http://dspace.flinders.edu.au/dspace/
‘This is the peer reviewed version of the following article:
Leach, M. J., Wiese, M., Thakkar, M., & Agnew, T. (2018).
Integrative health care - Toward a common
understanding: A mixed method study. Complementary Therapies in Clinical Practice, 30, 50–57. https://
doi.org/10.1016/j.ctcp.2017.12.007 which has been published in final form at http://dx.doi.org/10.1016/j.ctcp.2017.12.007
© 2017 Elsevier. This manuscript version is made available under the CC-BY-NC-ND 4.0 license:
http://creativecommons.org/licenses/by-nc-nd/4.0/
Accepted Manuscript
Integrative health care - Toward a common understanding: A mixed method study Matthew J. Leach, Marlene Wiese, Manisha Thakkar, Tamara Agnew
PII: S1744-3881(17)30366-3 DOI: 10.1016/j.ctcp.2017.12.007 Reference: CTCP 794
To appear in: Complementary Therapies in Clinical Practice Received Date: 14 August 2017
Revised Date: 22 October 2017 Accepted Date: 5 December 2017
Please cite this article as: Leach MJ, Wiese M, Thakkar M, Agnew T, Integrative health care - Toward a common understanding: A mixed method study, Complementary Therapies in Clinical Practice (2018), doi: 10.1016/j.ctcp.2017.12.007.
This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
M AN US CR IP T
AC CE PT ED
Integrative Health Care - Toward a Common Understanding: A
Mixed Method Study
Authors
Matthew J Leacha, Marlene Wieseb, Manisha Thakkarc, Tamara Agnewd
Affiliations
a Senior Research Fellow, Department of Rural Health, University of South Australia, Adelaide, South Australia. Email: [email protected]
b Adjunct Research Fellow, Southgate Institute for Health, Society & Equity, Flinders University of SA, Bedford Park, South Australia. Email: [email protected]
c Lecturer, Department of Bioscience, Endeavour College of Natural Health, Adelaide, South Australia. Email: [email protected]
d Research Assistant, Health Economics & Social Policy Group, University of South Australia, Adelaide, South Australia. Email: [email protected]
Corresponding author Dr Matthew J Leach Senior Research Fellow Department of Rural Health University of South Australia Adelaide, South Australia, 5000 Tel: +61 8 8302 2413
Fax: +61 8 8302 8156
Email: [email protected]
Running title
Defining integrative health care
Conflict of interest
The authors have no conflict of interest to declare.
Funding
This work was supported by an Endeavour Project Grant. The sponsor played no role in the design of the study, implementation of the study, data analysis, or the writing of the manuscript.
Acknowledgements
The authors would like to thank the consumers, clinicians and academics that participated in phase 1 of this study for sharing their views on integrative health care.
M AN US CR IP T
AC CE PT ED
Integrative Health Care - Toward a Common Understanding: A
Mixed Method Study
M AN US CR IP T
AC CE PT ED
Integrative Health Care - Toward a Common Understanding: A Mixed Method Study
ABSTRACT
Objective: To generate a multidisciplinary stakeholder-informed definition of integrative health care
(IHC).
Methods: A mixed-method study design was used, employing the use of focus groups/semi-
structured interviews (phase-1) and document analysis (phases 2 and 3). Phase-1 recruited a purposive sample of Australian health consumers/health providers. Phase-2 interrogated websites of international IHC organisations for definitions of IHC. Phase-3 systematically searched bibliographic databases for articles defining IHC. Data were analysed using thematic analysis.
Results: Data were drawn from 54 health consumers/providers (phase-1), 23 IHC organisation
webpages (phase-2) and 23 eligible articles (phase-3). Seven themes emerged from the data.
Consensus was reached on a single, 65-word definition of IHC.
Conclusion: An unambiguous definition of IHC is critical to establishing a clearer identity for IHC, as
well as providing greater clarity for consumers, health providers and policy makers. In recognising the need for a clearer description, we propose a scientifically-grounded, multi-disciplinary stakeholder-informed definition of IHC.
Key words: Definition; Integrated health care; Integrative medicine; Integrative health care; mixed-
method
M AN US CR IP T
AC CE PT ED
Integrative Health Care - Toward a Common Understanding: A Mixed Method Study
1.0 INTRODUCTION
The delivery of health care in developed countries has undergone significant transformation in recent decades1-3; these changes have been largely in response to an upsurge in the prevalence of chronic health conditions and an ageing population.1,4 Advancements in medical science, health technology, and health promotion have all contributed to the prolongment of life5; however, the extension of life comes at a cost - adding considerable financial burden to the healthcare system.6
Accompanying this changing landscape have been shifting views in the way health care is and should be, delivered. The health consumer today is now much more health savvy, with much higher expectations of the service they receive.1 Improved access to health information, and greater awareness of patient rights, have also contributed to a more informed and empowered health consumer.7,8
The dominant biomedical model has provided the framework for healthcare delivery for many decades.9 This reductionist model of “illness” equates ill health to an underlying abnormality9 and cure to the elimination of the abnormality.10 However, with chronic disease, cure is often not an option, rather the emphasis is on secondary/tertiary prevention; this focus on prevention does not align well with the treatment-/cure-focussed approach of the biomedical model.11
The biomedical model also places emphasis on the expertise of the medical professional12, where its main strengths are observed in life-saving situations in which decisions are often made in lieu of patient consent.13 However, this model disregards the sovereignty of the patient as there is a tendency to favour physician preference over a patient's unique needs.13 Similarly, the biomedical model places little emphasis on the biopsychosocial nature of health10, despite holism being an
M AN US CR IP T
AC CE PT ED
integral element of the World Health Organization's definition of health (i.e. “a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity”).14 This suggests (in the author’s view) that the biomedical model of care has not kept pace with the changing landscape of healthcare (in spite of the abovementioned consumer, social, financial and political drivers of change), and that a change in the approach to healthcare is warranted.
Integrative Heath Care (IHC) represents a model of care that has perhaps (among other possible reasons) responded to the needs of consumers (i.e. By adopting a holistic, patient-centred focus)15, government (i.e. By reducing health service demand, and focussing on prevention)16,17, and other health care providers (i.e. By fostering collaboration). However, what IHC actually signifies is uncertain as there is no consistent definition of integrative health care; to date, IHC has been described as a component of patient-centred care18; a combination of conventional medicine and complementary medicine19; the intermingling of two models of care in hospitals or primary care settings, and the employment of CAM providers in conventional healthcare settings.20 Others have defined IHC as an approach that includes aspects of CAM.21 Boon et al22 describe a continuum of care ranging from parallel practice to full integration; the further along the continuum the practice is placed, the more likely the client will experience diverse healthcare models, complex interventions, and encounter multiple clinicians who will address multiple aspects of the presenting condition. IHC is also used interchangeably with terms such as integrative medicine, which refers more to the individual approach of a provider than a service delivery approach.23
Developing a clearer definition of IHC is critical to fostering a common understanding of the term, both for those within and outside the discipline. Not only may this facilitate the generation of a shared identity and a shared agenda for those in the field, but it may also help to reduce ambiguity around the term, dissolve current (potentially misinformed) assumptions about IHC, and in turn, improve communication between IHC providers and relevant stakeholders (e.g. Consumers,
M AN US CR IP T
AC CE PT ED
government, educators, other health care providers). In recognising the necessity and value in creating a common understanding of IHC, this research set out to draw meaning from various sources of evidence in order to develop a shared, stakeholder-informed definition of integrative health care.
2.0 METHODS 2.1 Study design
The research uses a concurrent triangulation mixed-method design, employing the use of focus groups / semi-structured interviews (phase 1) and document analysis (phases 2 and 3). The study represents the first stage of The Integrative health care Model development and Evaluation (TIME) project, a seven-stage, mixed-method research program designed to develop and evaluate a stakeholder-informed integrative health care service delivery model.
2.2 Aims and objectives
The aim of the study was to explore the meaning that health consumers, health providers and key stakeholders attribute to the term integrative health care (i.e. at the health system level, and not at the individual consumer or clinician level); specifically, to identify the themes that are embedded within the term integrative health care, and to generate a scientifically-grounded, multidisciplinary stakeholder informed, international definition of integrative health care.
2.3 Sample
2.3.1 Phase 1: In order to capture a wide range of perspectives on integrative health care, a maximum variation sampling technique was used. Seventeen stakeholder/occupational groups were identified as playing an essential role in the delivery of IHC, including health consumers and those from the disciplines of acupuncture/traditional Chinese medicine, chiropractic/osteopathy, dentistry, dietetics, exercise physiology, general practice, naturopathy/western herbalism, homeopathy, massage therapy, occupational therapy, pharmacy, physiotherapy, podiatry, practice nursing, psychology, and social work. Participants from each group were informed about the study
M AN US CR IP T
AC CE PT ED
through their representative associations/organisations via newsletters, email blasts and website notices. The alumni of a large South Australian University and national college of complementary medicine (offering diverse undergraduate qualifications in nursing/allied health, and complementary medicine, respectively) were also notified of the study by email. This approach was supplemented with a snowballing sampling technique, in which participants expressing an interest in the study were invited to speak with, and distribute study information to, their professional contacts.
Purposive sampling was also employed to improve participant numbers, in which persons identified as having expert knowledge in their respective area (identified via the academic directories of South Australian tertiary education providers, and online clinical expert directories) were invited by email to participate. All participants were aged over 18 years and were actively involved (either clinically, academically, or in the case of consumers, personally) in their field of expertise. To ensure adequate representation from each of the 17 stakeholder/occupational groups, the study aimed to recruit between three and six participants per group.
2.3.2 Phase 2: The Google search engine was used to search for any national or international integrative health care organisations (including professional associations and clinical centres). The search terms included: [integrated or integrative] and [medicine or nursing or health] and [society or association or organization or college]. To contain the search, only the first 300 websites were assessed for eligibility. Whilst sites/documents had to be published in the English language by an IHC association, no limits were placed on the geographical location of the association. Sites/definitions referring to integration as a uni-disciplinary model of care were excluded. Each site was then interrogated to isolate a definition of integrative health care. Eligible source documents included association webpages, position statements and policy documents.
2.3.3 Phase 3: Definitions of IHC published in the peer-reviewed literature were identified by searching the following bibliographic databases (from their inception to May 2016): AMED, CINAHL,
M AN US CR IP T
AC CE PT ED
MEDLINE and PubMed. Search terms included: [Integrated health care OR integrative health care]
AND [define or definition]. Refereed articles of any type, published in the English language, and providing an explicit definition of IHC, were eligible. Articles referring to integration as a uni- disciplinary model of care, or the merging of administrative systems, were excluded.
2.4 Measures
2.4.1 Phase 1: Focus groups were conducted with the various stakeholder/occupational groups;
where focus groups were not feasible (i.e. due to geographical distance, inability to find a mutually suitable time or small group numbers), phone interviews were conducted with individual participants instead. Interview guides were used to elicit a richer, deeper and more meaningful understanding of the term integrative health care.24 Whilst the interview guide comprised 11 questions about various aspects of IHC, the focus of this paper (i.e. the definition of IHC) was limited to a single question: What does the term integrative health care mean to you? Responses to this question were explored in depth, with each component unpacked and examined in detail. Data saturation was reached when incremental findings from the focus groups / interviews reinforced prior accumulated information without providing any significant new explanations.25
2.4.2 Phases 2 and 3: Definitions of IHC were extracted from relevant documents / literature using a standardised template. The template comprised five components: name of association, year of publication, document type, origin of definition (e.g. original definition, referenced definition), and full definition of IHC.
2.5 Procedures
2.5.1 Phase 1: Subjects agreeing to participate in the study were asked to indicate their intention by return email. The researcher then contacted the potential participant to answer any questions and to assess their eligibility / availability to participate in a 90-120 minute focus group. If focus group participation was not feasible, participants were offered the opportunity to participate in a 40-60
M AN US CR IP T
AC CE PT ED
minute semi-structured telephone interview. Following verbal consent, participants were asked to sign and return a written consent form prior to the scheduled focus group / interview. All focus groups and interviews were facilitated by a researcher experienced in qualitative methods.
2.5.2 Phases 2 and 3: The search of the integrative health care literature / association websites and documents, and the extraction of data, were performed by two researchers, independently (ML, MT). Any disagreements were resolved by discussion.
2.6 Data analysis
2.6.1 Phase 1: Interviews / focus groups were audio-recorded and transcribed verbatim into written text. After transcribing, researchers listened to the recorded interviews whilst reading the transcript to ensure accuracy and to gain greater understanding of the participants’ experiences. The transcribed text was then entered into NVivo (v.10) for thematic analysis. Reoccurring terms in the verbatim text were first coded; general and specific themes relevant to the research objectives were then generated by MW, and validated by ML. The themes were then questioned and considered in detail by the research team to ensure they illustrated the views of the participants.
2.6.2 Phases 2 and 3: Using thematic analysis, reoccurring terms within each definition of IHC were coded. General and specific themes relevant to the research objectives were then produced by ML and validated by MW. The research team subsequently interrogated each of the themes to ensure they accurately represented the intention/context of the published definition. The themes that emerged from all three phases were then triangulated to identify themes common to all three phases; these themes were then merged to generate multiple definitions of IHC. The research team reviewed and refined the definitions until a single definition was agreed upon by consensus.
2.7 Ethics
M AN US CR IP T
AC CE PT ED
Ethical clearance was granted by the University of South Australia Human Research Ethics Committee.
3.0 RESULTS
3.1 PHASE 1: Interviews / focus groups 3.1.1 Description of participants
Fifty-four individuals responded to the Phase 1 recruitment campaign, of which 38 (70.4%) participated in a focus group and 16 (29.6%) in a telephone interview. Participants represented 15 distinct health groups (Table 1), with an almost even spread between orthodox (28/54 [51.9%]) and complementary (25/54 [46.3%]) health providers. Most participants were female (39/54 [72.2%]), and resided in South Australia (n=47 [87%]), followed by Queensland (n=4 [7.4%]), Western Australia (n=2 [3.7%]) and Tasmania (n=1 [1.9%]).
Table 1. Disciplinary composition of phase 1 sample (n=54)
Discipline represented N (%) Participant codes
Health consumers 7 (13.0) HC1 – HC7
Chiropractors / osteopaths 7 (13.0) CO1 – CO7
Psychology 7 (13.0) PS1 – PS7
Naturopathy / Western herbalism 7 (13.0) NW1 – NW7
Massage therapy 4 (7.4) MT1 – MT4
Acupuncture / Traditional Chinese medicine 4 (7.4) AT1 – AT4
Physiotherapy 4 (7.4) PT1 – PT4
Homeopaths 3 (5.6) HO1 – HO3
General practice 2 (3.7) GP1 – GP2
Podiatry 2 (3.7) PO1 – PO2
Social work 2 (3.7) SW1 – SW2
Exercise physiology 2 (3.7) EP1 – EP2
Practice nursing 1 (1.9) PN1
Occupational therapy 1 (1.9) OT1
Pharmacy 1 (1.9) PH1
Dietetics / Nutrition 0 (0.0) -
Dentistry 0 (0.0) -
Analysis of the interview / focus group data uncovered six central themes referring to the participant’s meaning of the term ‘Integrative Health Care’: (1) integration, (2) holism, (3) respect, (4) access, (5) client-centeredness, and (6) evidence-based practice.
M AN US CR IP T
AC CE PT ED
3.1.2 Integration
A fundamental feature of IHC was the principle of integration. For participants, this term referred to both the physical and functional aspects of integration. The physical element signified that “all kinds of healthcare services [be] provided under one roof” (PS2), providers “all work together in one place” (CO6), or “being in an environment where you are exposed to other professionals” (PS6). In terms of functionality, most participants highlighted the importance of being “collaborative”,
“interdisciplinary”, “interdependent”, “inclusive”, “collegial” and “team-focussed”, pointing out that integration is “where there is a clear cooperation between practitioners and other stakeholders in service delivery and there's a model of articulation with that” (EP1). Integration was also viewed as being an extension of multidisciplinarity of which there is “collaboration between practitioners both of allopathic medicine and of complementary medicine” (PN1).
3.1.3 Holism
Adopting “a holistic perspective” (HO3) was considered an important element of IHC. Participants viewed holism in different ways, however. Some referred to holism as “treating the whole person”
(PS3) in terms of the “physical, mental, emotional and spiritual” (NW1- 7) aspects of the client, or the individual’s “mind, body and soul” (HC6). Others considered holism from a health service delivery perspective, indicating that a holistic model of health care should cover “the four pillars of healthcare” (NW5) - that is, medicine, complementary medicine, bodywork, and emotional/spiritual work.
3.1.4 Respect
Participants pointed out that an IHC model of care should foster respect among stakeholders. This included the need to respect “patient choice” (NW1) as well as the consumer’s right to “go to lots of different people” (HC2). It also signified respect at the inter-professional level, including “being open to what other healthcare providers could offer” (HC3), the need for “all practitioners to be respected
M AN US CR IP T
AC CE PT ED
for their contribution to the team” (MT4) and for “respectful communication between practitioners”
(PN1, PO2). Beyond the individual practitioner, participants also valued the need for providers to
“respect other approaches” (NW4).
3.1.5 Access
Bi-directional client-practitioner access was another vital feature of IHC. This related to clients having “access to whatever form of health care the patient needs” (HO2), “wants” (PT1, SW1) or would “like to have done” (AT1). It also meant “everybody can access what is happening to the same client” (PS5), whether this be by ‘sharing’ clients or ‘sharing’ client information.
3.1.6 Client-centeredness
Another core feature of IHC was that it was considered to be “patient-centric” (GP1). Most study participants articulated IHC as a “client-centred” approach. Participants noted that this approach acknowledged that “every patient is an individual” (HC2) and providers “need to tailor it [their care]
to the patient” (PO2). Participants also recognised that a client-centred approach empowered individuals as “they [the client] are driving it [the care] to some degree” (GP1); it also “respected patient choice” (NW6). Embedded within the theme of client-centeredness was the need for client- focussed outcomes, including “what they [patients] want for their health outcome” (AT3) in order to
“give the patient the best outcome to live their life in the best possible way” (CO6).
3.1.7 Evidence-based practice
Participants indicated that practices included within an IHC model of care should be evidence-based.
Importantly, the issue was not about conventional versus complementary medicine disciplines, rather “more about therapies that have the evidence base” (MT3).
3.2 PHASE 2: Document analysis - IHC organisation websites / documents 3.2.1 Description of documents
M AN US CR IP T
AC CE PT ED
The Google search generated 493,000,000 hits, of which the first 30 pages (300 hits) were reviewed.
The search identified 23 eligible definitions from 23 webpages. The remaining 277 webpages were excluded as they were not an IHC organisation website (n=183), were a duplicated site (n=8), did not provide a definition of IHC (n=75) or referred to integration as a uni-disciplinary model of care (n=11).
Analysis of the definitions extracted from the IHC organisation websites uncovered eight central themes related to the term integrative health care: (1) holism, (2) promotion/optimisation of health, healing, wellness and prevention, (3) combining complementary and conventional medicine, (4) interdisciplinarity / collaboration, (5) evidence-based practice, (6) respectful practitioner-client relationships, (7) client-centeredness, and (8) individualisation / personalisation.
3.2.2 Holism
Fourteen organisations referred to the concept of holism in their definition of IHC26-39, stating that integrative health care “focuses on treating the whole person (mind/body/spirit)”28,38, “meet[s] each patient’s unique physical, emotional and spiritual health goals”34, and “addresses the full range of physical, emotional, mental, social, spiritual and environmental influences that affect a person's health”.32,35
3.2.3 Promotion/optimisation of health, healing, wellness and prevention Fourteen organisations26,27,29,30,33-39,40-42
characterised IHC as an approach that focussed “not just [on]
freedom from disease”33, but on “help[ing] people regain and maintain optimal health”35; this included “promoting and restoring health and creating wellness”41, emphasising “health creation and healing”40 and “prevention of illness”.30
3.2.4 Combining complementary and conventional medicine
M AN US CR IP T
AC CE PT ED
More than half (13/25) of the organisations described integrative health care as a combination of approaches and treatments that draw from both conventional medicine and complementary and alternative medicine.27-30,34,36,39,42-47
One organisation indicated that IHC was more than just a collection of therapies, but rather a model of care “bringing conventional and complementary approaches together in a coordinated way”.46
3.2.5 Interdisciplinarity / collaboration
The theme of interdisciplinarity / collaboration emerged from eleven of the twenty-three definitions.26,27,29,31-33,35,36,39,41,48
This theme referred to “a collaborative approach to patient care among practitioners”36 that “makes use of all appropriate therapeutic approaches, health care professionals and disciplines”27,29, “without subservience to any one school of medical thought”.48
3.2.6 Evidence-based practice
Evidence-based practice emerged as a theme in nine of the 23 definitions. Some definitions lacked specificity, referring to IHC as an approach “informed by evidence”.26,27,29,31,39,40,42,47
Others discriminated between systems, indicating that IHC “combines conventional medicine with evidence-based complementary medicine”.47 One definition was specific and inclusive, identifying IHC as “the practice of conventional, complementary, and alternative health care that is evidence- based”.36
3.2.7 Respectful practitioner-client relationships
For nine organisations, IHC was seen as a model of care that “reaffirms the importance of the relationship between practitioner and patient”26,27,29,36,37,47
and “emphasizes the therapeutic relationship”.39 Implicit within these definitions was a shift in the balance of power, with an emphasis on the “doctor as [a] partner”33, and the need for “mutual respect”.40
3.2.8 Client-centeredness
M AN US CR IP T
AC CE PT ED
Seven organisations identified IHC as being “patient-centered”28,31,33,40
, or putting “the patient at the center” of care32,35, with one organisation viewing “the patient as the most important member of the medical team”.48
3.2.9 Individualisation / personalisation
Individualised / personalised care was seen to be a core element of IHC for four organisations. These organisations viewed IHC as an approach “employing a personalized strategy”32,35, focussing “on individual patient care”29 and providing “patients with individually tailored health and wellbeing programmes”.42
3.3. PHASE 3: Document analysis - published literature 3.3.1 Description of documents
The literature search generated 210 hits, of which 23 eligible articles (containing 28 definitions of IHC) were included. The remaining 187 articles were excluded as they did not meet the inclusion criteria (n=164), did not provide a definition of IHC (n=15), or were a duplicate publication (n=8).
Analysis of the documentary evidence uncovered seven central themes: (1) combining complementary and conventional medicine, (2) promotion/optimisation of health, healing, wellness and prevention, (3) holism, (4) respectful practitioner-client relationships, (5) interdisciplinarity / collaboration, (6) client-centeredness, and (7) coordination.
3.3.2 Combining complementary and conventional medicine
The theme that emerged most frequently (i.e. in 19 of the 28 definitions of IHC) was the combining of complementary and conventional medicine.23,49-66 Two variations of this theme were evident: one focussing on the tools of the trade (e.g. “integrating the safest and most effective of conventional and CAM therapies”62; and “mak[ing] use of all appropriate therapies, both conventional and alternative”)53; and the other on the providers of services (e.g. the “non-hierarchical blending of
M AN US CR IP T
AC CE PT ED
both CAM and conventional medicine”52; and “integrating various professional health care providers and alternative therapists practicing within different treatment models”)57.
3.3.3 Promotion/optimisation of health, healing, wellness and prevention
Common to thirteen definitions was the promotion/optimisation of health, healing, wellness and prevention.23,50-53,58-60,62,63,67-69
These definitions referred to IHC as a model of care that “focuses on prevention and wellness”53 and the “achievement of optimal health”67, as well as being “healing- oriented”.53
3.3.4 Holism
Nine definitions referred to the principle of holism.20,23,50-53,56,58,62
IHC was seen to “treat the whole person”52 by “address[ing] the biological, psychological, social, and spiritual aspects of health and illness”56 in both “diagnosis and treatment”.23
3.3.5 Respectful practitioner-client relationships
A respectful practitioner-client relationship was a concept common to seven definitions.50-53,58,67,69
IHC was perceived as encompassing a “relationship-centered approach”58 that valued “mutual respect”52, “a shared vision of health care”52 and an “emphasi[s] [on] the therapeutic relationship”.53
3.3.6 Interdisciplinarity / collaboration
Seven definitions of IHC referred to interdisciplinarity or collaboration20,52,60,64,69-71
, stating that IHC
“employs a collaborative team approach guided by consensus building”52, with a focus on “shared patient care, shared practice guidelines, and shared common values and goals”.20
3.3.7 Client-centeredness
The theme of client-centeredness emerged from six of the 28 definitions of integrative health care.52,53,58,64,67,72
These definitions referred to IHC as “a health care system that focuses on…patient- centered care”67, which “places the patient at the center of care”.53
M AN US CR IP T
AC CE PT ED
3.3.8 Coordinated
An important element of IHC, as identified by four definitions64,69,71,72
, was the “coordination of clinical services”71 or the “coordination of physical and behavioral health care”64 by “health professionals who organize care”.72
4.0 DISCUSSION
This mixed-method study set out to explore, for the first time, the meaning that health consumers, health providers and key stakeholders attribute to the term integrative health care. The analysis of data from three distinct data sources (i.e. stakeholder focus groups/interviews, IHC organisation websites, and the published literature) revealed a number of themes common to all three sources:
holism, client-centeredness, respect, combining complementary and conventional medicine, and integration / interdisciplinarity / collaboration. Themes common to at least two of the three sources were evidence-based practice, and promotion / optimisation of health, healing, wellness and prevention. Other themes that emerged, which were not consistent across all three data sources, were access (from the stakeholder focus groups), individualisation / personalisation (from the IHC organisation websites), and coordination (from the published literature). The ten themes that were generated clustered around three core foci: the client, the team and the clinical approach (i.e. the triad of integrative health care).
The definitions of integrative health care focussed largely on the client, with five of the ten themes relating directly to this construct. These themes included ‘respect’ for client choice, enabling client
‘access’ to appropriate services, acknowledging the client as being at the centre of care (‘client- centredness’), recognition of the client as a whole person (‘holism’), and providing care tailored to the needs of the client (‘personalisation’). Interestingly, each of these themes align very closely with Morgan and Yoder’s model of patient centred care73, which identifies holistic care, individualised
M AN US CR IP T
AC CE PT ED
care, respectful care and empowering care as four key attributes of patient-centred care. This suggests that there is perhaps a level of overlap across the five ‘client-related’ themes.
There are several possible explanations as to why so much importance might be placed on the client in IHC. Fundamentally, the provision of client-centred care can be “justified on moral grounds alone”, and philosophically, can be “perceived as the right thing to do”.74 The simultaneous rise of neoliberalism and its focus on consumer freedom of choice possibly exerted some influence also.75 Another driver is the emerging evidence base for client-centred care, with numerous studies demonstrating positive associations between client-centred interventions (which encompass holistic, individualised and/or respectful care) and positive client and provider experiences, perceived health status and quality of care, efficiency of care, and more active client participation in care.76-78 Notwithstanding, the strength and quality of this body of evidence is not high.
Another major area that definitions of IHC gave considerable attention to was the health care team.
Four themes related to the health care team, including the provision of both complementary and conventional medicine services, a ‘respect’ for other disciplines and approaches, ‘collaboration’
across all disciplines, and the delivery of appropriately ‘coordinated’ health care services. The focus on a coordinated, collaborative and multiple disciplinary team is not surprising given that much of the attention afforded to team models of care to date has related to disciplinary composition and team dynamics.79 This shift toward multiple disciplinary team care (whether that be interdisciplinary or transdisciplinary) has largely been driven by a need to resolve complex, multifactorial, real world problems in a comprehensive and holistic way, by drawing from the diverse skills, expertise and experience of a coordinated team of multidisciplinary clinicians.79 Indeed, there is emerging evidence that shows interdisciplinary assessment and management to be more effective than usual care in improving patient morbidity, mortality, medication / medical intervention utilisation, hospital length of stay, processes of care and patient satisfaction80-83, while also being more cost-effective.84
M AN US CR IP T
AC CE PT ED
An effective interdisciplinary health care team is therefore essential to ensuring that the needs of the client and other key stakeholders can be adequately met, and that there is the capacity to deliver care in the most appropriate manner.
The clinical approach represents the third main construct in the definitions of integrative health care. Within this construct were four themes, including the provision of care that is ‘evidence- based’, ‘holistic’, ‘personalised’ and emphasises ‘health creation, healing, wellness and illness prevention’. These themes align well with current trends in the health care industry, such as the push for the adoption of evidence-based practice by all health disciplines85,86, the move toward personalised medicine/healthcare87,88, and the increasing emphasis on disease prevention89 and wellness.90 These themes also complement the other two constructs, which suggests that the clinical approach, the client and the health care team are interconnected and interdependent constructs of IHC.
If existing definitions of integrative health are in fact an accurate representation of current IHC practice, then this suggests that IHC may have kept pace with the changing health care landscape. In doing so, the field of IHC may have crafted a model of care that adequately represents the collective interests of the client, community, health providers, health care institutions and government. Of course, further work is needed to operationalise, and perhaps standardise, the integrative health care service delivery model.
This is the first known study to explore the meaning of IHC from diverse stakeholder perspectives.
The rigour of the study is strengthened through the use of a systematic approach and the triangulation of data from multiple primary and secondary data sources. Despite these strengths, there are some limitations that may impact the interpretation of these study findings. The small numbers of participants within each stakeholder group in phase 1 of the study (which is consistent
M AN US CR IP T
AC CE PT ED
with a qualitative approach) may mean that the findings of phase 1 are not generalizable to the broader membership of these stakeholder groups. Notwithstanding, the use of a qualitative approach may be seen as a strength of the study in that it enabled the collection of richer and more meaningful information relative to that collected through quantitative methods. Similarly, as phase 1 was limited to stakeholders residing in Australia, it is possible that the findings of the study may not be representative of these stakeholder groups in other countries. Although, drawing from international data in phases two and three of the study somewhat diminishes this limitation.
A revised definition of IHC
Drawing upon the findings of this study, as well as the importance of each of the themes (as previously discussed), we propose the following definition of integrative health care:
Integrative health care is a collaborative, coordinated, transdisciplinary, person-centred model of care informed by a holistic model of health and the best available evidence. Care is facilitated by an interdependent, multi-disciplinary team of like-minded, biomedical, allied and complementary health professionals that work together in a collegial, non-hierarchical, communicative and respectful environment in order to prevent illness and optimize health, healing and wellness in individual clients.
A more concise, less technical definition of IHC is also proposed, as follows:
Integrative health care is a client-centred model of care provided by a team of biomedical, allied and complementary health professionals, which work collaboratively and respectfully to deliver accessible, holistic, evidence-based, personalised, coordinated care that emphasises disease prevention and health, healing and wellness promotion.
5.0 CONCLUSIONS
The development of an unambiguous definition of integrative health care is critical to establishing a clearer identity for IHC and IHC practitioners, as well as serving to provide greater clarity for
M AN US CR IP T
AC CE PT ED
consumers, other health providers and policy makers. In recognising the need for a clearer description of IHC, this research has generated a scientifically-grounded, multi-disciplinary stakeholder-informed definition of IHC that draws from multiple data sources. The research identified seven distinct themes, which could be refined into three interrelated and interdependent constructs, which we refer to as the triad of integrative health care – the client, the team and the approach to care. Further work is underway to translate this definition into a standardised integrative health care service delivery model.
6.0 ACKNOWLEDGEMENTS
The authors would like to thank the consumers, clinicians and academics who participated in phase 1 of this study for sharing their views on integrative health care.
7.0 AUTHORSHIP
ML drafted the methods, co-wrote all other sections, and analysed the data for phases 2 and 3. TA co-wrote the introduction. MW co-wrote the results and conducted the phase 1 analysis. MT co- wrote the discussion, performed the literature search and extracted the data for phases 2 and 3. All authors reviewed and edited the final manuscript.
8.0 CONFLICT OF INTEREST
The authors have no conflict of interest to declare.
9.0 FUNDING
This work was supported by an Endeavour Project Grant. The sponsor played no role in the design of the study, implementation of the study, data analysis, or the writing of the manuscript.
M AN US CR IP T
AC CE PT ED
10.0 REFERENCES
1. Australian Institute of Health and Welfare (AIHW). Ageing and the health system: challenges, opportunities and adaptations. In: Australia's health 2014. Canberra: AIHW; 2014.
2. Bauer AM, Thielke SM, Katon W, Unützer J, Areán P. Aligning health information technologies with effective service delivery models to improve chronic disease care. Prev Med. 2014;66:167-72.
3. Flores M, Glusman G, Brogaard K, Price ND, Hood L. P4 medicine: how systems medicine will transform the healthcare sector and society. Per Med. 2013;10(6):565-576.
4. Australian Institute of Health and Welfare (AIHW). Chronic Disease - Australia's Biggest health challenge in Australia’s health series. Canberra: AIHW; 2014.
5. Quianzon CC, Cheikh I. History of insulin. J Comm Hosp Intern Med Perspect. 2012;2(2):np.
6. Australian Institute of Health and Welfare (AIHW). Burden of disease. In: Australia's health 2014. Canberra: AIHW; 2014.
7. Hibbard JH, Greene J. What the evidence shows about patient activation: better health outcomes and care experiences; fewer data on costs. Health Affair. 2013;32(2):207-214.
8. Kovacs E, Szocska G. Informed patient choice in treatment abroad - a response to recent commentaries. Int J Health Policy Manag. 2015;4(7):491-492.
9. Wade DT, Halligan PW. Do biomedical models of illness make for good healthcare systems?
Brit Med J. 2004;329(7479):1398-1401.
10. Engel GL. The need for a new medical model: a challenge for biomedicine. Sci. 1977;196:129- 136.
11. Campbell C, McGauley G. Doctor-patient relationships in chronic illness: insights from forensic psychiatry. Brit Med J. 2005;330(7492):667-670.
12. Emanuel EJ, Emanuel LL. Four models of the physician-patient relationship. J Am Med Assoc.
1992;267(16):2221-2226.
13. McKinstry B. Paternalism and the doctor-patient relationship in general practice. Brit J Gen Prac. 1992;42:340-342.
14. World Health Organisation. WHO definition of Health. International Health Conference. New York, New York; 1948.
15. Maizes V, Rakel D, Niemiec C. Integrative Medicine and Patient-Centred Care. IOM Summit on Integrative Medicine and the Health of the Public. Washington, District of Columbia;
2009.
16. Oliver-Baxter J, Brown L, O’Connor J, Lunnay B, Bywood P. Integrated care: What can be done at the micro level to influence integration in primary health care? PHCRIS Policy Issue Review. Adelaide: Primary Health Care Research & Information Service; 2013.
M AN US CR IP T
AC CE PT ED
17. Weisfeld V. Summit on Integrative Medicine & The Health of the Public: Issue background and overview. IOM Summit on Integrative Medicine and the Health of the Public.
Washington, District of Columbia; 2009.
18. Hsiao A, Ryan G, Hays R, Coulter I, Anderson R, Wenger N. Variations in provider conceptions in integrative medicine. Soc Sci Med. 2006;62(12):2973-2987.
19. Pelletier KR, Herman PM, Metz RD, Nelson CF. Health and medical economics: applications to integrative medicine. IOM summit on integrative medicine. Washington, District of Columbia; 2009.
20. Coulter I, Khorsan R, Crawford C, Hsiao A. Integrative health care under review: An emerging field. J Manipulative Physiol Ther. 2010;33(9):690-710.
21. Coulter ID. Integration and paradigm clash. In: Tovey P, Easthope G, Adams J (eds). The mainstreaming of complementary and alternative medicine: studies in social context.
London: Routledge Taylor & Francis Group; 2004.
22. Boon H, Verhoef M, O’Hara D, Findlay B. From parallel practice to integrative health care: a conceptual framework. BMC Health Serv Res. 2004;4:15.
23. Rees L, Weil A. Integrated medicine. Brit Med J. 2001;322(7279):119-120.
24. Merriam SB. Qualitative research: a guide to design and implementation. San Francisco, California: Jossey-Bass; 2009.
25. Seidman I. Interviewing as qualitative research: A guide for researchers in education & the social sciences. New York, New York: Teachers College Press; 2013.
26. Academic Consortium for Integrative Medicine & Health. About us.
https://www.imconsortium.org/about/about-us.cfm Accessed May 16, 2016.
27. Academy of Integrative Health & Medicine. What is Integrative Medicine?
https://www.aihm.org/about/what-is-integrative-medicine/ Accessed May 16, 2016.
28. Acupuncture & Integrative Medicine College, Berkeley. Mission and vision.
http://aimc.edu/about-aimc-berkeley/mission-vision/ Accessed May 16, 2016.
29. Australasian Integrative Medicine Association. What is integrative medicine?
https://www.aima.net.au/what-is-integrative-medicine/ Accessed May 16, 2016.
30. British College of Integrative Medicine. What is integrative medicine?
http://www.integrativemedicine.uk.com/what_is_im.php Accessed May 16, 2016.
31. Canadian Integrative Medicine Association. Canadian Integrative Medicine Association.
http://www.cimadoctors.ca/about/ Accessed May 16, 2016.
M AN US CR IP T
AC CE PT ED
32. Duke Integrative Medicine. What is integrative medicine?
https://www.dukeintegrativemedicine.org/about/what-is-integrative-medicine/ Accessed May 16, 2016.
33. National Integrated Health Associates. What is integrative medicine?
http://www.nihadc.com/ Accessed May 16, 2016.
34. Ohio State University - Center for Integrative Health and Wellness. Integrative medicine.
https://wexnermedical.osu.edu/integrative-complementary-medicine Accessed May 16, 2016.
35. The Bravewell Collaborative. What is integrative medicine?
http://www.bravewell.org/integrative_medicine/what_is_IM/ Accessed May 16, 2016.
36. University of California – Osher Centre for Integrative Medicine. What is integrative medicine and health? http://www.osher.ucsf.edu/about-us/what-is-integrative-medicine/
Accessed May 16, 2016.
37. University of Cincinnati - Center for Integrative Health & Wellness. What is integrative health? https://med.uc.edu/integrative/about/integrativehealthdefinition Accessed May 16, 2016.
38. University of Florida Health. About us. https://ufhealth.org/integrative-medicine/about-us Accessed May 16, 2016.
39. University of Vermont. What is integrative health? https://www.uvm.edu/medicine/pih/
Accessed May 16, 2016.
40. Academic collaborative for integrative health. ACIH vision, mission and values.
http://www.accahc.org/vision-mission-vals Accessed May 16, 2016.
41. American Public Health Association. Integrative, Complementary and Traditional Health Practices. https://www.apha.org/apha-communities/member-sections/integrative- complementary-and-traditional-health-practices Accessed May 16, 2016.
42. British Society of Integrated Medicine. Our definition of integrated medicine.
http://www.bsim.org.uk/ Accessed May 16, 2016.
43. Association of Integrative Medicine Malaysia. Introduction.
http://integrativemedicinemalaysia.org/introduction/ Accessed May 16, 2016.
44. American Psychiatric Association. Integrative medicine.
https://www.psychiatry.org/psychiatrists/practice/professional-interests/integrative- medicine Accessed May 16, 2016.
45. Florida College of Integrative Medicine. About FCIM. https://www.fcim.edu/about-fcim/
Accessed May 16, 2016.
M AN US CR IP T
AC CE PT ED
46. National Centre for Complementary and Integrative Health. Complementary, alternative, or integrative health: what’s in a name? https://nccih.nih.gov/health/integrative- health#integrative Accessed May 16, 2016.
47. National Institute of Integrative Medicine, Australia. Welcome to the National Institute of Integrative Medicine. https://www.niim.com.au/ Accessed May 16, 2016.
48. American Association of Integrative Medicine. About. http://www.aaimedicine.com/about/
Accessed May 16, 2016.
49. Adams J, Hollenberg D, Lui C, Broom A. Contextualizing integration: A critical social science approach to integrative health care. J Manipulative Physiol Ther. 2009;32(9):792-798.
50. Arthur K, Belliard J, Hardin S, Knecht K, Chen C. Practices, attitudes, and beliefs associated with complementary and alternative medicine (cam) use among cancer patients. Integr Cancer Ther. 2012;11(3):232-242.
51. Bell IR, Caspi O, Schwartz GE, Grant KL, Gaudet TW, Rychener D, Maizes V, Weil A.
Integrative medicine and systemic outcomes research: issues in the emergence of a new model for primary health care. Arch Intern Med. 2002;162(2):133-140.
52. Boon H, Verhoef M, O'Hara D, Findlay B, Majid N. Integrative healthcare: arriving at a working definition. Altern Ther Health Med. 2004;10(5):48-56.
53. Boon H, Mior S, Barnsley J, Ashbury F, Haig R. The difference between integration and collaboration in patient care: Results from key informant interviews working in multiprofessional health care teams. J Manipulative Physiol Ther. 2009;32(9):715-722.
54. Clark PA. The ethics of alternative medicine therapies. J Public Health Policy. 2000;21(4):447- 470.
55. Cohen M, Eisenberg D. Potential physician malpractice liability associated with complementary and integrative medical therapies. Ann Intern Med. 2002;136(8):596-603.
56. Coulter I, Khorsan R, Crawford C, Hsiao A. Challenges of systematic reviewing integrative health care. Integr Med Insights. 2013;8:19-28.
57. Gamst A, Haahr N, Kristoffersen A, Launso L. Integrative care and bridge building among health care providers in Norway and Denmark. J Altern Complement Med. 2006;12(2):141- 146.
58. Kemper KJ, Rosen LD, Vohra S, Shannon S. Integrative health care for children. Altern Complement Ther. 2008;14(5):243-245.
59. Mulkins A, Eng J, Verhoef M. Working towards a model of integrative health care: Critical elements for an effective team. Complement Ther Med. 2005;13(2):115-122.
M AN US CR IP T
AC CE PT ED
60. Potter P. Team spirit: Holistic nursing and the integrative health care model. Am J Nurs.
2000;100(7):24AAA-24DDD.
61. Rygh E, Hjortdahl P. Continuous and integrated health care services in rural areas. A literature study. Rural Remote Health. 2007;7(3):766.
62. Schneider CD, Meek PM, Bell IR. Development and validation of IMAQ: Integrative Medicine Attitude Questionnaire. BMC Med Educ. 2003;28(3):5.
63. Somkin CP, Hiatt RA. Screening mammography in an integrated health care system: the Kaiser permanente experience. Breast Dis. 1998;10(3-4):45-53.
64. Stanhope V, Videka L, Thorning H, McKay M. Moving Toward Integrated Health: An Opportunity for Social Work. Soc Work Health Care. 2015;54(5):383-407.
65. Templeman K, Robinson A. Integrative medicine models in contemporary primary health care. Complement Ther Med. 2011;19(2):84-92.
66. Trevithick S. Integrative health and the management of pain at the end of life. Home Health Care Manage Pract. 2008;20(5):380-388.
67. Institute of Medicine. Integrative Medicine and the Health of the Public: A Summary of the February 2009 Summit. Washington, District of Columbia: National Academies Press; 2009.
68. Mann D, Gaylord S, Norton S. Moving toward integrative care: rationales, models, and steps for conventional-care providers. Complement Health Pract Rev. 2004;9(3):155-172.
69. Singer SJ, Burgers J, Friedberg M, Rosenthal MB, Leape L, Schneider E. Defining and measuring integrated patient care: promoting the next frontier in health care delivery. Med Care Res Rev. 2011;68(1):112-127.
70. Hok J, Wachtler C, Falkenberg T, Tishelman C. Using narrative analysis to understand the combined use of complementary therapies and bio-medically oriented health care. Soc Sci Med. 2007;65(8):1642-1653.
71. Simoens S, Scott A. Integrated primary care organizations: to what extent is integration occurring and why? Health Serv Manage Res. 2005;18(1):25-40.
72. Seidell JC, Halberstadt J, Noordamb H, Niemerb S. An integrated health care standard for the management and prevention of obesity in The Netherlands. Fam Pract. 2012;29(Suppl 1):i153-i156.
73. Morgan S, Yoder LH. A concept analysis of person-centered care. J Holistic Nurs. 2012;30:6- 15.
74. Epstein RM, Street RL. The values and value of patient-centered care. Ann Fam Med.
2011;9(2):100-103.
M AN US CR IP T
AC CE PT ED
75. Glasdam S, Oeye C, Thrysoee L. Patients’ participation in decision-making in the medical field - ‘projectification’ of patients in a neoliberal framed healthcare system. Nurs Philos.
2015;16(4):226-238.
76. Jackson GL, Powers BJ, Chatterjee R, Bettger JP, Kemper AR, Hasselblad V, Dolor RJ, Irvine RJ, Heidenfelder BL, Kendrick AS, Gray R, Williams Jr JW. The patient-centered medical home: a systematic review. Ann Intern Med. 2013;158:169-178.
77. McMillan SS, Kendall E, Sav A, King MA, Whitty JA, Kelly F, Wheeler AJ. Patient-centered approaches to health care: a systematic review of randomized controlled trials. Med Care Res Rev. 2013;70(6):567-596.
78. Stewart M, Brown JB, Donner A, McWhinney IR, Oates J, Weston WW, Jordan J. The impact of patient-centered care on outcomes. J Fam Pract. 2000;49(9):796-804.
79. Choi BCK, Pak AWP. Multidisciplinarity, interdisciplinarity and transdisciplinarity in health research, services, education and policy: 1. Definitions, objectives, and evidence of effectiveness. Clin Invest Med. 2006;29(6):351-364.
80. Ellis G, Whitehead MA, O'Neill D, Langhorne P, Robinson D. Comprehensive geriatric assessment for older adults admitted to hospital. Cochrane Database Syst Rev.
2011;(7):CD006211.
81. Harris SJ, Janssen PA, Saxell L, Carty EA, MacRae GS, Petersen KL. Effect of a collaborative interdisciplinary maternity care program on perinatal outcomes. CMAJ. 2012;184(17):1885- 1892.
82. Nazir A, Unroe K, Tegeler M, Khan B, Azar J, Boustani M. Systematic review of interdisciplinary interventions in nursing homes. J Am Med Dir Assoc. 2013;14(7):471-478.
83. Trivedi D, Goodman C, Gage H, Baron N, Scheibl F, Iliffe S, Manthorpe J, Bunn F, Drennan V.
The effectiveness of inter-professional working for older people living in the community: a systematic review. Health Soc Care Community. 2013;21(2):113-128.
84. Fairhall N, Sherrington C, Kurrle SE, Lord SR, Lockwood K, Howard K, Hayes A, Monaghan N, Langron C, Aggar C, Cameron ID. Economic evaluation of a multifactorial, interdisciplinary intervention versus usual care to reduce frailty in frail older people. J Am Med Dir Assoc.
2015;16(1):41-48.
85. Leach MJ. Evidence-based practice: a framework for clinical practice and research design. Int J Nurs Pract. 2006;12(5):248-251.
86. Lizarondo L, Grimmer-Somers K, Kumar S. A systematic review of the individual determinants of research evidence use in allied health. J Multidiscip Healthc. 2011;4:261–
272.
M AN US CR IP T
AC CE PT ED
87. Bantel C, Laycock H, Ward S, Halmshaw C, Nagy I. Pain in Intensive Care: A Personalised Healthcare Approach. J Intens Care Soc. 2013;14(4):312-318.
88. Savard J. Personalised Medicine: A Critique on the Future of Health Care. J Bioeth Inq.
2013;10:197-203.
89. Bauer UE, Briss PA, Goodman RA, Bowman BA. Prevention of chronic disease in the 21st century: elimination of the leading preventable causes of premature death and disability in the USA. Lancet. 2014;384(9937):45-52.
90. Anderko L, Roffenbender JS, Goetzel RZ, Millard F, Wildenhaus K, DeSantis C, Novelli W.
Promoting prevention through the affordable care act: workplace wellness. Prev Chronic Dis.
2012;9:120092.
M AN US CR IP T
AC CE PT ED
Integrative Health Care - Toward a Common Understanding: A Mixed Method Study
Highlights
• Despite the growing popularity of integrative health care (IHC) across the globe, there has been no consistent definition of IHC.
• A clear and consistent definition of integrative health care is critical to facilitating a common understanding of the term.
• An analysis of current definitions of IHC revealed a number of themes common to all, including holism, client-centeredness, respect, combining complementary and conventional medicine, integration, evidence-based practice, and optimisation of health.
• The synthesis of these themes was able to foster the generation of a scientifically-grounded, multidisciplinary stakeholder informed, international definition of integrative health care.
