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IntroductionPostpartum health is in crisis in the United States, with rising pregnancy-related mortality and worsening racial inequities. The World Health Organization recommends four postpartum visits during the 6 weeks after childbirth, yet standard postpartum care in the United States is generally one visit 6 weeks after birth. We present community midwifery postpartum care in the United States as a model concordant with World Health Organization guidelines, describing this model of care and its potential to improve postpartum health for birthing people and babies.MethodsWe conducted semi-structured interviews with 34 community midwives providing care in birth centers and home settings in Oregon and California. A multidisciplinary team analyzed data using reflexive thematic analysis.ResultsA total of 24 participants were Certified Professional Midwives; 10 were certified nurse-midwives. A total of 14 midwives identified as people of color. Most spoke multiple languages. We describe six key elements of the community midwifery model of postpartum care: (1) multiple visits, including home visits; typically five to eight over six weeks postpartum; (2) care for the parent-infant dyad; (3) continuity of personalized care; (4) relationship-centered care; (5) planning and preparation for postpartum; and (6) focus on postpartum rest.ConclusionThe community midwifery model of postpartum care is a guideline-concordant approach to caring for the parent-infant dyad and may address rising pregnancy-related morbidity and mortality in the United States.

BackgroundSocioeconomically disadvantaged populations have a high prevalence of chronic pain, exacerbated by social isolation, intersectional stigma, and disparities in pain assessment and treatment. Effective interventions using a multilevel, biopsychosocial approach are needed to decrease the unequal burden of pain. Group-based integrative pain management in primary care safety net clinics is a promising model to improve pain care for racially and ethnically diverse low-income people.ObjectiveTo describe a study protocol to test the impacts of 2 group-based models - group acupuncture and integrative group medical visits - on multilevel pain-related outcomes.MethodsThe study uses a 2x2 factorial randomized clinical trial to test two 12 week group-based models: group acupuncture and integrative group medical visits (IGMV, with psychoeducation, mind-body approaches, and social support). English or Spanish-speaking adults with chronic pain for ≥3 months receiving care in San Francisco Department of Public Health primary care clinics are eligible for the trial. All participants will receive usual care and be randomized to group acupuncture, IGMV, both, or waitlist control. The primary outcomes are changes from baseline to 3 month follow-up in pain impact and in social support for chronic pain. Secondary outcomes include pain interference, pain intensity, depression, anxiety, quality of life, and social isolation. Data will include patient-reported outcomes, electronic health record data, and qualitative interviews, focus groups and observations to assess multilevel individual, interpersonal and organizational outcomes.DiscussionMultilevel approaches are needed to advance health equity in pain management. Our study contributes to knowledge of group-based integrative pain management in primary care safety net clinics to address multilevel barriers and disparities in pain care.

BackgroundMindfulness-based interventions (MBIs) are supported by clinical practice guidelines as effective non-pharmacologic interventions for common symptoms experienced by cancer patients, including anxiety, depression, and fatigue. However, the evidence predominately derives from White breast cancer survivors. Racial and ethnic minority patients have less access to integrative oncology care and worse cancer outcomes. To address these gaps, we designed and piloted a series of mindfulness-based group medical visits (MB-GMVs), embedded into comprehensive cancer care, for racially and ethnically diverse patients in cancer treatment.MethodsAs a quality improvement project, we launched a telehealth MB-GMV series for patients undergoing cancer treatment, delivered as four weekly 2-hour visits billable to insurance. Content was concordant with evidence-based guidelines and established MBIs and adapted to improve cultural relevance and fit (eg, access-centered, trauma-informed, with inclusive communication practices). Program structure was adapted to address barriers to participation, with ≥50% slots per series reserved for racial and ethnic minority patients. Intake surveys incorporated a demographic questionnaire and symptom assessments. Evaluations were sent following the visits.ResultsIn our first ten cohorts (n = 78), 80% of referred patients enrolled. Participants were: 22% Asian, 14% Black, 17% Latino, 45% non-Latino White; 65% female; with a median age of 54 years (range 27-79); and 80% had metastatic cancer. Common baseline symptoms included lack of energy, difficulty sleeping, and worrying. Most patients (90%) attended ≥3 visits. On final evaluations, 87% patients rated the series as "excellent"; 81% "strongly agreed" that they liked the GMV format; and 92% would "definitely" recommend the series to others. Qualitative themes included empowerment and connectedness.ConclusionTelehealth GMVs are a feasible, acceptable, and financially sustainable model for increasing access to MBIs. Diverse patients in active cancer treatment were able to participate and reported high levels of satisfaction with this series that was tailored to center health equity and inclusion.

Objectives: This study describes the development and feasibility of Integrative Nutritional Counseling (INC), a Chinese medicine (CM)+biomedicine-based nutrition curriculum for Chinese Americans with type 2 diabetes. Although Chinese Americans often incorporate CM principles into their diet, scant research has explored how to integrate CM with biomedical nutrition standards in a culturally appropriate manner or if such a program could improve diabetes self-management. Design: This is a 1-month pre-post study design including three points of contact: baseline, in-person class, and 1-month follow-up. Subjects: Participants (n = 15) were Cantonese-speaking/reading Chinese Americans diagnosed with type 2 diabetes who had used some form of CM/medicinal foods in the last 12 months. Interventions and Outcome Measures: The INC program included baseline surveys and a CM intake interview conducted by a licensed acupuncturist. The acupuncturist generated a CM diagnosis, which was shared with the participant, and used this diagnosis to tailor brief nutrition education. To bolster this brief education, a bilingual registered dietitian provided a 2-h group education class in Cantonese to all participants, during which time participants also received a Chinese/English INC booklet. Participants completed surveys immediately after the class and at 1-month follow-up, with qualitative exit interviews. Results: Participants reported improved attitudes and dietary habits aligning directly with INC, and improvement in biomedically valued measures of type 2 diabetes, such as weight loss, and CM-valued measures of digestion/elimination and hot/cold feeling. Satisfaction with INC was high, but challenges included confusion with some INC information, structural barriers, and comorbidities. Conclusions: Chinese Americans with type 2 diabetes and interventionists found integrative nutrition approaches acceptable and feasible. Future research should examine INC with a larger population and explore optimal delivery of INC given reported challenges.

Objectives: As part of a pragmatic effectiveness trial of integrative pain management among inpatients with cancer, the authors sought to understand the clinical context and adaptations to implementation of two study interventions, acupuncture and pain counseling (i.e., pain education and coping skills). Design: The larger study uses a 2 × 2 factorial design with inpatients randomized to: (1) usual care (UC), (2) UC with acupuncture, (3) UC with pain counseling, and (4) UC with acupuncture and pain counseling. The study is being conducted in two hospitals (one academic and one public) and three languages (Cantonese, English, and Spanish). The authors conducted a process evaluation by interviewing study interventionists. Analysis included deductive coding to describe context, intervention, implementation, and inductive thematic coding related to intervention delivery. Results: Interviewees included seven acupuncturists and four pain counselors. Qualitative themes covered adaptations and recognizing site-specific differences that affected implementation. Interventionists adhered closely to protocols and made patient-centered adaptations that were then standardized in broader implementation (e.g., including caregivers in pain counseling sessions; working in culturally nuanced ways with non-English-speaking patients). The public hospital included more patients with recent diagnoses and advanced disease, more ethnically and linguistically diverse patients, less continuity of staffing, and shared patient rooms. At the academic medical center, more patients were familiar with integrative therapies and all were located in single rooms. Providing acupuncture to hospital staff was a key strategy to establish trust, experientially explain the intervention, and create camaraderie and staff buy-in. Conclusions: Providing nonpharmacologic interventions for a pragmatic trial requires adapting to a range of clinical factors. Site-specific factors included greater coordination and resources needed for successful implementation in the public hospital. The authors conclude that adaptation to context and individual patient needs can be done without compromising intervention fidelity and that intervention design should apply principles such as centering at the margins to reduce participation barriers for diverse patient populations.

Purpose: Chinese Americans (CAs) with diabetes and limited English proficiency often struggle to adhere to standard diabetes diets focused on food measurement/restriction. Chinese medicine principles commonly inform food choices among CAs but are rarely acknowledged in nutritional interventions. We developed and tested feasibility of a theoretically informed integrative nutritional counseling (INC) program that combines Chinese medicine principles with biomedical nutrition standards. Methods: We randomized diabetes self-management education (DSME) classes to include either: (1) usual nutrition curriculum based on American Diabetes Association (ADA) recommendations delivered by a diabetes educator (control) or (2) INC curriculum based on a combination of ADA recommendations and Chinese medicine principles delivered by a diabetes educator and a licensed acupuncturist (intervention). All DSME enrollees were invited to participate in research entailing data collection at three time points: baseline, after the DSME nutrition class, and at 6-month follow-up. Using validated measures, we collected dietary self-efficacy, diabetes distress, diet satisfaction, and dietary adherence. We also measured weight and glycemic control. Results: Study participants were 18 Cantonese-speaking patients with diabetes who were predominantly female and older, with low levels of income and acculturation. Intervention and control groups were similar at baseline. INC performed similarly to usual DSME with 100% of participants reporting the INC booklet helped their learning. Dietary adherence significantly improved in participants who received the INC curriculum. Conclusion: INC is feasible to implement as part of DSME classes and shows promise as a complementary culturally sensitive addition to usual diabetes nutrition education for CA patients.

Meditation practices are often used to cultivate interoception or internally-oriented attention to bodily sensations, which may improve health via cognitive and emotional regulation of bodily signals. However, it remains unclear how meditation impacts internal attention (IA) states due to lack of measurement tools that can objectively assess mental states during meditation practice itself, and produce time estimates of internal focus at individual or group levels. To address these measurement gaps, we tested the feasibility of applying multi-voxel pattern analysis (MVPA) to single-subject fMRI data to: (1) learn and recognize internal attentional states relevant for meditation during a directed IA task; and (2) decode or estimate the presence of those IA states during an independent meditation session. Within a mixed sample of experienced meditators and novice controls (N = 16), we first used MVPA to develop single-subject brain classifiers for five modes of attention during an IA task in which subjects were specifically instructed to engage in one of five states [i.e., meditation-related states: breath attention, mind wandering (MW), and self-referential processing, and control states: attention to feet and sounds]. Using standard cross-validation procedures, MVPA classifiers were trained in five of six IA blocks for each subject, and predictive accuracy was tested on the independent sixth block (iterated until all volumes were tested, N = 2,160). Across participants, all five IA states were significantly recognized well above chance (>41% vs. 20% chance). At the individual level, IA states were recognized in most participants (87.5%), suggesting that recognition of IA neural patterns may be generalizable for most participants, particularly experienced meditators. Next, for those who showed accurate IA neural patterns, the originally trained classifiers were applied to a separate meditation run (10-min) to make an inference about the percentage time engaged in each IA state (breath attention, MW, or self-referential processing). Preliminary group-level analyses demonstrated that during meditation practice, participants spent more time attending to breath compared to MW or self-referential processing. This paradigm established the feasibility of using MVPA classifiers to objectively assess mental states during meditation at the participant level, which holds promise for improved measurement of internal attention states cultivated by meditation.

Mindfulness and compassion meditation are thought to cultivate prosocial behavior. However, the lack of diverse representation within both scientific and participant populations in contemplative neuroscience may limit generalizability and translation of prior findings. To address these issues, we propose a research framework called Intersectional Neuroscience which adapts research procedures to be more inclusive of under-represented groups. Intersectional Neuroscience builds inclusive processes into research design using two main approaches: 1) community engagement with diverse participants, and 2) individualized multivariate neuroscience methods to accommodate neural diversity. We tested the feasibility of this framework in partnership with a diverse U.S. meditation center (East Bay Meditation Center, Oakland, CA). Using focus group and community feedback, we adapted functional magnetic resonance imaging (fMRI) screening and recruitment procedures to be inclusive of participants from various under-represented groups, including racial and ethnic minorities, gender and sexual minorities, people with disabilities, neuropsychiatric disorders, and/or lower income. Using person-centered screening and study materials, we recruited and scanned 15 diverse meditators (80% racial/ethnic minorities, 53% gender and sexual minorities). The participants completed the EMBODY task - which applies individualized machine learning algorithms to fMRI data - to identify mental states during breath-focused meditation, a basic skill that stabilizes attention to support interoception and compassion. All 15 meditators' unique brain patterns were recognized by machine learning algorithms significantly above chance levels. These individualized brain patterns were used to decode the internal focus of attention throughout a 10-min breath-focused meditation period, specific to each meditator. These data were used to compile individual-level attention profiles during meditation, such as the percentage time attending to the breath, mind wandering, or engaging in self-referential processing. This study provides feasibility of employing an intersectional neuroscience approach to include diverse participants and develop individualized neural metrics of meditation practice. Through inclusion of more under-represented groups while developing reciprocal partnerships, intersectional neuroscience turns the research process into an embodied form of social action.

[This corrects the article DOI: 10.3389/fpsyg.2020.573134.].

ObjectiveExisting pharmacologic approaches for painful diabetic neuropathy (PDN) are limited in efficacy and have side effects. We examined the feasibility, acceptability, and effects of group acupuncture for PDN.Design and settingWe randomized patients with PDN from a public safety net hospital to 1) usual care, 2) usual care plus 12 weeks of group acupuncture once weekly, or 3) usual care plus 12 weeks of group acupuncture twice weekly.MethodsThe primary outcome was change in weekly pain intensity (daily 0-10 numerical rating scale [NRS] averaged over seven days) from baseline to week 12. We also assessed health-related quality of life and related symptoms at baseline and weeks 6, 12, and 18.ResultsWe enrolled 40 patients with PDN (baseline pain = 5.3). Among participants randomized to acupuncture, 92% attended at least one treatment (mean treatments = 10.1). We observed no significant differences between once- vs twice-weekly acupuncture and combined those groups for the main analyses. Compared with usual care, participants randomized to acupuncture experienced greater decreases in pain during the 12-week intervention period (between-group differences from baseline = -2.06, 95% confidence interval [CI] = -3.01 to -1.10), but benefits were not maintained after acupuncture ended (baseline to week 18 = -0.61, 95% CI = -1.46 to 0.24). Quality of life improved for acupuncture participants (baseline to week 12 difference = 11.79, 95% CI = 1.92 to 21.66), but group differences were not significant compared with usual care (25.58, 95% CI = -3.90 to 55.06).ConclusionsGroup acupuncture is feasible and acceptable among linguistically and racially diverse safety net patients. Findings suggest clinically relevant reduction in pain from PDN and quality of life improvements associated with acupuncture, with no differences based on frequency.

Objectives: This article describes the implementation of a group medical visit (GMV) model to increase access to integrative oncology (IO) care. The most challenging and critical time to access high-quality IO care is while patients are receiving conventional cancer therapy. Often demand for individual IO clinic consultations precludes this from occurring. A three-session GMV program was designed to alleviate barriers to receiving integrative care during active cancer treatment. Design: A consolidated framework was used for implementation research and focused ethnography methods to describe the IO GMV implementation process. Data sources included patient evaluations, participant observation, and brief provider and patient interviews. Setting: A pilot program was created to assess the feasibility and acceptability of implementing IO GMVs at a comprehensive cancer center. Intervention: Each three-session GMV consisted of a didactic session, followed by individual visits with the integrative oncologist. Results: The setting, intervention, and implementation process of the IO GMV program were described. Thirty-two patients participated in the first five cohorts of the program. Twenty-two were women; 24 were White. The median age of participants was 52. Patient evaluations demonstrate high levels of satisfaction with the program with all scored aspects rated >4.0 on a five-point Likert scale. For the medical center, group visits are a financially viable alternative to individual IO visits; revenue from group visits exceeded the revenue potential of 6 h of individual visits by an average of 38%. Conclusion: GMVs are a feasible and promising model for increasing access to IO. Patients in active cancer treatment were able to participate in the program. Future research and implementation efforts could examine health outcomes over time after participation in GMVs, as well as the feasibility of using this model with more diverse patient populations.

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.

Objective: To explore an interprofessional group of health care providers' perspectives on the facilitators and barriers to implementation of an inpatient acupuncture service for pain and symptom management. Design: Qualitative. Setting: An urban, academic, tertiary care health system. Subjects: Key interprofessional health care providers, including physicians, nurses, and administrators. Methods/interventions: We used interviews and focus group with questions guided by the Promoting Action on Research Implementation in Health Services framework to explore three domains of implementation-evidence, context, and facilitation. Data were analyzed using content analysis. Results: Thirty health professionals participated in 11 interviews and 1 focus group. We identified 12 codes or topics, grouped into 3 categories: (1) facilitators to implementation, (2) barriers to implementation, and (3) strategies to promote successful implementation. Health professionals' awareness of acupuncture was high, and the positive support was based on beliefs that acupuncture fills a biomedical gap in treatment and adds institutional value by enhancing the reputation of the health system. Many thought that to provide comprehensive care, acupuncture should be available to inpatients, but opinions varied on the appropriateness and timing of acupuncture in patients' disease or care trajectory. Concerns about inconsistencies in insurance coverage and resulting expenses patients may incur were noted. Strategies to overcome implementation challenges included ensuring buy-in, setting appropriate expectations of the benefits of acupuncture, and educating patients and providers. Conclusions: Our study finds clear support for acupuncture. These strong endorsements were the foundation of facilitating factors that can guide implementation of acupuncture in the inpatient setting. Although we also identified potential barriers to implementation that must be addressed, we also report a number of actionable steps to operationalize evidence-based acupuncture to patients who are inpatients.

Purpose: Integrative group medical visits (IGMVs) aim to increase access to complementary and integrative health care, which is particularly relevant for low-income people. We sought to describe IGMV programs in US safety-net clinics through a survey of providers. Methods: An online and paper survey was conducted to collect data on the use of complementary health approaches and characteristics of IGMV programs. We recruited a purposive sample of safety-net clinicians via national meetings and listservs. Results: Fifty-seven clinicians reported on group medical visits. Forty percent worked in federally qualified health centers, 57% in safety-net or teaching hospitals, 23% in other settings such as free clinics. Thirty-seven respondents in 11 states provided care in IGMVs, most commonly for chronic pain and diabetes. Nutrition (70%), mindfulness/meditation/breathing (59%), and tai chi/yoga/other movement practices (51%) were the most common treatment approaches in IGMVs. Conclusion: Safety-net institutions in 11 states offered IGMVs to treat a range of chronic conditions. IGMVs are an innovative model to improve access to non-pharmacologic approaches to chronic illness care and health promotion. They may advance health equity by serving patients negatively impacted by health and health care disparities.

Background: Socioeconomically disadvantaged populations have a high prevalence of chronic pain, exacerbated by social isolation, intersectional stigma, and disparities in pain assessment and treatment. Effective interventions using a multilevel, biopsychosocial approach are needed to decrease the unequal burden of pain. Group-based integrative pain management in primary care safety net clinics is a promising model to improve pain care for racially and ethnically diverse low-income people. Objective: To describe a study protocol to test the impacts of 2 group-based models – group acupuncture and integrative group medical visits – on multilevel pain-related outcomes. Methods: The study uses a 2x2 factorial randomized clinical trial to test two 12 week group-based models: group acupuncture and integrative group medical visits (IGMV, with psychoeducation, mind-body approaches, and social support). English or Spanish-speaking adults with chronic pain for ≥3 months receiving care in San Francisco Department of Public Health primary care clinics are eligible for the trial. All participants will receive usual care and be randomized to group acupuncture, IGMV, both, or waitlist control. The primary outcomes are changes from baseline to 3 month follow-up in pain impact and in social support for chronic pain. Secondary outcomes include pain interference, pain intensity, depression, anxiety, quality of life, and social isolation. Data will include patient-reported outcomes, electronic health record data, and qualitative interviews, focus groups and observations to assess multilevel individual, interpersonal and organizational outcomes. Discussion: Multilevel approaches are needed to advance health equity in pain management. Our study contributes to knowledge of group-based integrative pain management in primary care safety net clinics to address multilevel barriers and disparities in pain care. [ABSTRACT FROM AUTHOR]

ObjectivesCurrent cardiovascular disease (CVD) nutrition guidelines do not take into account Chinese medicine (CM) principles. We created a heart healthy integrative nutritional counseling (H2INC) curriculum consistent with CM principles and current nutrition guidelines.MethodsWe conducted three phases of semi-structured interviews with key stakeholders (CM and biomedical providers and Chinese American (CAs) patients with CVD) followed by iterative development of H2INC. First, we interviewed licensed CM providers (n = 9) and laypeople with CM foods expertise (n = 1). Second, we interviewed biomedical providers (n = 11) and licensed CM providers (n = 3). Third, we conducted four focus groups with CAs (n = 20) with CVD.ResultsStakeholders emphasized different principles for creating H2INC. Phase one emphasized alignment of CM diagnoses to biomedical CVD conditions. Phase two overlaid CM concepts like the nature of foods and constitution (hot/neutral/cool) with heart healthy nutrition recommendations such as MyPlate, and avoiding excess salt, fat, and sugars. Phase three demonstrated patient acceptability.ConclusionBy integrating CM foods principles with biomedical nutrition, this integrative approach yields culturally relevant health education for an underserved population.Practice implicationsIntegrative nutritional counseling shows promise for CAs and could support biomedical providers with little knowledge about patients' use of CM for CVD.

BackgroundChildbirth fear is linked with lower labor pain tolerance and worse postpartum adjustment. Empirically validated childbirth preparation options are lacking for pregnant women facing this problem. Mindfulness approaches, now widely disseminated, can alleviate symptoms of both chronic and acute pain and improve psychological adjustment, suggesting potential benefit when applied to childbirth education.MethodsThis study, the Prenatal Education About Reducing Labor Stress (PEARLS) study, is a randomized controlled trial (RCT; n = 30) of a short, time-intensive, 2.5-day mindfulness-based childbirth preparation course offered as a weekend workshop, the Mind in Labor (MIL): Working with Pain in Childbirth, based on Mindfulness-Based Childbirth and Parenting (MBCP) education. First-time mothers in the late 3rd trimester of pregnancy were randomized to attend either the MIL course or a standard childbirth preparation course with no mind-body focus. Participants completed self-report assessments pre-intervention, post-intervention, and post-birth, and medical record data were collected.ResultsIn a demographically diverse sample, this small RCT demonstrated mindfulness-based childbirth education improved women's childbirth-related appraisals and psychological functioning in comparison to standard childbirth education. MIL program participants showed greater childbirth self-efficacy and mindful body awareness (but no changes in dispositional mindfulness), lower post-course depression symptoms that were maintained through postpartum follow-up, and a trend toward a lower rate of opioid analgesia use in labor. They did not, however, retrospectively report lower perceived labor pain or use epidural less frequently than controls.ConclusionsThis study suggests mindfulness training carefully tailored to address fear and pain of childbirth may lead to important maternal mental health benefits, including improvements in childbirth-related appraisals and the prevention of postpartum depression symptoms. There is also some indication that MIL participants may use mindfulness coping in lieu of systemic opioid pain medication. A large-scale RCT that captures real-time pain perceptions during labor and length of labor is warranted to provide a more definitive test of these effects.Trial registrationThe ClinicalTrials.gov identifier for the PEARLS  study is: NCT02327559 . The study was retrospectively registered on June 23, 2014.

ObjectiveTo develop a group-based therapeutic yoga program for women with chronic pelvic pain (CPP) and explore the effects of this program on pain severity, sexual function, and well-being.MethodsA yoga therapy program for CPP was developed by a multidisciplinary panel of clinicians, researchers, and yoga consultants. Women reporting moderate to severe pelvic pain for at least six months were recruited into a single-arm trial. Participants attended twice weekly group classes focusing on Iyengar-based yoga techniques and were instructed to practice yoga at home an hour a week for six weeks. Participants self-rated the severity of their pelvic pain using daily logs. The impact of participants' pain on everyday activities, emotional well-being, and sexual function was assessed using an Impact of Pelvic Pain (IPP) questionnaire. Sexual function was further assessed using the Sexual Health Outcomes in Women Questionnaire (SHOW-Q).ResultsAmong the 16 participants (age range = 31-64 years), average ratings of the severity of pain "at its worst," "at its best," and "on average" decreased by 29%, 32%, and 34%, respectively, from start to six weeks (P

PurposeTo describe use of complementary health approaches (CHAs) among patients with type 2 diabetes, and independent associations between CHA use and Hemoglobin A1c (A1C) and lower-density lipoprotein (LDL) cholesterol.MethodsParticipants were enrolled onto the SMARTSteps Program, a diabetes self-management support program conducted between 2009 and 2013 in San Francisco. At the 6-month interview, CHA use in the prior 30 days was estimated using a 12-item validated instrument. Demographic and diabetes-related measures A1C were assessed at baseline and 6-month followup. AIC and LDL values were ascertained from chart review over the study period. Medication adherence was measured using pharmacy claims data at 6 and 12 months.ResultsPatients (n = 278) completed 6-month interviews: 74% were women and 71.9% were non-English speaking. Any CHA use was reported by 51.4% overall. CHA modalities included vitamins/nutritional supplements (25.9%), spirituality/prayer (21.2%), natural remedies/herbs (24.5%), massage/acupressure (11.5%), and meditation/yoga/tai chi (10.4%). CHA costs per month were $43.86 (SD = 118.08). Nearly one third reported CHA (30.0%) specifically for their type 2 diabetes. In regression models, elevated A1C (>8.0%) was not significantly associated with overall CHA use (odds ratio [OR] = 1.78; 95% confidence interval [CI], 0.7 to 4.52) whereas elevated LDL was (OR = 3.93; 95% CI, 1.57 to 9.81). With medication adherence added in exploratory analysis, these findings were not significant.ConclusionsCHA use is common among patients with type 2 diabetes and may be associated with poor cardiometabolic control and medication adherence.

We examined the birth experience of immigrant and minority women and how CenteringPregnancy (Centering), a model of group prenatal care and childbirth education, influenced that experience. In-depth interviews and surveys were conducted with a sample of racially diverse Centering participants about their birth experiences. Interview transcripts were analyzed thematically. Study participants (n = 34) were primarily low-income, Spanish-speaking immigrants with an average age of 29.7. On a scale from 1 (not satisfied) to 10 (very satisfied), women reported high satisfaction with birth (9.0) and care (9.3). In interviews, they expressed appreciation for the choice to labor with minimal medical intervention. Difficulties with communication arose from fragmented labor and delivery care by multiple providers. Centering provided women with pain coping skills, a familiar birth attendant, and knowledge to advocate for themselves. High reported satisfaction may obscure challenges to providing high quality childbirth care for marginalized women. Further study should examine the potential of Centering to positively impact underserved women's birth experiences.

BackgroundEffective pain management among hospitalized patients is an important aspect of providing quality care and achieving optimal clinical outcomes and patient satisfaction. Common pharmacologic approaches for pain, though effective, have serious side effects and are not appropriate for all inpatients. Findings from randomized controlled trials (RCTs) support the efficacy of acupuncture for many symptoms relevant to inpatients including postoperative pain, cancer-related pain, nausea and vomiting, and withdrawal from narcotic use. However, the extent to which findings from RCTs translate to real-world implementation of acupuncture in typical hospital settings is unknown.Methods/designIn partnership with the launch of a clinical program offering acupuncture services to inpatients at the University of California San Francisco's Mount Zion Hospital, we are conducting a pilot study using a hybrid effectiveness-implementation design to: (1) assess the effectiveness of acupuncture to manage pain and other symptoms and improve patient satisfaction; and (2) evaluate the barriers and facilitators to implementing an on-going acupuncture service for inpatients. During a two-month pre-randomization phase, we evaluated and adapted clinical scheduling and treatment protocols with acupuncturists and hospital providers and pretested study procedures including enrollment, consent, and data collection. During a six-month randomization phase, we used a two-tiered consent process in which inpatients were first consented into a study of symptom management, randomized to be offered acupuncture, and consented for acupuncture if they accepted. We are also conducting in-depth interviews and focus groups to assess evidence, context, and facilitators of key provider and hospital administration stakeholders.DiscussionEffectiveness research in "real-world" practice settings is needed to inform clinical decision-making and guide implementation of evidence-based acupuncture practices. To successfully provide clinical acupuncture services and maintain a rigorous research design, practice-based trials of acupuncture require careful planning and attention to setting-specific, contextual factors.Trial registrationThis trial has been registered in ClinicalTrials.gov. The identifier is NCT01988194, registered on November 5, 2013.

ObjectivesTo describe cancer inpatients' prior-year use of complementary and integrative health (CIH) therapies and interest in receiving CIH therapies while in the hospital.DesignObservational, cross-sectional survey of prior-year use of 12 different CIH approaches and interest in receiving any of 7 CIH services in the hospital.SettingSurgical oncology ward of an academic medical center.Participants166 hospitalized oncology patients, with an average age of 54 years.ResultsThe most commonly used CIH approach was vitamins/nutritional supplements (67%), followed by use of a special diet (42%) and manual therapies (39%). More than 40% of patients expressed interest in each of the therapies if it was offered during their hospital stay, and 95% of patients were interested in at least one. More than 75% expressed interest in nutritional counseling and in massage. CIH use and interest varied somewhat by demographic and clinical characteristics.ConclusionRates of CIH use among patients with cancer were high, as were their preferences to have these services available in the inpatient setting. Hospitals have the opportunity to provide patient-centered care by developing capacity to provide inpatient CIH services.

Postdural puncture headache (PDPH) is a recognized complication of neuraxial anesthesia. This case report documents 1 patient who developed PDPH following epidural anesthesia for postoperative pain control. The patient declined conventional treatments, including an epidural blood patch and intravenous caffeine. This report documents successful use of adjunct acupuncture for the management of PDPH. Additional research on acupuncture as a potential adjunctive therapy for PDPH is needed, particularly for patients who are reluctant to receive more invasive treatments.

The purpose of this study was to evaluate group medical visits using an integrative health approach for underserved women with chronic pelvic pain (CPP). We implemented an integrative medicine program to improve quality of life among women with CPP using Centering, a group-based model that combines healthcare assessment, education, and social support. Patients were from university-affiliated and public hospital-affiliated clinics. We evaluated the program with qualitative and quantitative data to address components of the RE-AIM framework: Reach, Effectiveness, Adoption, Implementation, and Maintenance. Participants of the Centering CPP Program participants (n = 26) were demographically similar to a sample of women with CPP who sought care at Bay Area hospitals (n = 701). Participants were on average 40 years of age, a majority of whom were racial/ethnic minorities with low household income (76%). Women who attended four or more sessions (n = 16) had improved health-related quality of life, including decreases in average number of unhealthy days in the past month (from 24 to 18, p < .05), depressive symptoms (from 11.7 to 9.0, p < .05), and symptom severity (from 4.2 to 3.1, p < .01). Sexual health outcomes also improved (30.5 to 50.3, p = .02). No improvements were observed for pain catastrophizing. Our pilot program provides preliminary data that an integrative health approach using a group-based model can be adapted and implemented to reach diverse women with CPP to improve physical and psychological well-being. Given these promising findings, rigorous evaluation of implementation and effectiveness of this approach compared with usual care is warranted.

ObjectiveThe aim of this study was to examine the prevalence of and factors associated with use of complementary health approaches among women with chronic pelvic pain (CPP).DesignWe analyzed data from the Study of Pelvic Problems, Hysterectomy, and Intervention Alternatives, a prospective cohort study of women seeking care for noncancerous pelvic problems with intact uteri at enrollment. Among a subset of 699 participants who reported having CPP, we analyzed the prevalence of complementary health approaches used and associated patient sociodemographic and clinical characteristics, health-related quality of life, attitudes and beliefs, and conventional health care practices.ResultsAt baseline, slightly over one-half (51%) of women with CPP used at least one complementary health approach in the past year, including acupuncture (8%), special foods or diets (22%), herbs (27%), and vitamins and minerals (29%). During follow-up surveys conducted annually for 4 years, a substantial proportion of women (44.8%) used complementary health approaches at more than half of the assessments. Users of complementary health approaches were more likely to undergo a hysterectomy or oophorectomy or to use gonadotropin-releasing hormone agonists or opioids during the study compared with nonusers. Women with CPP who used complementary health approaches also had more optimal health-related quality of life measured by the Pelvic Problem Impact Questionnaire (31.6 vs 25.6, P

The therapeutic benefits of acupoint injection of vitamin K in spleen-6 (SP6) for the treatment of primary dysmenorrhea have been observed in limited clinical settings. However, menadione, the form of vitamin K most studied for treating dysmenorrhea, is not routinely used in clinical practice in North America. As part of a larger clinical trial among women aged 18-25 years with primary dysmenorrhea, we conducted a substudy to test the plasma concentration of phylloquinone (vitamin K1). We collected blood samples from four women before and 24-48 hours after an acupoint injection of phylloquinone in SP6. Despite the rapid turnover of phylloquinone observed in previous studies, we found that the plasma phylloquinone concentrations increased significantly from preinjection to 1-2 days after the injection. Interestingly, higher phylloquinone concentrations were correlated with less pain intensity among women with dysmenorrhea. Additional research is needed to understand the association between vitamin K and menstrual pain, including the role of vitamin K deficiency in inflammation and pain, and on the possible mechanisms of acupoint injection of vitamin K for the treatment of primary dysmenorrhea.

ContextDysmenorrhea, the occurrence of painful menstrual cramping of the uterus, is a major cause of activity restriction and absences from school and work among young women. Standard pharmaceuticals used to treat dysmenorrhea are not effective for all women and have side effects that limit their use. Studies elsewhere have shown beneficial effects for use of vitamin K1 as an acupoint treatment, but the acceptability of this treatment to women in the United States has been unknown.ObjectiveThe study intended to examine the feasibility, acceptability, and preliminary effects of acupuncture point injection of vitamin K1 as an alternative treatment for primary dysmenorrhea among US women.DesignThe research team conducted a pilot study using a blinded, randomized, crossover trial design.SettingThe study took place at the University of California, San Francisco (UCSF).ParticipantsThe study was conducted in the San Francisco Bay Area among women 18 to 25 y of age who had been diagnosed with primary dysmenorrhea. Fourteen women completed all of the study's visits.InterventionWomen with primary dysmenorrhea were randomized into 2 groups to receive bilateral injections of vitamin K1 in the Spleen-6 (SP-6) acupuncture point at the start of menstruation and then, following a 2-mo washout period, saline in a nonacupuncture point at the start of menstruation. One group received the vitamin K1 injection first, while the other group received the saline injection first.Outcome measureDysmenorrhea pain intensity was measured using a 0-10 numeric rating scale (NRS), before and after injections.ResultsWomen had an average 2.5-point decrease in pain after a vitamin K1 injection in the SP-6 acupoint (P < .001), as compared with a 1.8-point decrease after a saline injection (P < .001). Change scores for vitamin K1, as compared with a saline injection, approached statistical significance (P < .10). Intensity and duration of menstrual symptoms, as measured by the Cox retrospective symptom scale, also decreased following injections. After participating, 94% of the women remained agreeable to receiving the injection therapy, and 77% reported they would come every month were the treatment available.ConclusionsFindings suggested high acceptability for an acupuncture point injection of vitamin K1 as treatment for primary dysmenorrhea among young women in San Francisco. Pain decreased with both treatments, with a trend toward greater pain reduction for the vitamin K1/SP-6 injection. This finding is consistent with outcomes from the Obstetrics and Gynecology Hospital in Shanghai, China, where the protocol was developed.

Abstract Background Community acupuncture is a recent innovation in acupuncture service delivery in the U.S. that aims to improve access to care through low-cost treatments in group-based settings. Patients at community acupuncture clinics represent a broader socioeconomic spectrum and receive more frequent treatments compared to acupuncture users nationwide. As a relatively new model of acupuncture in the U.S., little is known about the experiences of patients at community acupuncture clinics and whether quality of care is compromised through this high-volume model. The aim of this study was to assess patients’ perspectives on the care received through community acupuncture clinics. Methods The investigators conducted qualitative, thematic analysis of written comments from an observational, cross-sectional survey of clients of the Working Class Acupuncture clinics in Portland, Oregon. The survey included an open-ended question for respondents to share comments about their experiences with community acupuncture. Comments were received from 265 community acupuncture patients. Results Qualitative analysis of written comments identified two primary themes that elucidate patients’ perspectives on quality of care: 1) aspects of health care delivery unique to community acupuncture, and 2) patient engagement in health care. Patients identified unique aspects of community acupuncture, including structures that facilitate access, processes that make treatments more comfortable and effective and holistic outcomes including physical improvements, enhanced quality of life, and empowerment. The group setting, community-based locations, and low cost were highlighted as aspects of this model that allow patients to access acupuncture. Conclusions Patients’ perspectives on the values and experiences unique to community acupuncture offer insights on the quality of care received in these settings. The group setting, community-based locations, and low cost of this model potentially reduce access barriers for those who might not otherwise consider using acupuncture. In addition, the community acupuncture model may offer individuals the opportunity for increased frequency of treatments, which raises pertinent questions about the dose–response relationship of acupuncture and health outcomes. This study provides preliminary data for future evaluations of the quality and effectiveness of community acupuncture. Future studies should include the perspectives of patients who initiated, and subsequently, discontinued community acupuncture treatment.

Providing comprehensive care for chronic pelvic pain is impeded by time and resource constraints of the standard health care visit. To provide patient education, psychosocial support, and health care assessment, we developed group visits for women with chronic pelvic pain using an evidence-based, holistic nursing approach. In this article, we describe the structure of group visits, the process of conducting Centering group visits focused on empowerment, and the content of a holistic curriculum for women with chronic pelvic pain.

ObjectivesAcupuncture utilization in the United States has increased in recent years, but is less common among racial/ethnic minorities and those of low socioeconomic status. Group-based, community acupuncture is a delivery model gaining in popularity around the United States, due in part to low-cost treatments provided on a sliding-fee scale. Affordable, community-based acupuncture may increase access to health care at a time when increasing numbers of people are uninsured. To assess the population using local community acupuncture clinics, sociodemographic factors, health status, and utilization patterns compared to national acupuncture users were examined.DesignData were employed from (1) a cross-sectional survey of 478 clients of two community acupuncture clinics in Portland, Oregon and (2) a nationally representative sample of acupuncture users from the 2007 National Health Interview Survey.ResultsPortland community acupuncture clients were more homogeneous racially, had higher educational attainment, lower household income, and were more likely to receive 10 or more treatments in the past 12 months (odds ratio=5.39, 95% confidence interval=3.54, 8.22), compared to a nationally representative sample of U.S. acupuncture users. Self-reported health status and medical reasons for seeking acupuncture treatment were similar in both groups. Back pain (21%), joint pain (17%), and depression (13%) were the most common conditions for seeking treatment at community acupuncture clinics.ConclusionsStudy findings suggest that local community acupuncture clinics reach individuals of a broad socioeconomic spectrum and may allow for increased frequency of treatment. Limited racial diversity among community acupuncture clients may reflect local demographics of Portland. In addition, exposure to and knowledge about acupuncture is likely to vary by race and ethnicity. Future studies should examine access, patient satisfaction, frequency of treatment, and clinical outcomes of group-based models of community acupuncture clinics located in racially and socioeconomically diverse communities.

Objectives. We studied the use of complementary and alternative medicine (CAM) among women in 4 racial/ethnic groups: non-Hispanic Whites, African Americans, Mexican Americans, and Chinese Americans. Methods. We obtained a nationally representative sample of women aged 18 years and older living in the United States in 2001. Oversampling obtained 800 interviews in each group, resulting in a sample of 3068 women. Results. Between one third and one half of the members of all groups reported using at least 1 CAM modality in the year preceding the survey. In bivariate analyses, overall CAM use among Whites surpassed that of other groups; however, when CAM use was adjusted for socioeconomic factors, use by Whites and Mexican Americans were equivalent. Despite the socioeconomic disadvantage of African American women, socioeconomic factors did not account for differences in CAM use between Whites and African Americans. Conclusions. CAM use among racial/ethnic groups is complex and nuanced. Patterns of CAM use domains differ among groups, and multivariate models of CAM use indicate that ethnicity plays an independent role in the use of CAM modalities, the use of CAM practitioners, and the health problems for which CAM is used. (doi:10.2105/AJPH.2004.047688)

Relative to non-Latino whites, Latinos in the United States have a lower socioeconomic status (SES) profile, but a lower all-cause mortality rate. Because lower SES is associated with poorer overall health, a great deal of controversy surrounds the Latino mortality paradox. We employed a secondary data analysis of the 1991 National Health Interview Survey to test the health behavior and acculturation hypotheses, which have been proposed to explain this paradox. These hypotheses posit that: (1) Latinos have more favorable health behaviors and risk factor profiles than non-Latino whites, and (2) Health behaviors and risk factors become more unfavorable with greater acculturation. Specific health behaviors and risk factors studied were: smoking, alcohol use, leisure-time exercise activity, and body mass index (BMI). Consistent with the health behaviors hypothesis, Latinos relative to non-Latino whites were less likely to smoke and drink alcohol, controlling for sociodemographic factors. Latinos, however, were less likely to engage in any exercise activity, and were more likely to have a high BMI compared with non-Latino whites, after controlling for age and SES. Results provided partial support for the acculturation hypothesis. After adjusting for age and SES, higher acculturation was associated with three unhealthy behaviors (a greater likelihood of high alcohol intake, current smoking, a high BMI), but improvement in a fourth (greater likelihood of recent exercise). Gender-specific analyses indicated that the observed differences between Latinos and non-Latino whites, as well as the effects of acculturation on health behaviors, varied across men and women. Results suggest that the health behaviors and acculturation hypotheses may help to at least partially explain the Latino mortality paradox. The mechanisms accounting for the relationship between acculturation and risky behaviors have yet to be identified. Keywords: Latino mortality paradox; Smoking; Alcohol use; Exercise; Body mass index; USA

Objectives. We examined whether Latinas differ from non-Latinas in having undergone recent mammography, clinical breast examination, or Papanicolaou testing, as well as the contribution of sociodemographic and hearth care variables to screening. Methods. We used data from the 1991 National Health Interview Survey Health Promotion and Disease Prevention supplement. Results. Latinas were less likely than non-Latina Whites to have undergone mammography (odds ratio [OR]=0.71; 95% confidence interval [CI]=0.57, 0.88), but this difference was attenuated when we controlled for socioeconomic factors (OR=0.90; 95% CI=0.70, 1.15). Latinas did not differ from Whites on Papanicolaou tests or clinical breast examinations. Quality of and access to health care predicted screening. Conclusions. Latina ethnicity does not predict breast and cervical cancer screening behavior independent of sociodemographic and structural factors.