervention in a randomized control trial to increase PA and reduce cardiometabolic disease risk (ClinicalTrials.gov Identifier: NCT02823379).
We conceptualized religion and spirituality as similar, yet distinct concepts. We defined religion as adherence to a formal belief system in which practices are associated with tradition, and where there is agreement among members regarding what is believed and practiced [12]. Moreover, in most Christian religions (which is the predominant religion among AA women [13]), there is shared belief in a supernatural creator (i.e., God) that informs these formal practices and beliefs [12]. We defined spiritually as a more general, unstructured, personalized, and naturally occurring phenomenon where a person seeks closeness and/or connectedness between him/herself and a higher power or purpose [12,14,15]. Based on these definitions, both religion and spirituality focus on increasing connectedness with a higher power, but each has a different approach. It also is important to note that these concepts are not necessarily competing belief systems; rather, they can be complementary to each other or independent in their own right [16].

Methods
Data were collected from 23 sedentary and obese AA women. The primary study [17] from which the data were derived included a total sample of 25 AA women. The sample size in this report is smaller than the primary study because two participants did not attend the focus group sessions exploring the topics of religion and spirituality. Based on our previous research experience, the primary study's a priori sample size of 25 was determined as ideal to provide adequate coverage and depth of the topics explored. Readers are referred to a recently published article [17] for a more in-depth description of the study design, development process of focus group guides, and primary qualitative findings.
Participants were recruited using multiple communitybased strategies, including email listservs, newsletters, advertisements on social media, and local websites targeting the AA community. Eligibility for participation included: (a) self-reported as AA, (b) between the ages of 24-49 years, (c) body mass index (BMI) ≥ 30 kg m 2 , and (d) < 60 min/week of moderate-to-vigorous intensity PA according the 2-item Exercise Vital Sign questionnaire, which has been validated for PA assessment among AA women [18]. No further inclusion/exclusion criteria were specified.
Data reported are from three focus group sessions. The number of women attending each focus group session was 9, 8, and 6, respectively. Focus groups were led by an AA woman (LMM) with over 3.5 years of focus group facilitation experience. The P.I. of the study (RPJ) was also present during the focus group sessions to serve as note taker of participants' non-verbal communications. Topics explored during focus groups were derived from previous PA research with AA women [19][20][21][22][23][24] and a critical review of the extant literature. The discussion guide used in the focus group sessions is illustrated in Table 1. Of note, participants were not provided with the definitions spirituality or religion during the focus groups. Rather, it was up to them to operationalize these topics through group discussion.
All focus group sessions were audio recorded and transcribed verbatim. Participants were provided an identification number for reporting purposes. Transcripts were imported into NVivo qualitative analysis software (version 11) for analysis. Descriptive content analysis [25] was used to analyze the focus group data. Data were coded using a multi-phase approach, which has been reported elsewhere [17]. Saturation of themes was not formally evaluated by the research team, as we, along with other researchers [26], question its appropriateness in nongrounded theory qualitative research. Likewise, due to the collaborative nature of data analysis, a formal statistic of inter-rater reliability was not calculated. Quantitative analysis of demographic data was completed using SPSS version 23.

Results
Demographic characteristics of participants are presented in Table 2. Qualitative findings from participants were classified into three overarching themes: (1) Incorporating religion into a PA program was viewed as favorable, (2) Incorporating religion into a PA program was either cautioned or discouraged, and (3) Incorporating spirituality into a PA program: a universally accepted approach. Each of these themes is described in more detail below. Table 3 provides participant quotes supporting each theme.

Theme 1: Incorporating religion into a PA program was viewed as favorable
During initial discussions on this topic, several women discussed various religious institutions that offer group-based PA classes to both church members and non-members. Some women reported attending these sessions previously and having positive experiences, while others only reported awareness of their existence. As conversations progressed, numerous women spoke favorably about incorporating religion into a PA program. One participant stated the following when discussing how her religion motivates her to be physically active (Focus Group #1, Participant 17), "I would have to say that my spirituality, my faith, has a lot to do with encouraging me to increase my physical activity…reading in the Bible about my body being a temple of the Lord. How I am I to fulfill my purpose on the earth if I'm not healthy to accomplish that?" Participants described various ways in which religion can be incorporated into a PA program, including incorporating scripture into intervention messages and having religious leaders be a part of the program.

Theme 2: Incorporating religion into a PA program was either cautioned or discouraged
As conversations on the topic of religion progressed, several participants reported negative experiences they have had while attending church services or organized church events. One participant (Focus Group #1, Participant 3) described the following, "I haven't had any positive experiences at church, being there were comments… like, 'Oh, you're really heavy. '" These negative experiences tempered the desire for some women to participate in a PA program that incorporated religious references. Likewise, several women reported that they were not religious and including religious references would be offensive and/or irrelevant to their lives. Collectively, the women reached a consensus that if religion was to be incorporated into a PA intervention, the program should be delivered through a formal religious institution, as it would help alleviate any differences or concerns associated with offending women who were not religious.

Theme 3: incorporating spirituality into PA program: a universally accepted approach
In contrast to the diverse perspectives on whether religion should be incorporated into a PA program, women universally endorsed incorporating concepts of spirituality (i.e., words encouraging connectedness to a higher power, meditation, mind-body activities). Overall, participants emphasized that spirituality was a common ground among AA women, regardless of religious affiliation. One participant illustrated this with the following

Discussion
This results of this study explicate how religion and spirituality can be incorporated into a community-based PA program for AA women implemented outside of faith-based or faith-placed setting. A major finding was that spirituality was an acceptable and motivational concept to include in a PA program, regardless of the participant's religious beliefs. Conversely, religion, while desirable among some women, was considered irrelevant and/or inappropriate by others within the design of a PA program.
Our findings may reflect a changing religious landscape in the U.S. While AAs remain one of the most religious demographic groups in the U.S. [27], recent data indicate younger generations (i.e., Millennials and Generation X) are less religious than their older generation counterparts [28]. The mean age of participants in our study (i.e., 38 years) places our sample in these "less religious" generational cohorts. While interest in formal religion among younger generations may be waning, there appears to be an increase in the number of Americans who associate themselves with being spiritual [28], as data from the Pew Religious Landscape Survey show the number of all Americans who report feeling a "deep sense of spiritual peace and well-being" increased from 52 to 59% between 2007 and 2014 [29]. Although these data on spirituality are not race specific, they do provide some context to our qualitative findings. Despite some women opposing the use of religion in a community-based PA program, many women endorsed it. These findings highlight that faith-placed and faithbased PA programs have contemporary relevance among many AA women. However, future studies are needed to further explore the efficacy of faith-based and faithplaced approaches to increase PA among AA women. In particular, there is a need for in-depth preliminary work that includes knowledge and sensitivity to generational contextual differences among AA women.
The information gained from this report has implications for both research and practice. First, our data show that incorporating aspects of religion into PA programs for AA women of a homogenous religious faith through faith-based or faith-placed settings may help enhance the salience, uptake, and behavioral targets of the program. Second, when designing PA programs for AA women who do not self-identify as religious or for a diverse group of AA women who may or may not be religious, researchers should avoid mentions of specific religious concepts. Instead, they should consider designing intervention messages to include notions of spirituality or excluding mentions of religion and spirituality altogether.

Limitations
Limitations of our study include a sample comprised of predominantly highly educated AA women residing in a single in a Southwestern U.S. metropolitan area, truncating generalization to AA women with lower education levels or residing in other regions of the U.S. Despite these limitations, findings provide a basis for future research to explore these topics in a more diverse group of AA women. A strength of our study was that we explored PA design strategies that have not been studied in AA women in recent years. Given that sociocultural norms evolve overtime, these results provide preliminary data on how norms associated with PA, religion, and spirituality may be evolving in the AA community. Future studies are warranted to confirm and expand on our findings. Authors' contributions RPJ conceived the study, participated in the design and coordination, performed data collection and analysis, and helped to draft the manuscript. CK and BEA participated in the design of the study, data analysis, and helped draft the manuscript. SPH participated in the design of the study and helped draft the manuscript. LM participated in data collections and provided critical review and feedback of results presented. All authors read and approved the final manuscript.