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Byline: Marja J. Verhoef, PhD (Departments of Community Health Sciences and Medicine, University of Calgary, Calgary, AB, mverhoef@ucalgary.ca); Andrea Mulkins, MSc (Tzu Chi Research Group, Vancouver, BC); Linda E. Carlson, [...]

Because cancer care is presently developing into a complicated network of interventions delivered at different times and places with different intentions, there is a need to consider whether the current [...]

In Canada, naturopathic medicine is an emerging profession that is gaining formal recognition, including provincial/territorial regulation. While naturopathic medicine has undergone significant growth and legitimization, it still faces substantial challenges to acceptance as a full-fledged health care profession within the Canadian health care system. For example, professionalization theories indicate the importance of clear professional boundaries as well as the need for 'new' groups to find a place in the system of professions. This has been problematic for naturopathic practitioners who continue to practice within a broad scope of practice that encompasses many different therapeutic modalities. Development of statutory regulation also requires delineation of a specific, well-defined scope of practice. The purpose of this study was to describe naturopathic practitioners' perception of their training and their current scope of practice. Two thirds (n = 315) of all licensed Canadian naturopathic practitioners responded to the survey. The results showed that naturopathic practitioners are trained in, and practice, a wide range of therapeutic modalities and diagnostic procedures. Practitioners disagreed about their scope of practice, as 57% thought it was too restrictive, 31% felt it was about right and 13% thought it was too broad. A large majority felt there was some or a great deal of overlap with other practitioners' scope of practice. We conclude that multiple challenges are facing naturopathic medicine, including scope of practice, overlap with other professions, social closure, scarcity of vacancies and lack of cohesion. The future of naturopathic medicine will depend on how effectively the profession will use available strategies to overcome barriers to statutory self-regulation. Keywords: Naturopathic medicine; Professionalization; Canada; Scope of practice

Purpose: To conduct a systematic review of reasons for and sociodemographic and disease characteristics associated with complementary and alternative medicine (CAM) use in cancer patients. Methods: Eligible studies were identified [...]

To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/j.ctim.2005.05.001 Byline: Marja J. Verhoef (a), George Lewith (b), Cheryl Ritenbaugh (c), Heather Boon (d), Susan Fleishman (e), Anne Leis (f) Abstract: Complementary and alternative medicine (CAM) often consists of whole systems of care (such as naturopathic medicine or traditional Chinese medicine (TCM)) that combine a wide range of modalities to provide individualised treatment. The complexity of these interventions and their potential synergistic effect requires innovative evaluative approaches. Model validity, which encompasses the need for research to adequately address the unique healing theory and therapeutic context of the intervention, is central to whole systems research (WSR). Classical randomised controlled trials (RCTs) are limited in their ability to address this need. Therefore, we propose a mixed methods approach that includes a range of relevant and holistic outcome measures. As the individual components of most whole systems are inseparable, complementary and synergistic, WSR must not focus only on the 'active' ingredients of a system. An emerging WSR framework must be non-hierarchical, cyclical, flexible and adaptive, as knowledge creation is continuous, evolutionary and necessitates a continuous interplay between research methods and 'phases' of knowledge. Finally, WSR must hold qualitative and quantitative research methods in equal esteem to realize their unique research contribution. Whole systems are complex and therefore no one method can adequately capture the meaning, process and outcomes of these interventions. Author Affiliation: (a) Department of Community Health Sciences, University of Calgary, Faculty of Medicine, Canada (b) Complementary Medicine Research Unit, Primary Medical Care, Aldermoor Health Centre, Southampton, UK (c) Department of Family and Community Medicine, University of Arizona, AZ, USA (d) Faculty of Pharmacy, University of Toronto, Ont., Canada (e) Integrative Medicine Resource Group, Tucson, AZ, USA (f) Department of Community Health and Epidemiology, University of Saskatchewan, Sask., Canada

To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/j.ctim.2005.04.002 Byline: Andrea L. Mulkins (a), Joanna Eng (a), Marja J. Verhoef (b) Abstract: The objective of this study was to assess what factors the Tzu Chi Institute (TCI) practitioners identified as supports and barriers to providing care within an integrative health care setting. Author Affiliation: (a) Tzu Chi Research Group, Vancouver, BC (b) Department of Community Health Sciences, University of Calgary, 3330 Hospital Drive NW, Calgary, AB, Canada T2N 4N1 Article Note: (footnote) [star] Sources of Support: Funding was provided through grants from both the Samueli Institute for Information Biology and the Tzu Chi Foundation.

Despite the shift to patient-centered care in recent years, many clinical studies continue to reinforce the traditional researcher/subject relationship. In contrast, action research engages study participants in a collaborative relationship [...]

The purpose of this qualitative study was to explore arthritis management strategies among Chinese immigrants in Calgary, Canada, and to assess factors, that impact on these strategies. Purposive sampling was used to select 19 Chinese immigrants living with arthritis. Data were collected by means of in-depth interviews. The interview data were analyzed according to the following steps: (1) transcribing interview materials, (2) developing codes, categories and themes, (3) theoretical coding, and (4) laying out the theoretical framework. The results of this study describe factors, that impacted on illness management strategies. These include arthritic symptoms, beliefs about arthritis, beliefs about Western medicine based on treatment experience, beliefs about Chinese medicine, perceived barriers to using Chinese or Western medicine and social support. The emerging process of illness management shows that immigrants usually started using self-care remedies, followed by consulting Western physicians, consulting Chinese healers, and then returning to Western medicine. The results illustrate that disease management strategies among Chinese immigrants are impacted by disease, personal and cultural factors. These factors suggest helpful directions to providing culturally sensitive care, which can lead to greater satisfaction and well being for Chinese immigrants with arthritis. Keywords: Arthritis; Chinese immigrants; Traditional Chinese medicine; Canada

Canadian physicians' opinions about alternative medicine have, as yet, not been assessed. The objectives of this pilot study were to assess general practitioners': (1) desired involvement in alternative medicine; (2) perceived demand for alternative medicine; and (3) beliefs about the efficacy of different alternative approaches. The study design was a cross-sectional survey of 400 randomly selected Alberta and Ontario general practitioners. Of the 384 eligible physicians, 200 (52%) completed the questionnaire. Seventy-three percent of physicians felt that they should have some knowledge about the most important alternative treatments. However, with respect to other issues, physicians desired less involvement with alternative medicine. Sixty-five percent perceived a demand for alternative medicine from their patients, in particular chiropractic. Alternative medicine was perceived to be needed most for musculoskeletal problems and chronic pain or illness. Chiropractic, hypnosis and acupuncture (for chronic pain) were believed to be most efficacious, while homeopathy and reflexology were considered to be least efficacious. Undergraduate, graduate clinical and continuing medical education will need to address alternative treatments in order to provide physicians with up-to-date and relevant information. Key words - alternative medicine, general practitioners, efficacy

How women's social roles such as parenthood, marital status and employment status affect their exercise participation, is important for the rational planning of suitable and effective exercise programs for women in different social contexts. A secondary analysis of a large data-base of urban women aged 20-49 (n = 5939) was carried out to determine if social roles, their characteristics and their combinations were related to women's exercise participation. Parenthood and marital status were significantly related to whether women exercise, and among those exercising, all three roles were significantly related to the amount of exercise. Statistical modelling, including all three roles and their interactions, controlling for age and education, showed that with respect to whether women exercise, parenthood affected exercise participation most and that its effect was dependent on age. Of the role characteristic only the number of children and overall satisfaction with daily activities improved the prediction of exercising. With respect to how much women exercise, the effect of parenthood interacted with marital status. Married parents were least likely to exercise very much. Of the role characteristics only overall satisfaction with daily activities improved the prediction of the amount of exercise.

Abstract Background Patients receiving complementary and alternative medicine (CAM) therapies often report shifts in well-being that go beyond resolution of the original presenting symptoms. We undertook a research program to develop and evaluate a patient-centered outcome measure to assess the multidimensional impacts of CAM therapies, utilizing a novel mixed methods approach that relied upon techniques from the fields of anthropology and psychometrics. This tool would have broad applicability, both for CAM practitioners to measure shifts in patients' states following treatments, and conventional clinical trial researchers needing validated outcome measures. The US Food and Drug Administration has highlighted the importance of valid and reliable measurement of patient-reported outcomes in the evaluation of conventional medical products. Here we describe Phase I of our research program, the iterative process of content identification, item development and refinement, and response format selection. Cognitive interviews and psychometric evaluation are reported separately. Methods From a database of patient interviews (n = 177) from six diverse CAM studies, 150 interviews were identified for secondary analysis in which individuals spontaneously discussed unexpected changes associated with CAM. Using ATLAS.ti, we identified common themes and language to inform questionnaire item content and wording. Respondents' language was often richly textured, but item development required a stripping down of language to extract essential meaning and minimize potential comprehension barriers across populations. Through an evocative card sort interview process, we identified those items most widely applicable and covering standard psychometric domains. We developed, pilot-tested, and refined the format, yielding a questionnaire for cognitive interviews and psychometric evaluation. Results The resulting questionnaire contained 18 items, in visual analog scale format, in which each line was anchored by the positive and negative extremes relevant to the experiential domain. Because of frequent informant allusions to response set shifts from before to after CAM therapies, we chose a retrospective pretest format. Items cover physical, emotional, cognitive, social, spiritual, and whole person domains. Conclusions This paper reports the success of a novel approach to the development of outcome instruments, in which items are extracted from patients' words instead of being distilled from pre-existing theory. The resulting instrument, focused on measuring shifts in patients' perceptions of health and well-being along pre-specified axes, is undergoing continued testing, and is available for use by cooperating investigators.

Abstract Background Therapeutic massage and bodywork (TMB) practitioners are predominantly trained in programs that are not uniformly standardized, and in variable combinations of therapies. To date no studies have explored this variability in training and how this affects clinical practice. Methods Combined methods, consisting of a quantitative, population-based survey and qualitative interviews with practitioners trained in multiple therapies, were used to explore the training and practice of TMB practitioners in Alberta, Canada. Results Of the 5242 distributed surveys, 791 were returned (15.1%). Practitioners were predominantly female (91.7%), worked in a range of environments, primarily private (44.4%) and home clinics (35.4%), and were not significantly different from other surveyed massage therapist populations. Seventy-seven distinct TMB therapies were identified. Most practitioners were trained in two or more therapies (94.4%), with a median of 8 and range of 40 therapies. Training programs varied widely in number and type of TMB components, training length, or both. Nineteen interviews were conducted. Participants described highly variable training backgrounds, resulting in practitioners learning unique combinations of therapy techniques. All practitioners reported providing individualized patient treatment based on a responsive feedback process throughout practice that they described as being critical to appropriately address the needs of patients. They also felt that research treatment protocols were different from clinical practice because researchers do not usually sufficiently acknowledge the individualized nature of TMB care provision. Conclusions The training received, the number of therapies trained in, and the practice descriptors of TMB practitioners are all highly variable. In addition, clinical experience and continuing education may further alter or enhance treatment techniques. Practitioners individualize each patient's treatment through a highly adaptive process. Therefore, treatment provision is likely unique to each practitioner. These results may be of interest to researchers considering similar practice issues in other professions. The use of a combined-methods design effectively captured this complexity of TMB practice. TMB research needs to consider research approaches that can capture or adapt to the individualized nature of practice.

Abstract Background Integrative health care (IHC) is an interdisciplinary blending of conventional medicine and complementary and alternative medicine (CAM) with the purpose of enhancing patients' health. In 2006, we designed a study to assess outcomes that are relevant to people using such care. However, we faced major challenges in conducting this study and hypothesized that this might be due to the lack of a research climate in these clinics. To investigate these challenges, we initiated a further study in 2008, to explore the reasons why IHC clinics are not conducting outcomes research and to identify strategies for conducting successful in-house outcomes research programs. The results of the latter study are reported here. Methods A total of 25 qualitative interviews were conducted with key participants from 19 IHC clinics across Canada. Basic content analysis was used to identify key themes from the transcribed interviews. Results Barriers identified by participants fell into four categories: organizational culture, organizational resources, organizational environment and logistical challenges. Cultural challenges relate to the philosophy of IHC, organizational leadership and practitioner attitudes and beliefs. Participants also identified significant issues relating to their organization's lack of resources such as funding, compensation, infrastructure and partnerships/linkages. Environmental challenges such as the nature of a clinic's patient population and logistical issues such as the actual implementation of a research program and the applicability of research data also posed challenges to the conduct of research. Embedded research leadership, integration of personal and professional values about research, alignment of research activities and clinical workflow processes are some of the factors identified by participants that support IHC clinics' ability to conduct outcomes research. Conclusions Assessing and enhancing the broader evaluation culture of IHC clinics prior to implementing outcomes research may be a critical step towards ensuring productive and cost-effective research programs. However, as IHC clinics are often complex systems, a whole systems approach to research should be used taking into account the multidimensional and complex nature of such treatment systems so that the results are useful and reflect real life.

Abstract Background The extent to which a health care intervention causes or facilitates health-related change is a key question in research. The need to quantify such change has led to the development of an increasing number of change indicators, to measure what have come to be known as 'outcomes'. In the context of medical research into the efficacy or effectiveness of an intervention the term 'outcomes' has often been interpreted to mean single endpoints with a linear cause and effect link to an external intervention. Discussion In this paper we present a critical analysis of the nature and interpretation of the 'outcomes' concept and of the assumptions that underpin it. Drawing on our own work and that of others, we analyse the problems that arise when the concept is applied to complex interventions and discuss the use of other models, such as programme theory, as a basis for alternative conceptualisations for indicators of change. Our analysis demonstrates that the interpretation of 'outcomes' that may be appropriate for clinical trials of pharmaceutical products, is problematic when used in evaluations of complex interventions in areas such as complementary medicine, palliative care, rehabilitation, and health promotion. The 'outcomes' concept may impose inappropriate patterns of thought and meaning. We present alternative models, such as those based on programme theory, which conceptualise health-related change as resulting from the interaction between intervention, process and context over time. In this framework both the intervention and the patient are defined as causal factors, because the result of the treatment is dependent on the resources of the patient – such as the body's ability to heal itself – and the impact of the patient's situation. Summary Evaluations based on a model such as programme theory will encompass a wide range of health-related changes that include aspects of process, such as new meanings and understanding, as well as longer term changes in health, wellbeing and health-related competences and behaviours.

Abstract Background Central to the development of a sound evidence base for Complementary and Alternative Medicine (CAM) interventions is the need for valid, reliable and relevant outcome measures to assess whether the interventions work. We assessed the specific needs for a database that would cover a wide range of outcomes measures for CAM research and considered a framework for such a database. Methods The study was a survey of CAM researchers, practitioners and students. An online questionnaire was emailed to the members of the Canadian Interdisciplinary Network for CAM Research (IN-CAM) and the CAM Education and Research Network of Alberta (CAMera). The majority of survey questions were open-ended and asked about outcome measures currently used, outcome measures' assessment criteria, sources of information, perceived barriers to finding outcome measures and outcome domains of importance. Descriptive quantitative analysis and qualitative content analysis were used. Results One hundred and sixty-four completed surveys were received. Of these, 62 respondents reported using outcome measures in their CAM research and identified 92 different specific outcomes. The most important barriers were the fact that, for many health concepts, outcome measures do not yet exist, as well as issues related to accessibility of instruments. Important outcome domains identified included physical, psychological, social, spiritual, quality of life and holistic measures. Participants also mentioned the importance of individualized measures that assess unique patient-centered outcomes for each research participant, and measures to assess the context of healing and the process of healing. Conclusion We have developed a preliminary framework that includes all components of health-related outcomes. The framework provides a foundation for a larger, comprehensive collection of CAM outcomes. It fits very well in a whole systems perspective, which requires an expanded set of outcome measures, such as individualized and holistic measures, with attention to issues of process and context.

Abstract Background There is a general lack of information on the care of inflammatory bowel disease (IBD) in a broad, geographically diverse, non-clinic population. The purposes of this study were (1) to compare a sample drawn from the membership of a national Crohn's and Colitis Foundation to published clinic-based and population-based IBD samples, (2) to describe current patterns of health care use, and (3) to determine if unexpected variations exist in how and by whom IBD is treated. Methods Mailed survey of 4453 members of the Crohn's and Colitis Foundation of Canada. The questionnaire, in members stated language of preference, included items on demographic and disease characteristics, general health behaviors and current and past IBD treatment. Each member received an initial and one reminder mailing. Results Questionnaires were returned by 1787, 913, and 128 people with Crohn's disease, ulcerative colitis and indeterminate colitis, respectively. At least one operation had been performed on 1159 Crohn's disease patients, with risk increasing with duration of disease. Regional variation in surgical rates in ulcerative colitis patients was identified. 6-Mercaptopurine/Azathioprine was used by 24% of patients with Crohn's disease and 12% of patients with ulcerative colitis (95% CI for the difference: 8.9% – 15%). In patients with Crohn's disease, use was not associated with gender, income or region of residence but was associated with age and markers of disease activity. Infliximab was used by 112 respondents (4%), the majority of whom had Crohn's disease. Variations in infliximab use based on region of residence and income were not seen. Sixty-eight percent of respondents indicated that they depended most on a gastroenterologist for their IBD care. There was significant regional variation in this. However, satisfaction with primary physician did not depend on physician type (for example, gastroenterologist versus general practitioner). Conclusion This study achieved the goal of obtaining a large, geographically diverse sample that is more representative of the general IBD population than a clinic sample would have been. We could find no evidence of significant regional variation in medical treatments due to gender, region of residence or income level. Differences were noted between different age groups, which deserves further attention.