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Exploration and Description of Faith-Based Health Resources Findings Inform Advancing Holistic Health Care ■
Susan MacLeod Dyess, PhD, RN, AHN-BC, NE-BC It is important to use all holistic resource opportunities in communities, such as integrative healing centers, and mind-body-spirit approaches to health. These holistic approaches may be realized through nontraditional avenues, such as faith-based resources. This article reports on an exploratory study that describes faith-based resources supporting holistic health in a southeastern region of the United States. A working definition for “faith-based health resources” was “ecumenical and interfaith community-based, open-access health resources that include in mission for service a reference to faith.” Excluded from the definition were institutional services from hospitals, focused social services from area agencies, and federally funded services. KEY WORDS: faith-based resources, holistic health, research Holist Nurs Pract 2015;29(4):216–224
As health care reform advances, it is important to understand the available resources, including holistic approaches, for population health support in counties across the United States to maximize outcomes. The Centers for Disease Control and Prevention1 acknowledges that a variety of resources and services are needed for successful health outreach efforts; yet, most government and commercial payers currently do not support health care services that are not aligned with a medical model of health care. As a result, a number of nongovernmental initiatives have responded to perceived gaps in the health care system, including holistic models such as faith-based outreaches. In a Southeastern Regional County of the United States, there has been no effort to systematically describe faith-based health resources. Therefore, this study explored and described faith-based health resources available in the county and considered implications through the lens of health care reform. Author Affiliation: Christine E. Lynn College of Nursing, Florida Atlantic University, Boca Raton. The author gratefully acknowledges research funding support in the development of this article from Palm Healthcare Foundation. The author has disclosed that she has no significant relationships with, or financial interest in, any commercial companies pertaining to this article. Correspondence: Susan MacLeod Dyess, PhD, RN, AHN-BC, NE-BC, Christine E. Lynn College of Nursing, Florida Atlantic University, 777 Glades Rd, NU328 Boca Raton, FL 33431 ([email protected]). DOI: 10.1097/HNP.0000000000000096
BACKGROUND A growing body of research conducted by scholars from a wide range of disciplines suggests religion, spirituality, or faith to be an important contributor to health outcomes.2 It is also recognized that individuals are open to receiving comprehensive whole-person resources including faith-based care. Researchers have demonstrated that individuals in hospital and community settings desire support from health care professionals addressing faith, but often this aspect of holistic health is neglected.3-5 In fact, even adults who self-identify as nonreligious desire health resources that address their spiritual dimension.6 Not surprisingly, in recent years across the United States, communities have provided a variety of health programs that address spiritual as well as physical needs.7-12 According to the US Census Bureau13 data, the community of interest in this study represented more than 1.3 million residents accounting for approximately 7% of the state’s population, 25% being older than 62 years. There was significant income inequality, with approximately 14% of the population at or below poverty level. English was not the primary language for almost one-third of the residents, and 21% of the population was uninsured. Numerous health care resources were available for residents within the county; yet, there existed the challenge
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of “balancing the desire to provide residents access to quality health and human services in an environment of decreasing resources and increasing demand.”14(pxiii) While faith-based resources were available, they were not described in public documents.
PURPOSE The purpose of this study was to explore and describe resources that support health promotion in and through faith-based organizations in a southeast region of the United States. In addition to exploring and describing the initiatives, national best practices were identified and recommendations for future directions were considered for the community.
METHODS Data collection A mixed-methods parallel design was used for the study (D. Newman, S. Dyess, L. Chiang-Hanisko, L. Curnan, P. Liehr P, unpublished data, 2014). A university institutional review board approved the study, and consent was obtained from participants prior to research data collection. In addition, an advisory group was established for the study that consisted of 8 stakeholders and the principal investigator. The advisory group consisted of diverse county residents who had a background in community networking and faith-based health. A working definition for “faith-based health resources” was developed to be “ecumenical and interfaith community-based, open-access health resources that include in mission for service a reference to faith.” Excluded from the definition were institutional services from hospitals, focused social services from area agencies, and federally funded services. With advisory group support, the recruitment and data collection period was completed in 6 months. A total of 77 appropriate contacts obtained through purposive sampling were contacted. Then, 77 invitations to participate in the study were sent to the organizations via electronic mail messaging. The electronic mail message explained the purpose of the study, ensured confidentiality, and invited them for participation in a focus group, the electronic survey, or both. A password-protected link for the electronic survey was embedded within the invitation message.
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Furthermore, snowball sampling allowed for more invitations to be sent to organizations that were not included in original group. A total of 158 electronic invitations were ultimately sent out. From the 158 eligible contacts, 14 of 158 (9%) bounced back through electronic messaging as undeliverable. Thus, 144 eligible organizations were included in the initial sample. Eight reminders were then sent weekly to the contacts on the listserve. An acceptable return rate of 14 (10%) for the surveys occurred and 20 (15%) participated in focus groups or key informant interviews (see questions, Table 1).
Analysis The completed electronic survey results were analyzed (Table 2). Audio-taped interviews were transcribed verbatim and represent the base of the qualitative data. Field notes were collected by the researcher during the data collection period. More than 350 pages of data were generated. To manage the data, extra and irrelevant information was removed. The actual language used by those under investigation as they discussed responses to questions was captured, organized, and analyzed. The qualitative data were examined using a conventional content analysis approach and categorized with initial codes to convey meaning associated with describing the resources.15 Congruent with qualitative methods, a continued review of data occurred until the 3 main themes emerged (Table 3). Rigor was maintained by verifying the legitimacy of coding with one other researcher as well as member checking with the advisory group and interested participants occurred to ensure credibility.16 TABLE 1. Questions Used for Focus Groups, and Key Informant Interviews Focus Groups and Key Informants
Can you tell me about the health-related services provided by you or the organization you represent? How do community members know about and access the services? What are outcomes or changes in people lives do you see with the services? Can you describe how the services are faith based? Do you have any challenges or obstacles providing services? How do you address the challenges? Can you tell me about the records you keep? Can you tell me about the strengths of the services? What else can you share with me related to the faith-based services?
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TABLE 2. Survey Findings (N = 14; 10%)
TABLE 3. Descriptive Themes (N = 20; 14%)
Section
Whole person centric Realistically creative Profoundly meaningful (for faith)
Population Multiethnic Uninsured, underinsured, and underserved All developmental ages Focused programming After-school child programming Chronic illnesses (Alzheimer disease, cancer, diabetes, heart failure, hypertension, and Parkinson disease) Caregiver respite Crisis pregnancy Exercise Support groups Visitation-hospitalized and homebound Infrastructure Nonprofit Profit Not Sure Workforce Variations: Paid Non-paid Paid leaders with non-paid team Teams inclusive of Lay people, Non-licensed people, Inter-professional licensed people. Reporting Reports to an outside organization Monthly Annually As necessary No report to an outside organization Services On-site In-home Anywhere Outcomes Track no. of visits Track physical assessment changes Track reported sense of well-being No tracking
Findings
100% 100% 92%
FINDINGS
23% 15%
Electronic survey findings
7% 23% 28% 50% 23%
86% 7% 7% 7% 8% 85%
50% 7% 43% 29% 29%
50% 7% 43% 93% 50% 50% 7%
Qualitative and quantitative findings were considered and then merged to determine a meta-inference of findings.17
Diverse services were provided by faith-based resources reaching a multiethnic (100%) population that included US citizens, legal residents, and undocumented residents. Some targeted programs were offered that focused on particular diseases (15%) or age-specific issues (23%). Most services were across the life span (92%), provided at no cost (88%), and included social, physical, and spiritual support with referrals. Principally, the services were focused on health promotion and disease prevention, although minimal direct care was provided that included medical, dental, and vision care. Formal documentation and/or reporting of encounters occurred in less than half of the initiatives. There was wide variability in outcomes tracked; some organizations tracked the counted numbers of people seen (93%), whereas others counted changes in physical outcomes (50%). Still other organizations did not track outcomes or keep records at all (7%). The overwhelming majority of the organizational workforce among respondents was nonpaid. The most common workforce approach was to have a coordinator or director orchestrating nonpaid workers. The targeted services addressed perceived gaps in the current health care system, such as services for homeless, uninsured, and underinsured. Other services provided by the faith-based resources included those that were minimally or not reimbursed by insurance plans. The majority of services were preventive care, advocacy support, scriptural guidance that supported health, and education pertaining to health care navigation. For those living with chronic illness, guidance related to self-care management and care coordination was provided. The faith-based resources did not overtly align with county health initiatives or guidelines but were not contradictory. Interfaith scripture and language ascribed to religious doctrine were inclusive within paperwork provided to users and any documents describing services. Faith-based written words represented a Judeo-Christian emphasis as a reflection
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of the primarily Judeo-Christian population and congregations in the county. No holistic modality was highlighted, and the overall outreach for the resources was directed to all community members regardless of faith.
Focus group findings Conventional content analysis was used to understand phenomena such as faith-based resources behavior and the perceptions surrounding the behavior.16-20 Reported by those engaged in the work, faith-based health resources recognize the whole person in consideration of health, highlight health interventions that are realistically creative, and acknowledge the profoundly meaningful nature (for faith) for those providing the health services. The findings are discussed in depth Whole person centric The faith-based services’ approach was holistic, “from a perspective of that included mind, body, and spirit. One respondent clearly commented, “For us it has been looking at the really holistic piece of the person who comes in.” Also, a central piece of the services included the spiritual component of health. That notion of the centrality of spirituality within a holistic approach was summarized by the following remarks: There is a component of spirituality as wellness, you can’t take spirituality out of the dimensions of wellness, so wellness comprises of physical, emotional, spiritual, psychosocial wellness and that spirituality is part of like a wheel and if you take this spirituality or faith part out that wheel doesn’t move properly. I think probably for us it’s been the spiritual component of seeing people who have really felt lost and neglected by the community at large, those who’ve had great spiritual strife as well as family or work stress. We see them become more grounded spiritually and the more a part of the community. At the same time that they are healing spiritually, they are healing physically, they are healing emotionally and so the whole, that’s been probably for us the biggest win.
In addition, the faith-based services considered all aspects of a person and his or her environment such as the context of where he or she was in the community, within his or her family, schools, socioeconomic state, and geographic location within the county. These following statements highlight the all-inclusive focus that was shared:
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And when these children come in we can see, if there are deficiencies or if they have a deficiency. And, we talk with the teachers and parents; if their parents don’t know how to deal with something then we bring them in and point them to the right person. If they don’t have insurance—then we talk to Healthcare District, whatever they we need try to be with them, to walk with them, where ever they need to go to. We want to address all the issues that involve the population like literacy, understanding the culture of a community, the social structures; the health issues, the whole picture. It won’t be just health care; it’ll be more, because we’re really trying to look at the whole family picture even as a family of one. The ministry itself is really there to stand in the gap, for all people who we consider to come in with practical needs, and so often their financial family crisis issues have something to do with their health. They’ve lost their job, they’ve lost their benefits, and there are people who are ill, can’t provide for themselves so we provide resources, referrals.
The whole-person focus for the health care was voiced in all focus groups by all participants and by all key informants. This holistic focus was recognized as an asset within the services. The resources provided approaches that “want to help people with all aspects of their lives.” Realistically creative The faith-based resources in the county responded to their constituents with realistically creative approaches to services. The resources offered and provided varied depending on appraisals of perceived and expressed needs. As representatives commented when invited to discuss their goals, population, and outcomes, “It (the work) breathes differently on an annual basis.” While certain guidelines for services were maintained, there were not predetermined encounters; rather, responses were developed weekly, daily, or in the moment as needed, and regular referrals to other community resources were done. The faith-based outreaches seemed to respond to whatever needs arose in the community or for particular people. For example, one respondent noted, We’re here when and if you have needs, then we’re here. We don’t always know your needs, you have to come to us and tell us about it. If we can help you we’ll do it if not we’ll find somebody, you know, to consult.
The experiences from past encounters practically guided the work and evaluation that occurred. The
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past experiences often allowed the faith-based resources to best utilize their time and skill sets, as highlighted by the following comments: We provide nonemergency medical, dental, and vision care to those who do not have access to health care services and assist them is establishing a continuum of care through the conventional health care system. There are some things that we have done and as we’ve grown we found that we’re no longer able to do it with quality and so we work with a lot of resources, have a lot of partnerships in the community, refer individuals to existing health clinics, hospitals, programs, the vans, etc. We have what would be like a clinic without walls. What we’re really trying to do is to hit what we call the submerged tenth of society and so we offer all kinds of free services, try to hook them up with free services in the community. We offer an array of primary care services, such as medical care for all ages.
A number of resources provided to community members were offered in groups. Gatherings such as health screenings or health fairs were developed on an annual or quarterly basis. These gatherings provided access points to the potential services for community members. These comments portray the inventiveness of resources: We do annual health fairs and we service school physicals for school-age children. We open the church for education; we bring people in to talk about health. We do a lot of disease management; have a library with information about different diseases and nurses who come in and meet with people on an appointment-only basis. We don’t have any walk in appointments at all. We call our nurses Congregational Care nurses but we work in the community, do a lot of outreach to Belle Glade, to Okeechobee. Patients are guided to fill out forms, what we call navigation services, to apply for eligibility to local, state and sometimes federal assistance.
It was often through these group actions and events that other health needs were identified and then concrete approaches for accomplishing services were designed. Moreover, the faith-based resources drew upon inspired possibilities for responding to needs that presented themselves. The following example described a response that connected physicians, teachers, hospital administrators, and nonprofit
organizations to best utilize all potential resources such as favors within the community at large: We got a call from an elementary school in the south end. They had a little girl who was Haitian, who was five, who had been severely beaten in Haiti because she was cross eyed and they said she was possessed. At some point, she was brought here. Her family was non-English speaking and they asked the principal of her school who was a member of our church if there was anything that could be done for her. You know, we were able to go into the community and ask favors. I don’t mind, I am not a sales person at all but I can cast a vision for someone you know. I believe in our whole ministry. Everyone wants to be a hero, it’s just that they don’t want to be abused. Some of our doctors have chosen, many of them are in Project Access or involved with that but they prefer most of the time to just be available with a personal call. In in this case we were able to get help, coordinate with another organization. We had one anesthesiologist who could not donate his services but all else was paid for to get her care.
By making connections with exiting community health care resources, the faith-based services work to facilitate access to appropriate health care for those within the community who are without adequate means, “generally the people receiving services represent the homeless, the working poor, or undocumented residents.” Profoundly meaningful for faith The participants discussed that within all group or individual encounters, their approach was an intentional extension of their own faith and commitment to their God. Many of the participants explained that they gave of their time and talent as an “offering,” as a way of “serving God,” and in the presence of God. The offering and serving were profoundly meaningful demonstrations of scripture they quoted, or of their own personal faith represented in the following comments: In the faith-based care, there is something greater than us happening because we do it for the Lord. I was sitting here trying to think our work and I think it’s because we look into the person and see the reflection of Christ, that’s what makes it so powerful and faith based. It’s not so much what’s in us but it’s what’s in the person and who we’re serving. The fact that this is a human being, that he or she is God’s creation and as such deserves . . . . And I think in the three major faiths in the area that I can think of, all of their holy books refer to the medical person, the caregiver as this very special holy
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person who evokes God and Allah in their lives that you know this is a very special thing.
The county is so large, so getting clients to come down for access can limit our outreach.
It’s that idea from Matthew in the New Testament that whatever you do for these the least of my brethren you do unto me, and so that’s a very strong component of the work.
The main obstacle that we encounter is with transportation. Getting someone to a doctor or to treatment or dialysis is tricky.
The greatest gift that we can give someone and ourselves is love and to be present with them and because it’s not—that faith is just an activity, it’s who we are, it’s who we represent.
As the participants describe their actions, they use words that evoke intensely strong metaphors of health care as love. The stories shared evoked emotion and tears. Some of the language used to describe their holistic health care services included: Humane and loving, the whole team seems to work better, to feel better and there’s an emotional wellness that goes I think with the work, with giving selflessly to others. Staff are motivated by God’s love and to shower our patients with that love. Our aim is to show compassion to our patients. I think we are just like Mother Teresa, actually going out on the street and encountering people that are forgotten that nobody else cares about. People will walk over or drive by them. So the faith communities, the churches reach out to them. Everyone’s accepted, everyone’s helped to whatever degree, and nobody’s turned away. Well we pray before every class and when people come in with problems we pray together, we simply pray about it, bring it before the Lord.
There was a profound impact on the lives of those who were involved with the provision of faith-based services.
Challenges While organizations conversed about impacting health in a holistic manner, they also discussed a number of obstacles. Apart from funding, 3 main challenges related to faith-based health work were shared: (a) managing the sheer size of the county; (b) remaining culturally sensitive within a diverse population; and (c) not being taken advantage of or being susceptible to legal action. The challenges, however, did not seem to deter the provision of health care. Managing the size of the county A clear challenge for faith-based resources was the geographic size of the county. Simply put:
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The people have to go outside of town, and that is hard because most of the people walk where they want to go. They’ll walk from downtown to the clinic, that’s a two mile walk one way. Just recently they built a new library. Where did they put the new library? Way over on the other side of town, now we’re always trying to encourage the young children to use the library but what parent is going to allow a child to walk over there? They gotta cross probably two major streets, a canal and the library is way over there.
Remaining culturally sensitive The faith-based resources did aim to be responsive to expressed needs of many diverse people, but maintaining sensitivity to all belief structures and varieties of people was acknowledged as difficult. One approach to remaining culturally sensitive considered a few firm standards that directed care. Aptly stated in the following comments: So we serve Muslims, we serve Jewish people, we serve people who believe differently than we believe, so honoring what they believe and finding a standard to fall back on can be difficult. We work with all kinds of people, American people, Haitian people, Hispanic people that may be Guatemalan or Cuban or South American. We also work with people who are homeless or drug users, rich or poor, it does not matter we treat them all the same.
Realizing limitations and maintaining legal boundaries The faith-based resources worked to offer services that were not already being provided, but there also are limitations to what was possible to accomplish and the legal boundaries to their care. One respondent expressed that her organization was sometimes seen as being the “answer for everything,” but she emphasized, “We want to bridge the gaps within the community; we don’t want to be seen as some entity who can provide everything to all people.” There were also legal concerns. Another challenge we have is maintaining what we believe in our hearts is the next right thing to do and what the litigious society and being a church, but you know how much do you feel threatened by the fact you might be sued.
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As with all health care services, funding issues were a major concern. Many of the faith-based resources were accomplished through professional and nonprofessional volunteers giving of their time without remuneration. A popular model for services used at least 1 director of services who was in a paid role as an employee. This paid role often was charged not only with organizing the operation of the services but also with the fund-raising responsibilities. The funds were used to finance the paid role, provide for the building(s) and supplies used. Simply stated, “Funding is our biggest obstacle”; yet, many of the services relied on “God and His provision” and continued to be “funded by grants and private donations.”
Meta-inferences Limited, albeit important, services were provided through the county faith-based resources. A distinction of overall objective was noted between holistic resources with a “core business of health” and those with a “core business of faith.” The differences in the core business may have contributed to reasons for the variability in services, documentation, and tracking of output or outcomes. Health promotion, disease prevention, and advocacy primarily occurred. The holistic services provided a health safety net and complemented the overall health structure for the county. These resources comprised a myriad of organized initiatives that included but were not limited to the following examples: r Gatherings that reach in upwards of 1000 people such as a health fair, or immunization event; r A systematized health care provision clinic that provides office hours, appointments, and walk-ins for those who do not have other access to health care providers; r Individual encounters that provide guidance for medication adherence, or assist a person to access necessary, sometimes lifesaving, health care, such as calling 911 for an impending myocardial infarction; r Hospital and home visitation for acute and chronically ill individuals; and r Intercessory prayer and spiritual guidance. The holistic resources relied heavily on in-kind assets such as human time, wisdom and effort, building space, equipment, and basic donations of food, clothing, and medications. Referrals to formal
health care system services occurred regularly, yet strong, integrated, and official collaborative linkages were not apparent. The faith-based resources hesitated to group themselves within the formal health care services provided in the community; rather, they identified themselves as supplemental. The organizational resources provided attention to important perceived gaps in the health care system, but for the most part, they did not seem to desire oversight or accountability to outside organizations. Because the majority of the health outcomes were not systematically tracked, it was difficult to connect to or correlate with county, state, or federal health reports. Nonetheless, all faith-based health resources aimed to provide services that benefited community members and their efforts deserve due honor and admiration.
DISCUSSION Limitations of the method Although best practices for recruitment of focus groups, key informant interviews and Internet surveying were used, the study response rate was limited.21,22 Individuals and organizations were contacted on at least 8 occasions with invitations to participate. Four locations for the focus groups were offered that considered north, south, central, and western aspects of the community to target the geographic aspects of the county. Key informant interviews were completed at the location choice of the participant. Possible explanations for the lack of response to requests for participation in focus groups and key informant interviews might include the following: r The potential participants did not want to or were not interested in sharing information related to their contribution to faith-based health in the county. r The potential participants did not understand their contribution in a faith-based health resource. r The potential participants did not recognize the value of their faith-based health contribution. For the electronic survey data collection, typical response rates have fallen in recent years. One group of researchers asserts that a typical Internet response rate can range from 5% to 20%, yet potentially still provides representative data.22 Other researchers have noted that the lowest response rates are notoriously from needs assessment types of questionnaires.
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Reasons to explain a low response rate over the Internet might include the following: r The potential respondents believed that the survey was not relevant to them. r The potential respondents were not comfortable with responding, or did not know how to respond, to questions. r The increase in surveying in the United States, as well as the increase in unsolicited e-mail to Internet users and the ill will that this might generate among potential respondents. Despite the limited response rate, the advisory board and interested participants who checked findings believed that the results were reflective of the faith-based resources within the county. Nonetheless, the results cannot be generalized. Mounting international and national evidence supports potential benefits of partnering with faith-based resources as best practices in communities to address holistic needs of populations.23-27 In the United States, 40% of individuals attend religious ceremonies 1 or more times a week and an additional 20% attend organized services/activities 2 to 4 times per month.28 Working with faith-based organizations affords contact to a large part of the general population, across all racial and ethnic groups, age groups, and income levels. The health promotion activities and interventions delivered within the faith-based resources often appeal to underserved populations because they allow for more cultural tailoring, greater buy-in from community members, and a stronger potential for sustainability.7,8,12,29,30 The effectiveness of some faith-based initiatives confirms positive results across a wide variety of health conditions and behaviors.7,8
CONCLUSIONS As counties work to respond to advancing health care reform, an integrated holistic system that is inclusive of faith-based resources and a more collaborative approach with accountability is deemed necessary. The integration will require changes to most current county systems for health and will take time to realize. Interdisciplinary workforce development may need to emphasize faith-based aspects of holism, primary and secondary prevention, population-focused solutions, and community engagement such as those demonstrated in communities that are not overtly
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faith-based.31 In addition, attaining and measuring quality for faith-based services may require a unified method. Four specific suggestions are offered as next steps forward in linking holistic health resources to a community-wide action plan for any county. 1. Build strong community holistic health networks. 2. Educate community regarding holistic health and healing. 3. Promote the value of faith-based resources to overall health of residents in counties. 4. Expand and build faith-based capacity through strategic and sustainable planning. It is recognized that faith-based organizations are often trusted within populations and can be strategically referenced and included in many of the health care situations impacting uninsured, underinsured, and underserved persons. By engaging these faith-based resources in collaborative holistic partnerships, there is the potential of addressing the triple aim of expanding health care access, monitoring and improving health outcomes, and lowering costs.32 However, strategic actions are needed. The strategic actions should include building upon the holistic resources already in place such as those noted in this study. Examples of strategies could include intentionally inviting the representatives of faith-based resources to the community meetings where health initiatives are discussed and ensuring the services are interconnected to health objectives and action plans for communities. Models for faith-based care exist and include the specialty practice known as faith community nursing.33-37 Faith community nursing practice is described as the provision of nursing services within a congregation and primarily focused on health promotion, disease prevention, and spiritual support.33 It is acknowledged that more research is warranted.11,35 As health care reform advances with the goal of improving the health of all Americans, it will be necessary to maximize the utilization of innovative holistic resources, including but not limited to, faith-based resources. Health systems will need to be strengthened. Especially with a view to offering universal access to health care, many faith-based resources could be used to support the strategic aims of national and global health goals. Likewise, supporting the development of local networking initiatives is an important approach for strengthening holistic resources in counties across the United States. Faith-based resources can leverage opportunities
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created by the Affordable Care Act to reach varied individuals across the continuum with holistic health.
20.
REFERENCES 21. 1. Centers for Disease Control and Prevention. Chronic diseases and health promotion. http://www.cdc.gov/chronicdisease/overview/index. htm. Updated August 2012. Accessed November 12, 2012. 2. Koenig H, McCullough M, Larson D. Handbook of Religion and Health. New York, NY: Oxford University Press; 2001. 3. Anandarajah G, Hight E. Spirituality and medical practice: using the HOPE questions as a practical tool for spiritual assessment. Am Fam Physician. 2001;6(1):81-89. 4. Dunn K, Horgas A. The prevalence of prayer as a spiritual self-care modality in elders. J Holist Nurs. 2000;18:337-351. 5. Weierbach F, Glick D. Community resources for older adults with chronic illness. Holist Nurse Pract. 2009;23(6):355-360. 6. Creel E, Tillman K. The meaning of spirituality among nonreligious persons with chronic illness. Holist Nurs Pract. 2008;22(6):303-309. 7. Baruth M, Wilcox S, Laken M, Bopp M, Saunders B. Implementation of a faith-based physical activity intervention: insights from Church health directors. J Community Health. 2008;33:304-312. 8. Bopp M, Fallon E. Health and wellness programming in faith-based organizations: a description of a nationwide sample. Health Promot Pract. 2013;14:122-131. 9. DeHaven M, Hunter I, Wilder L, Walton JW, Berry J. Health programs in faith-based organizations: are they effective? Am J Public Health. 2004;94(6):1030-1036. 10. Dyess SM, Chase S, Hanaway K. Caring in the community: an exemplar within faith community nursing. Int J Hum Caring. 2013;17(2): 23-28. 11. Dyess SM, Chase SK, Newlin K. State of research for faith community nursing 2009. J Relig Health. 2009;49(2):188-199. 12. Newlin K, Dyess SM, Allard E, Chase S, Melkus G. A methodological review of faith-based health promotion literature: advancing the science to expand delivery of Diabetes education to black Americans. J Relig Health. 2011;51:1075-1097. doi:10.1007/s10943-011-9481-9. 13. US Census Bureau. The 2012 Statistical Abstract. http://www.census. gov/compendia/statab. Published June 2012. Accessed November 12, 2012. 14. Palm Beach County Community Health Assessment report. http:// www.naccho.org/topics/infrastructure/CHAIP/upload/PBC-CHA-Finalwith-Community-Perspective.pdf. Published 2012. Accessed August 2, 2013. 15. Hsieh H, Shannon SE. Three approaches to qualitative content analysis. Qual Health Res. 2005;15(9):1277-1288. 16. Lincoln YS, Guba EG. Naturalistic Inquiry. Beverly Hills, CA: Sage; 1985. 17. Onwuegbuzie A, Dickinson W, Leech N, Zooran A. A qualitative framework collecting and analyzing data in focus group research. Int J Qual Method. 2009;8(3):1-21. 18. Creswell J. Research Design: Qualitative, Quantitative and Mixed Methods Approach. 2nd ed. Thousand Oaks, CA: Sage; 2003. 19. Creswell J, Plano Clark V, Gutmann M, Hanson W. Advanced mixed methods research designs. In: Tashakkori A, Teddlie C, eds. Handbook
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of Mixed Methods in Social and Behavioral Research. Thousand Oaks, CA: Sage; 2003:209-240. Newman I, Newman D, Newman C. Writing research articles using mixed methods: methodological considerations to help you get published. In: Rocco T, Hatcher T, eds. The Handbook of Scholarly Writing and Publishing. San Francisco, CA: Jossey-Bass; 2011:191-208. Heckathorn D. Respondent driven sampling II: deriving estimates from chain referral samples of hidden populations. Soc Probl. 2002;49:11-34. Cook C, Heath F, Thompson R. A meta-analysis of response rates in Web-or Internet based surveys. Educ Psychol Meas. 2000;60(6): 821-836. Auerbach J, Chang D, Hester J, Magnan S. Opportunity Knocks: Population Health in State Innovation Models. Washington, DC: Institute of Medicine National Academy of Sciences; 2013. Florida State Faith Based and Community-Based Advisory Council annual report. http://www.flgov.com/wp-content/uploads/childadvocacy/ 2012 Annual Report FBCB Advisor %20Council.pdf. Published 2012. Accessed July 15, 2013. US Department of Health and Human Services. Partnerships for the Common Good: A Partnership Guide for Faith-Based and Neighborhood Organizations. Washington DC: The White House Office Publications. US Department of Health and Human Services. Healthy People 2020. http://www.healthypeople.gov/2020/default.aspx. Accessed July 15, 2013. World Health Organization. Part of the solution: faith-based responses to HIV/AIDS in Africa. http://ftguonline.org/ftgu-232/index.php/ftgu/ article/view/2053/4102. Accessed July 15, 2013. Pew Research Center. U.S. Religious Landscape Survey. Religious Beliefs and Practices: Diverse and Politically Relevant. Washington, DC: Pew Forum on Religion & Public Life; 2008. Sbrocco T, Carter M, Lewis E, et al. Church-based obesity treatment for African-American women improves adherence. Ethn Dis. 2005;15: 246-255. Yanek L, Becker D, Moy T, Gittelsohn J, Koffman D. Project Joy: faithbased cardiovascular health promotion for African American women. Public Health Rep. 2011;116(suppl 1):68-81. Brown N, Vaughn N, Lin A, Brown R, White M, Smith P. Healthy families Brooklyn: working with health advocates to develop a health promotion program for residents living in New York City housing authority developments. J Community Health. 2011;36:864-873. Institute for Healthcare Improvement. The IHI Triple Aim. http: //www.ihi.org/Engage/Initiatives/TripleAim/Pages/default.aspx. Published 2014. Accessed July 1, 2014. American Nurses Association. Scope and Standards of Faith Community Nursing Practice. Washington, DC: American Nurses Association; 2005. Solari-Twadell PA, McDermott MA, eds. Parish Nursing: Development, Education and Administration. St Louis, MO: Elsevier-Mosby; 2006. Dyess SM, Chase SK. Sustaining health in faith community nursing practice: emerging processes that support the development of a middlerange theory. Holist Nurs Pract. 2012;26(4):221-227. Apponte J, Cruz H, Acre S, Durso M. Partnership among a faithbased organization and a community. Holist Nurs Pract. 2013;27(3): 162-167. King M. Holistic nursing care in faith communities. Holist Nurs Pract. 2011;25(6):309-315.
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Exploration and Description of Faith-Based Health Resources Findings Inform Advancing Holistic Health Care ■
Susan MacLeod Dyess, PhD, RN, AHN-BC, NE-BC It is important to use all holistic resource opportunities in communities, such as integrative healing centers, and mind-body-spirit approaches to health. These holistic approaches may be realized through nontraditional avenues, such as faith-based resources. This article reports on an exploratory study that describes faith-based resources supporting holistic health in a southeastern region of the United States. A working definition for “faith-based health resources” was “ecumenical and interfaith community-based, open-access health resources that include in mission for service a reference to faith.” Excluded from the definition were institutional services from hospitals, focused social services from area agencies, and federally funded services. KEY WORDS: faith-based resources, holistic health, research Holist Nurs Pract 2015;29(4):216–224
As health care reform advances, it is important to understand the available resources, including holistic approaches, for population health support in counties across the United States to maximize outcomes. The Centers for Disease Control and Prevention1 acknowledges that a variety of resources and services are needed for successful health outreach efforts; yet, most government and commercial payers currently do not support health care services that are not aligned with a medical model of health care. As a result, a number of nongovernmental initiatives have responded to perceived gaps in the health care system, including holistic models such as faith-based outreaches. In a Southeastern Regional County of the United States, there has been no effort to systematically describe faith-based health resources. Therefore, this study explored and described faith-based health resources available in the county and considered implications through the lens of health care reform. Author Affiliation: Christine E. Lynn College of Nursing, Florida Atlantic University, Boca Raton. The author gratefully acknowledges research funding support in the development of this article from Palm Healthcare Foundation. The author has disclosed that she has no significant relationships with, or financial interest in, any commercial companies pertaining to this article. Correspondence: Susan MacLeod Dyess, PhD, RN, AHN-BC, NE-BC, Christine E. Lynn College of Nursing, Florida Atlantic University, 777 Glades Rd, NU328 Boca Raton, FL 33431 ([email protected]). DOI: 10.1097/HNP.0000000000000096
BACKGROUND A growing body of research conducted by scholars from a wide range of disciplines suggests religion, spirituality, or faith to be an important contributor to health outcomes.2 It is also recognized that individuals are open to receiving comprehensive whole-person resources including faith-based care. Researchers have demonstrated that individuals in hospital and community settings desire support from health care professionals addressing faith, but often this aspect of holistic health is neglected.3-5 In fact, even adults who self-identify as nonreligious desire health resources that address their spiritual dimension.6 Not surprisingly, in recent years across the United States, communities have provided a variety of health programs that address spiritual as well as physical needs.7-12 According to the US Census Bureau13 data, the community of interest in this study represented more than 1.3 million residents accounting for approximately 7% of the state’s population, 25% being older than 62 years. There was significant income inequality, with approximately 14% of the population at or below poverty level. English was not the primary language for almost one-third of the residents, and 21% of the population was uninsured. Numerous health care resources were available for residents within the county; yet, there existed the challenge
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of “balancing the desire to provide residents access to quality health and human services in an environment of decreasing resources and increasing demand.”14(pxiii) While faith-based resources were available, they were not described in public documents.
PURPOSE The purpose of this study was to explore and describe resources that support health promotion in and through faith-based organizations in a southeast region of the United States. In addition to exploring and describing the initiatives, national best practices were identified and recommendations for future directions were considered for the community.
METHODS Data collection A mixed-methods parallel design was used for the study (D. Newman, S. Dyess, L. Chiang-Hanisko, L. Curnan, P. Liehr P, unpublished data, 2014). A university institutional review board approved the study, and consent was obtained from participants prior to research data collection. In addition, an advisory group was established for the study that consisted of 8 stakeholders and the principal investigator. The advisory group consisted of diverse county residents who had a background in community networking and faith-based health. A working definition for “faith-based health resources” was developed to be “ecumenical and interfaith community-based, open-access health resources that include in mission for service a reference to faith.” Excluded from the definition were institutional services from hospitals, focused social services from area agencies, and federally funded services. With advisory group support, the recruitment and data collection period was completed in 6 months. A total of 77 appropriate contacts obtained through purposive sampling were contacted. Then, 77 invitations to participate in the study were sent to the organizations via electronic mail messaging. The electronic mail message explained the purpose of the study, ensured confidentiality, and invited them for participation in a focus group, the electronic survey, or both. A password-protected link for the electronic survey was embedded within the invitation message.
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Furthermore, snowball sampling allowed for more invitations to be sent to organizations that were not included in original group. A total of 158 electronic invitations were ultimately sent out. From the 158 eligible contacts, 14 of 158 (9%) bounced back through electronic messaging as undeliverable. Thus, 144 eligible organizations were included in the initial sample. Eight reminders were then sent weekly to the contacts on the listserve. An acceptable return rate of 14 (10%) for the surveys occurred and 20 (15%) participated in focus groups or key informant interviews (see questions, Table 1).
Analysis The completed electronic survey results were analyzed (Table 2). Audio-taped interviews were transcribed verbatim and represent the base of the qualitative data. Field notes were collected by the researcher during the data collection period. More than 350 pages of data were generated. To manage the data, extra and irrelevant information was removed. The actual language used by those under investigation as they discussed responses to questions was captured, organized, and analyzed. The qualitative data were examined using a conventional content analysis approach and categorized with initial codes to convey meaning associated with describing the resources.15 Congruent with qualitative methods, a continued review of data occurred until the 3 main themes emerged (Table 3). Rigor was maintained by verifying the legitimacy of coding with one other researcher as well as member checking with the advisory group and interested participants occurred to ensure credibility.16 TABLE 1. Questions Used for Focus Groups, and Key Informant Interviews Focus Groups and Key Informants
Can you tell me about the health-related services provided by you or the organization you represent? How do community members know about and access the services? What are outcomes or changes in people lives do you see with the services? Can you describe how the services are faith based? Do you have any challenges or obstacles providing services? How do you address the challenges? Can you tell me about the records you keep? Can you tell me about the strengths of the services? What else can you share with me related to the faith-based services?
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TABLE 2. Survey Findings (N = 14; 10%)
TABLE 3. Descriptive Themes (N = 20; 14%)
Section
Whole person centric Realistically creative Profoundly meaningful (for faith)
Population Multiethnic Uninsured, underinsured, and underserved All developmental ages Focused programming After-school child programming Chronic illnesses (Alzheimer disease, cancer, diabetes, heart failure, hypertension, and Parkinson disease) Caregiver respite Crisis pregnancy Exercise Support groups Visitation-hospitalized and homebound Infrastructure Nonprofit Profit Not Sure Workforce Variations: Paid Non-paid Paid leaders with non-paid team Teams inclusive of Lay people, Non-licensed people, Inter-professional licensed people. Reporting Reports to an outside organization Monthly Annually As necessary No report to an outside organization Services On-site In-home Anywhere Outcomes Track no. of visits Track physical assessment changes Track reported sense of well-being No tracking
Findings
100% 100% 92%
FINDINGS
23% 15%
Electronic survey findings
7% 23% 28% 50% 23%
86% 7% 7% 7% 8% 85%
50% 7% 43% 29% 29%
50% 7% 43% 93% 50% 50% 7%
Qualitative and quantitative findings were considered and then merged to determine a meta-inference of findings.17
Diverse services were provided by faith-based resources reaching a multiethnic (100%) population that included US citizens, legal residents, and undocumented residents. Some targeted programs were offered that focused on particular diseases (15%) or age-specific issues (23%). Most services were across the life span (92%), provided at no cost (88%), and included social, physical, and spiritual support with referrals. Principally, the services were focused on health promotion and disease prevention, although minimal direct care was provided that included medical, dental, and vision care. Formal documentation and/or reporting of encounters occurred in less than half of the initiatives. There was wide variability in outcomes tracked; some organizations tracked the counted numbers of people seen (93%), whereas others counted changes in physical outcomes (50%). Still other organizations did not track outcomes or keep records at all (7%). The overwhelming majority of the organizational workforce among respondents was nonpaid. The most common workforce approach was to have a coordinator or director orchestrating nonpaid workers. The targeted services addressed perceived gaps in the current health care system, such as services for homeless, uninsured, and underinsured. Other services provided by the faith-based resources included those that were minimally or not reimbursed by insurance plans. The majority of services were preventive care, advocacy support, scriptural guidance that supported health, and education pertaining to health care navigation. For those living with chronic illness, guidance related to self-care management and care coordination was provided. The faith-based resources did not overtly align with county health initiatives or guidelines but were not contradictory. Interfaith scripture and language ascribed to religious doctrine were inclusive within paperwork provided to users and any documents describing services. Faith-based written words represented a Judeo-Christian emphasis as a reflection
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of the primarily Judeo-Christian population and congregations in the county. No holistic modality was highlighted, and the overall outreach for the resources was directed to all community members regardless of faith.
Focus group findings Conventional content analysis was used to understand phenomena such as faith-based resources behavior and the perceptions surrounding the behavior.16-20 Reported by those engaged in the work, faith-based health resources recognize the whole person in consideration of health, highlight health interventions that are realistically creative, and acknowledge the profoundly meaningful nature (for faith) for those providing the health services. The findings are discussed in depth Whole person centric The faith-based services’ approach was holistic, “from a perspective of that included mind, body, and spirit. One respondent clearly commented, “For us it has been looking at the really holistic piece of the person who comes in.” Also, a central piece of the services included the spiritual component of health. That notion of the centrality of spirituality within a holistic approach was summarized by the following remarks: There is a component of spirituality as wellness, you can’t take spirituality out of the dimensions of wellness, so wellness comprises of physical, emotional, spiritual, psychosocial wellness and that spirituality is part of like a wheel and if you take this spirituality or faith part out that wheel doesn’t move properly. I think probably for us it’s been the spiritual component of seeing people who have really felt lost and neglected by the community at large, those who’ve had great spiritual strife as well as family or work stress. We see them become more grounded spiritually and the more a part of the community. At the same time that they are healing spiritually, they are healing physically, they are healing emotionally and so the whole, that’s been probably for us the biggest win.
In addition, the faith-based services considered all aspects of a person and his or her environment such as the context of where he or she was in the community, within his or her family, schools, socioeconomic state, and geographic location within the county. These following statements highlight the all-inclusive focus that was shared:
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And when these children come in we can see, if there are deficiencies or if they have a deficiency. And, we talk with the teachers and parents; if their parents don’t know how to deal with something then we bring them in and point them to the right person. If they don’t have insurance—then we talk to Healthcare District, whatever they we need try to be with them, to walk with them, where ever they need to go to. We want to address all the issues that involve the population like literacy, understanding the culture of a community, the social structures; the health issues, the whole picture. It won’t be just health care; it’ll be more, because we’re really trying to look at the whole family picture even as a family of one. The ministry itself is really there to stand in the gap, for all people who we consider to come in with practical needs, and so often their financial family crisis issues have something to do with their health. They’ve lost their job, they’ve lost their benefits, and there are people who are ill, can’t provide for themselves so we provide resources, referrals.
The whole-person focus for the health care was voiced in all focus groups by all participants and by all key informants. This holistic focus was recognized as an asset within the services. The resources provided approaches that “want to help people with all aspects of their lives.” Realistically creative The faith-based resources in the county responded to their constituents with realistically creative approaches to services. The resources offered and provided varied depending on appraisals of perceived and expressed needs. As representatives commented when invited to discuss their goals, population, and outcomes, “It (the work) breathes differently on an annual basis.” While certain guidelines for services were maintained, there were not predetermined encounters; rather, responses were developed weekly, daily, or in the moment as needed, and regular referrals to other community resources were done. The faith-based outreaches seemed to respond to whatever needs arose in the community or for particular people. For example, one respondent noted, We’re here when and if you have needs, then we’re here. We don’t always know your needs, you have to come to us and tell us about it. If we can help you we’ll do it if not we’ll find somebody, you know, to consult.
The experiences from past encounters practically guided the work and evaluation that occurred. The
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past experiences often allowed the faith-based resources to best utilize their time and skill sets, as highlighted by the following comments: We provide nonemergency medical, dental, and vision care to those who do not have access to health care services and assist them is establishing a continuum of care through the conventional health care system. There are some things that we have done and as we’ve grown we found that we’re no longer able to do it with quality and so we work with a lot of resources, have a lot of partnerships in the community, refer individuals to existing health clinics, hospitals, programs, the vans, etc. We have what would be like a clinic without walls. What we’re really trying to do is to hit what we call the submerged tenth of society and so we offer all kinds of free services, try to hook them up with free services in the community. We offer an array of primary care services, such as medical care for all ages.
A number of resources provided to community members were offered in groups. Gatherings such as health screenings or health fairs were developed on an annual or quarterly basis. These gatherings provided access points to the potential services for community members. These comments portray the inventiveness of resources: We do annual health fairs and we service school physicals for school-age children. We open the church for education; we bring people in to talk about health. We do a lot of disease management; have a library with information about different diseases and nurses who come in and meet with people on an appointment-only basis. We don’t have any walk in appointments at all. We call our nurses Congregational Care nurses but we work in the community, do a lot of outreach to Belle Glade, to Okeechobee. Patients are guided to fill out forms, what we call navigation services, to apply for eligibility to local, state and sometimes federal assistance.
It was often through these group actions and events that other health needs were identified and then concrete approaches for accomplishing services were designed. Moreover, the faith-based resources drew upon inspired possibilities for responding to needs that presented themselves. The following example described a response that connected physicians, teachers, hospital administrators, and nonprofit
organizations to best utilize all potential resources such as favors within the community at large: We got a call from an elementary school in the south end. They had a little girl who was Haitian, who was five, who had been severely beaten in Haiti because she was cross eyed and they said she was possessed. At some point, she was brought here. Her family was non-English speaking and they asked the principal of her school who was a member of our church if there was anything that could be done for her. You know, we were able to go into the community and ask favors. I don’t mind, I am not a sales person at all but I can cast a vision for someone you know. I believe in our whole ministry. Everyone wants to be a hero, it’s just that they don’t want to be abused. Some of our doctors have chosen, many of them are in Project Access or involved with that but they prefer most of the time to just be available with a personal call. In in this case we were able to get help, coordinate with another organization. We had one anesthesiologist who could not donate his services but all else was paid for to get her care.
By making connections with exiting community health care resources, the faith-based services work to facilitate access to appropriate health care for those within the community who are without adequate means, “generally the people receiving services represent the homeless, the working poor, or undocumented residents.” Profoundly meaningful for faith The participants discussed that within all group or individual encounters, their approach was an intentional extension of their own faith and commitment to their God. Many of the participants explained that they gave of their time and talent as an “offering,” as a way of “serving God,” and in the presence of God. The offering and serving were profoundly meaningful demonstrations of scripture they quoted, or of their own personal faith represented in the following comments: In the faith-based care, there is something greater than us happening because we do it for the Lord. I was sitting here trying to think our work and I think it’s because we look into the person and see the reflection of Christ, that’s what makes it so powerful and faith based. It’s not so much what’s in us but it’s what’s in the person and who we’re serving. The fact that this is a human being, that he or she is God’s creation and as such deserves . . . . And I think in the three major faiths in the area that I can think of, all of their holy books refer to the medical person, the caregiver as this very special holy
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person who evokes God and Allah in their lives that you know this is a very special thing.
The county is so large, so getting clients to come down for access can limit our outreach.
It’s that idea from Matthew in the New Testament that whatever you do for these the least of my brethren you do unto me, and so that’s a very strong component of the work.
The main obstacle that we encounter is with transportation. Getting someone to a doctor or to treatment or dialysis is tricky.
The greatest gift that we can give someone and ourselves is love and to be present with them and because it’s not—that faith is just an activity, it’s who we are, it’s who we represent.
As the participants describe their actions, they use words that evoke intensely strong metaphors of health care as love. The stories shared evoked emotion and tears. Some of the language used to describe their holistic health care services included: Humane and loving, the whole team seems to work better, to feel better and there’s an emotional wellness that goes I think with the work, with giving selflessly to others. Staff are motivated by God’s love and to shower our patients with that love. Our aim is to show compassion to our patients. I think we are just like Mother Teresa, actually going out on the street and encountering people that are forgotten that nobody else cares about. People will walk over or drive by them. So the faith communities, the churches reach out to them. Everyone’s accepted, everyone’s helped to whatever degree, and nobody’s turned away. Well we pray before every class and when people come in with problems we pray together, we simply pray about it, bring it before the Lord.
There was a profound impact on the lives of those who were involved with the provision of faith-based services.
Challenges While organizations conversed about impacting health in a holistic manner, they also discussed a number of obstacles. Apart from funding, 3 main challenges related to faith-based health work were shared: (a) managing the sheer size of the county; (b) remaining culturally sensitive within a diverse population; and (c) not being taken advantage of or being susceptible to legal action. The challenges, however, did not seem to deter the provision of health care. Managing the size of the county A clear challenge for faith-based resources was the geographic size of the county. Simply put:
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The people have to go outside of town, and that is hard because most of the people walk where they want to go. They’ll walk from downtown to the clinic, that’s a two mile walk one way. Just recently they built a new library. Where did they put the new library? Way over on the other side of town, now we’re always trying to encourage the young children to use the library but what parent is going to allow a child to walk over there? They gotta cross probably two major streets, a canal and the library is way over there.
Remaining culturally sensitive The faith-based resources did aim to be responsive to expressed needs of many diverse people, but maintaining sensitivity to all belief structures and varieties of people was acknowledged as difficult. One approach to remaining culturally sensitive considered a few firm standards that directed care. Aptly stated in the following comments: So we serve Muslims, we serve Jewish people, we serve people who believe differently than we believe, so honoring what they believe and finding a standard to fall back on can be difficult. We work with all kinds of people, American people, Haitian people, Hispanic people that may be Guatemalan or Cuban or South American. We also work with people who are homeless or drug users, rich or poor, it does not matter we treat them all the same.
Realizing limitations and maintaining legal boundaries The faith-based resources worked to offer services that were not already being provided, but there also are limitations to what was possible to accomplish and the legal boundaries to their care. One respondent expressed that her organization was sometimes seen as being the “answer for everything,” but she emphasized, “We want to bridge the gaps within the community; we don’t want to be seen as some entity who can provide everything to all people.” There were also legal concerns. Another challenge we have is maintaining what we believe in our hearts is the next right thing to do and what the litigious society and being a church, but you know how much do you feel threatened by the fact you might be sued.
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As with all health care services, funding issues were a major concern. Many of the faith-based resources were accomplished through professional and nonprofessional volunteers giving of their time without remuneration. A popular model for services used at least 1 director of services who was in a paid role as an employee. This paid role often was charged not only with organizing the operation of the services but also with the fund-raising responsibilities. The funds were used to finance the paid role, provide for the building(s) and supplies used. Simply stated, “Funding is our biggest obstacle”; yet, many of the services relied on “God and His provision” and continued to be “funded by grants and private donations.”
Meta-inferences Limited, albeit important, services were provided through the county faith-based resources. A distinction of overall objective was noted between holistic resources with a “core business of health” and those with a “core business of faith.” The differences in the core business may have contributed to reasons for the variability in services, documentation, and tracking of output or outcomes. Health promotion, disease prevention, and advocacy primarily occurred. The holistic services provided a health safety net and complemented the overall health structure for the county. These resources comprised a myriad of organized initiatives that included but were not limited to the following examples: r Gatherings that reach in upwards of 1000 people such as a health fair, or immunization event; r A systematized health care provision clinic that provides office hours, appointments, and walk-ins for those who do not have other access to health care providers; r Individual encounters that provide guidance for medication adherence, or assist a person to access necessary, sometimes lifesaving, health care, such as calling 911 for an impending myocardial infarction; r Hospital and home visitation for acute and chronically ill individuals; and r Intercessory prayer and spiritual guidance. The holistic resources relied heavily on in-kind assets such as human time, wisdom and effort, building space, equipment, and basic donations of food, clothing, and medications. Referrals to formal
health care system services occurred regularly, yet strong, integrated, and official collaborative linkages were not apparent. The faith-based resources hesitated to group themselves within the formal health care services provided in the community; rather, they identified themselves as supplemental. The organizational resources provided attention to important perceived gaps in the health care system, but for the most part, they did not seem to desire oversight or accountability to outside organizations. Because the majority of the health outcomes were not systematically tracked, it was difficult to connect to or correlate with county, state, or federal health reports. Nonetheless, all faith-based health resources aimed to provide services that benefited community members and their efforts deserve due honor and admiration.
DISCUSSION Limitations of the method Although best practices for recruitment of focus groups, key informant interviews and Internet surveying were used, the study response rate was limited.21,22 Individuals and organizations were contacted on at least 8 occasions with invitations to participate. Four locations for the focus groups were offered that considered north, south, central, and western aspects of the community to target the geographic aspects of the county. Key informant interviews were completed at the location choice of the participant. Possible explanations for the lack of response to requests for participation in focus groups and key informant interviews might include the following: r The potential participants did not want to or were not interested in sharing information related to their contribution to faith-based health in the county. r The potential participants did not understand their contribution in a faith-based health resource. r The potential participants did not recognize the value of their faith-based health contribution. For the electronic survey data collection, typical response rates have fallen in recent years. One group of researchers asserts that a typical Internet response rate can range from 5% to 20%, yet potentially still provides representative data.22 Other researchers have noted that the lowest response rates are notoriously from needs assessment types of questionnaires.
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Reasons to explain a low response rate over the Internet might include the following: r The potential respondents believed that the survey was not relevant to them. r The potential respondents were not comfortable with responding, or did not know how to respond, to questions. r The increase in surveying in the United States, as well as the increase in unsolicited e-mail to Internet users and the ill will that this might generate among potential respondents. Despite the limited response rate, the advisory board and interested participants who checked findings believed that the results were reflective of the faith-based resources within the county. Nonetheless, the results cannot be generalized. Mounting international and national evidence supports potential benefits of partnering with faith-based resources as best practices in communities to address holistic needs of populations.23-27 In the United States, 40% of individuals attend religious ceremonies 1 or more times a week and an additional 20% attend organized services/activities 2 to 4 times per month.28 Working with faith-based organizations affords contact to a large part of the general population, across all racial and ethnic groups, age groups, and income levels. The health promotion activities and interventions delivered within the faith-based resources often appeal to underserved populations because they allow for more cultural tailoring, greater buy-in from community members, and a stronger potential for sustainability.7,8,12,29,30 The effectiveness of some faith-based initiatives confirms positive results across a wide variety of health conditions and behaviors.7,8
CONCLUSIONS As counties work to respond to advancing health care reform, an integrated holistic system that is inclusive of faith-based resources and a more collaborative approach with accountability is deemed necessary. The integration will require changes to most current county systems for health and will take time to realize. Interdisciplinary workforce development may need to emphasize faith-based aspects of holism, primary and secondary prevention, population-focused solutions, and community engagement such as those demonstrated in communities that are not overtly
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faith-based.31 In addition, attaining and measuring quality for faith-based services may require a unified method. Four specific suggestions are offered as next steps forward in linking holistic health resources to a community-wide action plan for any county. 1. Build strong community holistic health networks. 2. Educate community regarding holistic health and healing. 3. Promote the value of faith-based resources to overall health of residents in counties. 4. Expand and build faith-based capacity through strategic and sustainable planning. It is recognized that faith-based organizations are often trusted within populations and can be strategically referenced and included in many of the health care situations impacting uninsured, underinsured, and underserved persons. By engaging these faith-based resources in collaborative holistic partnerships, there is the potential of addressing the triple aim of expanding health care access, monitoring and improving health outcomes, and lowering costs.32 However, strategic actions are needed. The strategic actions should include building upon the holistic resources already in place such as those noted in this study. Examples of strategies could include intentionally inviting the representatives of faith-based resources to the community meetings where health initiatives are discussed and ensuring the services are interconnected to health objectives and action plans for communities. Models for faith-based care exist and include the specialty practice known as faith community nursing.33-37 Faith community nursing practice is described as the provision of nursing services within a congregation and primarily focused on health promotion, disease prevention, and spiritual support.33 It is acknowledged that more research is warranted.11,35 As health care reform advances with the goal of improving the health of all Americans, it will be necessary to maximize the utilization of innovative holistic resources, including but not limited to, faith-based resources. Health systems will need to be strengthened. Especially with a view to offering universal access to health care, many faith-based resources could be used to support the strategic aims of national and global health goals. Likewise, supporting the development of local networking initiatives is an important approach for strengthening holistic resources in counties across the United States. Faith-based resources can leverage opportunities
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created by the Affordable Care Act to reach varied individuals across the continuum with holistic health.
20.
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