Partnering together? Relationships between faith-based community health centers and neighborhood congregations.

Objective: The US Bureau of Primary Health Care has promoted collaboration between federally funded community health centers and neighborhood religious congregations, yet little is known about how such organizations currently interact in underserved neighborhoods.

Methods: Semistructured interviews were conducted with leaders from five faith-based, urban community health centers and 23 neighborhood congregations. Transcripts were coded for prevalent concepts and themes regarding collaborations between the two types of organizations.

Results: Collaborations between health centers and congregations are generally limited to modest sharing of resources and personnel and intermittent health promotion programs. Leaders of both types of organizations desire greater collaboration, but such desires appear to be frustrated by inadequate resources and differing priorities, visions, and philosophies.

Conclusions: Increased collaboration between community health centers and neighborhood congregations will require efforts to overcome organizational differences, intercongregational tensions, and resource limitations. For the participants, comprehensive "faith partnerships" remain a desirable but elusive goal.

Key Words: faith-based organizations, community health centers, qualitative research 

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Faith-based organizations have recently received increased attention as providers of healthcare and other social services. President George W. Bush has expressed strong support for the work of faith-based organizations in social service roles through his proposed Faith-Based and Community Initiative. The President ordered multiple federal agencies to establish offices to "expand opportunities for faith-based and other community organizations and to strengthen their capacity to better meet social needs in America's communities." (1) The President and other supporters have argued that the Initiative provides faith-based social service providers equal footing to garner federal support, but critics of the Initiative have expressed multiple concerns including possible religious coercion of those seeking services, violation of the separation of church and state, and lack of data regarding the effectiveness of faith-based organizations in providing social services. (2,3) At present, the Faith-Based Initiative remains contested. (4)

In the meantime, The Bureau of Primary Health Care (BPHC), the agency that supports federally funded community health centers (CHCs) throughout the country, has endorsed the value of faith-based partnerships in the provision of healthcare to the underserved. In a monograph published in 2001 titled "Sharing a Legacy of Caring, Partnerships Between Health Care and Faith-Based Organizations," the Bureau described their "Faith Partnership Initiative." The initiative emphasizes that partnerships between CHCs and neighborhood religious congregations are necessary to provide the social and spiritual support that sustains patients in health-promoting behaviors and effective disease management. (5) The BPHC and others note that congregations share a mission and legacy of caring for those in need and so are natural partners in addressing the health of underserved populations. Furthermore, congregations often have resources that can be brought to bear to improve the capacity of healthcare services within a community. (5,6) In spite of increased attention to the role of faith-based organizations in providing social services, little is known about how CHCs and neighborhood congregations understand and collaborate with one another in underserved communities. This study qualitatively explores the relationships between comprehensive, faith-based, urban CHCs and nearby religious congregations from the perspective of leaders within both types of organizations. Our aim is to examine the extent to which health center/congregation collaborations exist, whether they are perceived as effective, and what barriers stand in the way of duplicating or expanding such partnerships.

Methods

Study participants

Key informants were identified from five faith-based CHCs located within urban underserved communities in four large US cities (Chicago, Dallas, Indianapolis, and Los Angeles). All CHCs in this study have mission statements that reflect a commitment to caring for the underserved in a manner that exemplifies Christian faith. Each of the CHCs is affiliated with, and was recruited through, the Christian Community Health Fellowship, a national organization of Christians working in healthcare to the underserved. All CHCs provide comprehensive outpatient medical services along with varied social support services to low-income, predominantly minority communities. The 13 key informants that participated in our study held varied management positions but were identified as individuals in a position to be well informed about the health center's prior experiences with, and current strategies toward, partnering with local congregations. Descriptive characteristics of CHCs and their key informants are included in Table 1.

For each CHC, lists of all surrounding religious congregations were generated using the Yahoo! Internet mapping and phonebook services. Interviewers drove and walked through each community to check the lists for completeness and accuracy, then randomly numbered the congregations and contacted them in numerical order by phone or in person. The congregations around the health centers were overwhelmingly Christian (>98% in four of the five communities), and although we attempted to include at least one non-Christian religious leader in each community, only one participated. Among the 29 English-speaking leaders to whom the project was described, 23 participated. Religious organizations varied according to size, the proportion of congregants who lived in the community, and the duration of the congregation within the community. Leaders of the congregations who participated were primarily pastors and priests who had been in positions of leadership from 1 to 46 years. Table 2 further summarizes the characteristics of the congregations and their leaders.

Data collection

Five health professions students conducted the interviews during a summer research fellowship after being trained in basic qualitative research interview skills. We conducted one-to-one, semistructured depth interviews to explore informants' perspectives on the existence of or possibilities for health center/congregation collaboration. Interviews followed an interview guide that centered on open-ended "grand tour" questions followed by probes and clarifying questions. (7) Semi-structured interviews, common in exploratory studies, were intended to "generate hypotheses and provide rich descriptive information about a phenomenon." (8) Interviews were tape-recorded and fully transcribed by the interviewers.

Transcripts of interviews were analyzed in an iterative process using common methods of qualitative inquiry. First, two investigators (FAC and LG) independently read and analyzed a portion of the transcripts, making notes and underlining important text, to identify concepts and themes that emerged from the data. This is a process often called open coding. (9) The investigators then met to compare their notes and to develop a consensus about the concepts and themes and formalize them into a working code book. Using qualitative software (Atlas.ti, Scolari Sage Publications Software, Thousand Oaks, CA), the investigators subsequently coded all transcripts according to the code book formulations, checked the coding for consistency, and then iteratively, systematically, and sequentially reviewed the data to identify relationships between concepts and emerging themes, and to develop a conceptual outline. This process is commonly called axial coding. (9) We found that latter transcripts produced no substantial new domains or themes, satisfying the qualitative principal of saturation. After the completion of data collection and initial analysis, a third investigator (DRS) systematically reviewed the transcripts and the interpretation for consistency and for competing conclusions. The involvement of multiple perspectives in analysis is called triangulation and is an important credibility check in qualitative research. Finally, we selected representative quotes to concretely demonstrate the concepts and themes.

The University of Chicago Institutional Review Board approved this study.

Results

Emerging concepts from the interviews were categorized into four domains: (1) characteristics of current collaborations, (2) conceptions of health and health delivery, (3) visions for future collaborations, and 4) perceived rewards of and obstacles to collaborations. Each domain with its emergent themes is discussed below. Quotes are verbatim or are modified only for grammatical clarity and to remove identifiers. Quotes from leaders of CHCs are identified by "CHC" and those from leaders of religious congregations by "RC."

Characteristics of current collaborations

Some CHCs were directly connected with one particular congregation. In such cases, the congregation may have founded the health center and/or comprise its governing board. The health center's leaders, employees, and volunteers might be members of both organizations, which may share physical space, finances, and other resources.

RC: ... our church founded [the CHC], so from the very beginning our church has been very active in that, and continues to be today ... We do a lot of things together. The majority of the board members are members of our church, so we have a very close relationship with [the CHC].

Some CHCs had more informal relationships with a small number of congregations. Yet the majority of congregations in our sample did not have any active relationship with their neighborhood faith-based CHC. Leaders of the two organizations rarely mentioned any pattern of intentional communication or partnership between them. One CHC leader commented on a mutual lack of knowledge:

CHC: I think the basis is having a good relationship with these churches, so we know each other. And right now we don't know each other. We don't know these churches--they don't know us, and neither of the two groups feels comfortable with the other.

The most commonly described interaction was a simple referral of parishioners and community members from congregations to CHCs for healthcare services. Some participants did mention ongoing programmatic collaborations between a CHC and the congregation with which it has a primary relationship. They described programs such as parish nursing, substance abuse treatment, and pastoral care. More often, they noted that CHCs provide professional assistance for intermittent health promotion and prevention activities sponsored by one or more congregations.

CHC: We will provide ongoing support for churches by coming in and doing teaching--educational components--if a church asks us to come in and wants us to provide leadership or clarify issues of a medical nature. Or we come in and do health fairs for churches.

We found that the CHCs and congregations in our sample, despite sharing explicitly Christian identities, often worked independently on areas of common interest. Religious leaders described efforts to improve physical health that were either independent of any healthcare organization or involved collaboration with non-faith-based healthcare organizations. Similarly, the CHCs in our study described efforts to provide spiritual care to patients in ways that were independent of the congregations.

Conceptions of health and health delivery

Leaders from CHCs and religious congregations both defined health as a condition with spiritual, social, and physical components, and they both emphasized the importance of addressing health in a holistic manner.

RC: Being a church, we recognize that [health is] more than just a physical, mental, social issue. We see spiritual ramifications to it as well.

CHC: [Our aim] would be for [patients] to have a better understanding of whole person health, meaning that your body, mind, and spirit are an integrated system, and you need to pay attention to all three ... You are created as a whole person, so you have to look at the whole person.

Participants emphasized the primary role that congregations have in maintaining health by providing pastoral care and other social support services. Religious leaders, it was noted, have regular interaction with members of the community and so are particularly aware of its needs, and they were described as specially equipped to address core spiritual, social, and psychological ills. Religious leaders also noted that individuals often seek healthcare and health assistance from the religious organization before turning to a medical clinic, and they acknowledged the resulting responsibility to connect patients to appropriate sources of healthcare.

RC: We realize that congregations need to be informed about healthcare, and who else better to do that than the church, especially in this community, which is mainly Hispanic. The people have trouble trusting hospitals to get the right information, but if they could get that information from a parish nurse in their community, it would be a lot easier for them and they would be a lot more trusting. It's just a fact of life that people trust their church.

CHC leaders described their centers as having a substantial role in the promotion of community health, mediated through faith-informed, holistic medical, and social services.

CHC: [This CHC] is a multichurch collaborative structured to demonstrate biblical concern for underemployed and uninsured persons, through pastoral care, preventative health education, episodic healthcare, and holistic case management. That's what we're trying to do--trying to approach it holistically, and in a way that we have employees who've been in their shoes and understand them to help them on their own terms.

Visions for future collaboration

Leaders from congregations and CHCs both expressed desires for stronger relationships and more programmatic interactions, but their emphases were different. CHC leaders hoped to involve multiple congregations in CHC-directed, community-wide programs.

CHC: I would like there to be a dozen churches in our community that would see [this CHC] as a health and counseling resource to the church--a resource that both addresses and treats to the extent possible any and all members of that church ... The leaders, elders, and pastors ought to be able to use our counseling services as that referral point for the people that ... need some real counseling that they cannot provide ... Similarly, we should be able to come in and use the congregations and the church programs to promote good health information like stress management and other kinds of services to the church, the congregation, and the community through them.

In contrast, religious leaders hoped to obtain increased technical assistance and programmatic support from CHCs for expanding the health-promoting activities that occur within their own particular congregations.

RC: I would really like to see [CHC] come in, not only to screen and test and for information. But I would like them to be connected [in such a way that] their program is visible in this church ... I would like to see a mobile unit really connected to the church, maybe on a weekly basis where each week its doors will be open, testing, screening, bringing information to the community and pointing them in the right direction to make their regular appointments and getting early intervention.

Some religious leaders hoped to open separate medical clinics

RC: My long-range goal is to open a clinic ... I intend to build a very large church on this corner, and I'd like to build a clinic in it. I'd like to do that. I think people ought to have that option from their church.

Perceived rewards and challenges of collaborations

Participants repeatedly described existing collaborations as "successful" or "good" and described mutual benefit in a number of ways. CHCs noted their dependence on the practical and moral support of the religious community and the religious leaders expressed appreciation of the services received in return. Participants also celebrated shared experiences of divine intervention and transcendence, providing comfort where medical intervention cannot.

CHC: ... the flesh we're healing, and when everything else fails, we're able to bring in a higher force, and that force being the power of the Lord ... and when you just sit and the Holy Spirit comes and dwells in your inner being, into your situation--it's a comfort that passes all understanding.

Collaborations were credited for directly improving community health by expanding access to basic medical care.

CHC: As [parish] nurses, we identify large numbers of people in our community that don't have any healthcare provider, don't have any healthcare services ... we're able to offer a more comprehensive system of care, refer them into our clinics, even refer to specialists, and to hospitalization if that's needed.

Despite the benefits that collaboration promises, participants noted persistent barriers to partnership. Importantly, CHC leaders were concerned that tensions between different congregations, due to competition for parishioners and to differing religious doctrines, will be difficult to overcome in building effective collaborations.

CHC: People might be steadfast in their own ideology and they don't want to be flexible and diplomatic as far as teachings go and how they relate to one another.

When asked about receiving public funds for the services they provide, some leaders from both CHCs and congregations expressed reservations about combining secular and religious resources and doctrines.

CHC: I personally see that the church should be the ones providing the resources to meet the needs of the homeless, the hungry, and the people that don't have insurance, rather than relying on governmental agencies. I see that when we wrestled with the issues of having governmental money to fund our work here, you really feel that tension, because it is potentially there--of saying who is calling the shots.

RC: ... I think it would be a [mistake] of the churches to be dispensing government money because, honestly, I have an innate distrust, across the board--I'm not talking about my own denomination--for churches to separate their need to proselytize from their need to take care of people ... And I am adamantly opposed to churches connecting what I think is meeting a basic human need with sort of selling the gospel on their own terms. To me, that's immoral. The message of the gospel stands on its own ... to take care of people is not something to be bartered out.

In addition, participants noted that their urban neighborhoods have many small, "storefront" congregations that have very limited resources. Some CHC leaders were reluctant to approach such congregations to form new working relationships.

CHC: I think one of the big challenges in the urban landscape ... is the number of congregations and the rapidity with which people are willing to classify those congregations. There is this sense about it being easier, or better, to make an outreach to an inner city Lutheran congregation that has a school (because there is always someone in the office that you can call and contact) than a storefront where they may not have an office number and whatnot. And so sometimes outreach and health efforts and promotions get directed at these more traditional churches rather than [others].

Finally, a substantial barrier to health center/congregation collaborations appears to be a simple lack of interest. Some religious leaders noted that they do not see medical issues as their concern and view the role of the CHC as independent of the focus and purpose of the congregation. Some CHC leaders also commented that extensive collaborations are not yet a priority of the CHC.

CHC: I think it's a lack of being a priority in finding where the synergy is, or lack of seeing if there really is opportunity. No one picked the ball up or had a vision for doing something with the community churches.

Discussion

Our sample of faith-based CHCs and local religious congregations do share some level of collaboration in addressing the healthcare needs of their underserved communities, but partnerships are generally few in number and limited in scope. Relationships are primarily characterized by an exchange of resources and services, with congregational members receiving customary medical care from the CHCs and CHCs providing expertise and support to congregations as part of intermittent health promotion and prevention activities such as health fairs and screening programs. The faith-based CHCs and neighborhood religious leaders share a holistic concept of health, which at times drives deeper relationships and synergistic efforts toward improving community health. However, comprehensive efforts to coordinate the two types of organizations are notable for their absence, and the development of partnerships appears to be inhibited by a lack of communication and by interpersonal and interorganizational differences. CHCs and religious leaders often differ on visions for future partnerships. Whereas CHCs envision community-wide efforts that involve multiple congregations but are organized around the CHC, religious leaders seem to prefer more activities within their particular congregations. Compromise between these visions appears necessary for fruitful collaboration.

In addition, the diversity, small size, and instability of congregations may present a substantial challenge to collaboration. Among the 22 Christian congregations in our sample, 21 denominations (or nondenominations) were represented, and religious leaders each expressed a particular focus for outreach, generally dependent on the availability of resources. We found that many religious leaders in these communities are bivocational and unavailable during the day. That may explain our difficulty in contacting religious leaders from smaller congregations that may be consumed with maintaining the basic functions of the organization and unable to focus on additional projects. In this context, it is perhaps not surprising that many focus their efforts exclusively on what they perceive as their top priority--spiritual health. Even some of the larger congregations with greater financial and personnel resources described few efforts to promote the physical health of the congregation or the community. Overall, the combination of organizational diversity, intercongregational tensions, and resource limitation appears to largely explain why comprehensive collaborations are uncommon. For our participants, forming stable, ongoing "faith partnerships" remains a desirable but elusive goal.

Our study has several limitations. First, qualitative methods are powerful for generating "thick descriptions" (10) of complex topics like this one. Yet, as with most in-depth qualitative studies, the sample was small and was chosen for theoretical reasons. As such, we cannot use any statistical inference to predict how the themes we found are distributed within the broader universe of CHCs and religious congregations. Our difficulty in contacting leaders of smaller congregations probably biased our sample toward larger congregations that are likely to be more visible to CHCs and have more resources to turn toward partnership. In addition, our study only includes urban faith-based CHCs, a logical starting point, but still a minority of health centers. The experiences of secular CHCs may be very different. Finally, the analysis and interpretations are those of the authors, and different investigators might have come to somewhat different interpretations of the same data. Future studies are warranted to see if these findings are corroborated by other investigators in other underserved settings.

Its limitations notwithstanding, this study provides what is to our knowledge the first empirical data regarding how CHCs and neighborhood congregations perceive one another as allies and/or partners in the promotion of holistic community health. As such, it takes an initial step toward understanding the basis for effective health center/congregation collaborations in urban, medically underserved communities. Further studies might include non-faith-based and rural CHCs and might focus on the organizational factors and cultures that support effective health center/congregation collaborations and on the effectiveness of different forms of collaboration in promoting community health. We hope the experiences and insights expressed by participants in this study will serve as a stimulus for critical reflection on ways to create, refine, and expand the sorts of comprehensive collaborations that the Bureau of Primary Health Care and others envision.

Acknowledgments

The authors acknowledge the following individuals for their tireless efforts in gathering this research data: Matthew G. Baker, Gregory M. Barker, Heather M. Harris, and Ellen E. Kennedy.

References

1. Bush, President George W. Executive Order 13198. January 29, 2001. Available at: http://www.whitehouse.gov/government/fbci/executiveorders.html. Accessed June 23, 2004.

2. Americans United for the Separation of Church and State. The 'faith-based initiative': churches, social services, and your tax dollars. Available at: http://www.au.org/site/DocServer/The_Faith_Based_Initiative.pdf?docID=111. Accessed June 23, 2004.

3. Humanists of Florida Association. Humanists of Florida Association opposes faith-based initiative. Available at: http://www.floridahumanist.org/news/faithbased.htm. Accessed June 23, 2004.

4. Fagan, A. Faith-based groups prosper under Bush rules, but critics say White House initiative compromises separation of church and state. Washington Times. March 21, 2004. p. A2.

5. Sharing a legacy of caring: partnerships between healthcare and faith-based organizations. Bureau of Primary Health Care, Health Resources, and Services Administration. Winter 2001.

6. Gunderson GR. Backing onto sacred ground. Public Health Reports 2000; 115:257-261.

7. Crabtree BF, Miller WL. Doing qualitative research. 2nd ed. Thousand Oaks, CA: Sage Publications; 1999.

8. Steinhauser KE, Clipp EC, McNeilly M, et al. In search of a good death: observations of patients, families, and providers. Ann Intern Med 2000; 132:825-832.

9. Strauss A, Corbin J. Basics of qualitative research: techniques and procedures for developing grounded theory, 2nd ed. Thousand Oaks, CA: Sage Publications; 1998.

10. Geertz C. The Interpretation of Cultures: Selected Essays. New York: Basic Books; 1973.

Leslie Gee, MD, Douglas R. Smucker, MD, MPH, Marshall H. Chin, MD, MPH, and Farr A. Curlin, MD

From the University of Chicago Pritzker School of Medicine, Chicago, IL; the Department of Family Medicine, University of Cincinnati, Cincinnati, OH; and the Section of General Internal Medicine, Robert Wood Johnson Clinical Scholars Program, MacLean Center for Clinical Medical Ethics, The University of Chicago, Chicago, IL.

Reprint requests to Farr Curlin, MD, The University of Chicago, 5841 South Maryland Avenue, MC 2007, Chicago, IL 60637. Email: [e-mail]

This study was funded by the Bureau of Primary Health Care through the Christian Community Health Fellowship "Best Practices Project," grant U30 CS 00207-03, Technical Assistance to Community and Migrant Health Centers Program. It was also funded through the Robert Wood Johnson Clinical Scholars Program (Drs. Chin and Curlin) and the National Institutes of Health, National Heart, Lung, and Blood Institute, and the Pritzker School of Medicine Office of Medical Education through the University of Chicago Pritzker School of Medicine Summer Research Program (Ms. Gee).

None of the authors have any commercial or proprietary interest in any drug, device, or equipment mentioned in the submitted article. None of the authors have any financial interest in any item mentioned in the article.

This study was approved by the University of Chicago Institutional Review Board.

Accepted January 31, 2005.

RELATED ARTICLE: Key Points

* Faith-based community health centers and neighborhood religious congregations collaborate in limited ways to promote individual and community health, yet comprehensive efforts to coordinate the two types of organizations are lacking.

* Leaders of faith-based community health centers and neighborhood congregations both embrace a holistic vision for health and endorse the importance of their complementary roles in community health promotion.

* Community health centers (CHCs) and religious leaders differ on visions for future partnerships. Whereas CHCs envision community-wide efforts that involve multiple congregations but are organized around the CHC, religious leaders prefer more activities within their particular congregations.

* Comprehensive "faith partnerships" between community health centers and neighborhood congregations are inhibited by the diversity and limited resources of religious congregations and by differences in vision between leaders of health centers and leaders of congregations.

Table 1. Characteristics of community health centers (n = 5)

Community health centers          Range

  Time in community (years)           4-25
  Total patient visits per year   2,000-75,500
  Patient population (%)
    Ethnic minority                  75-99
    Uninsured                        10-90
    Medicaid                         10-50
Key informants at CHCs
  Time in leadership (a) (years)     <1-25

(a) Leadership positions held by key informants: Chief Executive
Officer, Chief Organizations Officer, Chief Financial Officer, Director
of Clinical Pastoral Care, Chief Medical Officers, Director of Clinic
Operations, Vice President, Community Care Coordination Manager,
Director of Community Health Services, Program Director, Project
Coordinator, Board Member, Financial Coordinator, Billing Specialist,
Site Director.

Table 2. Characteristics of religious congregations and leaders
(n = 23) (a)

Religious congregations                      Range    Mean

  Time in the community (years)               1-107    61
  Number of congregants                      25-2300  550
  Congregants who live in the community (%)   0-85     43

Religious leaders                            Number
  Leadership position
    Pastor/minister                          19
    Priest                                    2
    President of church council               1
    Community development director            1
  Women                                       3
  Time in leadership position (years)         1-46     11

(a) Christian denominations represented: Greek Orthodox (2), Catholic,
Baplist, United Methodist, Christian Reformed, Korean Methodist,
Ukrainian Orthodox, Evangelical Lutheran Church for America, United
Church of Christ, Independent (Christian), Church of Christ, Disciples
of Christ, United Methodist, Southern Baptist, Missionary Baptist,
Apostolic, Episcopal, Presbyterian, Advent Christian, Church of God in
Christ, Nondenominational (2). Other religious tradition represented:
Tenrikyo.