Depression among homebound older adults is a significant problem. The number of community-dwelling older adults who experience depression ranges from 1% to 5%, with rates higher among those with chronic illness or decreased functioning (Centers for Disease Control and Prevention, 2017). As might be expected, depression rates for homebound older adults are much higher than in non-homebound older adults. In 2015, reports indicated that almost 30% of homebound older adults self-identified as depressed, with 50% taking antidepressants or diagnosed with depression (Musich, Wang, Hawkins, & Yeh, 2015). This high rate of depression among homebound older adults is a substantial public health problem, due to increased impairment in physical and psychosocial functioning and increased healthcare costs (Choi, Sirey, & Bruce, 2013).
Innovative and cost-effective interventions are needed to help decrease depression rates among homebound older adults. Faith community nursing, a specialty practice that provides holistic care within the context of a faith community, could be helpful in implementing interventions for this population. Faith community nursing focuses on the spiritual, physical, psychological, and social aspects of a person to "create a sense of harmony with self, others, the environment, and a higher power" (American Nurses Association & Health Ministries Association [ANA & HMA], 2017, p. 5). This small pilot study explored the effectiveness of a faith community nurse (FCN) delivered intervention on depression in homebound older adults.
Depression among homebound older adults has been examined in several studies. Choi et al. (2013) found effective programs for depression among homebound older adults included problem-solving therapy, problem-adaptation therapy, the Program to Encourage Active Rewarding Lives for Seniors (PEARLS), Healthy IDEAS (Identifying Depression, Empowering Activities for Seniors), and Beat the Blues for Older African Americans (BTB). Sirey et al. (2013) reported on a program called Open Door, that successfully integrated mental health treatment with meal delivery for older adults, in a home meal program. However, these programs can be costly and difficult to implement and sustain in homebound elders.
Religion has been found to have a positive effect on depression in older adults. For example, church attendance has been shown to have greater influence on decreasing suicide ideation, beyond the influence of private religious practices, importance of religion to the older adult, and social support (Rushing, Corsentino, Hames, Sachs-Ericsson, & Steffens, 2013). Another study found religious participation to be a positive predictor of social well-being (Wilmoth, Adams-Price, Turner, Blaney, & Downey, 2014). Religious participation included prayer, church attendance, and other religious practices and activities. Thus, spiritually-based interventions show promise in impacting depression in homebound older adults.
ASSESSING FCN OUTCOMES
Modern faith community nursing provides holistic care through faith communities of all kinds (ANA & HMA, 2017; Solari-Twadell & Westberg, 1991). Unfortunately, little research has been completed on the outcomes of faith community nursing. Dandridge (2014) explored interventions used by FCNs, identifying a lack of clear goals and documented outcomes as a principal weakness in prior research. Although interventions were described in detail, most involved behavioral change and only "anecdotal evaluations" (p. 105) were completed. Many studies needed clearer measurement processes. Due to the lack of documented outcomes, it is difficult to assess concrete outcomes of faith community nursing. More studies on the efficacy of faith community nursing are needed, including its influence on specific and targeted outcomes (Dandridge).
Several faith community nursing descriptive studies have identified services offered by FCNs and how these activities align with organization standards, such as Healthy People 2020, 2020 Health Indicators, or Faith Community Nursing Scope and Standards of Practice (King & Pappas-Rogich, 2011; Pappas-Rogich & King, 2013). Other qualitative studies have looked at spiritual care and interventions provided by FCNs (Shores, 2014; Van Dover & Pfeiffer, 2012). Currently, no research has studied the impact of faith community nursing on older adults or depression among homebound older adults.
Faith community nurses commonly serve the older adult population (Hixson & Loeb, 2018; Horton, Alvear, & Horton, 2014; Shackelford, Weyhenmeyer, & Mabus, 2014). However, there is a lack of research among homebound older adults and faith community nursing interventions. More specifically, there is little research regarding faith community nursing interventions for depression among homebound older adults. This pilot study looked at a faith community nursing intervention using the CREATION Health model to reduce the incidence of depression among homebound older adults.
THE CREATION HEALTH MODEL
The CREATION Health model, developed by Adventist Health System, offers a formula for healthy living, as found in the Genesis story of creation in the Bible (Genesis 1-2). The model provides a framework for discussing and recommending an evidence-based lifestyle approach for disease prevention and management, and is easily adapted to address depression (CREATION Health, 2018a; Edgerton, 2014).
Eight components comprise the CREATION Health model: Choice, Rest, Environment, Activity, Trust, Interpersonal relationships, Outlook, and Nutrition (Edgerton, 2014). This faith-based wellness plan assists individuals to have happier, healthier lives by incorporating these eight principles of wellness into daily life. The CREATION Health Model fits well into the interventions of faith community nursing in providing holistic healthcare. The eight areas of the model are defined in Table 1.
Faith community nurses integrate faith and holistic healing with compassion, respect, and presence (ANA & HMA, 2017; Pappas-Rogich & King, 2013). Spiritual and emotional support is provided to parishioners, as well as surrounding community members, connecting them to healing and health through the faith community. Faith community nurses are well-situated to reach out to older adults. Choi et al. (2013) found that isolation of homebound older adults can increase their risk of depression. A lack of ability to participate in regular church activities may be a contributing factor. A faith community nursing program directed to this population may be helpful in reducing depression. The CREATION Health model approaches health from a holistic view and provides opportunities for lifestyle change to improve health. Implementing aspects of CREATION Health may help reduce depression, while improving health holistically.
A CREATION HEALTH FCN INTERVENTION
The objectives of this pilot study were to: (a) provide a holistic CREATION Health-based faith community nursing intervention, and (b) decrease depression scores among homebound older adults in a rural Northern California faith community. The pilot study sought to answer the question: What is the impact of a faith community nurse-delivered CREATION Health intervention on depression in homebound older adults?
Institutional Review Board approval for this study was obtained from Southern Adventist University. A pilot study one-group pretest/posttest design was used with implementation of an FCN program aimed toward older adults who are homebound and no longer able to participate regularly in spiritual and social activities at the church. In collaboration with the pastor, a convenience sample of homebound older adults was selected from a small rural faith community in Northern California. To recruit participants, a short presentation was given during church services on two different weeks, asking for volunteers or referrals, and a brochure describing the study was distributed. Inclusion criteria were that participants needed to be age 65 or older, living in their own home or assisted living, be homebound, able to speak and understand English, and able to understand the questions on the Geriatric Depression Scale.
The Geriatric Depression Scale (GDS): Short Form, with 15 items, was developed in 1986 by selection of those items with the highest correlation to depressive symptoms from the original 30-item GDS questionnaire (Brink et al., 1982; Yesavage et al., 1983). The GDS: Short Form has 15 yes/no questions and has demonstrated acceptable reliability (r = .84, p < .001) (Sheikh & Yesavage, 1986). The form takes 5 to 7 minutes to complete. A score of greater than 5 is suggestive of depression and warrants further testing. A score greater than or equal to 10 is almost always indicative of depression (Stanford/VA/NIA Aging Clinical Research Center, n.d.).
For this study, homebound status was assessed with the following five questions (Musich et al., 2015, p. 446). Do you:
1. Have trouble getting around at home or outside your home?
2. Use a cane, wheelchair, or walker to move around at home or outside your home?
3. Need the help of another person to move around inside or outside your home?
4. Need to stay in the house most or all of the time?
5. Need to stay in bed most or all of the time?
Exclusion criteria included those living in a nursing home or the inability to understand the questions on the GDS. Although a few people volunteered, most participants were obtained through referrals. All referrals were followed up, but some persons declined to participate, did not qualify, and/or could not be reached. A total of six homebound older adults participated in this pilot project.
At the initial meeting, information about the study was given and questions were answered. Informed consent was obtained. During this initial visit, the demographic survey, CREATION Health general assessment (Table 2) and GDS: Short Form (Table 3) were completed. The GDS: Short Form also was repeated during the final visit.
Over the course of 3 months, the researcher visited each participant individually at home for seven biweekly sessions. Each of the eight holistic areas of the CREATION Health model were discussed in order, with emphasis on the low-scoring categories and the areas of Outlook, Trust, and Interpersonal Relationships. Each visit lasted 30 to 45 minutes, where one or two areas of the CREATION model were presented and discussed. Education and material were provided, based on the results of the CREATION Health general assessment. Each area of the model was covered, with greater attention focused on the areas of Outlook, Trust, and Interpersonal Relationships. Outlook generates each person's reality and influences the body and mind, affecting health and mood. As each area was covered, the relationship to outlook and depression was emphasized.
To assist with presenting the model, a CREATION Health Leader Kit was purchased. CREATION Health has developed presentation material for each aspect of the model. PowerPoint presentations from the CREATION Health materials were modified for focus on the retired older adult. This was the basis of the education provided at each visit. Each participant received a trifold guide, CREATION Health: A Seniors' Guide to Living Life to the Fullest (CREATION Health, 2006). The education and material were aimed at improving emotional and psychological health of participants. Emotional and psychological support was provided with a spiritual emphasis, incorporating functions of the FCN.
INTERVENTION OUTCOMES
Data were collected from participants via a demographic survey, and the GDS: Short Form. The demographic survey collected information about age, gender, and number of persons in the household. Chronic health conditions were listed, including any current diagnosis of depression. Regularly taken medications also were recorded. In addition to these two instruments, the CREATION Health general assessment was used as part of the intervention, but not as part of data collection. This assessment evaluates each of the eight principles of the CREATION Health model (Edgerton, 2014). Each principle has five areas that the participant rates on a 1 to 5 scale, with 1 being poor and 5 being excellent (Table 2).
Analysis of results was completed using IBM Statistical Package for the Social Sciences (SPSS) Version 24. Six participants (N = 6) completed the study, and all data were collected from each participant. Two-thirds of the participants were female (n = 4); two-thirds lived alone (n = 4), whereas one-third lived with one other person (n = 2). All participants denied a current depression diagnosis or use of antidepressant medication. The mean age of participants was 91.7 years, with an average of 2.5 chronic health conditions. The preintervention GDS mean score was 4.7 (SD = 2.50, range = 2-9); the postintervention GDS mean score was 3.7 (SD = 3.78, range = 1-11) (Table 4). Three participants' scores decreased from the first assessment to the final assessment, whereas two scores remained the same and one score increased.
Although the GDS score decreased from pre- to postintervention, statistical analysis (related-samples Wilcoxon Signed-Rank test) revealed no significant difference between GDS pre- and posttest scores (Z = -1.300, p = -.194). Spearman's Rank correlation calculations showed no significant relationships between GDS posttest scores and age (r = -0.462, p = 0.178), number in household (r = -0.525, p = 0.142), number of chronic conditions (r = -0.194, p = 0.356), and GDS pretest score (r = 0.529, p = 0.140). A Mann-Whitney U test revealed no relationship between GDS posttest score and gender (U = 0.000, p = 0.133).
DISCUSSION
Although two participants had a pretest score greater than 5 and suggestive of depression, the total number of participants had a mean GDS score of 4.7. Thus, only 33% of the participants had scores suggestive of depression. The sample in general was not as depressed as the general population, where rates of depression as high as 50% in homebound older adults have been found (Sirey et al., 2013). Furthermore, though GDS posttest scores improved, they were not significantly different from the GDS pretest score.
The participants in this study were able to attend church, but only with assistance. They could not leave home independently but could attend church if transportation and assistance was provided. Most still attended church regularly (at least once or twice per month), so the fact that they remained partially engaged in the faith community may have acted as a buffer to depression, accounting for the lower rate of depression in the GDS scores.
The first objective of the pilot study to provide a holistic CREATION Health-based faith community nursing intervention was accomplished. All participants were assessed on the first visit with the CREATION Health general assessment. This assessment results in a score for each of the eight areas of CREATION Health. Scores range from a low of 5 to a high of 25. A score of 25 in an area indicates the person is making excellent lifestyle choices. The three lowest scoring areas and three highest scoring areas were examined for each participant. All participants had low scores in the categories of Rest and Activity and most had low scores in the category of Choice. In examining the highest scores, all participants had Trust as their highest score, with Interpersonal Relationships and Outlook also having high scores. The CREATION Health general assessment was effective in targeting education to help these homebound older adults identify and improve lifestyle choices.
The second objective was to decrease depression scores among homebound older adults through a CREATION Health intervention. Although not statistically significant, the results show a downward trend in depression scores (from 4.7 to 3.7). In addition, all participants expressed appreciation for the visits and education, and were eager to participate. It should be noted that all participants lived alone and verbalized gratitude at having someone come to their home to talk with them. As noted earlier, homebound older adults may experience loneliness and isolation. Further, in this group, still being able to attend church at least monthly may have contributed to lower depression scores and better mental health.
The small sample size of six participants is a significant limitation of this pilot study and reduces any generalizability of the study findings. Another limitation is the lack of a control group. A control group of participants visiting with a faith community nurse for seven visits without discussion of the CREATION Health areas would have helped differentiate between the influence of the intervention and the visit alone. The sample was selected from faith community members; participants may not be representative of the general population of homebound older adults. The participants volunteered or were recommended by other faith community members. Although the participants were all homebound, needing assistance to leave their home, each one generally had assistance to attend church. Thus, those who are not able to attend church and benefit from fellowship with other believers were not part of the study. Some people who were recommended for participation declined to participate. Those who declined may be more likely to have depression than those who agreed to participate.
Another limitation of this pilot study is that no screening was done for dementia or cognitive impairment. Dementia and cognitive impairment are associated with increased rates of depression (Snowden et al., 2015). Additionally, this study represents one option related to a curriculum using the CREATION model. The question must be posed whether a visit from a faith community nurse would have been effective in decreasing depression scores, as compared with the interventions included in the CREATION model.
IMPLICATIONS FOR FCN PRACTICE
The ANA and HMA (2017) describe 17 standards of practice for faith community nurses. This pilot study and CREATION Health intervention align with the standards. For example, the first standard is Assessment. This intervention assessed depression and the person's activities surrounding the eight CREATION Health principles. Standard 4, Planning, was carried out as specific education, and support plans were developed for each participant. The implementation of the plan met Standard 5, Implementation. Standard 5B includes Health Teaching and Health Promotion, which occurred through the education and material provided at each visit. Standard 6, Evaluation, occurred through data collection and analysis. Using the CREATION Health intervention is an effective way for FCNs to align their practice with the scope and standards of faith community nursing.
Faith community nursing has been shown to be effective in bringing holistic lifestyle changes to members of the faith community, as well as help the surrounding general community. This intervention, using the CREATION Health model, is a viable option for FCNs to implement for their faith and surrounding community, including homebound older adults. Lay health workers and volunteers can be trained to assist in referring older adults and help with implementation of the intervention.
Faith community nurses can help homebound and other older adults implement holistic lifestyle changes to improve depression. The reduction of mean depression score in this pilot study suggests that FCNs could make a difference in the lives of homebound older adults. FCNs can develop programs and lead faith community members in interventions that decrease depression. A holistic lifestyle approach, such as CREATION Health, can positively impact outlook and depression.
Web Resources
* CREATION Health-http://creationhealth.com/
* Florida Hospital and CREATION Health-https://www.floridahospitalpublishing.com/additional-resources
* Centers for Disease Control-https://www.cdc.gov/aging/mentalhealth/depression.htm
* Geriatric Depression Scale: Short Form (available as a phone app)-https://web.stanford.edu/~yesavage/GDS.html
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