University–church partnerships: A mechanism to enhance relationship health

Abstract Romantic relationship distress leads to decreased satisfaction and dissolution. While therapy is effective for helping distressed couples, it is often inaccessible due to cost, time, and childcare barriers. Churches are often able to offer lower-cost services and provide childcare. In partnership with a network of local churches, university staff trained lay leaders to deliver an evidence-based relationship education program and collected data from 97 couples to evaluate pre- to post-workshop changes in couple functioning. Multilevel modeling was used to examine changes from pre- to post-workshop and thematic analysis was used to analyze open-ended feedback responses. Results showed improvements in communication, relationship satisfaction, commitment, and intimacy safety, with the largest effect found for communication. Participants also reported improved communication skills were one of the most beneficial parts of the program. Through the partnership with a university, churches can offer and rigorously evaluate evidence-based programs to strengthen couple relationships in their communities.

linked to problematic parenting issues such as poorer discipline, increased negativity, and decreased warmth (Davies, Sturge-Apple, & Cummings, 2004;Gerard, Krishnakumar, & Buehler, 2006). Additionally, children in homes with parents experiencing relationship distress experience more adjustment problems (Booth & Amato, 2001). Given the deleterious effects on the individual, couple, and family functioning, providing interventions that are easily accessible for distressed couples is essential.
One avenue is through local churches as there is a natural overlap between the research community that recognizes individuals' need for healthy relationships and the faith community which believes marriage is central to personal and communal spiritual growth (Zarean & Barzegar, 2016). At times, religious and scientific communities have been estranged due to conflicts over values, goals, and lack of trust (Sullivan et al., 2014). However, when these two communities are integrated through the identification of a mutual goal (Sandage & Brown, 2015), churches can provide a unique platform for dissemination. Stanley et al. (1995) asserted that religious organizations are a viable avenue for delivering couple relationship education (CRE) because many couples get married in churches, churches recognize the importance of preventative interventions, they have systems for delivering educational programs, and they provide an avenue to reach different cultural groups.
Churches can provide a wide array of programming and wrap-around services to decrease barriers that couples often face when seeking couple therapy. For example, churches often offer childcare and low-cost services thereby reducing the financial barrier (Sareen et al., 2007). Churches also have the space capacity to offer programs in large group formats, which can create a sense of community and normalize participants' experiences (Wheeler, Harris, & Young, 2018). Further, therapy is often stigmatizing (Vogel, Wade, & Hackler, 2007), and couples may find the church setting to be a space of familiarity and increased comfort, in turn decreasing the burden of stigma. Lastly, religious individuals are more likely to turn to the church first when experiencing distress in part because religious beliefs are an important source of meaning-making and coping (e.g., Bryant-Davis & Wong, 2013). Despite these benefits, churches typically do not deliver evidence-based programming and thus could benefit from collaborating with university partners to offer and rigorously evaluate couple services.

The intervention
The Prevention and Relationship Enhancement Program (PREP) is an evidence-based CRE program delivered in a multi-couple workshop format that focuses on communication and conflict management, problem-solving, fun and friendship, and relationship expectations and commitment. Research suggests PREP is effective in improving relationship satisfaction, communication, commitment, and bonding between partners compared to non-distressed couples (e.g., Allen, Stanley, Rhoades, Markman, & Loew, 2011;Quirk, Strokoff, Owen, France, & Bergen, 2014;Stanley et al., 2001). Despite its secular content, PREP has also been successfully delivered in religious settings; a dissemination trial found that clergy and lay leaders trained in PREP offered some parts of the program after the training, demonstrating that church leaders can disseminate empirically supported relationship education material once they are trained (Markman, Stanley, Blumberg, Jenkins, & Whaley, 2004). Another effectiveness study with premarital couples randomly assigned to PREP delivered by trained clergy or lay leaders, university staff, or naturally occurring premarital services showed reduced negative communication and increased positive communication for couples in the PREP groups compared to the naturally occurring services, and clergy and lay leaders had communication ratings at least as strong as those who received PREP from university staff (Stanley et al., 2001).
While these findings support the effectiveness of CRE delivered by lay leaders to premarital couples, more research with couples with varying relationship lengths and statuses is needed. There is also a concern in the field that lay leaders delivering CRE in the community will not be able to help distressed couples. However, recent data suggest that more distressed couples experienced greater gains in relationship functioning compared to non-distressed couples, perhaps because they have more room for change (Halford et al., 2015;Williamson et al., 2015), thus it is likely that these programs are equally if not more beneficial for distressed couples. Consequently, it is important to include the level of distress when assessing the effectiveness of these interventions.

Current study
The primary aim of the current study was to replicate previous findings and assess the effectiveness of PREP delivered by lay leaders from local churches, accounting for the level of distress. Quantitative and qualitative data were collected pre-and post-workshop on relationship satisfaction, communication patterns, intimacy safety, and commitment, which are associated with positive relationship health (e.g., Amato & Hohmann-Marriott, 2007;Cordova, Gee, & Warren, 2005;Markman, Rhoades, Stanley, Ragan, & Whitton, 2010). This mixed-methods approach is critical to understand the impact of PREP on targeted relationship outcomes and nuances of couples' experiences of the program. Based on prior research we had two hypotheses: Hypothesis 1: PREP would have a positive, significant effect on relationship satisfaction, communication patterns, intimacy safety, and commitment.
Hypothesis 2: Participants reporting greater levels of relationship distress preworkshop would experience more rapid improvements for all relationship outcomes compared to those with lower levels of distress.

Procedures
This study was approved by the Institutional Review Board at The University of Tennessee. University staff partnered with local churches whose leadership recognized the importance of strengthening couples relationships within their congregation and in the broader community. Lay facilitators identified by church leadership met with university staff to determine goodness of fit based on interpersonal skills and desire to serve couples. The selected facilitators completed a 2-day PREP training lead by university staff following training guidelines through an agreement with PREP Inc. Relevant scripture also was provided in the training for facilitators to use in their workshops. Facilitators also participated in ongoing supervision with a Licensed Marriage and Family Therapy (LMFT) supervisor, who was overseen by a clinical psychology professor who was trained in PREP. The LMFT supervisor attended at least one module at each workshop to assess for fidelity to the content and competence in delivering the material. While university staff initially proposed to videotape sessions for fidelity, churches were concerned about the willingness of their facilitators to partake in this and were more comfortable with a trusted member of the staff attending sessions in person. The supervisor provided individualized feedback to facilitators regarding their strengths, accuracy of the content, and interpersonal interactions with participants.
Couples were recruited for the relationship education workshops through advertisements, such as flyers and postings on the churches' websites, and church leaders promoting the workshops during church services. The cost of workshop attendance was $100 per couple. Many of the churches offered food and childcare, and some were able to offer scholarships to cover either a portion or all of the cost. The workshop format was left to the discretion of each church, offered either as a 2-day intensive or over several (typically 8-12) consecutive weeks. With guidance from the LMFT supervisor, facilitators also decided which of the 12 PREP modules to include if their workshop format did not allow time for all of the modules. See  for more information about the workshop content. Quantitative and qualitative data were collected at the first session prior to the content delivery and at the last session after content delivery. Data were collected from 14 workshops across seven churches, including Methodist, Anglican, and non-denominational, over the course of two years.

Measures
Descriptive information for all of the relationship outcomes is presented in Table 1. Relationship satisfaction was measured with the Couple Satisfaction Index (CSI-16; Funk & Rogge, 2007), a 16-item self-report scale measuring overall relationship satisfaction. Total scores range from 0 to 81 with higher scores indicating greater satisfaction. Typical items include, "Please indicate the degree of happiness, all things considered, of your relationship" and "I have a warm and comfortable relationship with my partner." In the current study, the CSI-16 demonstrated excellent internal consistency (pre-PREP: a ¼ .98; post-PREP: a ¼ .97).

Communication was measured with the Communication Patterns
Questionnaire-Short Form (CPQ-SF; Heavey, Larson, Zumtobel, & Christensen, 1996), an 11-item self-report scale designed to measure the type of communication patterns used during conflict. Total scores range from 0 to 88 with higher scores on each subscale indicating a greater likelihood of using that communication pattern. Typical items include, "When some problem in the relationship arises, both you and your partner try to discuss the problem" and "During a discussion of a relationship problem, both you and your partner express your feelings to each other." In the current study, the CPQ-SF demonstrated good internal consistency (pre-PREP: a ¼ .76; post-PREP: a ¼ .84).
Intimacy safety was measured with the Intimacy and Safety Questionnaire-Short Form (ISQ-SF; Cordova et al., 2005), a 10-item selfreport scale designed to measure the level of vulnerability in the relationship. Total scores range from 0 to 40 with higher scores indicating greater intimacy safety. Typical items include, "I feel comfortable telling my partner things I would not tell anyone else" and "I enjoy sharing my successes with my partner." In the current study, the ISQ-SF demonstrated excellent internal consistency (pre-PREP: a ¼ .91; post-PREP: a ¼ .91).
The commitment was measured with the Commitment Inventory-Short Form (CI-SF; Stanley & Markman, 1992), a 12-item self-report scale designed to measure commitment or dedication to the current relationship. Total scores range from 0 to 72 with higher scores indicating a greater commitment to the relationship. Typical items include, "My relationship with my partner is more important to me than almost anything else in my life" and "My relationship with my partner is clearly part of my future life plans." In the current study, the CI-SF demonstrated good to fair internal consistency (pre-PREP: a ¼ .82; post-PREP: a ¼ .78).
Participants also responded to a series of open-ended feedback questions post-workshop. The questions were: (1) "How has this program impacted you?"; (2) "How have you applied what you learned in the workshop to your relationship?"; and (3) "What would you tell your friends about this program?"

Data analysis
Analyses of quantitative data were conducted using Mplus 8.0 (Muth en & Muth en, 1998). The self-reported measures of relationship functioning were examined at the individual level on the pre-workshop and post-workshop surveys. To test hypothesis 1, that PREP would have a positive, significant effect on relationship satisfaction, communication patterns, intimacy safety, and commitment, we conducted a three-level multi-level model where time points are nested in individuals and individuals are nested in couples to account for the repeated measures and dependence of the data. The targeted relationship health indicators were regressed onto a categorical measure of "time" (0 ¼ pre-PREP, 1 ¼ post-PREP) in the first level. The dropout rate from pre-to post-workshop was 19% (i.e., did not complete the postworkshop assessments), which is commensurate with prior CRE research (e.g., Halford et al., 2017). We conducted a series of preliminary Chi-square tests to determine which demographic variables were linked to missing data and included the variables that were statistically linked to patterns of missing data as controls. The couple-level control variable of marital status was included in the third level of all of the statistical models for this hypothesis. The missing data were handled within Mplus using full information maximum likelihood (FIML; Muth en & Muth en, 1998). We also included a Maximum Likelihood Robust (MLR) estimator in order to reduce estimation bias due to non-normally distributed outcome variables. We reported the effect sizes (Cohen's d) for the change in each outcome variable, and used Cohen's (1988) guidelines for determining small (<0.20), medium (<0.50), and large (<0.80) effects. To determine clinical significance we used Jacobson-Truax's Reliability Change Index (RCI; Speer, 1992), which posits that values greater than 1.96 indicate that clinically meaningful change occurred.
To test hypothesis 2, that participants reporting greater levels of distress pre-workshop would experience more rapid improvements on all of the relationship outcomes compared to those with lower levels of distress, we conducted a three-level multi-level model with the targeted relationship health indicators regressed onto a categorical measure of "time" (0 ¼ pre-PREP, 1 ¼ post-PREP) in the first level. We also conducted a series of preliminary Chi-square tests, however, none of the demographic variables were significantly related to the level of distress. We included the individual-level control variable of the distress group (0 ¼ not distressed, 1 ¼ distressed) in the second level of all of the statistical models. Group identification was determined based on the level of distress reported pre-workshop, using the clinical cutoff on the CSI (Funk & Rogge, 2007). We also included a Maximum Likelihood Robust (MLR) estimator in order to reduce estimation bias due to non-normally distributed outcome variables.
Qualitative data were analyzed using thematic analysis (Braun & Clarke, 2006). Two of the authors read through all of the participant responses for each open-ended feedback question. Each of these authors generated a list of initial codes for each question based on participant responses. These authors then met to discuss their initial codes and developed a final list of codes for each question based on saturation of responses. From there, these authors searched for common themes amongst the codes and reviewed the data to ensure that the themes were accurately capturing all responses. Final themes were identified for each question and examples to demonstrate each theme were selected from the data.

Hypothesis 1
We examined change from pre-to post-workshop for relationship satisfaction, communication, intimacy safety, and commitment (see Table 2). Each of these outcome variables changed in the expected direction. Relationship satisfaction increased (B ¼ 2.04, SE ¼ 0.51, p < .001), constructive communication increased (B ¼ 8.30, SE ¼ 0.97, p < .001), intimacy safety increased (B ¼ 1.65, SE ¼ 0.45, p < .001), and commitment increased (B ¼ 1.60, SE ¼ 0.47, p < .01). Effect sizes were moderate for commitment (0.28), intimacy safety (0.34), and relationship satisfaction (0.36), however, a large effect size (0.82) was found for communication patterns. RCI scores on all outcome variables were above 1.96 indicating that the increase occurred at a greater rate than would have been found without intervention.

Hypothesis 2
At pre-workshop, 40.2% of the sample was clinically distressed (CSI > 51.5; Funk & Rogge, 2007), and at post-workshop, 31.4% of the sample was clinically distressed. We examined differences in the rate of change from pre-to post-workshop for relationship satisfaction, communication,  intimacy safety, and commitment, based on the level of distress reported pre-workshop (see Table 3). All relationship outcomes significantly increased from pre-to post-workshop. Relating to the first theme, better communication, participants talked about the communication skills they gained through the program that improved overall communication in their relationship. One participant stated, "It changed the way that we approach everything with communication." Another said, "It helped us to talk things through and to be a better listener." The second theme, increased understanding of my partner, emerged as participants reflected on developing a greater understanding of their partner's needs and hidden issues that directly impact their relationship. One participant said, "The program helped me understand my partner better; learning about my partner's personality style and love language was beneficial." The third theme, increased self-awareness, encompassed both an increased self-reflection and understanding of oneself and an awareness of how he/she impacts the relationship. For example, one participant described, "It made me look at myself and how I may be negatively impacting our marriage." Question #2: applied learning The first theme, communication tools, refers to the tools that participants implemented from the program. Participants frequently mentioned the speaker-listener technique as a very helpful tool. One participant said, "We have used the speaker-listener technique when having a discussion so that we can see the other person is listening to us and we know that we'll have the opportunity to be heard." Participants also talked about creating a time-out plan and being able to apply it. One participant stated, "We had previously used the timeout technique in a way, but now we have more information to make it productive." In the second theme, implementation of the three keys, participants described how they were able to apply this foundational concept to their relationship. The three keys are (1) make it safe to connect, (2) do your part, and (3) decide, don't slide. Participants referenced applying one or more of the three keys to their relationship as one participant described, "We have utilized the three keys often." Question #3: what they would tell friends The first theme was that the program was helpful for all couples, regardless of relationship length. One participant stated that the program is "a great idea for upcoming relationships as well as established relationships," and another remarked that "the course works on relationships of all ages-in terms of skills, it can be applied from dating to fifty years of marriage." The second theme was that the program is worth the time. Participants would tell their friends that the program allows couples to set aside dedicated time in their busy schedules to focus on enhancing their relationships. The final theme was that couples gain communication skills and tools.
Participants would encourage their friends to attend the program because it provides a safe space to discover practical ways to improve communication.
One participant stated, "Even after many years of marriage, [the program] opened up conversations we'd never had before." Another remarked that the program "provides some new ways of communication to keep your relationship on healthy ground."

Discussion
These findings demonstrate that PREP delivered by church lay leaders can improve couples' communication, relationship satisfaction, intimacy safety, and commitment. Participants reported enhanced mutual understanding with their partners and greater self-efficacy to strengthen their relationship after the workshop. Additionally, the level of distress decreased from preto post-workshop and clinically distressed participants made significantly more rapid improvements in communication, relationship satisfaction, and commitment than those who were not clinically distressed. These results suggest that church lay leaders who are trained to lead evidence-based relationship education workshops can significantly improve couple functioning, even for couples who are distressed, and contributes to the literature suggesting that this is an effective mechanism to enhance couple relationship health. Constructive communication increased from pre-to post-workshop with an effect size of 0.82, which is consistent with previous PREP research (Allen et al., 2011;Baucom, Hahlweg, Atkins, Engl, & Thurmaier, 2006;Stanley et al., 2001), including studies that also used a flexible delivery format (e.g., Baucom et al., 2006). In interpreting similar effect sizes, it is important to acknowledge that previous studies have included treatment as the usual control group (e.g., Stanley et al., 2001) and a no-treatment control group (e.g., Allen et al., 2011), and the lack of a control group is an identified limitation of the current study. Communication patterns also significantly improved for more distressed couples, which has been found in prior PREP research with low-income minority couples (Quirk et al., 2014). In addition to this quantitative evidence, participants' qualitative reports suggested they had better experiences communicating with their partners and implemented some of the communication tools they learned during the workshop. Although we could not assess this possibility, it is likely that couples who participated in the consecutive week format had more opportunity to implement the communication tools they learned over the course of the workshop, and may have been more likely to report this benefit.
Increases in relationship satisfaction also emerged from pre-to postworkshop with moderate effect size, replicating results from previous PREP research with lay leaders (e.g., Allen et al., 2011). It is important to note that relationship satisfaction scores were used to determine the pre-workshop level of distress and that distressed participants experienced more rapid improvements in satisfaction compared to non-distressed participants. While some are skeptical about the effectiveness of CRE for distressed couples, recent research has found that PREP significantly reduces relationship distress (e.g., Carlson, Rappleyea, Daire, Harris, & Liu, 2017) and that more distressed participants experience greater improvements in marital quality through CRE programs (e.g., Bradford, Drean, Adler-Baeder, Ketring, & Smith, 2017). The findings of this study contribute to this growing area of research, but more research on the impact of PREP for distressed couples in the community is needed.
Participants in the current study also experienced increases in commitment with a moderate effect size. Other PREP studies have shown increased commitment in female partners only when delivered by religious lay leaders to premarital couples (Stanley et al., 2001). Acute issues affecting commitment during the premarital period may have been present for the men in that study, but not in the current sample. In addition to an average increase in commitment across the sample, participants who were distressed at baseline experienced more rapid gains in commitment, which is commensurate with previous research (e.g., Quirk et al., 2014) and instills hope for distressed couples to renew a sense of commitment to their relationship.
Additionally, participants experienced increases in intimacy safety with a moderate effect size. Previous PREP studies have not included this construct, but a related measure of positive bonding, which assesses intimacy and felt support, demonstrated small, but significant increases when delivered by lay leaders (Allen et al., 2011). Qualitative results demonstrated an increased understanding of oneself, one's impact on the relationship, and their partners' needs and insecurities. These insights can lead to increased comfort with vulnerability. Considered through the lens of attachment theory, increased understanding of needs and insecurities may represent important facets of a secure attachment bond (e.g., Fraley & Davis, 1997), and larger gains in intimacy safety might be achieved through an additional attachment-focused workshop, such as Hold Me Tight based on Emotionally Focused Couple Therapy (Johnson, 2008).
Results from qualitative analyses found that participants would share positive messages about the program with others. Specifically, participants believed PREP would be helpful for all couples regardless of relationship length, the program was worth the time invested, and it allowed them to dedicate time to their relationship. Some participants had already recommended the program to others. Personal referrals are a common way for programs to reach community members and other community-based interventions have found word-of-mouth to be an effective recruitment strategy (e.g., Gordon et al., 2019). Future studies should track how participants heard about the program and whether they made any referrals.
In addition to providing wrap-around services to mitigate some of the common barriers to therapy services, churches can provide effective, evidence-based relationship education that aids in strengthening couple relationships in their community. Churches provide a space of familiarity for many community members as they are accustomed to regular attendance and may participate in other programming, which might make couples feel more comfortable seeking help in this environment and also more likely to "buy in" to these types of services. Anecdotally, this suggestion is supported by the fact that we know couples were often invited to participate by the facilitators, which could increase their feelings of comfort. Furthermore, the churches in this study were recruited based on recognizing the need in their community for this type of service and the ability to allocate church resources to support the workshops. It is likely that these findings are influenced by these contextual factors and that successful delivery requires more than just the training of lay leaders, but necessitates a church culture that recognizes the importance of strengthening couple relationships in their community.

Limitations and future directions
A number of limitations may affect the interpretations of the results presented here. First, this pilot study demonstrates the potential utility of church-university partnerships to improve couple relationship functioning in local communities, but future work should include comparison groups to evaluate more rigorously the contribution that churches can make to enhancing couples' relationship health. Second, the workshops did not follow a standardized format and it is not known whether the single weekend or multi-week modalities could have differential effects on relationship outcomes. Future research should include this potential moderator. Third, no long-term follow-up data were collected and it is possible that the need to rationalize time and expense of the workshop enhanced their self-reports of the relationship variables. Future studies should include follow-up surveys to examine and monitor the maintenance of gains. Finally, sample characteristics prohibit generalizability to churches' capacity to serve racial/ethnic minority and low-income couples. As these couples often face significant barriers to accessing therapy services, this is an important consideration for future research.

Conclusion
These findings suggest that lay leaders can effectively deliver evidence-based relationship education workshops to couples and that universities can support this initiative through providing training, ongoing supervision, and evaluation of outcomes. These workshops can significantly enhance relationship health as demonstrated by improvements in functioning and vivid descriptions of the workshop's impact on communication skills and relationship satisfaction. Through improving the health of couple relationships, churches have immense potential to function as agents of change within local communities.