The Psychology of Religion and Happiness

O R I G I N A L P A P E R

Religion and Health-Promoting Behaviors Among Emerging Adults

Shalonda E. B. Horton

Published online: 13 September 2013 � Springer Science+Business Media New York 2013

Abstract Studies suggest we capitalize upon religion’s health benefits to prevent obesity. The purpose of this qualitative descriptive study was to determine how emerging adults

used religion to manage their health. Two focus groups were conducted among White and

African American participants. Content analysis of the data revealed categories about their

attitudes regarding parental and religious influences, religion’s influence on behavior,

negative health effects of religion, barriers, obesity prevention, and health promotion

programs. Society sends out ‘‘easy’’ solutions for unhealthy behaviors, but we should focus

on healthy behavior benefits, remove barriers, and consider religion’s part in health pro-

motion (obesity prevention).

Keywords Emerging adults � Religion � Obesity � Health promotion

Introduction

The ‘‘fastest-growing cause of disease and death’’ in the United States (US) is obesity

(Office of the Surgeon General 2007). Over the past 20 years, there has been a significant

rise in the prevalence of obesity in the United States [Centers for Disease Control and

Prevention (CDC) 2012b]. According to the Behavioral Risk Factor Survey (BRFS) for the

years 2006–2008, the prevalence of obesity was C30 % in 40 states and 5 states had a

prevalence C40 % (Alabama, Maine, Mississippi, Ohio, and Oregon) (CDC 2012b).

According to the 2007–2008 National Health and Nutrition Examination Survey, 31.7 % of

children, ages 2–19 years, were overweight, of which 16.9 % were obese (Ogden et al.

2010).

Obese individuals are at risk for cardiovascular diseases, type 2 diabetes, cancer,

respiratory problems, osteoarthritis, and gynecological problems (CDC 2012a). Obesity

S. E. B. Horton (&) School of Nursing, The University of Texas at Austin, 1710 Red River Street, Austin, TX 78701, USA e-mail: shorton@mail.nur.utexas.edu

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J Relig Health (2015) 54:20–34 DOI 10.1007/s10943-013-9773-3

has been associated with depression and anxiety (Strine et al. 2008) and low self-esteem

(Strauss 2000). US medical expenses for overweight and obesity in 1998 were about $78.5

billion (CDC 2012a). In 2006 that figure drastically increased to $147 billion annually

(Holden 2010).

Religion and Obesity

Religion is the belief in a divine or supernatural power and made up of a system of beliefs,

thoughts, feelings, and actions shared by a group of individuals (Koenig et al. 2001). It may

be possible to prevent obesity through religious practices and support services built within

religious settings. Idler et al. (2003) encourage researchers not to overlook the part religion

plays in health.

It may be possible to capitalize upon the health benefits associated with religion

(Hummer et al. 1999; Koenig et al. 2001) to address the obesity epidemic. For example,

social support within religious settings and religious practices (e.g., prayer) has been

associated with increased physical activity (Kanu et al. 2008; Kim and Sobal 2004).

Researchers have found a positive association between health-promoting behaviors and

religion (Callaghan 2006; Chester et al. 2006; Rew et al. 2007). Additionally, a study

conducted by Ayers et al. (2010) suggested that religion might help prevent obesity among

Korean women in California. Prevention is key to thwart the development of obesity and

its associated health problems.

Purpose of the Study

As emerging adults, ages 18–25 years (Arnett 2000), approach adulthood they make life-

changing decisions (e.g., marriage) (Arnett 2004). These decisions, which may include

health behaviors, may be influenced by religious beliefs. A goal of Healthy People 2020 is

to promote the consumption of healthy diets and to achieve healthy body weight in the US

(US Department of Health and Human Services 2013). Specific objectives identified in

Healthy People 2020 related to obesity include increasing the proportion of adults who

have healthy weights (NWS-8), reducing the proportion of adults who are obese (NWS-9),

and preventing inappropriate weight gain among youth and adults (NWS-11). Consistent

with the goals of Healthy People 2020, the purpose of this pilot qualitative study was to

conduct two focus groups among emerging adults to examine the following: (1) determine

any changes in religious beliefs as they have matured; (2) obtain their attitudes regarding

parental and religious influences; (3) determine how religion influences their behaviors; (4)

determine any negative health effects of religion; (5) identify barriers that make it difficult

for them to practice healthy behaviors; (6) identify ways in which religion could prevent

obesity; (7) identify characteristics of a health promotion program that encourages the

practice of healthy behaviors, which may prevent obesity; and (8) compare the results

between the two focus groups.

Method

The methodology used in this study was qualitative description using qualitative content

analysis for understanding the data. By collecting data through focus groups from the

participants and writing procedural notes, the researcher was able to obtain data in an

organized manner (Sandelowski 2000). This methodology aided the researcher in

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collecting data from the participants’ perspective and stay close to their words without

trying to interpret the meaning (Elo and Kyngäs 2008; Sandelowski 2000). Focus groups

have been known to produce a considerable amount of data in a short span of time and

have been used in obtaining data about health matters (Green and Thorogood 2009).

Religion may be a sensitive topic to discuss within focus groups. However, individuals will

readily talk about a variety of personal topics, as long as the topic is not inappropriate for

the participants (Green and Thorogood 2009; Morgan 1993). An additional advantage of

using focus groups for data collection was that it allowed the participants to discuss

potentially sensitive issues (Green and Thorogood 2009).

Sample and Recruitment

After an Institutional Review Board approved the proposed study, a convenience sample of

participants, ages 18–24 years, living in a central Texas community were recruited for the

study. Flyers and a cover letter describing the study were distributed to local religious

organizations for recruitment purposes. Participants interested in the study contacted the

researcher. If the participant was within the previously stated age group, White or African

American (AA), spoke English, and had his/her own way of transportation to and from the

focus group location, then the participant was enrolled into the study and provided

information about the focus group (date, time, and place for the focus group). With the

participants’ permission, the researcher called and emailed participants reminders and

directions for their focus group.

Data Collection

Data were collected during two focus groups lasting 60–90 min each. One focus group

consisted of five White participants, and the second focus group consisted of seven AA

participants. America is a highly religious nation, which means many Americans attend

church services and pray frequently and religion seems to be an important part of their lives

(Putnam and Campbell 2010; Sahgal and Smith 2009). African Americans tend to be more

religious compared to Whites (Hunt and Hunt 2001; Putnam et al.). However, AAs are not

more likely to attend church regularly compared to Whites (Hunt and Hunt 2001). Due to

these ethnic/racial differences, the researcher decided to conduct two focus groups to

compare findings. If ethnicity/race matters arose during the focus groups by the partici-

pants, a moderator of the same ethnic background was used to facilitate each focus group.

Each focus group was conducted on separate dates (same day of the week) a week apart.

On the day of each focus group participants arrived at the designated site (local survey

research office). The researcher reviewed the consent form with participants, answered

their questions, and had them sign the consent if they wished to continue their participation

in the study before the focus group was initiated. During each focus group, the facilitators

used the same interview schedule and protocol. The participants responded to semi-

structured open-ended questions detailed in Table 1. Light refreshments and a $20 gift card

were provided to each participant for their time in participating in the focus group.

Data Management

A professional transcriptionist transcribed the audio-recorded focus groups. The researcher

verified the transcription of the focus groups. The de-identified transcript word document

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files of each focus group were saved on a password-protected computer in the researcher’s

office. Field notes were used to document the content, context, and tone of each focus

group. The notes also provide an audit trail and increase the trustworthiness of the data

(Lincoln and Guba 1985).

Qualitative content analysis was conducted as described by Lincoln and Guba (1985)

(as cited in Phillips 2006). First, answers relating to religion, health, and obesity were

identified and removed from the main text for further analysis. Secondly, after reading and

rereading the text, line by line coding was done to mark key concepts, phrases, sentences,

or small narrative groupings related to religion, health, and obesity. Next, each new code

was given an assigned numerical digit, and the codes were then collapsed to form sub-

categories. Once the subcategories were developed, the researcher met with an expert

qualitative researcher and colleagues (third party consultant) for feedback regarding the

labeling of the subcategories, which helped to reduce researcher bias (Turner 2010). The

subcategories were then collapsed into categories. Lastly, once the categories were

developed, the researcher met with expert qualitative researcher and colleagues again for

additional feedback and verification.

In order to increase confidentiality, the participants used fictitious names during the

focus groups, which are used in reporting the results. The participants were instructed that

once outside the focus group setting, they should not reveal their or other participants’

identities nor discuss comments made during the discussion. All research reports and this

present article use fictitious names in lieu of the participants’ real names. Additionally, all

research materials (procedural notes and de-identified transcriptions) were stored in a

locked file, and all digital recordings of the focus groups were destroyed.

Table 1 Focus group semi-structured open-ended questions

1. Based on your definition of religion, how has your definition changed as you have aged or enter into adulthood?

2. How do you think your definition of religion will change as you become older?

3. What persons, things, or factors have influenced your definition of religion?

4. What are your feelings regarding the statement that parents are the strongest influence among adolescents (Wallace et al. 2003)?

5. What are your feelings regarding the statement that religion is the second strongest influence among adolescents (Wallace et al. 2003)?

6. How does religion influence your actions, behaviors, thinking, the way you communicate, talk, or your worldview perspective?

7. How has religion influenced your health?

8. In what negative ways has religion influenced your health?

9. How do you use religion to manage your health?

10. How can religion help prevent weight gain that can lead to obesity?

11. How can religion help those who are overweight or obese?

12. What does ‘‘healthy behaviors’’ mean to you?

13. What are some reasons why it might be hard for people to practice healthy behaviors?

14. If I were to develop an ideal program for people your age to practice healthy behaviors, what should the program include?

15. How might religion be incorporated into this program?

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Results

Although most of the interview questions focused on the participants’ attitudes and ideas

about religion and health, the data analysis revealed that AA participants often spoke of

health behaviors as an entity not directly connected with their religious beliefs. Conversely,

the White participants spoke of their health behaviors as intertwined with their religious

beliefs. Nonetheless, the analysis revealed commonalities between both focus groups:

religious beliefs changing as they age, attitudes regarding parental and religious influences,

and ways in which religion influenced their behavior. The focus groups’ ideas regarding

negative health effects related to religion were different. They shared slightly similar ideas

regarding what factors served as barriers to them practicing healthy behaviors and ways in

which religion could prevent obesity. Although their ideas for a health promotion program

were different, they provided similar recommendations on how religion could be incor-

porated into such a program. The following seven categories were identified from the data:

(1) changes in religious beliefs, (2) attitudes regarding parental and religious influences, (3)

religion influences behavior, (4) negative health effects of religion, (5) barriers to healthy

behaviors, (6) religion and obesity prevention, and (7) health promotion program

characteristics.

Changes in Religious Beliefs

The category of changes in religious beliefs was defined as a level of spiritual maturity

experienced by the participants as they have aged. When both groups were asked if their

definition of religion had changed as they have grown older, they shared three ways in

which their religious beliefs had changed over time. That is, as they aged and experienced

life, they understood the purpose of religion, discovered their own set of religious beliefs

separate from family’s beliefs, and shifted from a doing-based to a Him-based focus.

The participants discussed that when they were young children, they did not really

understand religion and were just going ‘‘through the motions.’’ However, as they aged and

encountered various life experiences, they began to recognize the purpose of religion. A

few participants discussed that when they are away from their parents (e.g., go off to

college), then their parents will no longer be able to influence their religious beliefs. Thus,

participants are given a chance to discover their own set of religious beliefs.

Only the White focus group discussed how their religious beliefs changed from a

‘‘doing-based to a Him-based’’ focus. They discussed that as they have matured (chro-

nologically and spiritually), they have experienced a shift in their focus from doing reli-

gious tasks and practices to a focus on a relationship with God. For example, Douglas

(White focus group) stated,

I guess religion to me has changed from a very doing based, like you were saying,

and a very selfish base…And I think that’s really shifted from a me based to a Him- based and just the belief in God and a relationship that started there, and the rela-

tionship that’s grown there through experiences, through suffering, through good

times.

Attitudes Regarding Parental and Religious Influences

The category of attitudes regarding parental and religious influences was defined as the

participants’ feelings regarding the results from Lerman’s national poll reporting that

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‘‘religion was the second strongest influence in their lives, second only to their parents’’ (as

cited in Wallace et al. 2003, p. 101). Both groups were asked to respond to this poll.

Both groups were equivocal about whether parents or religion was the strongest

influence on behavior. Some participants responded with statements agreeing that their

parents or guardians and religion influenced their behavior because ‘‘they [parents or

guardians] instill those core values. And so just like whatever they put into you is always

going to be there.’’ One male participant, Michael (AA focus group), mentioned that

parental influence could be positive or negative. He mentioned that his father’s mistreat-

ment of others pushed him to want to treat others better.

While some participants agreed that parents and religion were the strongest influence in

their lives, others stated that neither influenced them. Instead, both parents and their friends

or only their friends were the strongest influence. Few of the participants used age to

explain parental influence. They said that their parents had an enduring influence, but the

influential tension between parental and peer groups was linked to age. Their parents

influenced their behavior before a certain age. Once that age was reached, then peer groups

had a greater influence. For example, Evelyn stated (AA focus group),

Your parents’ influence is always going to be there, but I feel like when you’re

younger, you’ll do things. Your peers will influence you to do things that even

though in the back of your head, you’ll know what’s right, you’re going to go with

what your peers [want you to do]….So in my opinion, I feel like it’s peers from I guess like 12–18 [years of age]. And then I feel like as you get older, you move away

from being influenced by peers.

Religion Influences Behavior

The category of religion influences behavior was defined as ways in which religious beliefs

affected how the participants conducted themselves, such as their actions, communication,

and thinking. They described two ways in which religion influenced their behavior: taking

care of their mental and physical health and regulating their behaviors. For example, they

said it was their responsibility to practice behaviors that promote health for their body,

‘‘temple.’’ Several participants described how their bodies were a gift from God and that it

was important to take care of their bodies. For example, Amy (White focus group) said,

‘‘He [God] entrusts us for a little while with these physical bodies. And, um, we should be

good stewards of that.’’ A sense of stewardship was noted between both focus groups as

they described the importance of taking care of their ‘‘temple.’’

Participants positively spoke of religion in relation to their mental health. For example,

Carol (White focus group) discussed how religion helped her to deal with stress in her

workplace,

I have a peace and a confidence and an ability to let go of things and to not be

anxious over things…I know that God’s in control as compared to a lot of people in the workplace who are constantly anxious.

Carol went on to say that not being anxious or worried could potentially affect your

health long term (e.g., decreased risk for heart disease). Other participants agreed that

stress and anxiety could affect one’s health negatively and that their religious practices

helped to decrease their stress or anxiety.

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Both focus groups shared how religion regulated their behaviors in relation to how they

made decisions, communicated with others, treated others, and invested their time. For

example, Diane (White focus group) stated,

It [religion] influences what I decide to invest my time in, what I think is purposeful,

and it influences what like the big decisions in my life. It influences the way I treat

people…it’s not really a part of my life, it’s like the foundation of my life.

However, only the AA focus group data revealed how religion was used to regulate their

risky behaviors, particularly in limiting, setting boundaries, or cutting down on risky

behaviors and behaviors that God would disapprove. The most common risky behaviors

discussed by the participants included, but are not limited to, substance use (e.g., alcohol

and cigarettes/weed), overeating, and unsafe sex. For example, when talking about over-

eating, Michael (AA focus group) stated,

I used to eat to the point where I couldn’t walk, you know what I mean?…You go out and just load up on food. And that’s kind of like gluttonous….I think it goes back to the whole limiting what you eat….I just have a lot of people in my family that are way, way obese. And health wise it’s just like you can do something better for

yourself just by like limiting yourself to like your portions. And like not being

gluttonous.

Examples of behaviors that God would disapprove of included cursing, talking bad

about people, and disrespecting God’s name.

Negative Health Effects of Religion

The category of negative health effects of religion was defined as the harmful conse-

quences resulting from practicing one’s religious beliefs. When both groups were asked

about how religion had negatively affected their health, both groups had different

responses: physical and/or psychological health problems (White focus group only) and

prevent individuals from performing health-promoting behaviors (AA focus group only).

For example, Carol (White focus group) discussed how she got physically sick while on a

mission trip in another country after eating ‘‘something not right.’’ She stated,

He [God] could call you to risk your health or, you know, put your health aside for

something that is more important. And, you know, there are a lot of people in the

bible who did just that. And, you know, they were tortured and, and, you know, all of

that for the sake of God and for the sake of his name. So I can see how, um,

sometimes you may be called to do something that negatively affects your health,

whether it’s long-term mission work in an area that’s dangerous or, um, where you

don’t have, you know, the benefits of the healthcare system in America behind you.

The AA focus group described how practicing one’s religious beliefs could prevent

individuals from performing health-promoting behaviors. Participants described how

religious beliefs could prevent individuals from seeking health information and obtaining

preventive health care (e.g., vaccines). For example, female participant, Lisa (AA focus

group), stated,

Religion doesn’t encourage having sex [outside of marriage]…they’re scared to seek help or seek options to find healthy ways to engage in sexual activity because of the

religious views of sexual health. They don’t want to be looked down on.

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Barriers to Healthy Behaviors

The category of barriers to healthy behaviors was defined as the factors that prevent

individuals from performing actions that promote health. When both groups were asked for

factors that make it difficult to perform healthy behaviors, there were six common

responses: comfort with body image, lack of time, motivation, money, habits, and envi-

ronment. For example, Hannah (AA focus group) said, ‘‘If you’re comfortable with who

you are, then there should be no reason for somebody to bring you down.’’ If individuals

are comfortable with their body image, then they may not perform healthy behaviors to

change it. Monica (AA focus group) provided another example of how barriers prevent

individuals from performing actions that promote health by saying, ‘‘We live in a fast

paced society, so eating fast food and eating out is just easier than cooking sometimes.

People are busy. They say they don’t have time to work out or time to eat healthy.’’ Busy

people may not have the time to incorporate healthy behaviors into their daily lives and/or

may be too tired to find the ‘‘will’’ or motivation to practice them. The participants

discussed how the availability of ‘‘dollar menus’’ helps people save money and time: ‘‘I

think it’s a lot cheaper to eat unhealthy than it is to eat healthy’’ and it is ‘‘faster.’’ Most

participants agreed that in the midst of a recession, ‘‘everybody [restaurants] has some kind

of special. You know, a special [food discount or savings] for each day [of the week].’’ An

example of how the environment created barriers was reports of limited availability of

healthy food choices within their physical environments. In addition, family and peers

were examples of social environments that may serve as barriers. Lisa (AA focus group)

discussed how family upbringing in AA households may be different from White house-

holds by stating, ‘‘Upbringing, I feel like in African American households health isn’t as

encouraged as it is with White households or non-African American households.’’ Lisa

went on to say that girls at her school counted their consumption of calories and if one of

those girls gained a pound, her ‘‘parents will notice or like her parents will talk about her.’’

Lisa stated that when she had gained weight while at college, ‘‘my parents were like oh, we

can tell you gained some weight, but it wasn’t a big deal. It was like we knew you were

going to do it [gain weight].’’

Each focus group identified distinct barriers to healthy behaviors: stress and lack of

knowledge (White focus group only) and easy or quick solutions (AA focus group only).

The White focus group discussed how stress might lead to unhealthy coping strategies

(e.g., stress eating). If an individual lacked knowledge, then he/she would not have the

needed information to practice healthy behaviors. Amy (White focus group) stated,

‘‘Knowledge is a huge one. I mean, I’ve heard of a teenage mom feeding her baby like soda

pop out of a bottle. That’s not okay, but she doesn’t know.’’ The AA focus group identified

barriers that serve as ways or excuses to continue practicing unhealthy behaviors: easy or

quick solutions. They said in today’s society individuals can do any behavior that they

want (e.g., eat unhealthy) and then have the results of the behavior corrected (e.g., sur-

gery). For example, two participants (AA focus group) stated that you can ‘‘go out and eat

and do whatever, and then get that surgery [referring to surgical band placed around small

intestines], and everything be cool’’ and ‘‘if you can go have liposuction, then why not eat

whatever you want because you know you’re having liposuction.’’ With financial

resources, individuals can have greater access to these solutions: ‘‘with money, you can do

anything you want.’’

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Religion and Obesity Prevention

The category of religion and obesity prevention was defined as ways in which religious

beliefs and practices could stop individuals from gaining an unhealthy amount of weight or

help overweight individuals lose weight. When both groups were asked how religion could

aid in obesity prevention, two common responses were identified: take care of the body and

coping strategies. They described a sense of stewardship and responsibility to God to

practice health behaviors that may prevent obesity. However, a couple of the AA partic-

ipants believed that religion and obesity should be separate from each other to decrease the

risks of individuals performing religious practices inappropriately to lose weight (e.g.,

fasting). These two AA participants believed that fasting to lose weight might move

individuals away from God or take away from the spiritual significance of fasting. They

suggested that instead of using religious practices that perhaps churches could serve as a

setting for sharing health messages and providing exercise classes. The second way reli-

gion could aid in preventing obesity was by individuals using it as a coping strategy.

Participants shared that religion helped individuals to deal with or manage the reasons why

they practiced unhealthy behaviors that could lead to obesity. For example, Michael (AA

focus group) suggested that reading the bible would help individuals cope with stress by

saying,

They eat or they go out and they go drink [to cope with stress], which is also having

to deal with your health and having to deal with what you consume. They need to

figure out another way to deal with that issue…So then most times how you deal with it, you eat. And I think that if there would be another way that you could deal with

that situation, like a better support group, whatever, something. Like go further into

the book [bible].

Among the White focus group data, two additional responses emerged in which religion

could aid in preventing obesity that were not present in the AA data: encouragement from

God and accountability. For example, one participant shared how she receives direct

inspiration or help from God in practicing healthy behaviors (encouragement). Other White

participants discussed individuals’ responsibility to others in practicing healthy behaviors.

For example, Debra (White focus group) stated that she is accountable to the people in her

life in doing what God wants her to do, such as ‘‘having people ask you about how it’s been

going and keep you accountable [to practicing healthy behaviors].’’ Krystal (White focus

group) discussed an interesting perspective in that she could not perform the responsi-

bilities of her religion if she was obese and that the activity level of obese individuals may

be restricted. She stated that as a Christian she is responsible for helping others and ‘‘if you

become so obese, it can get to a point where you can’t help others’’ because of possible

physical limitations.

Health Promotion Program Characteristics

Health promotion refers to the actions, both physical and psychosocial, performed to

increase one’s well-being (Pender et al. 2006). Using this definition, the participants were

asked to describe an ideal health promotion program for individuals within their age group.

Both focus groups’ responses were different. The White focus group described activities

and the content for the program (program content-oriented responses). The AA focus group

described public health actions that would support the program (social change-oriented

responses).

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For example, the White focus group said that programs directed toward emerging adults

should include education classes and organized social activities that are performed as a

group. They recommended having a personal trainer for the group when it came to exercise

classes and not an individual or one-on-one personal trainer approach. The education

classes should be linked to organized social activities (i.e., nutrition education and nutrition

activities). The participants shared that they would not only like to have ‘‘some sort of

skills in learning how to cook’’ but also wanted the classes to ‘‘teach you how to cook

healthy. Not just the recipes, but actually the task of doing it [hands on cooking class as a

group].’’ Another participant even recommended having the cooking classes at someone’s

home. Other social activities included canoeing and playing soccer as a group.

The White focus group participants said that if the program was not group focused, then

individuals who participate in the program should be assigned an ‘‘accountability partner’’

to follow-up on how the individual is coming along on his/her healthy behaviors and to

offer encouragement. The participants said an accountability partner is someone ‘‘who

cares about the decisions that you’re making.’’ Along with assigning individuals an

accountability partner, the focus group participants recognized that some individuals might

practice unhealthy behaviors due to psychological concerns. Therefore, the White focus

group participants recommended having a counselor for the health promotion program.

One participant stated that a counselor would be good to have for the group ‘‘because

people tie food with emotions so much that it would be good to have somebody there for

that.’’

While the White focus group’s responses were program content-oriented, such as

group exercise and education classes and organized social activities, the AA focus

group’s responses were social change-oriented by describing public health actions that

are needed for health promotion programs. A majority of the public health actions were

primary prevention and school focused. For example, Evelyn (AA focus group)

emphasized the importance of teaching healthy behaviors at a young age by stating, ‘‘I

just think that [teaching healthy behaviors] should start at elementary school, start young

instilling the importance of being healthy and eating healthy.’’ Learning healthy

behaviors at a young age makes it easier for the behaviors to become routine as shared

by Monica (AA focus group), ‘‘So you won’t have to force yourself to eat a carrot

instead of a hamburger or whatever. So it will be like normal for you instead of

abnormal.’’

Several of the AA participants recommended changes in the school cafeteria food

options, such as increasing funding spent on healthy food for school cafeterias and offering

organic foods and home cooked meals as described by the following participant (AA focus

group):

And don’t give kids choices to eat crappy food at school…you get a decision to eat like pizza, hamburgers, hot dogs, fried chicken. …[but] you go to these private schools, they’re having like home cooked meals and have a spread of vegetables, a

spread of meats.

Another area of social change within schools was through education and encouraging

innovative ways to teach healthy behaviors. For example, Lisa (AA focus group) stated

that education helps ‘‘instill health values into the students, then from there, they can make

better decisions.’’ She went on to say, ‘‘People can’t make decisions on what they don’t

know.’’ Lisa also described an example in how educators can get health information and

behaviors to ‘‘stick’’ in the following:

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They do teach you in school. But I feel like to me it’s not valued. I feel like it’s going

to have to be something innovative or different. I know when I was a junior [in high

school], my teacher made us read Super Size Me, the book, and we got to watch the

movie or whatever. And I feel like that really stuck with me to actually see it or

whatever.

She said that her teacher at the time had to go through some bureaucratic or time-

consuming process to receive approval for the students to read the book and school

administrators should support teachers who are trying to be innovative in teaching healthy

behaviors.

Many of the participants recommended social change at the societal level by stating that

you have to start ‘‘at the top.’’ They discussed how health should not be about how you

look, but it should focus on feeling better and performing better when you are healthy.

They discussed how societal messages through media tend to communicate that health is

based on looks instead of the positive results and benefits of practicing healthy behaviors

(i.e., feel better or more energy). The participants emphasized the need to work upstream in

changing how society focuses on the aesthetics of healthy behaviors in the media. They

gave an example of students leaving school and driving by conflicting advertisement

messages on their way home: ‘‘by the time they get home, they’ve seen like 15 adver-

tisements for stuff like that [aesthetics and health].’’

Lastly, the AA focus group said that if the health promotion program targeted indi-

viduals who are overweight, then everyone in the program should be overweight ‘‘because

it forms a sense of camaraderie, a group of people who kind of have the same goal as you.’’

Evelyn (AA focus group) disagreed with having the health promotion program targeting a

specific group of individuals by stating, ‘‘I feel like when you target obese people, you

move away from the health aspect, and you move toward a weight loss aspect. Because I

feel like skinny people, obese people, everyone should be healthy.’’ Thus, reemphasizing

the importance of connecting healthy behaviors to health and not just appearance or size.

Along with describing the characteristics of a health promotion program for emerging

adults, both focus groups were asked how to incorporate religion into the program. There

was a diversity of opinions when both focus groups responded. They had mixed feelings

about rather it would be appropriate or not because it depended on the individual’s reli-

gious beliefs. Although there were mixed feelings, both focus groups recommended having

a basic religious module or core program and then allowing religious groups to tailor the

program to their particular religious beliefs (e.g., individualize the program according to a

particular religious group). The program could be offered through the religious group’s

place of worship (e.g., church-based program). One participant recommended periodical

themes connected with the religious group’s readings (e.g., scripture from the bible).

Another recommendation was to have individuals with similar religious beliefs be

‘‘accountability partners.’’ Accountability also referred to one’s religious beliefs. The

participants said that it was important for them to take care of their bodies so they could

serve others and fulfill the purpose of their religion, which a health program could help

them do.

The White focus group went on to mention that the program should include a com-

munity service component, ‘‘outward focus.’’ A few of the participants discussed how they

could combine health promotion and their religious beliefs by helping others in society.

Some of the organized social activities could be the platform for helping others, such as

picking up trash in the community (physical activity) and feeding the homeless one of the

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healthy meals the participants would have learned to cook (nutrition). Additionally, the

health promotion program should have a reward system.

The results of this study revealed commonalities between both focus groups: how their

religious beliefs have changed as they have grown older, attitudes regarding parental and

religious influences, and ways in which religion influenced their behavior. They differed

regarding the negative health effects related to religion. Their ideas regarding barriers to

practicing healthy behaviors and ways in which religion could prevent obesity were

similar. Although their ideas for a health promotion program differed slightly, they pro-

vided recommendations on how religion could be incorporated into a health promotion

program.

Discussion

The participants discussed ways in which their religious beliefs had changed over time,

including an understanding of the purpose of religion, discovering their own set of reli-

gious beliefs, and a shift in their focus toward a relationship with God. Arnett and Jensen

(2002) reported as individuals move from childhood into emerging adulthood their beliefs

become ‘‘highly individualized’’ and they express ‘‘high value on thinking for themselves

with regard to religious questions and on forming a unique set of religious beliefs rather

than accepting ready-made dogma’’ (p. 459). Stoppa and Lefkowitz’s (2010) longitudinal

study with emerging adults revealed similar findings for this ‘‘individualization

phenomenon.’’

After being told about Lerman’s national poll (as cited in Wallace et al. 2003), the

participants discussed their attitudes regarding the findings from the poll in which parents

and religion were the strongest influences in adolescents’ lives. Some participants agreed

that parents and religion were the strongest influence in their lives. Others stated that

neither, parents or religion, influenced them. Instead, both parents and their friends or only

their friends were the strongest influence in their lives. Although Wallace and colleagues’

study was conducted with a different age group population (8th, 10th, and 12th grade

students) from this current study, 60 % of the students reported that religion was ‘‘pretty

important’’ and 31–34 % reported that it was ‘‘very important.’’ Their study found a

relationship between family structure (no parent, one parent, or two parents living in the

home) and the importance of religion to the adolescent.

The participants discussed how religion influenced their behaviors in that they felt

responsible for taking care of their body and used religion to guide their behaviors and/or

limit risky behaviors. This finding is similar to Ayers et al. (2010), Callaghan (2006), and

Rew et al. (2007) studies. They found a positive association between health-promoting

behaviors and religion.

The participants described negative health effects of religion and avoidance of health-

promoting behaviors. Koenig et al. (2001) reported studies with similar findings related to

health risks (e.g., depression) due to religious beliefs. The participants in this current study

also linked health risks to religious beliefs (i.e., mission work). In addition, Koenig et al.

reported studies in which individuals delayed medical care and did not receive immuni-

zations due to religious beliefs, which were similar findings in this study. Oken (2005) also

reported on how individuals may avoid medical care due to their religious beliefs.

The participants described barriers that prevented them from practicing healthy

behaviors. Pender et al. (2006) also reported environmental and interpersonal barriers.

J Relig Health (2015) 54:20–34 31

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‘‘Quick and easy solutions’’ may be a particular area of research that has not yet been

studied or minimal research has been conducted among emerging adults.

Although a few of the AA participants believed that religion and obesity should be

separate from each other to decrease abuse of religious practices to lose weight, they

recommended offering health promotion programs through church settings. Monay et al.

(2010, p. 540) found that nurses working in religious community settings could increase

‘‘self-management and lifestyle behavioral change’’ among community members. Social

support associated with religion has been found to increase health-promoting behaviors

among individuals (Callaghan 2006; Chester et al. 2006; Kanu et al. 2008; Kim and Sobal

2004; Rew et al. 2007).

The characteristics of a health promotion program among the White focus group were

program content-oriented, while the AA focus group were social change-oriented. Smith

et al. (2004) recommend using an upstream public health and policy approach to foster

health-promoting environments. In addition, Cohen et al. (2000) recommend interventions

that focus on the media and cultural messages to change behavior.

Limitations of the Study

There were four limitations of this study. First, only two focus groups were conducted.

Having more than one White and AA focus group and including other ethnicities, such as

Hispanic and Asian, could have improved the study. Having a more diverse sample of the

population for future focus groups would increase the generalizability of the study. Second,

data saturation was not met since only one focus group per ethnicity was interviewed.

Future studies should include multiple focus groups per ethnicity. Third, the religious

background, such as denomination, of the participants was not obtained. Including such

information in future studies will help set the context for the participants’ responses and

health beliefs. The religious practices (e.g., church attendance) among the participants

within and between the focus groups may have been significantly different from each other

but that information was not obtained and cannot be assessed. Future studies should

include such information in order to obtain a better description of the sample. Lastly, using

focus groups to collect data limits the opportunity to obtain in-depth accounts of health and

religious practices and beliefs as with one-to-one interviews (Green and Thorogood 2009).

Implications for Future Research

Despite these limitations, this study serves as a building block for policy development and

future studies. At the national level, policy developers should assist in shifting society’s

focus and media messages from the aesthetics of health (i.e., appearance) to the positive

results and benefits of practicing healthy behaviors (i.e., feel better or more energy). At the

school district level, including collegiate environments, cafeteria food menus should

include home cooked meals and organic food options and barriers that impede innovative

teaching of healthy behaviors should be removed. Lastly, future health promotion pro-

grams targeting emerging adult populations should include ‘‘accountability partners’’ and a

community service component. Faith community nurses (also known as parish nurses)

could play an integral role in implementing such health promotion programs. Faith com-

munity nursing uses a holistic approach in caring for individuals (mind, body, and spirit)

and empowers individuals to achieve their full potential (Hickman 2006; Weis et al. 1997).

Granger Westberg (as cited in Hickman 2006) identified seven roles for faith community

nurses, all of which can assist emerging adults in adopting healthy life styles: ‘‘integrator

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of faith and health, personal health counselor, health educator, health advocate, referral

agent, coordinator of volunteers, and developer of support groups’’ (p. 29).

Conclusion

Sadly, our society is sending messages that lead emerging adults to believe that quick and

easy solutions, such as surgery and medication, are a way to fix health problems associated

with unhealthy behaviors. Individuals can do any behavior that they want (i.e., eat

unhealthy) and then have the negative results of the behavior corrected (i.e., surgery).

‘‘Everyone should be healthy’’ and not just ‘‘skinny’’ or ‘‘obese people.’’ We should focus

attention on the benefits of practicing healthy behaviors, remove barriers that prevent such

behaviors, and consider what part religion plays in health promotion and obesity

prevention.

Acknowledgments Regina Jones Johnson, DrPH, MSN, RN, The University of Texas at Austin; Marc Musick, PhD, MA, BA, The University of Texas at Austin; Deborah Volker, PhD, AOCN, RN, The University of Texas at Austin; Joseph D. Jamail Scholarship; Lillie S. Matthews Endowed Scholarship; Reunion Alumni Fund Scholarship from The University of Texas at Austin; Good Samaritan Foundation Scholarship; The University of Texas Office of Survey Research; and Focus Group Participants.

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