Application of a faith-based integration tool to assess mental and physical health interventions

Background To build on current research involving faith-based interventions (FBIs) for addressing mental and physical health, this study a) reviewed the extent to which relevant publications integrate faith concepts with health and b) initiated analysis of the degree of FBI integration with intervention outcomes. Methods Derived from a systematic search of articles published between 2007 and 2017, 36 studies were assessed with a Faith-Based Integration Assessment Tool (FIAT) to quantify faith-health integration. Basic statistical procedures were employed to determine the association of faith-based integration with intervention outcomes. Results The assessed studies possessed (on average) moderate, inconsistent integration because of poor use of faith measures, and moderate, inconsistent use of faith practices. Analysis procedures for determining the effect of FBI integration on intervention outcomes were inadequate for formulating practical conclusions. Conclusions Regardless of integration, interventions were associated with beneficial outcomes. To determine the link between FBI integration and intervention outcomes, additional analyses are needed.


INTRODUCTION
Over the last two decades, there has been growing evidence linking faith practices and spirituality to health benefits and clinical outcomes. For example, a review by Koenig (2013), revealed consistent increases in published articles on this topic: 1988-1993, 1976 articles; 1994-1999, 2782 articles; 2000-2005, 4108 articles; and 2006-2011, 5155 articles. Published articles yielded by these reviews -which have included editorial reports and concept papers, epidemiological studies, as well as clinical trials that were primarily conducted in clinical settings such as hospitals and clinics and have included faith measures and practices in the range of risk factors and outcomes involved in these trials -have repeatedly confirmed the health benefits of the 'faith factor'. Such benefits have included (but are not limited to) longer life, greater life satisfaction and well-being, lowered risk of depression and suicide, improved coping and management of stress, lowered cardiovascular risks, lowered risk and successful recovery from alcohol and other drug addiction, and faster surgical recovery (Larson et al. 1992, Larson, 1994, Matthews et al. 1997, Koenig, 2013. To offset healthcare costs and increase the reach for influencing the reduction of public health risks in America, interest among healthcare providers, clinical researchers, and public health experts in the incorporation of faith practices and the faith community into the design and implementation of prevention intervention strategies has increased. H. Koenig, psychiatrist and clinical researcher, points out that through the faith community, early detection and prevention of disease, respite care, and facilitation of compliance with treatment can be advanced (Koenig 2013). Also worth noting is that according to a national study (Catanzaro et al., 2007), one third of churches in the United States now have health ministry programs signifying a growing interest for meeting the health needs of parishioners.
Given the emergence of faith-based interventions (FBIs) in public health and the clinical literature addressing health problems ranging from obesity and other cardiac risks to HIV/ AIDS prevention to recovery from alcohol and other drug addictions, we sought to investigate the nature and characteristics of FBI integrations and to link them to outcomes. In our preliminary search for published reviews of FBIs, we found only one that probed the extent to which these interventions were truly faith based that is, incorporated some aspect of faith practices or experiences. This study, conducted by Lancaster et al. (2014), however, distinguished only between interventions that were faith-placed (e.g., a non-FBI conducted in a church) and FBIs, and provided no formal procedures for quantifying the extent of FBI integration. Our review, therefore, investigated Lancaster's topic further by quantifying the extent of FBI integration involved in the faith-based intervention -that is, interventions that were identified as faith-based by virtue of being conducted in a faith community and/or making faith practices and/or beliefs central to the intervention -and by probing how FBI integration was linked to intervention outcomes. The following were our focus: a) What is the extent of research involving FBIs for addressing health concerns -that is, medical, public health, and/or mental health -under empirically controlled conditions?; b) Once found, what is the extent of faith integration, as evaluated by a rating scale designed to assess faith-health integration, that is, the extent to which faith concepts and practices were interwoven into the health intervention?; c) To set the tone for future studies, a secondary

Assessment of Faith-Based Integration
The Saunders-Leak Faith-Based Integration Assessment Tool (SL-FIAT) (2017) operationalized a fully integrated FBI -that is, one in which the intervention's target is, when quantitatively assessed, fully faith-based -as one that: a) gave equal or nearly equal time in its session topics (e.g., prayer, reading and teaching of sacred text, and inspirational music) to faith practices as given to the health topic; and b) utilized four or more of the dimensions of faith experience and practices recognized in the faith-health literature (Larson et al., 1992;Koenig, 2013). This method for operationalizing program targets and measuring an organization's progress toward achieving program intervention targets along a quantified continuum is utilized in organizational and social psychology (O'Conner, 2002) and makes use of Prochaska and DiClemente's 5 stages of change (1982). Using this approach, the identified studies were assessed along a continuum of 1-10, where FBI scores of 1-2 reflect no integration, 3-4 reflect low integration, 5-6 reflect moderate or inconsistent integration, 7-8 reflect high integration, and 9-10 reflect full or achieved integration, the derived FBI integration score reflected the sum of the Faith Practices (FP) score and the Faith Measures (FM) score (Table 1).

FP & FM Scoring
FP scoring ranged from 1-5, where a score of 5 reflected the full integration described above (e.g., time devoted to scriptural teaching vs. time devoted to teaching about diabetes is equal or close to equal). FM scoring, also ranging from 1-5, reflected the amount of faith measures according the criterion for full integration stated above (e.g., four or more faith measures used) ( Table 2). Scorable measures were derived from a list reported in the literature (Larson et al, 1992;Koenig, 2013).

SL-FIAT Reliability Procedures
Reliability of the tool was tested by use of an inter-rater procedure. Initially, the entire team used the tool to rate five studies (Chang et al., 2007, Koenig et al., 2015, Koszycki et al., 2014, Petry et al., 2008, Schoenthaler et al., 2015 that were randomly selected from the 36 studies, revealing strong inter-rater agreement for three of the five studies. After discussing the variation of the remaining two (e.g., how scores were derived) and reviewing methods for extracting faith practices and faith measures from articles, each team member independently re-rated the two outlier studies (Chang et al., 2007, Koszycki et al., 2014. Results of the re-rating were unanimous, suggesting strong inter-rater reliability of the tool. To examine results of this review, basic statistical analyses, including measures of frequency, central tendency, percentage data collection, and, if conducive, correlational procedures were performed to address the research questions. or at least one intervention group. Of the studies assessed, 80% were RCTs. P/P was determined by the availability of before and after intervention data; five (14%) studies had this design. Two (6%) were observational studies. The location of interventions in the sample was defined as church, clinic (hospital, outpatient), or other community setting. Most studies were conducted in churches (46%), followed by community (26%), and clinics (25%). Both men and women were included in most studies (71%), eight targeted only women, one included men only, and one included children as participants (Table 3).

Included vs. Excluded Studies
The initial search of basic terms (e.g., faith based and interventions) yielded 20,774 results, of which 17,717 were excluded because they were not empirical trials and/or were not published in peer-reviewed journals (N=3057). An advanced search using the same terms yielded 319 studies, for which their abstracts and full texts were reviewed to determine what publications would be assessed by the team using the S-L FIAT. The resulting N for the included studies was 36 ( Figure 1).
Of the studies, 27 (75%) used one or more faith measures (e.g., denomination, frequency of religious attendance, extent of religious beliefs), and 27 (75%) incorporated use of faith/ spiritual practices in the interventions, with the proportion of time devoted to faith practices falling within ranges from 10-25% to 40-50%. Regarding use of faith measures and proportion of time involving use of faith practices in the interventions, most of the studies incorporated both at least at a minimum level.
Five of the 36 studies included neither faith measures nor faith practices. These were identified as faith-placed interventions, as they made use only of the faith community as their base of operation, making no apparent attempt to incorporate faith practices or measures into them (Table 3).

FBI Integration, FP, and FM Score Distributions
The mean FBI integration score was 5.75, placing the degree of faith-health integration of these studies at the moderate or inconsistent level. The mode or most frequent categorical score also fell within the moderate integration category, accounting for 11 of the 36 studies (31%) The average score for faith practices (FP) was 3.17, indicating moderately low use of FPs, suggesting no more than 30% of intervention time being devoted, with use of FPs being either inconsistent or unscheduled. The studies that fell within the moderately high-to-high use of faith practices (N=18) tended to consist of outlined curricula that designated faithbased practices and topics to specific sessions or made faith practices (e.g., daily reading of sacred text) central to the intervention. The larger proportion of studies with high integration involved chaplaincy and pastoral counseling service disciplines or 12-step programs as treatment interventions. These disciplines were recognized for making faith practices part of treatment.
The mean faith measure (FM) score for the studies was 2.58, suggesting relatively weak or low use of faith measures. Of the 36 studies, 22 (61%) fell at or below a score of 2 for FM, indicating the presence of no more than one of the many measures of faith/spirituality reported in the faith-health literature. Eleven studies (31%) yielded moderately high-to-high use of faith measures, using three or more faith/spirituality measures. Such studies were well planned and reflected awareness of current research on the faith-health link and the methods used for measuring the multi-dimensions of this construct.

FBI Integration and Intervention Outcomes
To probe the relationship between FBI integration and outcomes, the outcomes were divided into two categories: a) negative or non-significant intervention outcomes and b) positive or beneficial significant intervention outcomes. Of the 36 studies, 32 (89%) yielded beneficial and significant outcomes; only 4 yielded negative or non-significant outcomes (Allicock et al., 2012, Cowart et al., 2010, Holt et al. 2013, Koenig et al 2015. Results from this approach to analyzing the relationship between faith-based integration and intervention outcomes reveal little for addressing this point.

DISCUSSION
This review revealed a prevalence of literature involving the topic of faith and a growing use of FBIs in association with public health prevention and education efforts and with mental/ physical health treatment. Consistent with Koenig's work, published articles involving the topic or the inclusion of faith practices, measures, and/or beliefs in the pool of selected dependent and independent variables for survey studies, epidemiological reports, and clinical trials is also prevalent with outcomes confirming a consistent association of faith involvement, including religious attendance, with health benefits (e.g., longer life, faster recovery, decreased risk of suicide and the negative impact of stress/anxiety and depression, lowered cardiovascular risks, etc.).
As with Lancaster, however, when interventions were identified as faith-based where the focus of the study was highlighted as centrally involving faith (e.g., in the title and/or abstract) and, more importantly, involving the faith community, particularly in the public health arena, the number of studies that were completed and fit our criteria was narrowed. This suggests that while faith as a factor in health is increasingly being included in research literature as revealed by the work of Koenig, Larson, and others (evidence found more in the clinical literature and integrative disciplines like chaplaincy and pastoral care/counseling) and found to be beneficial to health, relatively few completed, scientifically rigorous studies have been done on the integration of faith into health promotion, a principle focus of public health.
Having assessed the 36 FBI studies with our integration tool, which yielded a moderate degree of integration (inconsistent use of faith practices and low use of faith measures), we conclude that, as used in the literature, the term 'faith-based intervention' refers to a range of health interventions involving low to inconsistent use of faith practices in interventions and, when FBI integration is quantified, weak to non-existent use of faith measures. In the absence of adequate measures of faith/spirituality, it is difficult to establish the relationship or overall impact of this variable for predicting treatment outcomes in FBIs (e.g., determining for whom a truly integrated FBI is an appropriate treatment or good match for reducing identified health risks and what forms of faith expression are useful for achieving behavior change among varying populations at risk). Further, refining of the definition and measurement of integrated FBIs allows comparisons of their usefulness in relation to non-FBIs in reducing health risks.
Since most (all but four) of the studies were linked to beneficial outcomes (likely an indication of publication bias), the results suggest that more procedures are required to determine the nature and characteristics of the link between the extent of FBI integration and treatment outcomes, providing the basis for a follow-up review. However, three of the four studies whose outcomes were negative or non-significant had FBI scores ranging between low to moderate integration due to low to moderately low use of faith practices (Allicock et al., 2012, Cowart et al., 2010, Holt et al. 2013. This suggests that low use of faith practices in FBIs reduces the likelihood of beneficial treatment outcomes. However, additional analyses of FBI outcomes are needed to substantiate this assertion. The one highly integrated study that yielded a non-significant outcome was conducted in a clinical setting, comparing the effects of religiously based cognitive behavior therapy (RCBT) with cognitive behavior therapy (CBT) on intervention outcome (Koenig et al., 2015). The conclusion was that RCBT is at least as useful as CBT for reducing symptoms of depression resulting from non-psychotic chronic illness. Consequently, for studies such as this, non-significant results support the hypothesis that FBIs are viable alternatives in the treatment of depression among individuals for whom faith is important.
Relative to the FBI integration-outcome link, the results suggest that: a) a distinction should be made between studies with goals to determine if faith-based approaches to health behavior change are better or worse than non-faith-based interventions and studies of nonfaith based interventions; b) investigators should examine under what conditions and for whom FBIs are more appropriate for achieving changes in health behavior; and c) procedures should be identified for determining the strength of outcomes based on a set of criteria (e.g., amount of expected health outcomes that are found significant and how much of the faith-based health outcomes are found to be significant), and, based on these criteria, assess the cumulative strength of significance of each study, correlating strength of outcomes with FBI integration scores. Notwithstanding, results of this review suggest that more analyses of the outcomes of these studies are needed to define the link between FBI integration and intervention outcomes. This provides the basis for a follow-up to this review.

CONCLUSIONS
Future studies should attempt to incorporate a moderately high to high level of faith practices and a high level of faith measures into the design of the interventions. Studies in which faith concepts and practices are integrated into the health intervention should be measured with tools such as the faith-based integration instrument introduced in this article. Finally, such studies should be approached with greater scientific rigor where study limitations that were characteristic of this cohort (e.g., low quality evidence, small sample size) are addressed.   Table 1 Score index for FBI score result  Table 2 Faith practice, faith measure score, and faith-based integration score criteria

FAITH PRACTICE (FP)
Select the rating that best fits the degree to which the intervention includes faith practices (e.g., prayer, application of sacred text/scripture, worship, music, etc.). FP =

5
Large proportion of curriculum devoted to use of faith practices (within 40-50% range or ½ of the curriculum to FP)

4
Moderately high proportion of curriculum devoted to use of faith practices (within 30-40% range) 3 Moderately low or inconsistent, unscheduled proportion of curriculum devoted to use of faith practices (within. 25-30% range) 2 Very low proportion of curriculum devoted to use of faith practices (within 10-25% range)

1
No discernable use of faith practices included in the curriculum OR unknown OR only placed in a faith community (e.g., faith-placed).

FAITH MEASURE (FM)
Select the rating that best fits the degree to which the intervention used faith measures (e.g., religious attendance, importance of religion, religious coping, religious satisfaction, religious motivation, denomination, religious support, sacredness of the body, etc) FM =

5
High/strong use of faith measures (at least 4 dimensions)

4
Moderately high/strong use of faith measures (at least 3)

3
Moderately low or weak use of faith measures (no more than 2) 2 Very Low or weak use of faith measures (no more than 1 measure)