Integrative Health Equity: Definition, Principles, Strategies, and Reflections

In this viewpoint, we define integrative health equity as optimal health for all through a whole-person approach that explicitly recognizes cultural, social, and structural determinants of health. We describe seven guiding principles, along with organizational goals, strategies, and reflections to advance integrative health equity.

A Qualitative Examination of Perceptions of Mindfulness Among Arab, Middle Eastern, and North African Americans: Implications for Cultural Adaptation of Mindfulness-Based Interventions

Background

Mindfulness-based interventions (MBIs) are well-positioned to address health disparities among racial-ethnic minority communities, given their focus on stress reduction and potential for greater accessibility and acceptability than conventional mental health treatments. Yet, there are currently no peer-reviewed studies of MBIs in an Arab, Middle Eastern, or North African (MENA) American sample. Addressing this gap in the literature is critical for advancing integrative health equity, given the high burden of stress and high prevalence of stress-related health conditions among Arab/MENA Americans.

Objective

The present study sought to explore perceptions of mindfulness among Arab/MENA Americans and identify potential cultural adaptations to MBIs for this population.

Methods

4 focus groups were conducted with 26 Arab/MENA American adults who had participated in an introductory mindfulness workshop. Participants were asked about their experience learning mindfulness skills, the usefulness of mindfulness for problems they face, the alignment of mindfulness with their cultural values and practices, and suggestions for adapting mindfulness programs. Qualitative coding of focus group session transcriptions was conducted to identify themes in the data.

Conclusion

The participants in this study described experiencing high levels of stress and identified micro- and macro-level stressors related to their Arab/MENA American identity, including discrimination, exclusion, historical and intergenerational trauma, and protracted sociopolitical crises in their heritage countries. They viewed mindfulness as a potentially useful approach to coping with stress. At the same time, participants identified aspects of mindfulness that could be adjusted to better align with their cultural values and experiences. Potential adaptations to MBIs for Arab/MENA Americans were identified based on suggestions from participants and issues they raised while discussing cultural strengths, stressors they face, and perceived barriers and facilitators to engaging in mindfulness practice.

Preventing Depression Relapse: A Qualitative Study on the Need for Additional Structured Support Following Mindfulness-Based Cognitive Therapy

Background

Mindfulness-based cognitive therapy (MBCT) is an effective group intervention for reducing rates of depression relapse. However, about one-third of graduates experience relapse within 1 year of completing the course.

Objective

The current study aimed to explore the need and strategies for additional support following the MBCT course.

Methods

We conducted 4 focus groups via videoconferencing, two with MBCT graduates (n = 9 in each group) and two with MBCT teachers (n = 9; n = 7). We explored participants' perceived need for and interest in MBCT programming beyond the core program and ways to optimize the long-term benefits of MBCT. We conducted thematic content analysis to identify patterns in transcribed focus group sessions. Through an iterative process, multiple researchers developed a codebook, independently coded the transcripts, and derived themes.

Results

Participants said the MBCT course is highly valued and was, for some, "life changing." Participants also described challenges with maintaining MBCT practices and sustaining benefits after the course despite using a range of approaches (ie, community and alumni-based meditation groups, mobile applications, taking the MBCT course a second time) to maintain mindfulness and meditative practice. One participant described finishing the MBCT course as feeling like "falling off a cliff." Both MBCT graduates and teachers were enthusiastic about the prospect of additional support following MBCT in the form of a maintenance program.

Conclusion

Some MBCT graduates experienced difficulty maintaining practice of the skills they learned in the course. This is not surprising given that maintained behavior change is challenging and difficulty sustaining mindfulness practice after a mindfulness-based intervention is not specific to MBCT. Participants shared that additional support following the MBCT program is desired. Therefore, creating an MBCT maintenance program may help MBCT graduates maintain practice and sustain benefits longer-term, thereby decreasing risk for depression relapse.

The Reliability of Rating via Audio-Recording Using the Mindfulness-Based Interventions: Teaching Assessment Criteria

Background

The Mindfulness-Based Interventions: Teaching Assessment Criteria (MBI:TAC) is an important tool for assessing teacher skill and aspects of the fidelity of mindfulness-based interventions, but prior research on and implementation of the MBI:TAC has used video recordings, which can be difficult to obtain, share for assessments, and which increase privacy concerns for participants. Audio-only recordings might be a useful alternative, but their reliability is unknown.

Objective

To assess evaluator perception of the rating process and inter-rater reliability of MBI:TAC ratings using audio-only recordings.

Methods

We prepared audio-only files from video recordings of 21 previously rated Mindfulness-Based Stress Reduction teachers. Each audio recording was rated by 3 trained MBI:TAC assessors drawn from a pool of 12 who had previously participated in rating the video recordings. Teachers were rated by evaluators who had not viewed the video recording and did not know the teacher. We then conducted semi-structured interviews with evaluators.

Results

On the 6 MBI:TAC domains, the intraclass correlation coefficients (ICCs) for audio recordings ranged from .53 to .69 using an average across 3 evaluators. Using a single rating resulted in lower ICCs (.27-.38). Bland-Altman plots showed audio ratings had little consistent bias compared to video recordings and agreed more closely for teachers with higher ratings. Qualitative analysis identified 3 themes: video recordings were particularly helpful when rating less skillful teachers, video recordings tended to provide a more complete picture for rating, and audio rating had some positive features.

Conclusions

Inter-rater reliability of the MBI:TAC using audio-only recordings was adequate for many research and clinical purposes, and reliability is improved when using an average across several evaluators. Ratings using audio-only recordings may be more challenging when rating less experienced teachers.

What Do Placebo and Nocebo Effects Have to Do With Health Equity? The Hidden Toll of Nocebo Effects on Racial and Ethnic Minority Patients in Clinical Care

A placebo effect is a positive clinical response to non-specific elements of treatment with a sham or inert replica of a drug, device, or surgical intervention. There is considerable evidence that placebo effects are driven by expectation of benefit from the intervention. Expectation is shaped by a patient's past experience, observations of the experience of others, and written, verbal, or non-verbal information communicated during treatment. Not surprisingly, expectation in the clinical setting is strongly influenced by the attitude, affect, and communication style of the healthcare provider. While positive expectations can produce beneficial effects, negative information and experiences can lead to negative expectations, and consequently negative or nocebo effects. Key components identified and studied in the placebo and nocebo literature intersect with factors identified as barriers to quality care in the clinical setting for Black patients and other patients of color, including poor patient-clinician communication, medical mistrust, and perceived discrimination. Thus, in the context of discrimination and bias, the absence of placebo and presence of nocebo-generating influences in clinical settings could potentially reinforce racial and ethnic inequities in clinical outcomes and care. Healthcare inequities have consequences that ripple through the medical system, strengthening adverse short- and long-term outcomes. Here, we examine the potential for the presence of nocebo effects and absence of placebo effects to play a role in contributing to negative outcomes related to unequal treatment in the clinical encounter.

A 4-Month Whole-Systems Ayurvedic Medicine Nutrition and Lifestyle Intervention Is Feasible and Acceptable for Breast Cancer Survivors: Results of a Single-Arm Pilot Clinical Trial

PURPOSE

Ongoing symptoms and impairments in quality of life (QOL) among breast cancer survivors remain a significant problem. We tested the feasibility and acceptability of a manualized Ayurvedic nutrition and lifestyle intervention for breast cancer survivors.

METHODS

Eligible participants had Stage I-III breast cancer, underwent treatment within the past year that included chemotherapy, and were without active disease. The 4-month individualized Ayurvedic intervention included counseling on nutrition, lifestyle, yoga, and marma (like acupressure) during 8 one-on-one visits with an Ayurvedic practitioner. Feasibility and acceptability were the primary outcomes. QOL (European Organization for Research and Treatment of Cancer Quality of Life Questionnaire [EORTC QLQ C30]) and symptoms-sleep disturbance (General Sleep Disturbance Scale [GSDS]), fatigue (Lee Fatigue Scale [LFS]), depressive symptoms (Center for Epidemiological Studies-Depression Scale [CES-D]), anxiety (Spielberger State-Trait Anxiety Inventory [STAI-S, STAI-T]), and stress (Perceived Stress Scale [PSS])-were measured prior to, at midpoint, and at the end of the 4-month intervention. Effect sizes (Cohen's d) were calculated along with paired t tests comparing baseline to end of month 4 time points. Mixed effects models were used for repeated measures analyses.

RESULTS

Participants (n = 32) had a mean age of 48 years (SD = 10). Retention at the end of the intervention was 84%. Among those who completed the intervention (n = 27), adherence was high (99.5% of visits with practitioners attended). Large improvements were seen in QLQ-C30 emotional functioning (d = 0.84, P < 0.001), QLQ-C30 cognitive functioning (d = 0.86, P < 0.001), GSDS (d = -1.23, P < 0.001), and CES-D (d = -1.21, P < 0.001). Moderate improvements were seen in QLQ-C30 global health (d = 0.65, p = 0.003), LFS (d = -0.68, P = 0.002), and PSS (d = -0.75, P < 0.001). No adverse events were observed due to the intervention.

CONCLUSION

This 4-month Ayurvedic whole-systems multimodal nutrition and lifestyle intervention was feasible and acceptable for breast cancer survivors. Promise of clinical benefit was seen in terms of improvements in symptoms and QOL that warrants further investigation.

End-of-Life Concerns and Experiences of Living With Advanced Breast Cancer Among Medically Underserved Women

CONTEXT

Breast cancer morbidity and mortality disproportionately affect medically underserved women. Most studies of the experience of living with advanced breast cancer do not focus on this population. A deeper understanding of racial/ethnic minorities' and low-income patients' experiences is needed to reduce breast cancer health and health care disparities.

OBJECTIVES

This qualitative, community-based participatory research study explores the lived experiences of medically underserved women with advanced breast cancer.

METHODS

We conducted in-depth, semistructured interviews with low-income patients from a community clinic and safety-net hospital, focusing on issues related to advanced breast cancer and end of life. Six team members independently coded transcripts, jointly reconciled coding differences, and identified key themes.

RESULTS

All 63 participants (83% response rate) had an income ≤200% of the federal poverty level; 68% identified as a racial/ethnic minority. Four predominant themes emerged: compounding of pre-existing financial distress, perceived bias/lack of confidence in medical care received, balancing personal needs with the needs of others, and enhanced engagement with sources of life meaning.

CONCLUSION

Participants resiliently maintained engaged lives yet described extreme financial duress and perceived provider bias, which are known contributors to worse quality of life and health outcomes. Participants downplayed their desire to discuss dying to accommodate pressure to "stay positive" and to mitigate others' discomfort. Improving care for underserved women with advanced cancer will require addressing disparities from screening through hospice, developing personalized opportunities to discuss death and dying, and enhancing access to and affordability of medical and social support.

Vulnerable Patients' Psychosocial Experiences in a Group-Based, Integrative Pain Management Program

Objectives: To use a psychosocial framework to examine the pain experiences of low-income, ethnically diverse patients before and after an Integrative Pain Management Program (IPMP). Design and methods: IPMP is a 12-week, multimodal pain group incorporating mindfulness, acupuncture, massage, education, movement, and health coaching. The authors conducted semistructured interviews at the beginning, end, and 3 months following completion of IPMP. Interviews were digitally recorded and transcribed and analyzed using inductive coding methods. Setting: A primary care clinic in San Francisco, CA, serving low-income, ethnically diverse patients, many of whom are marginally housed and living with disabilities. Subjects: Forty-one patients with a diagnosis of chronic pain, currently receiving prescription opioids and referred by their primary care provider, who participated in IPMP. Results: Authors thematically analyzed 104 individual interviews with 41 IPMP participants, including 41 baseline, 35 three-month follow-up, and 28 six-month follow-up. Before IPMP, participants described a psychologic "vicious cycle" of pain symptoms that worsened with movement and anxiety, while increasing their sense of disempowerment and social isolation. Following IPMP, patients reported using new strategies to manage pain, including lowering medication use, resulting in an emerging sense of psychologic resilience, and more social connections. Conclusions: IPMP offers an accessible model for addressing psychosocial aspects of chronic pain. Vulnerable patients engaged with integrative medicine groups and developed new perspectives and tools for managing their pain; they emerged feeling hopeful and resilient. These results support the use of integrative medicine groups for targeting psychosocial aspects of chronic pain within primary care.

Integrative Health: An Interprofessional Standardized Patient Case for Prelicensure Learners

Introduction

Integrative health care and complementary medicine are widely used by the U.S. population, yet health professions learners are typically inadequately educated to counsel patients on the use of these approaches. This interprofessional standardized patient exercise (ISPE) provides learners the opportunity to discuss various health care professionals' roles in caring for a patient interested in integrative health strategies, and to collaborate on a care plan. Utilizing this ISPE format aligns with the principles of integrative health as it requires interprofessional collaboration to address the multifaceted needs of patients.

Methods

The ISPE is approximately three hours in duration, and required of all UCSF, third-year dentistry, physical therapy, and medical students; second-year nurse practitioner students, and fourth-year pharmacy students. Social work, nutrition, and chaplain trainees also participated. Working in interprofessional teams of 4-5 learners, team members discuss case information, interview the standardized patient (SP) individually, jointly formulate a care plan, and, discuss the plan with the SP. The experience is debriefed with a facilitator.

Results

In 2016-17, 520 learners participated in the ISPE. They agreed that they learned about the roles of other health care professionals (M = 5.24 on a six-point scale, SD = 1.27), and that they would recommend the ISPE to fellow students in their profession (M = 5.25, SD = 1.30).

Discussion

Students appreciated the ability to observe learners from other health professions interacting with the SP, and how different perspectives and expertise were integrated to create a comprehensive care plan. The exercise can be adapted to accommodate local health professions learners.

The impact of intramural grants on educators' careers and on medical education innovation

PURPOSE

The University of California, San Francisco (UCSF), Haile T. Debas Academy of Medical Educators Innovations Funding program awards competitive grants to create novel curricula and faculty development programs, compare pedagogical approaches, and design learner assessment methods. The authors examined the principal investigators' (PIs') perceptions of the impact of these intramural grants on their careers and on medical education innovation.

METHOD

At 12 months (project completion) and 24 months (follow-up), PIs submit a progress report describing the impact of their grant on their careers, work with collaborators, subsequent funding, project dissemination, and the UCSF curriculum. The authors analyzed these reports using qualitative thematic analysis and achieved consensus in coding and interpretation through discussion.

RESULTS

From 2001 to 2012, the program funded 77 PIs to lead 103 projects, awarding over $2.2 million. The authors analyzed reports from 88 grants (85.4%) awarded to 68 PIs (88.3%). PIs noted that the funding led to accelerated promotion, expanded networking opportunities, enhanced knowledge and skills, more scholarly publications and presentations, extramural funding, and local and national recognition. They also reported that the funding improved their status in their departments, enhanced their careers as medical educators, laid the foundation for subsequent projects, and engaged an array of stakeholders, including trainees and junior faculty.

CONCLUSIONS

These modest intramural education grants not only created innovative, enduring programs but also promoted educators' professional identity formation, fostered collaborations, supported junior faculty in finding their desired career paths, provided advancement opportunities, and raised the local and national profiles of recipients.

Perceptions of interprofessional teamwork in low-acuity settings: a qualitative analysis

CONTEXT

Working effectively in interprofessional teams is a core competency for all health care professionals, yet there is a paucity of instruments with which to assess the associated skills. Published medical teamwork skills assessment tools focus primarily on high-acuity situations, such as cardiopulmonary arrests and crisis events in operating rooms, and may not generalise to non-high-acuity environments, such as in-patient wards and out-patient clinics.

OBJECTIVE

We undertook the current study to explore the constructs underlying interprofessional teamwork in non-high-acuity settings and team members' perspectives of essential teamwork attributes.

METHODS

We used an ethnographic approach to study four interprofessional teams in two different low-acuity settings: women's HIV (human immunodeficiency virus) clinics and in-patient paediatric wards. Over a period of 17 months, we collected qualitative data through direct observations, focus groups and individual interviews. We analysed the data using qualitative thematic analysis, following an iterative process: data from our observations (20 hours in total) informed the focus group guide and focus group data informed the interview guide. To enhance the integrity of our analysis, we triangulated data sources and verified themes through member checking.

RESULTS

We conducted seven focus groups and 27 individual interviews with a total of 39 study participants representing eight professions. Participants emphasised shared leadership and collaborative decision making, mutual respect, recognition of one's own and others' limitations and strengths, and the need to nurture relationships. Team members also discussed tensions around hierarchy and questioned whether doctor leadership is appropriate for interprofessional teams. Our findings indicate that there are differences in teamwork between low-acuity and high-acuity settings, and also provide insights into potential barriers to effective interprofessional teamwork.

CONCLUSIONS

Our study delineates essential elements of teamwork in low-acuity settings, including desirable attributes of team members, thus laying the foundation for the development of an individual teamwork skills assessment tool.

Correlating traditional Ayurvedic and modern medical perspectives on cancer: results of a qualitative study

OBJECTIVE

To characterize Ayurvedic perspectives on the etiopathogenesis and supportive treatments for a biomedical diagnosis of cancer.

METHODS

Hour-long, digitally recorded interviews were conducted with 10 experienced Ayurvedic clinicians, transcribed verbatim, and analyzed using techniques of qualitative thematic analysis.

RESULTS

Four major themes were identified. The Ayurvedic description of the pathophysiology of cancer uses traditional concepts translated into a modern context. Although the biomedical treatment of cancer is considered valuable, from an Ayurvedic perspective it results in degeneration and depletion. In cases where biomedical treatment of cancer is not feasible, an Ayurvedic approach focusing on strengthening digestion, eliminating toxins, reducing tumor growth, and improving tissue metabolism is useful. An Ayurvedic approach to cancer supportive care focuses on restoring equilibrium, building strength, and rejuvenation.

CONCLUSION

Ayurvedic medicine offers a unique perspective on the biomedical diagnosis of cancer that emphasizes restoring wholeness, uses natural remedies, includes a focus on emotional health, and emphasizes prevention strategies.

Creating an ideal social and behavioural sciences curriculum for medical students

OBJECTIVES

Undergraduate medical education programmes universally struggle with overfull curricula that make curricular changes quite challenging. Final content decisions are often influenced by available faculty staff, vocal champions or institutional culture. We present a multi-modal process for identifying 'need-to-know' content while leveraging curricular change, using the social and behavioural sciences (SBS) as an exemplar.

METHODS

Several multi-modal approaches were used to identify and triangulate core SBS curricula, including: a national survey of 204 faculty members who ranked the content importance of each of the SBS content areas; a comprehensive review of leading medical SBS textbooks; development of an algorithm to assess the strength of evidence for and potential clinical impact of each SBS construct; solicitation of student input, and review of guidelines from national advocacy organisations. To leverage curricular change, curriculum mapping was used to compare the school's 'actual' SBS curriculum with an 'ideal' SBS curriculum to highlight educational needs and areas for revision. Clinical clerkship directors assisted in translating core SBS content into relevant clinical competencies.

RESULTS

Essential SBS content areas were identified along with more effective and efficient ways of teaching SBS within a medical setting. The triangulation of several methods to identify content raised confidence in the resulting content list. Mapping actual versus ideal SBS curricula highlighted both current strengths and weaknesses and identified opportunities for change.

CONCLUSIONS

This multi-modal, several-stage process of generating need-to-know curricular content and comparing it with current practices helped promote curricular changes in SBS, a content area that has been traditionally difficult to teach and is often under-represented. It is likely that this process can be generalised to other emerging or under-represented topic areas.

"I'm sitting here by myself ...": experiences of patients with serious illness at an Urban Public Hospital

OBJECTIVE

To describe experiences of serious illness including concerns, preferences, and perspectives on improving end-of-life (EOL) care in underserved inpatients.

METHODS

Qualitative analysis of 1-hour interviews with inpatients at a public hospital whose physician "would not be surprised" by the patient's death or intensive care unit (ICU) admission within a year. Patients who were non-English speaking, lacked mental capacity, or had uncontrolled symptoms were excluded. A semistructured interview guide was developed and used for all interviews. We digitally recorded, transcribed, and conducted a thematic analysis of the interviews.

RESULTS

Twenty patients participated. Difficult events such as estrangement, homelessness, substance abuse, and imprisonment shaped patients' approaches to serious illness. This influence manifested in interpersonal relationships, conceptualizations of death and concerns about dying, and approaches to coping with EOL. Because patients lacked social support, providers played significant roles at EOL. Patients preferred honest communication with providers and sharing in medical decision-making. A prolonged dying process was feared more than sudden death. Concerns included pain, dying in the hospital, and feeling unwelcome in the hospital. Patients coped by advocating for their own care, engaging with religion/spirituality, and viewing illness as similar to past trauma. Participants suggested that providers listen to their concerns and requested accessible chaplaincy and home-based services.

CONCLUSIONS

Providers should consider that difficult life events influence underserved patients' approaches to dying. Attention to patients' specific preferences and palliative care in public hospitals and locations identified as home may improve care for patients who lack social support.

Encouraging scholarship: medical school programs to promote student inquiry beyond the traditional medical curriculum

Many medical curricula now include programs that provide students with opportunities for scholarship beyond that provided by their traditional, core curricula. These scholarly concentration (SC) programs vary greatly in focus and structure, but they share the goal of producing physicians with improved analytic, creative, and critical-thinking skills. In this article, the authors explore models of both required and elective SC programs. They gathered information through a review of medical school Web sites and direct contact with representatives of individual programs. Additionally, they discuss in-depth the SC programs of the Warren Alpert Medical School of Brown University; the University of South Florida College of Medicine; the University of California, San Francisco; and Stanford University School of Medicine. The authors describe each program's focus, participation, duration, centralization, capstone requirement, faculty involvement, and areas of concentration. Established to address a variety of challenges in the U.S. medical education system, these four programs provide an array of possible models for schools that are considering the establishment of an SC program. Although data on the impact of SC programs are lacking, the authors believe that this type of program has the potential to significantly impact the education of medical students through scholarly, in-depth inquiry and longitudinal faculty mentorship.

Why doctors choose small towns: a developmental model of rural physician recruitment and retention

Shortages of health care professionals have plagued rural areas of the USA for more than a century. Programs to alleviate them have met with limited success. These programs generally focus on factors that affect recruitment and retention, with the supposition that poor recruitment drives most shortages. The strongest known influence on rural physician recruitment is a "rural upbringing," but little is known about how this childhood experience promotes a return to rural areas, or how non-rural physicians choose rural practice without such an upbringing. Less is known about how rural upbringing affects retention. Through twenty-two in-depth, semi-structured interviews with both rural- and urban-raised physicians in northeastern California and northwestern Nevada, this study investigates practice location choice over the life course, describing a progression of events and experiences important to rural practice choice and retention in both groups. Study results suggest that rural exposure via education, recreation, or upbringing facilitates future rural practice through four major pathways. Desires for familiarity, sense of place, community involvement, and self-actualization were the major motivations for initial and continuing small-town residence choice. A history of strong community or geographic ties, either urban or rural, also encouraged initial rural practice. Finally, prior resilience under adverse circumstances was predictive of continued retention in the face of adversity. Physicians' decisions to stay or leave exhibited a cost-benefit pattern once their basic needs were met. These results support a focus on recruitment of both rural-raised and community-oriented applicants to medical school, residency, and rural practice. Local mentorship and "place-specific education" can support the integration of new rural physicians by promoting self-actualization, community integration, sense of place, and resilience. Health policy efforts to improve the physician workforce must address these complexities in order to support the variety of physicians who choose and remain in rural practice.

Patients' interactions with physicians and complementary and alternative medicine practitioners: older women with breast cancer and self-managed health care

Older patients are more likely than ever to be under the care of both physicians and complementary and alternative medicine (CAM) practitioners, yet there is little research on older patients' experience of these different relationships. This article addresses older breast cancer patients' seeking of concurrent care and examines patients' understandings of interactions with physicians and CAM practitioners. This is a qualitative study of a random, population-based sample of 44 older women with breast cancer who are simultaneously under the care of at least 1 physician and 1 CAM practitioner.

Use of focus groups in multi-site, multi-ethnic research projects for women's health: a Study of Women Across the Nation (swan) example

OBJECTIVE

To outline the lessons learned about the use of focus groups for the multisite, multi-ethnic longitudinal Study of Women Across the Nation (SWAN). Focus groups were designed to identify potential cultural differences in the incidence of symptoms and the meaning of transmenopause among women of diverse cultures, and to identify effective recruitment and retention strategies.

DESIGN

Inductive and deductive focus groups for a multi-ethnic study.

SETTING

Seven community research sites across the United States conducted focus groups with six ethnic populations: African American, Chinese American, Japanese American, Mexican American, non-Hispanic white, and Puerto Rican.

PATIENTS OR PARTICIPANTS

Community women from each ethnic group of color.

INTERVENTIONS

A set of four/five focus groups in each ethnic group as the formative stage of the deductive, quantitative SWAN survey.

MAIN OUTCOME MEASURES

Identification of methodological advantages and challenges to the successful implementation of formative focus groups in a multi-ethnic, multi-site population-based epidemiologic study.

RESULTS

We provide recommendations from our lessons learned to improve the use of focus groups in future studies with multi-ethnic populations.

CONCLUSIONS

Mixed methods using inductive and deductive approaches require the scientific integrity of both research paradigms. Adequate resources and time must be budgeted as essential parts of the overall strategy from the outset of study. Inductive cross-cultural researchers should be key team members, beginning with inception through each subsequent design phase to increase the scientific validity, generalizability, and comparability of the results across diverse ethnic groups, to assure the relevance, validity and applicability of the findings to the multicultural population of focus.

Minority faculty voices on diversity in academic medicine: perspectives from one school

PURPOSE

To examine the perceptions and experiences of ethnic minority faculty at University of California-San Francisco regarding racial and ethnic diversity in academic medicine, in light of a constitutional measure outlawing race- and gender-based affirmative action programs by public universities in California.

METHOD

In 2005, underrepresented minority faculty in the School of Medicine at University of California-San Francisco were individually interviewed to explore three topics: participants' experiences as minorities, perspectives on diversity and discrimination in academic medicine, and recommendations for improvement. Interviews were tape-recorded, transcribed verbatim, and subsequently coded using principles of qualitative, text-based analysis in a four-stage review process.

RESULTS

Thirty-six minority faculty (15 assistant professors, 11 associate professors, and 10 full professors) participated, representing diversity across specialties, faculty rank, gender, and race/ethnicity. Seventeen were African American, 16 were Latino, and 3 were Asian. Twenty participants were women. Investigators identified four major themes: (1) choosing to participate in diversity-related activities, driven by personal commitment and institutional pressure, (2) the gap between intention and implementation of institutional efforts to increase diversity, (3) detecting and reacting to discrimination, and (4) a need for a multifaceted approach to mentorship, given few available minority mentors.

CONCLUSIONS

Minority faculty are an excellent resource for identifying strategies to improve diversity in academic medicine. Participants emphasized the strong association between effective mentorship and career satisfaction, and many delineated unique mentoring needs of minority faculty that persist throughout academic ranks. Findings have direct application to future institutional policies in recruitment and retention of underrepresented minority faculty.

A novel clinical-trial design for the study of massage therapy

OBJECTIVES

To develop and test the feasibility and acceptability of a structured design for a massage therapy clinical trial that included a treatment arm designed to control for the non-specific effects of a massage therapy intervention.

DESIGN

Pilot randomized controlled clinical trial.

SETTING

University-integrated medicine research clinic.

INTERVENTIONS

Participants were randomized to a structured Swedish-style massage therapy intervention, a light-touch bodywork control intervention, or usual medical care. Details of the interventions are provided.

MAIN OUTCOME MEASURES

The primary outcome measures were the adherence of the participants to the study protocol and the perception of the intervention experience.

RESULTS

Forty-four participants were randomized. Participants often found adherence to the twice-weekly outpatient bodywork interventions to be somewhat difficult; while, overall, 84% of participants completed the study, only 76% of those in an intervention arm successfully completed the trial. Participants randomized to the massage arm expressed uniformly positive attitudes both before and after the intervention. While some participants randomized to the light-touch bodywork arm initially expressed some reservations about their randomization assignment, all participants available for interview were pleased with their experience after the intervention period.

CONCLUSIONS

The proposed design was found to be relatively straightforward to implement and acceptable to participants. Early disappointment with not receiving massage therapy expressed by the light-touch intervention participants dissipated quickly. Twice-weekly outpatient intervention appointments were found to be highly burdensome for many patients actively undergoing chemotherapy, thus reducing adherence.

Relationships among older patients, CAM practitioners, and physicians: the advantages of qualitative inquiry

Older patients are increasingly likely to be under the simultaneous care of both physicians and alternative practitioners, often for treatment of the same condition. In the majority of cases, however, alternative care is not integrated with biomedical care; indeed, most patients do not inform their physicians of their concurrent use of complementary and alternative medicine (CAM). Because of the increased use of CAM in recent years, this is a critical juncture at which to study healthcare relationships in which the patient is treated by practitioners from different medical systems who are usually not in contact with and often not aware of one another. The purpose of this paper is to (a) review the limited literature that addresses healthcare relationships among patients, physicians, and alternative practitioners; (b) suggest that understanding all 3 sides of the patient-physician CAM practitioner triangle creates a more comprehensive and realistic view of current healthcare practices; and (c) propose that qualitative research methodologies can provide unique and essential understandings of these emerging healthcare relationship configurations. An ongoing qualitative research study of older women with breast cancer and their interactions with their physicians and alternative practitioners is described as an example.

Ethnic differences in use of complementary and alternative medicine at midlife: longitudinal results from SWAN participants

OBJECTIVES

We estimated the prevalence and longitudinal correlates of use of complementary and alternative medicine (CAM) at midlife among participants of the Study of Women's Health Across the Nation (SWAN).

METHODS

Multiple logistic regression was used to evaluate the relationship between baseline survey-reported symptoms and use of herbal, spiritual, and physical manipulation therapies 1 year later.

RESULTS

Almost half of all women had used CAM in the past year. Baseline psychological symptoms were associated with subsequent use of spiritual therapies among White and Chinese women. Baseline CAM use was a major predictor of subsequent use in White, Japanese, and Chinese women.

CONCLUSIONS

Baseline CAM use, rather than presence of symptoms, was the major predictor of subsequent CAM use. Premenopausal health behaviors are important determinants of choice of therapy during midlife.

Conceptualizing menopause and midlife: Chinese American and Chinese women in the US

OBJECTIVES

The purpose of this qualitative project was to describe and examine expectations and experiences of menopause and midlife in pre- and postmenopausal Chinese American and Chinese women in the United States.

METHODS

Four focus groups were formed from a total of 44 women: two groups of premenopausal Chinese/Chinese American women (one conducted in English and one in Cantonese) and two groups of postmenopausal Chinese/Chinese American women (one conducted in English and one in Cantonese). Qualitative data, in the form of transcripts, were interpreted using text-based content analysis.

RESULTS

The major thematic findings were: meanings of menopause are inextricably bound with meanings of midlife; the borders and timing of the menopausal transition are ambiguous; the menopausal transition represents a natural progression through the life cycle; the expectations of the premenopausal women did not match the experiences of the postmenopausal women; menopause is viewed as a marker for aging; and the menopausal transition must be prepared for and managed.

CONCLUSIONS

Study findings indicate that the participants did not share the strictly medicalized view of menopause as a discrete, biological entity. Menopause was typically described as a natural transition that was virtually interchangeable with midlife. While most of the participants characterized menopause as signaling the end of fertility and virtually synonymous with old age, some women described it as a new opportunity and a second chance at life. Participants felt a sense of their own agency in addressing what they viewed as a complex life stage, the experience of which could be manipulated.

Alternative therapies used by women with breast cancer in four ethnic populations

BACKGROUND

Interest in alternative therapies is growing rapidly in the United States. We studied the types and prevalence of conventional and alternative therapies used by women in four ethnic groups (Latino, white, black, and Chinese) diagnosed with breast cancer from 1990 through 1992 in San Francisco, CA, and explored factors influencing the choices of their therapies.

METHODS

Subjects (n = 379) completed a 30-minute telephone interview in their preferred language. Logistic regression models assessed factors associated with the use of alternative therapies after a diagnosis of breast cancer.

RESULTS

About one half of the women used at least one type of alternative therapy, and about one third used two types; most therapies were used for a duration of less than 6 months. Both the alternative therapies used and factors influencing the choice of therapy varied by ethnicity. Blacks most often used spiritual healing (36%), Chinese most often used herbal remedies (22%), and Latino women most often used dietary therapies (30%) and spiritual healing (26%). Among whites, 35% used dietary methods and 21% used physical methods, such as massage and acupuncture. In general, women who had a higher educational level or income, were of younger age, had private insurance, and exercised or attended support groups were more likely to use alternative therapies. About half of the women using alternative therapies reported discussing this use with their physicians. More than 90% of the subjects found the therapies helpful and would recommend them to their friends.

CONCLUSIONS

Given the high prevalence of alternative therapies used in San Francisco by the four ethnic groups and the relatively poor communication between patients and doctors, physicians who treat patients with breast cancer should initiate dialogues on this topic to better understand patients' choices with regard to treatment options.

Complementary and alternative medicine use among women with breast cancer

The legacy of 19th-century social theories applied to the study of non-mainstream treatment use continues to affect contemporary research into complementary and alternative medicine (CAM). Quantitatively based studies of CAM use have been hindered by the lack of an adequate lexicon, inaccurate characterizations of the people who use CAM, and underestimates of the prevalence of usage. Results from a qualitative prospective cohort study challenge previous stereotypes by indicating that CAM usage does not increase dramatically with the initial diagnosis of cancer and that younger women are more likely to use CAM than older women. Qualitative research methods are uniquely appropriate for obtaining accurate information about health practices that, despite growing acceptance in some areas of society, are still viewed as outside of the mainstream.

Disclosing complementary and alternative medicine use in the medical encounter: a qualitative study in women with breast cancer

BACKGROUND

Despite recent findings that patients who use complementary and alternative medicine (CAM) typically choose not to mention this to their physicians, little is known about the reasons for this lack of communication. Understanding the reasons for nondisclosure of CAM use is critical to improving physician-patient communication and patient care.

METHODS

We are conducting a 5-year prospective cohort study consisting of 4 interview cycles. The multiethnic, population-based sample consists of 86 San Francisco residents with recently diagnosed breast cancer (response rate = 87%). Findings are determined using qualitative analysis of transcribed interviews.

RESULTS

At initial contact, 72% of the participants were using at least 1 CAM therapy for breast cancer. Six months later, 65% of participants were using CAM. Of the women being treated by an alternative practitioner, 54% disclosed their CAM use to their physicians. Conversely, 94% discussed details of their biomedical treatments with their alternative practitioner. Reasons for not disclosing CAM use included anticipating the physician's disinterest, negative response, or unwillingness or inability to contribute useful information; the perception that the CAM therapies used were irrelevant to the biomedical treatment course; and the patients' views regarding the appropriate coordination of disparate healing strategies.

CONCLUSIONS

Discussions of patients' CAM use are more poorly integrated into the medical encounter than discussions of biomedical treatment are with alternative practitioners. Patients' disclosure is often cautiously modulated, even by those who would welcome an open discussion with their physicians. Specific suggestions for discussing CAM use with patients are presented.

Refugee stress and folk belief: Hmong sudden deaths

Since the first reported death in 1977, scores of seemingly healthy Hmong refugees have died mysteriously and without warning from what has come to be known as Sudden Unexpected Nocturnal Death Syndrome (SUNDS). To date medical research has provided no adequate explanation for these sudden deaths. This study is an investigation into the changing impact of traditional beliefs as they manifest during the stress of traumatic relocation. In Stockton, California, 118 Hmong men and women were interviewed regarding their awareness of and personal experience with a traditional nocturnal spirit encounter. An analysis of this data reveals that the supranormal attack acts as a trigger for Hmong SUNDS.

Ethnomedical pathogenesis and Hmong immigrants' sudden nocturnal deaths

Scores of seemingly healthy Hmong immigrants have died mysteriously and without warning from what has come to be known as Sudden Unexpected Nocturnal Death Syndrome (SUNDS). To date medical research has provided no adequate explanation for these sudden deaths. This study is an investigation into the role of powerful traditional beliefs in illness causation. In Stockton, California, 118 Hmong men and women were interviewed regarding their awareness of and personal experience with a traditional nocturnal spirit encounter. An analysis of this data reveals that the supranormal encounter acts as a trigger for Hmong SUNDS.

Treatment of intraventricular hemorrhage in the premature infant with urokinase. A preliminary report

Hydrocephalus secondary to intraventricular hemorrhage in the premature infant is common and is secondary to the presence of blood in the subarachnoid space. Rapid clearance of the blood may reduce the incidence of permanent hydrocephalus and mitigate the need for shunt placement. We have treated 4 premature infants with posthemorrhagic hydrocephalus with urokinase, a thrombolytic agent, instilled into the ventricles via a surgically paced ventricular access device. The infants were treated with 10,000 IU of urokinase twice a day for 1 week. No adverse reactions have occurred and none of the infants has required shunt placement. In a group of historical controls, the shunt rate was 87%.