Abstract
BackgroundPractitioners of complementary and alternative medicine (CAM) therapies are an important and growing presence in health care systems worldwide. A central question is whether evidence-based behavior change interventions routinely employed in conventional health care could also be integrated into CAM practice to address public health priorities. Essential for successful integration are intervention approaches deemed acceptable and consistent with practice patterns and treatment approaches of different types of CAM practitioners – that is, they have context validity. Intervention development to ensure context validity was integral to Project CAM Reach (CAMR), a project examining the public health potential of tobacco cessation training for chiropractors, acupuncturists and massage therapists (CAM practitioners). This paper describes formative research conducted to achieve this goal.MethodsIntervention development, undertaken in three CAM disciplines (chiropractic, acupuncture, massage therapy), consisted of six iterative steps: 1) exploratory key informant interviews; 2) local CAM practitioner community survey; 3) existing tobacco cessation curriculum demonstration with CAM practitioners; 4) adapting/tailoring of existing curriculum; 5) external review of adaptations; 6) delivery of tailored curriculum to CAM practitioners with follow-up curriculum evaluation.ResultsCAM practitioners identified barriers and facilitators to addressing tobacco use with patients/clients and saw the relevance and acceptability of the intervention content. The intervention development process was attentive to their real world intervention concerns. Extensive intervention tailoring to the context of each CAM discipline was found unnecessary. Participants and advisors from all CAM disciplines embraced training content, deeming it to have broad relevance and application across the three CAM disciplines. All findings informed the final intervention.ConclusionsThe participatory and iterative formative research process yielded an intervention with context validity in real-world CAM practices as it: 1) is patient/client-centered, emphasizing the practitioner’s role in a healing relationship; 2) is responsive to the different contexts of CAM practitioners’ work and patient/client relationships; 3) integrates relevant best practices from US Public Health Service Clinical Practice Guidelines on treating tobacco dependence; and 4) is suited to the range of healing philosophies, scopes of practice and practice patterns found in participating CAM practitioners. The full CAMR study to evaluate the impact of the CAMR intervention on CAM practitioners’ clinical behavior is underway.
Highlights
Practitioners uniformly felt that tobacco use was detrimental to patient’s health and that cessation training was relevant to their practices
Three practitioners viewed engaging in tobacco cessation as a public service or public health role for their complementary and alternative medicine (CAM) discipline
“And I think there’s a lot of chiropractors there, and they see a lot of patients, and this [tobacco cessation] would be one way—chiropractic is supposed to be about creating a healthier body, and I think chiropractors are perfect for this [promoting tobacco cessation]
Summary
Overall knowledge and skills goals for the training, three guiding principles of Reach training, four steps of a Helping conversation, video example of helping conversation between practitioner and patient.Module 1 - AwarenessScope of the tobacco problem, tobacco’s effects on health and healing, importance of linking effects of tobacco use to patient’s health concerns, practice systems to identify tobacco use, harm from second hand and third hand smoke exposure, the CAM practitioner’s role in helping, context of helping, getting the helping conversation started, skills practice role playModule 2 - Understanding Tobacco products and their harmful constituents, aspects of tobacco addiction (biological, psychological, social), active listening and communication skills (open-ended questions, reframing, body language), motivators and barriers to quitting (i.e. giving up tobacco), assessing readiness to quit, skills practice role playModule 3 - HelpingPHS guideline, types of cessation behavioral support services, cessation medications, referral skills, CAM approaches for tobacco cessation, motivational strategies (i.e. motivating and clarifying questions, eliciting ‘change talk’, ‘rolling with resistance’, emphasizing benefits of quitting, negotiating action), importance of continuing to offer helping conversations – even with patients not ready to quit, components of a simple quit plan, skills practice role playModule 4 - RelatingFinishing the helping conversation on a positive note, setting the stage/leaving door open to have future helping conversations, tips and strategies for following up, two final skills practice role play ClosureDistribution of printed practice support materials, discussion of how to use/implement printed materials to engage patients and promote practitioner’s willingness to help tobacco users quit, explanation of practice patient (standardized patient) office visitStep 5 results - External subject matter expert review The purpose was to gather feedback and advice for further necessary revisions from nationally/internationally recognized experts in the three CAM disciplines, tobacco cessation, and integrative medicine. PHS guideline, types of cessation behavioral support services, cessation medications, referral skills, CAM approaches for tobacco cessation, motivational strategies (i.e. motivating and clarifying questions, eliciting ‘change talk’, ‘rolling with resistance’, emphasizing benefits of quitting, negotiating action), importance of continuing to offer helping conversations – even with patients not ready to quit, components of a simple quit plan, skills practice role play. National advisors provided substantive contextual input on specific issues including: typical content/training received in typical CAM school curricula, professional scopes of practice, integration of conventional therapies, and potential practitioner role in discussing/providing information on cessation medications. Intervention development to ensure context validity was integral to Project CAM Reach (CAMR), a project examining the public health potential of tobacco cessation training for chiropractors, acupuncturists and massage therapists (CAM practitioners). Harris and colleagues [6] note in their international review of CAM use studies that more population-based assessment (i.e. through government sponsored health surveys) of CAM use is necessary to provide a more accurate picture of trends in prevalence of CAM use over time
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