Abstract
Objectives:
This research took place at Pathways: A Healing Center in Minneapolis, MN, before and during the COVID pandemic. We compare the results of two surveys conducted during in-person and on-line service delivery regarding perceived changes in quality-of-life, and we compare the level of utilization in both periods, to evaluate the change from in-person to virtual programs.
Design:
Data collection: Pathways participants were surveyed in 2018/2019 (In-Person Survey) and 2021 (Virtual Survey) using a web-based questionnaire covering individual characteristics and quality-of-life per Self-Assessment of Change (SAC). Utilization is reported as individual and group monthly contacts.
Analysis:
Participation levels and demographics were compared. The SAC assessed changes in quality of life over 14 domains.
Setting/Location:
Pathways offers complementary health services for those facing serious health challenges and their caregivers. Services are free-of-charge through community financial support and qualified volunteer practitioners. In 2020, Pathways shifted from in-person to on-line services due to the pandemic.
Participants:
In-Person survey respondents (178) attended Pathways on-site from January 2018 to May 2019, before COVID. Virtual survey respondents (92) used Pathways' on-line programming during COVID, between June 2020 and March 2021.
Interventions:
Self-selected services offered on-site in the Pathways building compared with those offered on-line.
Results:
Quantitative: Monthly group participant counts on-line during COVID recovered to 75% of in-person levels. Participants reported experiencing significant changes across all components of the SAC measure in both surveys.
Qualitative:
Gratitude for continued services and for the virtual option.
Conclusions:
The data suggest that participation in pathways services is associated with improvements in quality of life. Benefits reported by virtual participants were of similar magnitude to those reported by in-person participants. The on-line platform solved transportation issues; however, on-line participants faced restrictions due to inadequate computers and Internet connections. Participants recommend that both versions be offered when attendance on-site becomes possible.
Introduction
In 1988, a group of visionaries from Minnesota responded to the increasing awareness of the healing possibilities of mind/body/spirit approaches for living with life-threatening illnesses such as HIV/AIDS and cancer. Pathways: A Healing Center was incorporated in November of 1988 and began offering services 1989. In 1992, it moved to a larger facility that includes space for individual sessions, educational programs, and practice groups as well as a small library for books and materials related to healing.
Volunteer providers and support staff grew from approximately a dozen in 1989 to over 123 by 1993. Today, Pathways reaches out to all who are facing health problems, as well as their care-givers, to explore and experience complementary healing approaches free of charge. 1
Before the COVID-19 pandemic, Pathways was scheduling and implementing ∼8500–9000 visits per year; 20% of these visits were 1 on 1 services, and 80% consisted of group participant attendance. All sessions were offered free of charge inside the Pathways facility, with 3–4 individual session rooms and 2–3 larger group session rooms, by an estimated 100 volunteer providers on an ongoing basis.
In March of 2020, Pathways closed due to COVID-19 and began working on a virtual services platform for what had previously been strictly in-person programming. Pathways piloted virtual programming with a 4-week group in April 2020 and a one-time special program in May. The virtual services platform was officially launched in June with 20 providers and grew to 36 providers by the year's end.
Pathways offered training opportunities for interested providers in the development of technical skills and in the enhancing of on-line presence and facilitation capacities. Pathways began to use its email to reach out to those who had participated in its services over the years before the pandemic; this method has served as the main outreach portal throughout the closure due to COVID-19.
Methods
This research project was approved by the St. Olaf College Institutional Review Board. 2 The surveys include demographic data supplied by each participant, responses on items from the Self-Assessment of Change (SAC) measurement, and open-ended questions related to participant experiences.
Data were gathered from a survey in 2019 on people who used Pathways resources at the center between January 2018 and May 2019 (referred to below as the In-Person survey). A second survey was sent to those using virtual programs only during the pandemic between June 2020 and March 2021 (referred to below as the Virtual survey), with the goals of comparing responses with a new delivery approach and guiding further programming. These surveys were provided on-line to all; mailed versions were provided if requested.
Invitations to participate in the In-Person survey were sent to 727 people who participated on-site at Pathways between January 2018 and May 2019. In both surveys, the invitations described the purpose of the study, the basis for selecting the individuals who received the survey, and an estimate of the amount of time it would take to complete the survey. Confidentiality and anonymity were assured, and participants were informed that all information would be aggregated before being shared.
Invitations to participate in the Virtual survey were sent to 269 people who had participated in Pathways services on-line between June 2020 and March 2021, to evaluate the effect of on-line programming. Additional questions concerning the effect of on-line programming were added, and questions about transportation to the center that had been part of the In-Person survey were removed.
Over the years, Pathways has conducted multiple evaluations of its programs, using focus groups, interviews, and respondent-driven questionnaires. In 2009, the team learned of the quantitative SAC measurement at a research conference in Minneapolis, Minnesota. This tool became a regular part of Pathways program evaluation in 2013. It provides a whole person method of assessing the multi-dimensional impact and shifts in well-being that can occur when a person participates in complementary services.2–5 This measurement tool added depth and meaning to Pathway's evaluation process.
The SAC measurement tool was designed to identify changes in quality of life and well-being that often occur due to participation in complementary services across the physical, cognitive, affective, social, and spiritual aspects of the whole person. 3 Those working in the arena of Complementary and Integrative Medicine have been aware of the complexity of an individual's healing process, and the importance of active participation in the choice of healing modalities.6–9
Both surveys included the SAC measure to evaluate changes from “before” to “now” across a series of domains chosen to represent a range of human functioning. The scale is based on 100 mm lines connecting the two poles of each domain, so that a score of 50 is halfway between the two poles. The domains are listed on the horizontal axis of Figure 2. However, the SAC was administered with a small difference between the two surveys.
For the In-Person survey, participants were asked to consider “before” to represent before coming to Pathways. In the Virtual survey, they were asked to evaluate “before” as the time during COVID-19 when they were no longer attending Pathways programs on site, and before coming to Virtual Pathways, to understand both the impact of COVID-19, as well as the degree of improvement associated with on-line attendance in contrast to in-person.
Because the center had reached out to enrolled participants to join Virtual Pathways, this second sample derives predominantly from those who had been approached in the In-Person survey. Because of the anonymity involved, we could not determine the exact overlap. We have tested the differences within surveys between Before and Now using paired t-tests at the <0.001 level of significance; the differences between surveys are tested using a two-sample t-test, and they have chosen the p < 0.005 level of significance to be conservative.
Results
For the In-Person survey (2019), we received 153 responses (21%) from 727 invitations. For the Virtual survey (2021), we received 92 responses (34%) from 269 invitations. The responses to the demographic and participation components of the survey are shown in Tables 1 and 2.
Demographic Characteristics of the Two Surveys
Use of Pathways
Demographic characteristics
Table 1 shows the demographic responses to the surveys. Categories in Table 1 reflect the exact survey questions. The majority of respondents were female (86% In-Person, 90% Virtual), and not of Hispanic ethnicity (97%). Race data are shown in Table 1. The survey populations were predominantly middle-aged (57% 41–64 in both), with 35% (In-Person) and 37% (Virtual) above 65. The remainder were 21–40. (The age groups were binned on the survey form.) Income has a broad distribution (Table 1).
Employment is similar in both surveys: 58% were unemployed in both surveys, with approximately one-quarter employed part time, and the remainder full time. About half were retired, slightly more than one-third on disability, and the remainder distributed across various employment categories (Table 1).
There was a slight shift upward in the income distribution on the Virtual survey, possibly due to the advantages for Zoom participation provided by adequate computers and Internet connectivity.
Service characteristics
Table 2 provides additional information about the population characteristics and center utilization. Outreach communication was heavily weighted toward email in the second survey, as this was the main portal of program scheduling during virtual programming (vs. health care professional or friend/family referrals when the programming was on site). Similarly, there were fewer individuals participating in “New Participant Orientation” as most of the on-line participants were from within the existing Pathways participant community.
Both survey respondent groups found benefit (“Very Helpful”) whether on site or on-line (data not shown). There were no significant shifts in the types of illnesses bringing people to Pathways. In data not shown, there were no meaningful shifts in the primary care facilities they used. Most participants had health insurance in both surveys, and the sources of health care showed little change.
Pathways participation
Figure 1 shows the attendance at sessions on-site from January 2019 through June 2021 (before COVID). The center facility closed during the first COVID-19 lockdown, and it has not yet reopened for on-site interaction as of January 2022. The effect of the shutdown from March through May 2020 is quite visible in Figure 1. All participants before the COVID-19 shutdown came to the Pathways site; all participants after the shutdown participated on Zoom. Although the number of sessions and participants has not fully returned to pre-COVID-19 levels, participants clearly wanted Pathways, and they returned in numbers above what had been anticipated.
Continuous record of pathways participation, January 2019 to June 2021. The data are based on Pathways program monthly attendance counts of individuals engaging with Pathways. They are separated into two sets—participating in individual sessions (mostly acupuncture and massage before COVID lockdown) or participating in virtual groups. See text for further descriptions. The months are shown on the horizontal access as month-year, where month is represented by the first letter, and year by the final two digits. (J-19 = January 2019). The closure period was a Minneapolis city-wide lockdown.
Individual sessions before COVID-19 included acupuncture and massage, as well as health coaching. During the pandemic only, the “talking sessions” were possible, resulting in the decrease in number of participants in individual activities. “Talking sessions” continued to include meditation, guided movement (yoga, etc.), guided self-massage, energy healing, distance healing touch, guided imagery, writers' groups, and a variety of other sessions; the decline in attendance largely resulted from the disappearance of in-person massage and in-person acupuncture.
One group event, called Renewing Life (a signature group for Pathways), includes a variety of hands-on activities. This group stopped during the pandemic and is responsible in part for the lower group participation numbers. Overall, participation has continued to be high. Respondents to the In-Person survey indicated transportation difficulties that they encountered in getting to the facility in Uptown Minneapolis; respondents to the Virtual survey described the difficulties that they encountered using Zoom, particularly if they only had a cell phone.
Wellness assessed through the SAC
Figure 2 shows the responses to the SAC for the two cohorts, along with the standard errors. Note that the value of 50 represents responses halfway between the negative and positive poles, so that values above 50 suggest a greater endorsement of the positive attribute. The graph is arranged with the Befores adjacent and the Nows adjacent. All the changes within cohorts between Before and Now are statistically significant by paired t-test at the <0.001 level. The amount of change from Before to Now on the Isolated-Connected domain is among the greatest in this measure, and it provides numerical evidence of the importance to the participants of the community experience provided by Pathways.
Self-assessment of change, in-person and virtual surveys. The domain pairs are shown on the horizontal axis. Respondents rate where they fall on a 100 mm line between the two poles of the domain, with 1 the negative pole, and 100 the positive pole. Values below 50 move closer to the negative pole; values above 50 move closer to the positive pole. All Before-Now pairs are statistically significant at p < 0.001 using a paired t-test. The graph is arranged with the Before values for the two surveys, followed by the Now value for the two surveys; the pairing permits an easier visualization of the differences in the Before values, and the similarities in the Now values. Value labels with **indicate domains where the Before values are statistically significantly different between periods at the p < 0.01 level using a two-sample t-test.
At an overall level, it is clear that the Now values are remarkably similar between cohorts, with no significant differences between any Nows. This may represent the Pathways “signature” values regarding flourishing and thriving. This pattern shows particularly high values (≥70) for the qualities of Hopeful, Forgiving, and Open-hearted. Whole, and “Not defined by my illness” are nearly as high.
The Before values in Figure 2, however, do differ between cohorts, with five meeting the conservative significance level p < 0.005 (see variable names labeled with ** on Fig. 2); the Virtual participants Before values were significantly higher than the In-Person participants Before values on Overwhelmed-Empowered, Closed-hearted-Open-hearted, Anxious-Calm, Broken-Whole, and Unbalanced-Balanced. In contrast, the Virtual participants' Before values are almost as low (toward the negative pole) as In-Person Before values (referencing the time before beginning to attend Pathways on site) on Scattered, Stuck, and Isolated.
Qualitative analysis
To gain a more complete understanding of the perception of the virtual programming provided by Pathways during the pandemic, survey respondents were asked to comment in an open text field on their experience with the Pathways program at this time. Participants expressed profound gratitude for the ability to access programs that helped them continue on their healing journey. Many stated they were having difficulty with transportation (although Pathways is located on the main north-south arterial in south Minneapolis and on the bus line) and fitting an in-person visit into their schedule.
The virtual programming allowed them to feel connected with the healing community, especially those with disabilities that isolate them. One participant summed up the feelings of many in her comment: “Pathways has been a wonderful place for me since I hit a tipping point and fell apart physically and emotionally in 2016. Things could have gotten really ugly again, during Pandemic isolation, had Pathways not have gone virtual. In addition to the virtual offerings, the emails, with links to helpful articles, have been invaluable. Thank you so much!”
Many participants voiced the suggestion that, when Pathways did open their doors to in-person programming, they should continue to offer virtual programs as well.
Discussion
The COVID-19 pandemic has rapidly and radically transformed the landscape of health care delivery. All around the world, people suddenly became apprehensive to enter health settings for fear of contracting the virus and health care providers were concerned about unnecessary exposure for both patients and themselves. 10 For the continued provision of safe and effective health services, providers needed to quickly adapt from in-person to virtual (i.e., telephone and video) visits and other telehealth/telemedicine programs. 12
Within weeks, the application of patient-facing technology spread across outpatient settings, hospitals, and interdisciplinary services such as occupational and physical therapy. 11 This rapid expansion of telehealth transpired to lower the risk of exposure to COVID-19, especially during periods of increased outbreaks in transmission of the virus. 11 In nonurgent care settings, the transition to virtual visits has demonstrated benefits in feasibility, maximization of efficiency, patient and provider satisfaction, promotion of social distancing, accessibility to essential care, management of prolonged waiting times, lowering the risk of disease progression, expansion in the capacity to provide health care, and reduction in the loss of needed resources through the mobilization of quarantined but asymptomatic providers to deliver care remotely.11–13
At Pathways, the implementation of virtual services successfully met a need during the COVID-19 period. The SAC values seem to show both the negative effects of the lockdown (isolation, scattered, stuck) and the capacity of Pathways virtual programming to help participants recover from the stress of the pandemic as well as maintain themselves during the ongoing closure of the center. The SAC Now responses were extremely similar for both the In-person and Virtual time periods.
Some features, however, are notable. “Open-hearted” had the highest values on the Virtual survey both “before” (meaning during the lockdown) and “now,” when participants were engaged in virtual Pathways. In fact, the average value during lockdown remained about 50, suggesting that perhaps the pandemic was helping to inspire compassion in the face of individual difficulties. On the “Before” measure for the Virtual survey, the values were significantly higher than the In-Person cohort on Overwhelmed-Empowered, Open-hearted, Anxious-Calm, Broken-Whole, and Unbalanced-Balanced, suggesting that changes in some of these parameters associated with attendance at Pathways before the pandemic may have been partially sustainable through the COVID-19 lockdown difficulties.
For another set of domains, Scattered, Stuck, and Isolated, participants reported Before values on the Virtual survey (referencing lockdown) that were nearly equivalent to In-Person (pre-Pathways) values. Nevertheless, Now values on these domains were equivalent in the two time periods. This suggests that Virtual Pathways may have played a key role in helping these participants feel more Focused, More able to Let Go, and Connected to others, so that they could maintain their lives during the ongoing partial lockdown and COVID-19 concerns.
Clients have traditionally faced issues regarding transportation to and from the center, issues not different from those found in other organizations serving low-income populations. It is on a bus route, and low-cost transportation is available in Minneapolis. With virtual programming, these issues transferred to the availability of appropriate technology to participate in Zoom groups and sessions.
Examining the utilization data (Fig. 1), these issues are consistent with the peak utilization in the two time periods—peak in warmer months at the Pathways facility when public transportation is easier, and peak in colder months during Zoom when isolation was more intense. Going forward after COVID-19, it is likely that Pathways will adopt a blended model, offering programming both in-person and virtual.
Limitations
The results reported here are limited by the nature of the self-report instrument employed, the difficulty of responding to a survey on-line, and the size and demographics of the Pathways population. In addition, analyses were limited in scope because it was not possible to match the responses of individuals who responded to both surveys because of the anonymity features of the original IRB approval. Personal reports on the SAC provide the only details of the changes in quality of life that participants in the study are experiencing, but their continuing participation at Pathways suggests that the center is providing valuable services.
Conclusions
As we consider the challenges of health care during this pandemic, it has become critical to encourage individuals to actively participate in their own health and well-being. To this end, health care systems are increasingly interested in becoming whole health systems that include complementary and integrative health approaches. 13 Positive shifts in the perceptions of well-being and quality of life have been shown to be associated with patient satisfaction, compliance with treatment regimens, participation in healthy life-styles changes for disease management, and fewer hospitalizations, all crucial outcomes during this pandemic.
Integrative health services have traditionally been delivered in-person, and that has created a limitation for individuals without adequate transportation or those who are housebound. The successful shift to virtual programming, with similar outcomes of positive change, suggests that a mixed model of virtual plus in-person programming in the future may expand the reach of integrative services, beyond the limitations of previous programming.
Footnotes
Acknowledgments
Data curation: Pathways staff members Erica Nelson, Dan Averitt, and Laura Nelson; Formal analysis, 2019: Olivia Reyes, graduate student, University of Minnesota; Formal analysis 2021: Mikel Aickin, PhD.
Authors' Contributions
M.B.J.: Conceptualization (equal); investigation (equal); methodology (supporting); supervision (equal); writing (lead); C.R.: Conceptualization (equal), formal analysis (lead); investigation (equal); methodology (lead); visualization (equal); software (lead); writing (supporting); D.O.N.: Conceptualization (equal); investigation (equal); methodology (supporting); writing (supporting); B.F.: Conceptualization (equal); reviewing and editing (supporting); T.T.: Conceptualization (equal), formal analysis (contributor), investigation (equal); funding acquisition (lead); visualization (equal); project administration (lead); resources (lead); supervision (equal); writing (supporting). The paper is a product of the Pathways Research Group, which meets regularly to discuss what is worthy of study in Pathways and includes those individuals named above plus Mikel Aickin.
Author Disclosure Statement
T.T. is an employee of Pathways; M.B.J. is an unpaid member of the Pathways Board of Directors; and M.B.J., C.R., D.O.N., and B.F. have no financial ties to disclose.
Funding Information
The Pathways Board of Directors authorized use of Pathways funds for survey design and mailing (2019), a modest student stipend for survey creation and data analysis (2019, O Reyes, see Acknowledgments section above), and submission costs for the journal.