Themes of holism, empowerment, access, and legitimacy define complementary, alternative, and integrative medicine in relation to conventional biomedicine

What is Effective in Massage Therapy? Well, "It Depends…": a Qualitative Study of Experienced Orthopaedic Massage Therapists

Background

Massage has been used as a treatment for musculoskeletal pain throughout history and across cultures, and yet most meta-analyses have only shown weak support for the efficacy of massage. There is a recognised need for more research in foundational questions including: how massage treatments are constructed; what therapists actually do within a treatment, including their clinical reasoning; and what role therapists play in determining the effectiveness of a massage treatment.

Purpose

The aim of this study was to explore what experienced orthopaedic massage therapists consider to be the aspects of their work that contribute to effectiveness.

Setting and Participants

Semi-structured interviews were conducted via Zoom with six experienced orthopaedic massage therapists in Australia.

Research Design

The interviews were analysed using inductive thematic analysis, seeking insights that might be practically applied, rather than theory-driven interpretations.

Results

The participants focused on the underlying differences between clients, between therapists, and between treatments, and clearly indicated that this concept of "difference" was foundational to their view of their work and was the underlying context for the comments they made. Within that frame of "difference", three key themes were interpreted from the data: (1) "Everyone is different so every treatment is different": how they individualised treatment based on these differences; (2) "How therapists cope with difference": how they managed the challenges of working in this context; and (3) "What makes a difference": the problem-solving processes they used to target each treatment to meeting the client's needs.

Conclusions

Participants did not identify specific techniques or modalities as "effective" or not. Rather, a therapist's ability to provide effective treatment was based on an iterative process of treatment and assessment that allowed them to focus on the individual needs of the client. In this case "effectiveness" could be considered a process rather than a specific massage technique.

"I Want People to Be Able to Make an Informed Choice": How Quebec naturopaths discuss vaccination in their practice

Health care providers' recommendations can play an important role in individuals' vaccination decisions. Despite being one of the most popular complementary and alternative medicine (CAM), naturopathy is understudied in relation to vaccination decisions. We sought to address this gap through this study of vaccination perspectives of naturopathy practitioners in the province of Quebec, Canada. We conducted in-depth interviews with 30 naturopaths. Thematic analysis was conducted. Main themes were developed deductively (i.e., based on prior literature) and expanded through inductive coding of the data. Participants noted that they discuss vaccination in their practice, but only when clients asked questions or wanted advice. Naturopaths described refraining from explicitly recommending for or against vaccination. Instead, they focus on empowering their clients to make their own informed decision regarding vaccination. Most participants noted that they direct clients towards sources of information so that clients could decide for themselves, but some mentioned they discussed with clients what they considered to be risks associated with vaccination, as well as its benefits. These discussions were framed through a personalized and individual approach with clients.

Reasons for Engaging in Complementary and Alternative Medicine Among Highly Educated Women With Multiple Sclerosis

BACKGROUND

Previous research has shown that users of complementary and alternative medicine (CAM) among persons with multiple sclerosis are more likely to be women and to have a higher level of education compared with nonusers. This qualitative study was performed to explore the motivations linked to CAM use among highly educated women with multiple sclerosis.

METHODS

The study was based on a phenomenological approach, and 8 semistructured, in-depth qualitative interviews were performed. Data were transcribed verbatim and analyzed through meaning condensation and identification of recurring themes.

RESULTS

Regarding the informants' motivations for CAM use, 3 main themes emerged: (1) Self-reliance is essential in disease management, (2) conventional health care lacks a holistic approach, and (3) personal experience is the primary guide.

CONCLUSIONS

The interviewees wanted approaches to health care that supported their desire to actively participate in the management of their disease. They were critical of the conventional health care system, and they emphasized the importance of letting their own personal experiences, as well as those of others, guide their decisions.

Complementary and Alternative Medicine legitimation efforts in a hostile environment: The case of Portugal

This article explores complementary and alternative medicine (CAM) organisations' legitimation efforts that face extra obstacles as they are subject to more than one institutional logics (hybrids) and operate in a contested organisational space (hostile environment). CAM organisations espouse the health and market logics and their practices are questioned at an institutional level. The study is conducted in Portugal, where the legalisation of CAM therapies was a contested process over 10 years. Taking an abductive approach and drawing on qualitative interviews, the authors analyse CAM managers' efforts to legitimise their practices and build viable organisations despite hostile conditions. Contrary to prior studies of hybrid healthcare organisations, CAM organisations derive moral legitimacy from the market logic rather than the health logic. The findings show that relationships, trust-building and consumer education appear to be the primary vehicles for establishing pragmatic legitimacy. Thus, pragmatic legitimacy relies on the health logic. The market logic dominates the pursuit of moral legitimacy through financial sustainability, human capital, marketing communications and partnerships, and advocating complementarity with biomedicine. We propose a model through which organisations use pragmatic legitimacy to enhance moral legitimacy and to create recursive feedback between moral and pragmatic legitimacy on the path to cognitive legitimacy.

Impact of Inclusive Leadership on Innovation Performance During Coronavirus Disease 2019 Outbreak: Mediating Role of Employee Innovation Behavior and Moderating Role of Psychological Empowerment

This study investigates the effect of inclusive leadership on innovation performance with a mediating role of employee innovation behavior and the moderating role of psychological empowerment (PE). Supervisors and employees of Saudi manufacturing firms are the participants of this study. This study used a quantitative research technique with a cross-sectional approach and a self-administrative survey questionnaire to collect the data. The data were analyzed by using the Smart PLS 3 software. The results depict that inclusive leadership has a significant positive impact on the firm's innovation performance. Employees' innovation behavior has a significant mediating effect on the association of inclusive leadership and innovation performance. Findings revealed that PE has an important moderating role in the association of inclusive leadership and innovation performance. The findings of this study contribute to the body of knowledge by finding that inclusive leadership has a significant effect on the firm's innovative performance and PE is crucial to enhance innovation performance.

Use of Complementary and Alternative Medicine (CAM) in Patients With Colorectal Cancer

This study was conducted to analyze the relationship between cancer-related stress and the types of complementary and alternative medicine (CAM) used by subjects diagnosed with colorectal cancer. The number of study subjects was 142, and for data analysis, descriptive statistics, t-test, χ² test, logistic regression procedures were performed. Of the subjects, 114 were CAM users, who accounted for 79.6%. When it came to using CAM, 82 (72.6%) said they did “to prevent cancer recurrence.” The most popular reason for not using CAM was “to focus on treatment as instructed by the doctor,” with 22 (75.8%) respondents selecting the answer. Of those who used CAM, 79 (55.6%) said they took “dietary supplements,” followed by 65 (45.8%) who picked “vitamins and minerals.” Regarding CAM usage, ginger, aloe, swimming, and walking had the highest satisfaction (4.25 ± 0.71). The cancer-related stress of subjects who use CAM (18.21 ± 15.37) was higher than that of subjects who did not use CAM (10.11 ± 12.08). Logistic regression analysis determined that cancer-related stress were factors significantly associated with CAM use. Patients using CAM had higher cancer-related stress, suggesting that stress on cancer increased CAM interest. Safe and reliable CAM information and standardized recommendations should be provided to cancer survivors. We propose the development of training programs for CAM to improve communication between medical staff and patients and to protect patients.

Development of an Integrative Care Program in a Pediatric Oncology Unit

PURPOSE

The aim of this article is to describe what needs to be considered in implementing care practices, in this case an integrative care program consisting of anthroposophic treatments, in an intensive care unit (ICU) of a teaching hospital.

METHODS

We used a pediatric oncology department to implement an integrative care program. We conducted a qualitative study including participant observation and semi-structured interviews with parents, nurses, doctors, and therapists. Data analysis was based on a grounded theory approach and focused on the status quo of care in the ICU.

RESULTS

The following factors needed to be considered: the structure of the ICU, communication and information dissemination, and time constraints. This led to the following components of the integrative care program: (1) a training plan in anthroposophic treatments for all nurses that was conducted by 2 trained anthroposophic nurses, and (2) the introduction of an integrative shift that was on top of regular care at the ICU and focused on delivery of integrative care to patients.

CONCLUSION

To add new care components to an ICU, the existing context has to be considered. Time constraints and high workload are factors that need to be recognized. In this particular context, a highly flexible program was the solution.

Using Electronic Data Collection Platforms to Assess Complementary and Integrative Health Patient-Reported Outcomes: Feasibility Project

BACKGROUND

The Veteran Administration (VA) Office of Patient-Centered Care and Cultural Transformation is invested in improving veteran health through a whole-person approach while taking advantage of the electronic resources suite available through the VA. Currently, there is no standardized process to collect and integrate electronic patient-reported outcomes (ePROs) of complementary and integrative health (CIH) into clinical care using a web-based survey platform. This quality improvement project enrolled veterans attending CIH appointments within a VA facility and used web-based technologies to collect ePROs.

OBJECTIVE

This study aimed to (1) determine a practical process for collecting ePROs using patient email services and a web-based survey platform and (2) conduct analyses of survey data using repeated measures to estimate the effects of CIH on patient outcomes.

METHODS

In total, 100 veterans from one VA facility, comprising 11 cohorts, agreed to participate. The VA patient email services (Secure Messaging) were used to manually send links to a 16-item web-based survey stored on a secure web-based survey storage platform (Qualtrics). Each survey included questions about patient outcomes from CIH programs. Each cohort was sent survey links via Secure Messaging (SM) at 6 time points: weeks 1 through 4, week 8, and week 12. Process evaluation interviews were conducted with five primary care providers to assess barriers and facilitators to using the patient-reported outcome survey in usual care.

RESULTS

This quality improvement project demonstrated the usability of SM and Qualtrics for ePRO collection. However, SM for ePROs was labor intensive for providers. Descriptive statistics on health competence (2-item Perceived Health Competence Scale), physical and mental health (Patient-Reported Outcomes Measurement Information System Global-10), and stress (4-item Perceived Stress Scale) indicated that scores did not significantly change over time. Survey response rates varied (18/100, 18.0%-42/100, 42.0%) across each of the 12 weekly survey periods. In total, 74 of 100 participants provided ≥1 survey, and 90% (66/74) were female. The majority, 62% (33/53) of participants, who reported the use of any CIH modality, reported the use of two or more unique modalities. Primary care providers highlighted specific challenges with SM and offered solutions regarding staff involvement in survey implementation.

CONCLUSIONS

This quality improvement project informs our understanding of the processes currently available for using SM and web-based data platforms to collect ePROs. The study results indicate that although it is possible to use SM and web-based survey platforms for ePROs, automating scheduled administration will be necessary to reduce provider burden. The lack of significant change in ePROs may be due to standard measures taking a biomedical approach to wellness. Future work should focus on identifying ideal ePRO processes that would include standardized, whole-person measures of wellness.

Attitudes Underlying Reliance on Complementary and Alternative Medicine

Objective: We aimed to map attitudes underlying complementary and alternative medicine (CAM) use, especially those involved in "dysfunctional CAM reliance," that is, forgoing biomedical treatment in a life-threatening situation in favor of alternative treatment. Analyses of modifiable determinants of CAM use were conducted at a sufficiently specific level to inform intervention development. Methods: We collected usable data on CAM-related attitudinal beliefs from 151 participants in Budapest with varying degrees of CAM use, which we analyzed using confidence interval-based estimation of relevance plots. Results: Although there were beliefs that the entire sample shared, there was a marked difference between the biomedical and CAM groups. These differences were beliefs concerning trust in various medical systems, the level of importance assigned to emotions in falling ill, and vitalism or Eastern concepts. Regarding CAM users in general, the most successful intervention targets are beliefs in vitalism on the one hand, and distrust in biomedicine on the other. In addressing dysfunctional CAM use specifically, the most significant beliefs pertain to "natural" cures and reliance on biomedical testing. Conclusions: Albeit much research has been carried out on the motivations behind CAM use, rarely do studies treat CAM users separately in order to scrutinize patterns of nonconventional medicine use and underlying cognition. This is the first study to begin pinpointing specific attitudes involved in dysfunctional CAM use to inform future intervention development. Such interventions would be essential for the prevention of incidents and mortality.

Evaluation of an Integrative Care Program in Pediatric Oncology

Purpose: This article discusses the results of an evaluation of the one-year implementation period of an integrative care program at a pediatric oncology ward, which consists of integrative care treatments offered three times a week to the patients. The guiding questions are how the model was implemented, which factors have to be considered for successful implementation, and which factors showed to be obstacles during implementation. Methods: A mixed-methods approach was applied for data saturation. Qualitative data consist of participant observations and informal conversations during the implementation phase. All observational records were filed in the data program MAXQDA. For the quantitative data, all integrative care treatments applied on the intensive care unit were documented and subsequently filed in an Excel sheet. Both sets of data were analyzed for the evaluation. Results: Four main thematic clusters influenced the implementation: (1) the organization and structure of the intensive care unit; (2) mood and atmosphere; (3) feedback on treatment; and (4) time and experience. All factors are interlinked and cannot be looked at independently. Results of the quantitative data show that the most frequent used treatments were those with calming and relaxing effects, followed by treatments for stomachache, nausea, and obstipation. Conclusions: The implementation of an integrative model of care is a process that demands thorough understanding of the complex setting of the ward, ongoing adaptation to the structures and organization of the ward, and the integration of factors like feedback, time, atmosphere, and the mood of parents, patients, and nurses.

Utilisation of and Attitude towards Traditional and Complementary Medicine among Ebola Survivors in Sierra Leone

Background and objectives: In addition to conventional healthcare, Ebola survivors are known to seek traditional and complementary healthcare (T&CM) options to meet their healthcare needs. However, little is known about the general beliefs of Ebola survivors regarding T&CM and the impact of these beliefs in influencing their decisions around T&CM use. This study examines Ebola survivors' attitudes towards T&CM use in Sierra Leone. Materials and Methods: We conducted a nationwide quantitative cross-sectional study of 358 Ebola survivors in Sierra Leone between January and August 2018. We used descriptive analysis, chi-square tests and backward stepwise binary logistic regression for data analysis. Results: Close to half of the survivors (n = 163, 45.5%) had used T&CM since their discharge from an Ebola treatment centre. Survivors who viewed T&CM as boosting their immune system/resistance were 3.89 times (95%CI: 1.57-9.63, p = 0.003) more likely to use T&CM than those who did not view T&CM as boosting their immune system/resistance. Additionally, survivors who viewed T&CM as having fewer side effects than conventional medicine were more likely to use T&CM [OR = 5.03 (95%CI: 1.92-13.19, p = 0.001)]. Ebola survivors were more influenced to use T&CM based on their personal experience of the effectiveness of T&CM than by clinical evidence [OR = 13.72 (95%CI: 6.10-30.84, P < 0.001)]. Ebola survivors who perceived T&CM as providing them with more control than conventional medicine over their health/body were more likely to use T&CM [OR = 4.15 (95%CI: 1.74-9.89, p = 0.001)] as opposed to those who did not perceive T&CM in this way. Conclusions: Considering the widespread use of T&CM, an understanding of Ebola survivors' attitudes/beliefs towards T&CM is useful to healthcare providers and policymakers with regard to public education and practitioner-survivors communication, T&CM regulation and research in Sierra Leone. Ebola survivors appear to turn to T&CM not only for treatment, but also to fill gaps in conventional health care services.

What’s in a Definition?Holistic Nursing, Integrative Health Care, andIntegrative Nursing: Report of an Integrated Literature Review

Background: Nurses and others have used various terms to describe our caring/healing approach to practice. Because terms used can influence our image of ourselves and the image others have of us, we sought to clarify their meanings. Questions: How are the terms holistic nursing, integrative health care, and integrative nursing defined or described? Do we identify with these definitions/descriptions? Are the various terms the same or are they distinct? Method: We conducted an integrated review of peer-reviewed literature following the process described by Whittemore and Knafl. Using standard search methods, we reviewed full texts of 94 published papers and extracted data from 58 articles. Findings: Holistic describes “whole person care” often acknowledging body–mind–spirit. Holistic nursing defines a disciplinary practice specialty. The term integrative refers to practice that includes two or more disciplines or distinct approaches to care. Both terms, integrative and holistic, are associated with alternative/complementary modalities and have similar philosophical and/or theoretical underpinnings. Conclusions: There is considerable overlap between holistic nursing and integrative nursing. The relationship of integrative nursing to integrative health care is unclear based solely on definitions. Consideration of terms used provides opportunities for reflection, collaboration, and growth.

Behaviors and Attitudes toward the Use of Complementary and Alternative Medicine among Korean Cancer Patients

Purpose

A cross-sectional survey was conducted to explore the current awareness and use of complementary and alternative medicine (CAM), as well as attitudes toward CAM, in patients with cancer and their family members in South Korea.

Materials and Methods

Between September 21 and October 31, 2017, a 25-item questionnaire regarding CAM experiences among cancer patients and their family members was conducted in 10 oncology clinics in South Korea after institutional review board approval at each institution.

Results

In total, 283/310 patients were analyzed. The median age was 60 years, and 60% were male. Most of the patients were actively receiving anticancer treatment at the time of the survey. A total of 106 patients (37%) had experienced a median of two types (interquartile range, 1 to 3) of CAM. Belief in CAM (odds ratio [OR], 3.015; 95% confidence interval [CI], 1.611 to 5.640) and duration of disease (OR, 1.012; 95% CI, 1.004 to 1.020) were independent factors for using CAM in multivariable analysis. Belief in CAM was significantly associated with current use of CAM (OR, 3.633; 95% CI, 1.567 to 8.424). Lay referral was the most common reason for deciding to use CAM, and only 25% of patients (72/283) discussed CAM with their physicians.

Conclusion

Patient attitudes toward and confidence in CAM modalities were strongly associated with their CAM experiences, and only a small number of patients had an open discussion about CAM with their physicians. A patient education program for CAM is needed.

The Pulse-Respiration Quotient: A Powerful but Untapped Parameter for Modern Studies About Human Physiology and Pathophysiology

A specific and unique aspect of cardiorespiratory activity can be captured by dividing the heart rate (HR) by the respiration rate (RR), giving the pulse-respiration quotient (PRQ = HR/RR). In this review article, we summarize the main findings of studies using and investigating the PRQ. We describe why the PRQ is a powerful parameter that captures complex regulatory states of the cardiorespiratory system, and we highlight the need to re-introduce the use of this parameter into modern studies about human physiology and pathophysiology. In particular, we show that the PRQ (i) changes during human development, (ii) is time-dependent (ultradian, circadian, and infradian rhythms), (iii) shows specific patterns during sleep, (iv) changes with physical activity and body posture, (v) is linked with psychophysical and cognitive activity, (vi) is sex-dependent, and (vii) is determined by the individual physiological constitution. Furthermore, we discuss the medical aspects of the PRQ in terms of applications for disease classification and monitoring. Finally, we explain why there should be a revival in the use of the PRQ for basic research about human physiology and for applications in medicine, and we give recommendations for the use of the PRQ in studies and medical applications.

A narrative synthesis scoping review of life course domains within health service utilisation frameworks

Background: Current thinking in health recognises the influence of early life experiences (health and otherwise) on later life outcomes. The life course approach has been embedded in the work of the World Health Organisation since the Ageing and Health programme was established in 1995. Yet there has been limited debate on the relevancy of a life course lens to understanding health service utilisation. Aim: The aim of the review was twofold. Firstly, identify existing healthcare utilisation frameworks other than the dominant Andersen's behavioural model currently in use. Secondly, to identify if current frameworks incorporate the advocated life course perspective in understanding health service utilisation.     Methods: A scoping review of PubMed, Cinahl Plus, Emerald, PsycINFO, Web of Knowledge and Scopus was conducted. Data extraction used a framework approach with meta-synthesis guided by the four domains of the life course proposed by Elder (1979): human agency, location, temporality and relationships, and interdependencies. Results: A total of 551 papers were identified, with 70 unique frameworks (other than Andersen's Behavioural Model) meeting the inclusion criteria and included in the review. Conclusion: To date there has been limited explicit discussion of health service utilisation from a life course perspective. The current review highlights a range of frameworks that draw on aspects of the life course, but have been used with this perspective in mind. The life course approach highlights important gaps in understanding and assessing health service utilisation (HSU), such as utilisation over time. HSU is a complex phenomenon and applying a structured framework from a life course perspective would be of benefit to researchers, practitioners and policy makers.

Design of a Multidisciplinary Training Program in Complementary and Integrative Health Clinical Research: Building Research Across Interdisciplinary Gaps

Despite wide use by the public, limited evidence is available for many complementary and integrative health (CIH) practices. Thus, clinical researchers knowledgeable about CIH disciplines are necessary to study the efficacy and effectiveness of CIH practices to benefit the public health. To partially address the need for clinical researchers versed in CIH, the authors of this study report the design of an interprofessional clinical research training program focused on CIH, the Building Research across Interdisciplinary Gaps (BRIDG) program, supported by a 5-year T90/R90 grant from the National Center for Complementary and Integrative Health. The T90-supported arm of the program trains doctoral-level CIH providers in clinical research at the research-intensive University of Washington. The R90-supported arm of the program trains researchers with conventional backgrounds in the practices of CIH at the clinic-intensive National University of Natural Medicine. The "Translational Science Spectrum" provides a common conceptual framework for both programs. Specific program elements include: individualized didactic training in clinical research and CIH disciplines; placement with clinical research mentors; placement with clinical mentors in CIH disciplines; shared and independent research project development; and interdisciplinary experiences through seminars and retreats. Program evaluation includes annual completion of the Clinical Research Appraisal Inventory (CRAI), which queries confidence in research skills and methods and periodic evaluation of training elements using the Supplemental Kellogg Logic-World Health Organization model, which emphasizes relevance, adequacy, efficiency, effectiveness, process, impact, equity, and sustainability. The BRIDG program exemplifies a new standard in interprofessional clinical research training, made possible through strong collaboration between disparate research- and clinically intensive institutions.

Complementary medicine products used in pregnancy and lactation and an examination of the information sources accessed pertaining to maternal health literacy: a systematic review of qualitative studies

BACKGROUND

The prevalence of complementary medicine use in pregnancy and lactation has been increasingly noted internationally. This systematic review aimed to determine the complementary medicine products (CMPs) used in pregnancy and/or lactation for the benefit of the mother, the pregnancy, child and/or the breastfeeding process. Additionally, it aimed to explore the resources women used, and to examine the role of maternal health literacy in this process.

METHODS

Seven databases were comprehensively searched to identify studies published in peer-reviewed journals (1995-2017). Relevant data were extracted and thematic analysis undertaken to identify key themes related to the review objectives.

RESULTS

A total of 4574 articles were identified; 28 qualitative studies met the inclusion criteria. Quantitative studies were removed for a separate, concurrent review. Herbal medicines were the main CMPs identified (n = 21 papers) in the qualitative studies, with a smaller number examining vitamin and mineral supplements together with herbal medicines (n = 3), and micronutrient supplements (n = 3). Shared cultural knowledge and traditions, followed by women elders and health care professionals were the information sources most accessed by women when choosing to use CMPs. Women used CMPs for perceived physical, mental-emotional, spiritual and cultural benefits for their pregnancies, their own health, the health of their unborn or breastfeeding babies, and/or the breastfeeding process. Two over-arching motives were identified: 1) to protect themselves or their babies from adverse events; 2) to facilitate the normal physiological processes of pregnancy, birth and lactation. Decisions to use CMPs were made within the context of their own cultures, reflected in the locus of control regarding decision-making in pregnancy and lactation, and in the health literacy environment. Medical pluralism was very common and women navigated through and between different health care services and systems throughout their pregnancies and breastfeeding journeys.

CONCLUSIONS

Pregnant and breastfeeding women use herbal medicines and micronutrient supplements for a variety of perceived benefits to their babies' and their own holistic health. Women access a range of CMP-related information sources with shared cultural knowledge and women elders the most frequently accessed sources, followed by HCPs. Culture influences maternal health literacy and thus women's health care choices including CMP use.

Justifications for using complementary and alternative medicine reported by persons with musculoskeletal conditions: A narrative literature synthesis

BACKGROUND

Complementary and alternative medicine (CAM) is very popular with patients frequently combining it with orthodox health care. The high prevalence of CAM use and satisfaction with CAM reported by patients directly challenges an orthodox system that can only approve such use if it results from the application of biomedical concepts and science. Studies highlighting this as a cultural, sociological and historical phenomenon emphasise the value of choice for consumers of health care. Musculoskeletal conditions typify common problems for which the effectiveness of orthodox care is often unclear. We postulated that the reasons people give for using or not using CAM for musculoskeletal conditions, would therefore indicate the full range of expectations that people have of health care. Furthermore, these reasons would indicate how much people feel orthodox health care is or is not meeting their expectations. Therefore, this study aims to investigate people's reasons for choosing or avoiding CAM for non-traumatic musculoskeletal conditions.

METHODS

A systematic search and narrative synthesis was conducted of published qualitative and quantitative studies related to CAM and non-traumatic musculoskeletal conditions.

RESULTS

We identified 169 relevant papers detailing 152 separate studies, from which 1486 justifications were extracted concerning CAM use. Content analysis resulted in 11 distinct categories across four themes: practical aspects of care, clinical effectiveness, non-clinical outcomes of care, and a person's philosophy of illness and care. People provided similar rationales for both using and avoiding CAM, emphasising that, whilst CAM is perceived by many patients with musculoskeletal conditions to fill gaps in care (such as practitioner time or quality of the therapeutic relationship), orthodox care also seeks to deliver these aspects of care. However, people who used CAM also highlighted its alignment with their general philosophy and ideas about illness and health care, and often emphasised CAM's capacity to give them control over their condition and its treatment.

CONCLUSION

Currently, CAM appears to have a significant role for patients with common painful long-term conditions in providing choices to enable individual needs to be met.

Advocating for integrative medicine: providers' stories of resonance, negotiation, and community

Integrative medicine (IM) is a holistic health care option that blends complementary, alternative medicine with biomedical models of care. Many medical care facilities do not offer IM treatment for patients, yet the demand for IM is growing. Therefore, IM providers are in the position of educating and promoting IM to patients and other medical practitioners. There is limited research literature focusing on how IM providers communicate advocacy for IM. Therefore, this research is designed to explore the perspectives of providers about the ways that they communicate advocacy for IM in their lives and their medical practice. Interview data we collected at The Center reveals the ways that IM providers continuously advocate for IM through their resonance with IM philosophy, by negotiating systemic tensions that revolve around IM, and by forming communities of practice with patients and other providers. Results of this investigation offer insight about IM, communication, and advocacy.

Perceptions of traditional, complementary and alternative medicine among conventional healthcare practitioners in Accra, Ghana: Implications for integrative healthcare

OBJECTIVE

Integrative medicine refers to ongoing efforts to combine the best of conventional and evidence-based complementary therapies. While this effort for collaboration is increasing, traditional complementary and alternative medicine (TM-CAM) remains poorly integrated into the current healthcare system of Ghana. At present, it is not clear if practitioners of mainstream medicine favor integrative medicine. The present study, therefore, sought to explore the perceptions of conventional healthcare professionals on integrative medicine.

METHODS

A qualitative design composed of semi-structured interviews was conducted with 23 conventional healthcare professionals comprising pharmacists, physicians, nurses and dieticians from two quasi-government hospitals in Accra, Ghana.

RESULTS

Participants' knowledge of TM-CAM was low, and although they perceived alternative medicine as important to current conventional healthcare in Ghana, they expressed anxieties about the potential negative effects of the use of TM-CAM. This paradox was found to account for the low levels of use among these professionals, as well as the low level of recommendation to their patients. The practitioners surveyed recommended that alternative medicine could be integrated into mainstream allopathic healthcare in Ghana through improving knowledge, training as well as addressing concerns of safety and efficacy. These findings are discussed under the themes: the knowledge gap, the paradox of TM-CAM, experience of use and prescription, and guided integration. We did not observe any differences in views among the participants.

CONCLUSION

The conventional healthcare professionals were ready to accept the idea of integrative medicine based on knowledge of widespread use and the potential role of TM-CAM products and practices in improving healthcare delivery in the country. However, to achieve an institutional integration, practitioners' understanding of TM-CAM must be improved, with specific attention to issues of safety, regulation and evidence-based practice of TM-CAM products and services in Ghana.

Prevalence and patterns of use of mantra, mindfulness and spiritual meditation among adults in the United States

BACKGROUND

Despite a growing body of scientific literature exploring the nature of meditation there is limited information on the characteristics of individuals who use it. This is particularly true of comparative studies examining prevalence and predictors of use of various forms of meditation.

METHODS

A secondary analysis was conducted using data from the 2012 National Health Interview Survey (n = 34,525). Three popular forms of meditation were compared-mantra, mindfulness, and spiritual-to determine lifetime and 12-month use related to key sociodemographic, health behavior, health status, and healthcare access variables.

RESULTS

The 12-month prevalence for meditation practice was 3.1% for spiritual meditation, 1.9% for mindfulness meditation, and 1.6% for mantra meditation. This represents approximately 7.0, 4.3, and 3.6 million adults respectively. A comparison across the three meditation practices found many similarities in user characteristics, suggesting interest in meditation may be more related to the type of person meditating than to the type of practice selected. Across meditation styles use was more prevalent among respondents who were female, non-Hispanic White, college educated, physically active; who used other complementary health practices; and who reported depression. Higher utilization of conventional healthcare services was one of the strongest predictors of use of all three styles. In addition to similarities, important distinctions were observed. For example, spiritual meditation practice was more prevalent among former drinkers. This may reflect use of spiritual meditation practices in support of alcohol treatment and sobriety. Reasons for use of meditation were examined using the sample of respondents who practiced mindfulness meditation. Wellness and prevention (74%) was a more common reason than use to treat a specific health condition (30%). Common reasons for use included stress management (92%) and emotional well-being (91%), and to support other health behaviors. Meditation was viewed positively because it was self-care oriented (81%) and focused on the whole person (79%).

CONCLUSION

Meditation appears to provide an accessible, self-care resource that has potential value for mental health, behavioral self-regulation, and integrative medical care. Considering consumer preference for distinct types of meditation practices, understanding the underlying mechanisms, benefits, and applications of practice variations is important.

'Basically, it's sorcery for your vagina': unpacking Western representations of vaginal steaming

Vaginal steaming made global headlines in 2015 after its promotion by celebrity Gwyneth Paltrow. One of many female genital modification practices currently on offer in Anglo-Western nations - practices both heavily promoted and critiqued - vaginal steaming is claimed to offer benefits for fertility and overall reproductive, sexual or even general health and wellbeing. We analysed a selection of online accounts of vaginal steaming to determine the sociocultural assumptions and logics within such discourse, including ideas about women, women's bodies and women's engagement with such 'modificatory' practices. Ninety items were carefully selected from the main types of website discussing vaginal steaming: news/magazines; health/lifestyle; spa/service providers; and personal blogs. Data were analysed using thematic analysis, within a constructionist framework that saw us focus on the constructions and rationalities that underpin the explicit content of the texts. Within an overarching theme of 'the self-improving woman' we identified four themes: (1) the naturally deteriorating, dirty female body; (2) contemporary life as harmful; (3) physical optimisation and the enhancement of health; and (4) vaginal steaming for life optimisation. Online accounts of vaginal steaming appear both to fit within historico-contemporary constructions of women's bodies as deficient and disgusting, and contemporary neoliberal and healthist discourse around the constantly improving subject.

Complementary and alternative medicine (CAM) among Australian hospital-based nurses: knowledge, attitude, personal and professional use, reasons for use, CAM referrals, and socio-demographic predictors of CAM users

OBJECTIVE

This study was intended to examine CAM among Australian hospital-based nurses, identifying their knowledge, attitude, personal and professional use, reasons for use, CAM referrals, and socio-demographic predictors of CAM users.

METHODS AND MATERIALS

Nurses holding a qualification in nursing and working in surgical wards were included using a convenience sampling technique. A self-complete questionnaire was developed to achieve the aims of the study. Descriptive and non-parametric statistics were calculated to describe and analyse data.

RESULTS

Overall, 95.7% and 49.7% of nurses reported personal and professional use of CAM, respectively. The most popular CAM/CAM domain personally and professionally used by nurses was massage therapy and mind-body therapies. The primary reason for personal use of CAM was "[it] fits into my way of life/philosophy". Furthermore, massage therapists were the most commonly recommended CAM practitioners to patients. Only 15.8% of nurses would always ask patients about use of herbal medicines as part of nursing history taking. Over one-fifth (22.4%) of nurses rated their attitude as having a very positive, and 60.3% rated themselves as having very little or no knowledge of CAM. A positive correlation was also found between knowledge and attitude about CAM. Positive attitude and higher knowledge about CAM were positively correlated to CAM referrals. Several socio-demographic factors predicted personal and professional use of CAM.

CONCLUSION

This study revealed that nurses generally believe not to have sufficient knowledge of CAM but are open to use CAM with patients. Nurses' positive attitude toward and personal use of CAM could be an indication that they are poised for further integration of evidence-based CAM into nursing practice to treat whole person.

Patient perceptions of clinical care in complementary medicine: A systematic review of the consultation experience

OBJECTIVE

This review aims to describe the prevalence of empathy, empowerment and patient-centred clinical care experienced by patients in complementary medicine (CM) consultations.

METHODS

A systematic review was undertaken of original research exploring patient perceptions of CM clinical care. Ten databases were searched: Alt HealthWatch, AMED, CINAHL Plus, MEDLINE Complete, Cochrane Library, PubMed, Proquest Medical Collection, PsycInfo, Social Sciences Citation Index and Psychology Collection. Studies were included which reported patient perceptions of consultation with CM practitioners and were excluded where experimental methods controlled the nature of consultation processes.

RESULTS

Findings of included studies (n=34) were categorised under the a priori themes of empathy, empowerment and patient-centred care. This produced a substantial pool of qualitative data detailing patient-reported experiences which consistently confirmed occurrence of these themes in CM consultation. Quantitative data was correlative, yet was insufficient to definitively describe prevalence of such experiences.

CONCLUSION

While it is evident that CM consultations provide a patient experience of empathy, empowerment and patient-centredness, further research is warranted to quantify this experience before it can be defined as characteristic of CM clinical care.

PRACTICE IMPLICATIONS

This review draws attention to the potential role of CM as a resource for patients' psychosocial health needs.

Diabetes Mellitus Type 2 and Yoga: Electro Photonic Imaging Perspective

Background:

Yoga is the most popular form of alternative medicine for the management of diabetes mellitus type 2. The electro-photonic imaging (EPI) is another contribution from alternative medicine in health monitoring.

Aim:

To evaluate diabetes from EPI perspective.

Objectives:

(1) Compare various EPI parameters in normal, prediabetic and diabetic patients. (2) Find difference in controlled and uncontrolled diabetes. (3) Study the effect of 7 days diabetes-specific yoga program.

Materials and Methods:

For the first objective, there were 102 patients (normal 29, prediabetic 13, diabetic 60). In the second study, there were 60 patients (controlled diabetes 27, uncontrolled diabetes 33). The third study comprised 37 patients. EPI parameters were related to general health as well to specific organs.

Results:

In the first study, significant difference was observed between (1) Diabetics and normal: average intensity 5.978, form coefficient 3.590, immune organs 0.281 all P < 0.001; (2) Diabetics and prediabetics: average intensity 6.676, form coefficient 4.158, immune organs 5.890 P < 0.032; (3) Normal and prediabetes: immune organs (−6.171 P = 000). In the second study, remarkable difference was in the immune organs (0.201, P = 0.031). In the pre- and post-study, the mean difference was: area 630.37, form coefficient 1.78, entropy 0.03, liver 0.24, pancreas 0.17, coronary vessels 0.11, and left kidney 29, with all P < 0.02.

Conclusion:

There is a significant difference in EPI parameters between normal, prediabetics and diabetics, the prominent being average intensity, form coefficient, and immune organs. Between controlled and uncontrolled diabetes, immune organs show significant change. Intervention of yoga results in change in most parameters.

Curricular Inclusion of Complementary and Alternative Medicine Content in Occupational Therapy Education in the United States

An exploratory, cross-sectional survey design was used to explore the extent to which CAM was included, what factors impacted its inclusion, topics and student learning outcomes covered, who taught the material, and what sources were used to prepare for delivering course content. While the vast majority of responding occupational therapy educators reported curricular inclusion of CAM, educational experiences for occupational therapy students varied widely. This overview of the curricular inclusion of CAM by faculty in occupational therapy programs in the United States indicated that many occupational therapy educators are responding to the demands of a more integrative healthcare system. Resolving ethical and pragmatic issues, providing faculty development opportunities, and standardizing student learning outcomes would align all stakeholders and mitigate ambiguities that currently exist surrounding the inclusion of CAM in occupational therapy education.

Mapping the Health Care Policy Landscape for Complementary and Alternative Medicine Professions Using Expert Panels and Literature Analysis

OBJECTIVES

The purpose of this project was to examine the policy implications of politically defining complementary and alternative medicine (CAM) professions by their treatment modalities rather than by their full professional scope.

METHODS

This study used a 2-stage exploratory grounded approach. In stage 1, we identified how CAM is represented (if considered as professions vs modalities) across a purposely sampled diverse set of policy topic domains using exemplars to describe and summarize each. In stage 2 we convened 2 stakeholder panels (12 CAM practitioners and 9 health policymaker representatives), and using the results of stage 1 as a starting point and framing mechanism, we engaged panelists in a discussion of how they each see the dichotomy and its impacts. Our discussion focused on 4 licensed CAM professions: acupuncture and Oriental medicine, chiropractic, naturopathic medicine, and massage.

RESULTS

Workforce policies affected where and how members of CAM professions could practice. Licensure affected whether a CAM profession was recognized in a state and which modalities were allowed. Complementary and alternative medicine research examined the effectiveness of procedures and modalities and only rarely the effectiveness of care from a particular profession. Treatment guidelines are based on research and also focus on procedures and modalities. Health plan reimbursement policies address which professions are covered and for which procedures/modalities and conditions.

CONCLUSIONS

The policy landscape related to CAM professions and modalities is broad, complex, and interrelated. Although health plan reimbursement tends to receive the majority of attention when CAM health care policy is discussed, it is clear, given the results of our study, that coverage policies cannot be addressed in isolation and that a wide range of stakeholders and social institutions will need to be involved.

A Systematic Review of Beliefs Involved in the Use of Complementary and Alternative Medicine

People might be attracted to and use complementary and alternative medicines (CAM) because they hold beliefs that are congruent with CAM. This article collates, examines and synthesizes the evidence surrounding this hypothesis. Most studies are cross-sectional and focus on a limited number of beliefs. Multivariate studies suggest that beliefs related to control and participation, perceptions of illness, holism and natural treatments, and general philosophies of life predict CAM use when controlling for demographic and clinical factors. Further research should examine the robustness of these relationships in different illness groups and the prospective relationships among beliefs and CAM use over time.

Coping with future epidemics: Tai chi practice as an overcoming strategy used by survivors of severe acute respiratory syndrome (SARS) in post-SARS Hong Kong

BACKGROUND

Although SARS had been with a controversial topic for a decade at the time of this study, numerous SARS survivors had not yet physically, psychologically or socially recovered from the aftermath of SARS. Among chronically ill patients, the use of complementary and alternative medicine (CAM) is reported to be widespread. However, extremely little is known about the use of CAM by SARS survivors in the post-SARS period and even less is known about how the use of CAM is related to the unpleasant social and medical-treatment experiences of SARS survivors, their eagerness to re-establish social networks, and their awareness to prepare for future epidemics.

OBJECTIVE

To investigate the motivations for practising tai chi among SARS survivors in post-SARS Hong Kong.

DESIGN, SETTING AND PARTICIPANTS

Using a qualitative approach, I conducted individual semi-structured interviews with 35 SARS survivors, who were purposively sampled from a tai chi class of a SARS-patient self-help group in Hong Kong.

RESULTS

Health concerns and social experiences motivated the participants to practise tai chi in post-SARS Hong Kong. Experiencing health deterioration in relation to SARS-associated sequelae, coping with unpleasant experiences during follow-up biomedical treatments, a desire to regain an active role in recovery and rehabilitation, overcoming SARS-associated stigmas by establishing a new social network and preparing for potential future stigmatization and discrimination were the key motivators for them.

CONCLUSION

The participants practised tai chi not only because they sought to improve their health but also because it provided a crucial social function and meaning to them.

Disease Prevention and Health Promotion: How Integrative Medicine Fits

As a discipline, preventive medicine has traditionally been described to encompass primary, secondary, and tertiary prevention. The fields of preventive medicine and public health share the objectives of promoting general health, preventing disease, and applying epidemiologic techniques to these goals. This paper discusses a conceptual approach between the overlap and potential synergies of integrative medicine principles and practices with preventive medicine in the context of these levels of prevention, acknowledging the relative deficiency of research on the effectiveness of practice-based integrative care. One goal of integrative medicine is to make the widest array of appropriate options available to patients, ultimately blurring the boundaries between conventional and complementary medicine. Both disciplines should be subject to rigorous scientific inquiry so that interventions that are efficacious and effective are systematically distinguished from those that are not. Furthermore, principles of preventive medicine can be infused into prevalent practices in complementary and integrative medicine, promoting public health in the context of more responsible practices. The case is made that an integrative preventive approach involves the responsible use of science with responsiveness to the needs of patients that persist when conclusive data are exhausted, providing a framework to make clinical decisions among integrative therapies.

Integrative Health and Healing as the New Health Care Paradigm for the Military

Background: The field of integrative health and healing (IH₂) is emerging out of the dark recesses of "voodoo" stereotypes and into the light as a new and much needed health care paradigm. It is a philosophy of health and healing that seeks to place patients as the preeminent players in health management, disease prevention, and injury recovery. There is an emphasis of patient responsibility, which includes a holistic approach that merges allopathic with complementary medicine. Objective: The aim of this article is to explore the historical origins of integrative medicine and investigate the future role of the IH₂ paradigm. Methods: This article reviews current available data and information regarding complementary and alternative medicine utilized in civilian and military populations as the basis for a new paradigm for a system of care-a system that empowers patients. Conclusions: The current U.S. health care system is reactive and disease-based, with a focus on reductionism. This system is not serving us well. IH₂ is a new model of cost-effective patient-centered health care.

MERGING conventional and complementary medicine in a clinic department - a theoretical model and practical recommendations

Background

Today, the increasing demand for complementary medicine encourages health care providers to adapt and create integrative medicine departments or services within clinics. However, because of their differing philosophies, historical development, and settings, merging the partners (conventional and complementary medicine) is often difficult.

It is necessary to understand the similarities and differences in both cultures to support a successful and sustainable integration. The aim of this project was to develop a theoretical model and practical steps that are based on theories from mergers in business to facilitate the implementation of an integrative medicine department.

Methods

Based on a literature search and expert discussions, the cultures were described and model domains were developed. These were applied to two case studies to develop the final model. Furthermore, a checklist with practical steps was devised.

Results

Conventional medicine and complementary medicine have developed different corporate cultures. The final model, which should help to foster integration by bridging between these cultures, is based on four overall aspects: culture, strategy, organizational tools and outcomes. Each culture is represented by three dimensions in the model: corporate philosophy (core and identity of the medicine and the clinic), patient (all characteristics of the professional team’s contact with the patient), and professional team (the characteristics of the interactions within the professional team).

Conclusion

Overall, corporate culture differs between conventional and complementary medicine; when planning the implementation of an integrative medicine department, the developed model and the checklist can support better integration.

Electronic supplementary material

The online version of this article (doi:10.1186/s12906-015-0696-2) contains supplementary material, which is available to authorized users.

The role of global traditional and complementary systems of medicine in treating mental health problems

Traditional and complementary systems of medicine (TCM) encompass a broad range of practices which are commonly embedded within contextual cultural milieu, reflecting community beliefs, experiences, religion and spirituality. Evidence from across the world, especially from low- and middle-income countries (LMIC), suggests that TCM is commonly used by a large number of persons with mental illness. Even though some overlap exists between the diagnostic approaches of TCM and conventional biomedicine (CB), there are major differences, largely reflecting differences in the understanding of the nature and etiology of mental disorders. However, treatment modalities employed by providers of TCM may sometimes fail to meet common understandings of human rights and humane care. Still, there are possibilities for collaboration between TCM and CB in the care of persons with mental illness. Research is required to clearly delineate the boundaries of such collaboration and to test its effectiveness in bringing about improved patient outcomes.

Complementary medicine as a path toward empowerment of Arab-Palestinian women in Israel

Arab-Palestinians in Israel compose a traditional minority population that previously relied on traditional folk medicine and religious healing. Today some among this minority population are adopting imported complementary medicine. We interviewed Arab-Palestinians of the first generation of complementary medicine practitioners. Their decision to study complementary medicine constitutes a path toward empowerment, providing healers with an aura of modernity, enabling integration into the predominantly Jewish Israeli medical establishment to gain professional recognition as experts, and to acquire a sense of belonging. Practicing complementary medicine provides financial independence, liberation, and self-fulfillment and an opportunity to help female patients break through constraining barriers.

Knowledge, Attitudes, and Personal Use of Complementary and Alternative Medicine among Occupational Therapy Educators in the United States

The purpose of this study was to establish a baseline description of American occupational therapy educators' knowledge, attitudes, and personal use of complementary and alternative medicine (CAM) as a first step in exploring the larger issue of future occupational therapy practitioners' preparedness for meeting clients' occupational needs in today's evolving healthcare environment. Results of this cross-sectional survey highlighted limitations of occupational therapy educators' knowledge of common CAM concepts and therapies across all demographic variables, varying attitudes towards CAM in general and its inclusion in occupational therapy education, and personal use of common CAM therapies. Without increased occupational therapy educator knowledge about CAM and engagement in the current healthcare practices, occupational therapy practitioners are at risk for having a limited role in integrative healthcare.

Faculty survey to assess research literacy and evidence-informed practice interest and support at Pacific College of Oriental Medicine

CONTEXT

Educating healthcare practitioners to understand, critically evaluate, and apply evidence to the clinical practice of complementary and alternative medicine has been an important initiative for the National Institutes of Health National Center for Complementary and Alternative Medicine.

OBJECTIVE

To determine the self-assessed research skills and interest of faculty at Pacific College of Oriental Medicine (New York campus) and their likely support of, and participatory interest in, an evidence-based medicine (EBM) training program.

DESIGN

The survey was administered in Survey Monkey. All questions were close-ended with 5-point Likert answers, except for one open-ended question at the end of the survey.

SETTING

One of three campuses of Pacific College of Oriental Medicine (PCOM), the largest Chinese medicine college in the United States.

PARTICIPANTS

102 faculty employed at PCOM.

RESULTS

The response rate was 88.7%. Responses illustrated a generally high degree of interest and support for research, EBM, and institutional participation in research activities. Faculty who responded to the open-ended question (19.6% of respondents) expressed concerns about the relevance of research to Chinese medicine and the possibility of co-option by biomedicine.

CONCLUSIONS

While faculty were overall supportive and interested in research and EBM, the results are consistent with the hypothesis that success of EBM training programs could be enhanced by soliciting and addressing faculty concerns and by being inclusive of approaches that honor the traditions of Chinese medicine and its own forms of clinical evidence.

Perceptions of benefit of complementary therapy use among people with diabetes and cardiovascular disease

BACKGROUND

Little is known about why and how people with type 2 diabetes and cardiovascular disease (CVD) use CAM, or of the perceived benefits of CAM use. The CAMELOT study explored care-seeking, self-management, costs, barriers and benefits of CAM use among this population. We report here on CAM used for treatment of diabetes and CVD, and non-clinical outcomes of CAM use.

METHODS

Data were collected in 2009-2010 via in-depth interviews (n = 69) and a self-report questionnaire (n = 2,915) among people with diabetes and/or CVD, throughout an Australian state. Analysis included contingency tables, chi-square analysis and thematic coding of interview and long answer survey data.

RESULTS

CAM use was generally part of a multi-component approach to chronic condition management. Choice of CAM practitioners and products varied and included CAM not usually associated with diabetes or CVD treatment, such as massage or manipulative therapies (44%). Most survey respondents perceived that CAM consultations resulted in symptom relief, improved general health and increased knowledge, understanding and confidence in condition management. Few people reported that they experienced any side effects from CAM. Economic barriers were significant in limiting access to CAM.

CONCLUSION

More research is required to understand how the appropriate use and perceived benefits of CAM can be reinforced by stronger interaction or integration with mainstream health service delivery for chronic condition management and illness prevention.

Creating integrative work: a qualitative study of how massage therapists work with existing clients

INTRODUCTION

As one of the most often used complementary treatments, massage is increasingly positioned as an essential component of integrative medicine. Recent studies evaluate the clinical efficacy of massage therapy, but few studies explore how massage therapists (MTs) execute their work and exercise clinical reasoning in natural settings.

PURPOSE

To gain foundational knowledge about clinical reasoning and applied knowledge, this study examined how 10 MTs executed an entire session with established clients. Results support translational research design and inform educators.

METHODS

Ethnomethodology and phenomenology informed the qualitative design. Data were collected by videotaping actual sessions and interviewing the participants immediately afterward while viewing the videos. Computer-aided analysis identified data patterns for thematic interpretation.

RESULTS

The MTs shared tacit knowledge that directed their work: a) maintaining a primarily biomechanical focus, b) prerequisite safe touch, c) multitasking not allowed, d) MTs assume physical risk, and e) the work affects multiple bodily systems. The MTs sensed effectiveness experientially by adopting common tactics: a) visualizing the manual engagement points, b) assuming the client controlled the physiological release, and c) educating the client. Within these commonalities, they operationalized their work in complex and singular ways, with the particular client relationship critical to structuring the session and evaluating the outcome.

CONCLUSION

MTs viewed their work primarily as a biomechanical intervention, but understood therapeutic massage as serving multiple functions. Process-oriented clinical reasoning mirrored models found in psychotherapy and was informed by experience, intuition, and training, which resulted in an intentionally holistic approach.

Patient agency revisited: "healing the hidden" in South India

It is often argued that biomedicine alienates patients from doctors, from ailments and from understanding treatment processes, while indigenous and alternative healing systems are portrayed as respectful of patients and their experience. Specifically, South Indian siddha medicine has been seen as diverging from biomedicine in empowering its patients. This approach not only assumes biomedicine to be a homogeneous practice, but also lumps together diverse therapeutic techniques under the labels of "traditional" or "alternative." Analysis of a manual subdiscipline of siddha medicine cautions against such analytic imprecision and active/passive binaries in physician-patient encounters. Practitioners of vital spot medicine claim to "heal the hidden." They rarely communicate diagnostic insights verbally and object to auxiliary devices. However, their physical engagement with patients' ailing bodies highlights the corporeal nature of manual medicine in particular and processual, situational, and reciprocal characteristics of curing in general.

Undoing gender? The case of complementary and alternative medicine

Despite a rich body of sociological research that examines the relationship between gender and health, scholars have paid little attention to the case of complementary and alternative medicine (CAM). One recent study (Sointu 2011) posits that men and women who use CAM challenge traditional ascriptions of femininity and masculinity through the exploration of self-care and emotions, respectively. Drawing on 25 in-depth interviews with middle-class Americans who use CAM, this article instead finds that men and women interpret their CAM use in ways that reproduce traditional gendered identities. Men frame their CAM use in terms of science and rationality, while simultaneously distancing themselves from feminine-coded components of CAM, such as emotions. Women seek CAM for problems such as abusive relationships, low self-esteem, and body image concerns, and frame their CAM use as a quest for self-reinvention that largely reflects and reproduces conventional femininity. Further, the reproduction of gendered identities is shaped by the participants' embrace of neoliberal tenets, such as the cultivation of personal control. This article contributes to ongoing theoretical debates about the doing, redoing and undoing of gender, as well as the literature on health and gender.

[A method for the implementation and promotion of access to comprehensive and complementary primary healthcare practices]

The rendering of integrated and complementary practices in the Brazilian Unified Health System is fostered to increase the comprehensiveness of care and access to same, though it is a challenge to incorporate them into the services. Our objective is to provide a simple method of implementation of such practices in Primary Healthcare, derived from analysis of experiences in municipalities, using partial results of a master's thesis that employed research-action methodology. The method involves four stages: 1 - defininition of a nucleus responsible for implementation and consolidation thereof; 2 - situational analysis, with definition of the existing competent professionals; 3 - regulation, organization of access and legitimation; and 4 - implementation cycle: local plans, mentoring and ongoing education in health. The phases are described, justified and briefly discussed. The method encourages the development of rational and sustainable actions, sponsors participatory management, the creation of comprehensivenessand the broadening of care provided in Primary Healthcare by offering progressive and sustainable comprehensive and complementary practices.

Serious decisions: chronic conditions and choice of provider

People with chronic health conditions combine conventional medical care with different complementary and alternative medicine (CAM) therapies for varying reasons. The data on which we drew to elucidate this derive from a large mixed-methods study utilizing participant observation, in-depth interviews with 69 people with type 2 diabetes mellitus and/or cardiovascular disease (CVD), and interviews with 20 health care providers. Although integrative practices are increasingly common, people make clear choices about and trade-offs between conventional medical care and CAM, often using CAM and prescribed pharmaceuticals in tandem for different conditions and distinct purposes and outcomes. As we illustrate, some people perceived type 2 diabetes and CVD as "too serious" for CAM treatment, but concurrently, many turned to CAM providers in appreciation of the serious attention these providers paid to their health-related concerns.

Older adults' perspectives on naturopathic medicine's impact on healthy aging

CONTEXT

High rates of complementary and alternative medicine (CAM) utilization among older adults are of interest because studies suggest relationships among CAM, self-care, and healthy lifestyle. These potential relationships are of particular interest because of the contribution of self-care in maintaining physical, emotional, and spiritual health as key strategies to successful aging. Naturopathic medicine (NM) is a type of primary care CAM used by older adults, yet little is known about older adults' use of NM or its role in healthy aging.

OBJECTIVES

We sought to examine perceptions about, and utilization of, NM and the experience of addressing health and wellness as part of the aging process.

DESIGN

Phenomenology-based qualitative inquiry.

SETTING

A total of 13 community-based clinics affiliated with a naturopathic medical school.

PARTICIPANTS

A total of 47 adults aged 58-100 years.

METHODS

Qualitative analysis of semi-structured focus groups with quantitative analysis of clinical administrative data.

RESULTS

Over 2543 older adults used NM services affiliated with a natural academic clinic in Seattle in 2011 for diagnoses consistent with primary care: fatigue, anxiety, diabetes, diarrhea, and depression, in rank order. Participants reported they sought NM because it offered a different system of care aligned with their values. Themes included (1) feeling heard, (2) a focus on health education including prevention and self-care, and (3) feeling supported. Themes further distilled into optimal descriptive characteristics of patient-centered providers that may best support older adults' healthy aging. A final theme described barriers to further utilization.