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Response and Impact of COVID-19 Pandemic on Faith Communities in Johnson City, Tennessee Cindy Yang B.S., Kenneth Olive M.D. Within Tennessee, religion and faith are a predominant part in the population’s daily lives and local culture, and the sudden disruption of the traditional religious practices in the U.S. by the COVID-19 pandemic had profound impact on the faith communities (FC). There is little information available nationwide on how the COVID-19 pandemic has impacted religious practices, faith communities’ (FC) ability to worship, and subsequent FCs responded. This study interviewed nineteen FCs around Johnson City, Tennessee, and provides detailed evidence on faith communities’ efforts to continue worshipping and their efforts to maintain congregants’ spiritual, physical, and mental health. Pastors (53%), faith community Nurses (26%), or other religious leaders (21%) from 19 local faith communities around Johnson City consented to an interview. Interviews were conducted (from May to June 2022) either in person or via Zoom, and questions focused on the impact of COVID-19 on their local community, worship services, and their subsequent response. Each interview lasted for ~1-2 hours. Conversations were transcribed and analyzed. Following the March 2020 outbreak, all FCs shut down abruptly when COVID cases started to spike nation-wide, and almost all in-person worship services were cancelled. Most of them immediately resorted to different platforms of technology, including Facebook and Zoom to maintain Sunday service. The reopening process was slow and varied among the faith communities and their respective leaders. As rapid testing, vaccinations, and new treatments became available in the Spring of 2021, all churches reopened to resume in-person services to combat declining mental health among congregation members, especially in the elderly. Despite the challenges that the pandemic posed via disrupting in-person services, all FCs that were interviewed stated that their organization tried their best to offer as much support to their members during this difficult time. The results from this study showed that COVID-19 impact affected different faith communities very greatly, ranging from minimal effect to permanent closure, but it ubiquitously disrupted in-person service and forced an abrupt scramble to adapt, one that paralleled other institutions and businesses. Decisions fell on local faith community leaders, many of whom had to turn to creative and more modernized ways to practice faith to stay COVID-19 friendly. Faith communities discussed the difficulty of navigating COVID-19 due to the lack of standardized knowledge and over-politicization of the pandemic, which led to internal chaos and confusion. Much of the responsibility and fault was put on local religious leaders, many of whom suffered mental health decreases. The FCs that had access to faith community nursing, healthcare community members, or internal health groups more easily navigated COVID-19 and felt more confident with health promotions and advocacy. One leader mentioned how s/he wished the government could give more direction and transparency to the faith communities, so leaders could make more well-informed decisions. In the future, involvement of faith community leaders in public health decisions could improve overall community health.

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Heart failure (HF) is a chronic condition affecting older adults. It is estimated over 5.8 million Americans are currently diagnosed with HF, with an anticipated increase to seven million by 2030. HF patients are faced not only with the physical symptoms, but also with emotional tolls, and socioeconomic burdens related to HF. Low income and rural facilities, which lack financial resources, are at greater risk for closure if there are concerns of loss of reimbursement. Hospitals are now challenged to prevent readmissions and to avoid penalties associated with HF admission within the 30-day window. Incorporating various interventions have shown improvements in readmission rates. Nurse practitioners and registered nurses can serve as patient educators regarding topics such as diagnoses, procedures, disease monitoring, medications, and medication side effects. In most hospitals, RNs at patients' bedside are at the forefront of providing HF patients discharge instructions and education, which should include symptom recognition and management. The aim of this project inquiry was to assess the knowledge of HF education and perceived barriers to providing HF education by nurses and nurse practitioners, such that improved transition of care for patients in the rural health setting can occur.

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Economic, political and social forces are driving the implementation of reforms in health service systems worldwide. As the health industry concentrates on ways to improve operations and to achieve overall cost effectiveness, health service organisations are developing and implementing structural changes to address issues of cost containment, utilisation and resource allocation. One approach has been to devolve resource allocation and utilisation decisions to the program or unit level. Clinical practitioners have been required to assume general management responsibilities in addition to their clinical role. A new type of clinician, the clinician manager has emerged to take on this task. Despite the trend towards the clinician manager role in many sections of health care world wide, there is little research in the area and a poor understanding of the experience of the role.The aim of this research was to explore clinician managers' perceptions of their experiences in their adaptation to and their enactment of the new role. The study was based in the symbolic interactionist paradigm. Sensemaking, the process by which individuals ascribe meaning to the events in their environment, provided a theoretical context that directed the inquiry. Grounded theory was the methodological approach. The research sample was made up of Directors of Nursing/Health Service Managers, a clinician manager role that had emerged from the restructuring of rural health services in Western Australia. Data was gathered from in-depth interviews.Findings suggested that sensemaking was influenced by structural and personal elements. Structural elements were created by the stakeholders, individuals and groups who relied on the clinician manager for the achievement of their goals but upon whom, in turn, the clinician manager relied upon for their support and cooperation. The sensemaking process of the ++ / clinician manager was mediated by the interaction with the stakeholders - the most influential factors being the clinician manager's perceptions of the trustworthiness of the stakeholders, the political behaviour that characterised the interactions with the stakeholder and role stress. In particular, role conflict, role ambiguity and role overload emerged. Personal elements were the personal characteristics of the clinician manager - the most salient being the experience of role strain, self-efficacy (i.e. their belief in their ability to do the job) and their commitment to the sensemaking process.Circumstances in the environment constrained their reliance on others for validation of their explanations of events and the actions they took. Most made decisions based on intuition and "gut feeling" - validating these decisions with subjective evaluations of outcomes and retrospective explanations. These processes were further mediated by the characteristics of the individual, particularly perceptions of self-efficacy. The ways in which the clinician managers adapted to and interpreted their role was diverse, which made the role more an expression of individual preferences than a coherent part of a larger organisational structure. Findings indicated that the clinician managers relied on their sensemaking processes in order to explain the ambiguous nature of their practice environment and to plan actions within the context of a role that was poorly defined by the organisation.

Background General practice’s population health and public health role is being promoted internationally to improve health outcomes. 1-6 This Thesis aims to: • Describe and evaluate projects which are relevant to exploring the interface of population health and public health with Australian rural general practice; and • Describe and evaluate projects which can increase population health and public health expertise and capacity amongst our future rural general practice workforce. Methods This Thesis uses a descriptive design. A series of research papers published in the peer reviewed literature are presented in each chapter. These papers are used as case studies to explore the aims of this Thesis. A variety of quantitative and qualitative methods have been used to conduct research in remote communities of the Northern Territory, rural South Australia and New South Wales from 1992 to 2005. Results Public health and population health can interface with Australian rural general practice in sustainable models described in case studies within this Thesis. There is a continuum of roles in this interface from population health in practice, public health, ‘new’ public health and leadership. Population health activities include screening and promotion of lifestyle factors to patients.7 Public health activities can be developed to extend the reach of health programs to the broader community. This may include participation in population based surveillance systems and health promotion projects. Promoters of ‘new’ public health 8,9 support an expansion of public health’s scope to include advocating social development through community participation and empowerment. Leadership can extend to policy development and liaison with general practice, population health and public health practitioners to promote collaborative models of health care. A sustainable model of increasing rural workforce recruitment via developing workforce capacity in public health and population health has been developed and evaluated as part of this Thesis. Conclusions This Thesis presents rural Australian case studies demonstrating integration of population health and public health roles with general practice. Vertically integrated workforce models have been developed, as part of this Thesis, which can facilitate recruitment to the rural health workforce. In the long term, educational models have been developed and evaluated as part of this Thesis. These models can increase the population health and public health expertise and capacity of this workforce. / MD Doctorate

Past research advocates the need for long-term care (LTC) facilities to adopt a person-centred model of care to optimize residents quality of life. The construct of quality of life in LTC has been defined by satisfaction with a set of domains identified by Kane and colleagues (2003). One goal of this study was to determine which domain is the most predictive of overall well-being among LTC residents in a rural setting. Based on past research and on Deci and Ryans (1985; 1991) self-determination theory, satisfaction with autonomy was predicted to emerge as most predictive of overall well-being. The present study also examined the relation between resident quality of life and well-being, and the degree of routinization (i.e., adherence to a rigid, inflexible daily schedule) within the LTC environment. Routinization is conceptually at odds with a person-centred model of care, yet its relation to the well-being of care recipients had not been examined prior. One hundred and ninety-eight residents from 15 LTC facilities in rural Saskatchewan participated in individual interviews to measure their satisfaction with 11 quality of life domains (Kane et al., 2003), and their overall well-being (using the Memorial University of Newfoundland Scale of Happiness; MUNSH; Kozma & Stones, 1980). One hundred and thirty-one staff from the 15 facilities completed a questionnaire designed to assess routinization within the LTC environment. Contrary to predictions, autonomy failed to emerge as a significant predictor of overall well-being among sample residents. The domain of meaningful activity received residents lowest satisfaction rating of the 11 domains, and also accounted for the most unique variance in overall well-being. Routinization was negatively related to resident quality of life, with staff rating routinization higher in facilities which residents reported lower satisfaction with quality of life. Results provide focus for improving the quality of life of LTC residents, and point to areas for further study.

Immunization has been used as an upstream, protective measure in public health for decades. Although immunization programs have been introduced in Pakistan, new and emerging infectious disease remains a concern in the country. The province of Sindh, Pakistan is of special concern because of its large rural population.<p>The purpose of this study was to: 1) determine and compare complete and age-appropriate immunization uptake in children 12 to 36 months and birth to 9 months, respectively living in Sindh, Pakistan in 1994 and 1997; and 2) determine the correlates of complete and age-appropriate immunization in children 12 to 36 months and birth to 9 months, respectively living in Sindh, Pakistan in 1997.<p>This study reviewed data that was collected as part of the School Nutrition Program (SNP) and Family Health Project (FHP) in 1994 and 1997, respectively. Analyses included immunization data on 1877 children from the SNP survey and 1694 children from the FHP survey.<p>Females were found to have higher statistically significantly age-appropriate uptake than males in 1997 (p=0.015). Complete immunization status was also found to vary significantly by district of residence in 1994 and 1997 (p<0.001). Both complete and age-appropriate immunization status was found to decrease from 1994 to 1997.<p>Multivariable logistic regression revealed that not owning a radio, electricity, or bicycle was indicative of lower odds of complete immunization uptake (OR<1, p<0.05). Other correlates predictive of lower odds of complete immunization included owning a water pump (OR=0.360), not having a Lady Health Worker (LHW) visit the home (OR=0.489), living in a kucha house (OR=0.637), and living in Tharparkar (OR=0.290), Badin (OR=0.599), or Mirpur Khas (OR=0.271).<p>A similar regression analysis revealed childs sex, ownership of a refrigerator, and having heard of contraception to be correlates of age-appropriate immunization (p<0.05). Females had higher odds of age-appropriate immunization (OR=1.851) compared to males. Not having a refrigerator was indicative of lower odds (OR=0.079). Not having heard of at least one type of contraception was a predictor age-appropriate immunization (OR=1.925).

Background: Rural Saskatchewan cancer survivors have reported a lack of support once their cancer treatments have been completed. This problem is more acute the further away one lives from Saskatoon and Regina. A chronic disease self-management program titled LiveWell with Chronic Conditions (LWCC) is available to all people with any chronic condition in rural areas across Saskatchewan. This program addresses key areas of concern to survivors; however, participation is low for cancer survivors. Purpose: To determine how LWCC can reach and respond to the needs of rural cancer survivors in Saskatchewan. Objectives: 1. To gain an understanding of how the program responds to the needs of rural cancer survivors from the perspective of program leaders and cancer survivors. 2. To explore how the existing LWCC program could be enhanced in terms of content, format, delivery and marketing strategy. 3. Based on results, develop recommendations in coordination with agencies and institutions that provide services to cancer survivors. Methods: A mixed-methods case study approach was adopted. Needs questionnaires were completed by cancer survivors who participated in the LWCC program offered in rural health regions across the province (n=4). Consenting survivors who attended the program and several program facilitators, some of whom were cancer survivors themselves, were interviewed in order to provide their opinion regarding content, format, and other relevant feedback that would improve the fit of the program with the needs of rural cancer survivors (n=10). Results: Results indicate the material covered in the program is appropriate for cancer survivors who have finished acute treatment and are making the transition to life after cancer. Program benefits include improved self-efficacy and being able to manage emotional and physical issues from cancer including fatigue and pain. Rural survivors would like access to additional information to address issues specific to cancer survivorship including dealing with the fear of cancer recurrence, lymphedema and sexuality. A cancer specific rural health program would not be very feasible due to small populations. Cancer survivors felt comfortable in a group among people with other chronic conditions although support of another person with cancer participating in the LWCC group would be preferred. Knowledge Translation: A think tank was held with key stakeholders who provide services to cancer survivors to review these findings and form recommendations for improving rural cancer survivor care. These recommendations are: 1) to promote LWCC to rural cancer survivors who have finished acute cancer treatment, 2) to broaden the awareness of the program among cancer care providers, and 3) to refer cancer survivors to an existing cancer survivorship single day workshop after participation in LWCC. This workshop is available in up to 10 communities outside of Regina and Saskatoon. Conclusion: The Live Well with Chronic Conditions program is appropriate and beneficial for cancer survivors who have completed acute cancer treatments. As more cancer care providers make referrals to this program and an online version of the program becomes available, uptake will likely improve among rural cancer survivors in Saskatchewan.