Langevin 1 rightly points to the reductionist mindset being the stumbling block for providing person-centered care. While considering the interconnections between the various domains underpinning health is a necessary first step towards more person-centered care, it ultimately is not sufficient. Person-centered care arises from the appreciation of the interdependencies and interactions between the various domains across its large-scale supersystems as much as its small-scale subsystems. Viewed with a complex-adaptive systems mindset health and disease are the phenotypical outcome categorisations of a person’s whole-of-systems dynamics across all scales of organisation. 2 , 3 Keywords health services research , personalized care , whole person care
The number of people with diabetes globally, is rising at an alarming rate. South Asia is one of the hot spots of the diabetes epidemic. In India alone, there are over 74 million people with diabetes today. Unfortunately, 70% of the doctors in India practice in urban areas while 70% of India's population lives in rural areas. This mismatch between the availability of health care professionals and the rapid spread of diabetes in rural areas, provides an opportunity to use technology to deliver the diabetes care to remote rural areas. The first part of this presentation will talk about a model of successful delivery of diabetes health care in rural India. The Chunampet Rural Diabetes Program was carried out in a group of 42 villages in Kancheepuram District in Tamilnadu. Using a Mobile van, a population of 27,014 individuals (86.5% of the adult population) were screened for diabetes. All those detected with diabetes were offered a follow up care at a rural diabetes centre which was set up during the project. The results were very impressive and led to good improvement in A1c levels using low cost generic drugs. The second use of technology was during the COVID ± 19 pandemic and the lock down which was enforced in India. Thankfully, Telemedicine was also legalized in India at that time. Using technology, a system was created whereby the doctor and the patient stayed at home but blood tests were arranged at home for the patient. With the results, teleconsultation was done by doctors using the Electronic Medical Records which were made available on their mobile phones. Thus, despite the lockdown, patients managed to get their tests and diabetes consultations done remotely. The third use of technology which will be presented is through our network of diabetes clinics across India. Even at centres where there was no ophthalmologist, retinal photographs were obtained using a lowcost retinal camera and were uploaded for centralized diabetic retinopathy grading unit where the images were read by trained retina specialists. The eye reports were sent back to the peripheral clinics in real time. Over one year period, 25,316 individuals with diabetes could have their eyes screened for diabetic retinopathy. Only 11.4 % needed referral to an ophthalmologist for further management. In conclusion, judicious use of technology can help to bridge the socioeconomic and geographical challenges in delivering diabetes health care in developing countries.
Background Cancer is associated with trauma and stress which impacts the physical, psychological, and spiritual/existential well-being of patients. Psychological/behavioral healing may help alleviate this distress and the associated health-related suffering. Psycho-Social-Spiritual healing outcome measures are thus needed to stimulate service development. The NIH Healing Experiences in All Life Stressors (NIH-HEALS), is a novel 35-item measure of psycho-social-spiritual healing, developed in USA and is yet to be validated and adapted for use in African countries. Objectives This study aimed to assess the face and content validity of the NIH-HEALS in the population of cancer patients in Uganda and to culturally adapt this measure. Methods Cross-sectional study using cognitive interviewing alongside standard piloting. We recruited adult (18 years and above) patients with advanced cancer from Hospice Africa Uganda. Interviews were conducted in two phases, using the think aloud technique and concurrent probing and were audio recorded. Phase 1 was used to identify initial concerns around clarity of the statements, and phase 2 further explored whether the issues of clarity had been addressed, alongside the standard cognitive interview parameters. The transcripts were imported into NVivo-12 analyzed using the content analysis technique and categorized using Tourengeau’s information processing model. Results We recruited thirty-five (35) patients: phase one (n = 5) two (n = 30). The median completion time was 20 minutes. Problems identified included comprehension of some statements, words, and phrases, suggestions to include local examples, highlighting of potentially sensitive statements that lean towards difficult conversations, and some cultural differences in the construction of the “Trust and Acceptance” construct, our sample showed less emphasis on family/friend relations. This feedback was used to adapt the NIH-HEALS for the local context. Conclusion The NIH-HEALS has sufficient face and content validity properties to be used among palliative cancer patients in Uganda. We propose some changes to inform the adaptation of this measure for the local context.
Naturopathy, recognized by the National Institutes of Health and the World Health Organization as a distinct system of complementary and integrative health care, is an existing model of whole health delivery. Its unifying principles, respect for the interconnectedness of biological systems, and representation globally uniquely positions naturopathy to serve an integral role in addressing the needs of primary health care. In this viewpoint, we aim to 1) highlight key areas and existing literature supporting the use of naturopathy for health promotion and disease prevention of noncommunicable diseases; 2) describe how naturopathy can addresses the mental health needs of today’s societies; and 3) discuss the importance of naturopathy in the access and navigation of complementary and integrative health therapies.
Background Integrative medicine (IM) is a growing subspecialty among the American healthcare system, but little is known about geographical and sociodemographic variability in access to services. Objective To better understand access to IM healthcare services, we aim to: 1.) document the number of IM providers within the hospital service area (HSA) of various hospitals across the United States (US) and, 2.) explore the relationship between age, income, and race as predictors of the number of IM providers. Methods We conducted an environmental scan to document the number of IM providers including naturopathic, acupuncture, chiropractic, and massage therapy providers within the HSA of 16 US hospitals using state and national search databases. We examined predictors of the number of providers per HSA using population and demographic data from the U.S. Census Bureau. Search database quality was evaluated using the Center for Disease Control and Prevention Clear Communication Index. Results The number of IM providers varied from 11.6 – 67.4 providers/100,000 persons. Massage therapists were the most prevalent (n = 13.8/100,000), followed by chiropractors (n = 5.2/100,000), acupuncturists (n = 4.6/100,000), and naturopathic physicians (n = .5/100,000). Higher average household income and population >65 years old were associated with more IM providers within an HSA (Rate Ratio (RR) 4.22, 95% CI 1.49-12.01; and 1.14, 1.05 - 1.24, respectively). In addition, the quality of publicly available search databases varied widely among US states (4.84 - 8.00/10), but less so among IM provider types (6.21 - 7.57/10). Conclusions The high variability in number of IM providers and search database quality among various HSAs across the US warrants further investigation into factors influencing access to services. Our findings regarding income and older adult population raise concern for inequitable access to care, but are also promising when considering the increasing demand for healthcare services among the older adult population.
Background Valued living is the extent to which an individual’s behavior is consistent with what they believe is important or good. It is unknown whether many complementary and integrative treatments and psychotherapies for posttraumatic stress disorder enhance valued living, and for whom. Objectives Measure within- and between-group changes in valued living in Veterans who completed cognitive processing therapy (CPT) and sudarshan kriya yoga (SKY) for posttraumatic stress disorder (PTSD); evaluate moderators of improvement. Methods Participants with clinically significant symptoms of PTSD were assigned to CPT, a first line, evidence-based psychotherapy for PTSD or SKY, an emerging breath-based meditation with strong preliminary empirical support in a parallel-groups randomized controlled trial at a single Veterans Affairs healthcare center. The Valuing Questionnaire subscales for progress in valued living (VQ-P) and obstruction in valued living (VQ-O) were exploratory outcome measures. Assessors were blind to treatment assignment. Results 59 participants completed treatment (29 CPT, 30 SKY). Participants in the CPT group improved from baseline to end of treatment in both VQ-Progress ( d=0.55, p=0.02) and VQ–Obstruction ( d=-0.51, p=0.03), while the SKY group did not improve on either subscale ( d=0.08, p=0.69; d=0.00, p=1.00). However, differences between treatments were not statistically significant ( p=0.16, 0.11, respectively). Participants reporting less valued living and more depression symptoms at baseline reported greater improvements in valued living following treatment. Conclusion CPT may have a positive effect on valued living. Individuals lower in valued living and with more depression may derive relatively more benefit.
Perhaps, the biggest risk facing the efforts to improve health and well-being for all, is to fail to realize that this requires not simply improvement upon the existing systems, but TRUE transformation. And, transformation not of one massive, complex system but of a multitude of systems. The Whole Health Institute has identified thirteen large systems that impact health and well-being and are in need of true transformation.
Background The effect of a forest therapy in a natural environment noted that the forest therapy induced a state of relaxation among workers, thereby decreasing cortisol levels and work-related stress. Objective The primary objective of this study is to determine the effects of the forest therapy for employees in the manufacturing industry on psychological stress responds, stress hormone and heart rate variability (HRV). The secondary objective is to determine the effects of the forest therapy for employees in the manufacturing industry on cytotoxic activity of natural killer (NK) cells, health-related quality of life and mood states compare to urban untreated and remained in urban environment. Methods Forty-two employees were recruited from a single workplace located in Incheon city, Republic of Korea. Participants were allocated to either an experimental group (n= 21), wherein they participated in the forest therapy and or a control group (n= 21), wherein they were given no treatment. Participants were assigned to these groups on a randomized, open-label basis. Pre and post-test measures of natural killer (NK) cell activity, salivary cortisol, heart rate variability (HRV), health-related quality of life, stress response, and mood states were taken for both groups. Results The results showed that participants who took part in the forest therapy showed greater physiological improvement when compared to those in the control group, as indicated by a significant increase in some HRV measures. The forest therapy also contributed to a significantly greater decrease in work-related stress symptoms and a significantly greater improvement in health-related quality of life and mood states compared to participants in the control group. Conclusions These results may suggest that the forest therapy could be an effective means of relaxation technique, reducing stress and leads to an increase in positive mood for employees in the manufacturing industry.
Background:The Veterans Health Administration (VA) is undergoing a transformation in how healthcare is organized and provided. This transformation to a Whole Health System of Care encompasses the integration of complementary and integrative health services, education, and Whole Health coaching to develop Veterans' self-care skills. During the COVID-19 pandemic, these services were provided via telehealth (tele-WH). Objective:We sought to understand Veteran and provider perspectives on how tele-WH impacts Veteran engagement in Whole Health-aligned services and the impact on their well-being. Methods:Semi-structured interviews were conducted with 51 providers who delivered tele-WH at 10 VA Medical Centers (VAMCs) and 19 Veterans receiving tele-WH at 6 VAMCs. Participants were asked about their experiences with tele-WH, what they perceived to be the impact of tele-WH on Veterans, and their preferences moving forward. Interviews were transcribed, and a content analysis was performed using a rapid approach. Results:We identified 3 major themes that describe the perceived impact of tele-WH on Veterans. These include: (1) increased use of Whole Health-aligned services; (2) deeper engagement with Whole-Health aligned services; and (3) improvements in social, psychological, and physical well-being. Conclusion:Tele-WH is perceived to be a strong complement to in-person services and is a promising mechanism for improving engagement with Whole Health-aligned services and promoting Veteran well-being. Future research is needed to measure outcomes identified in this study and to support more equitable access to telehealth for all.
Objectives To determine acute effects of stress-reduction guided imagery delivered in group format on stress biomarkers salivary cortisol and salivary amylase, and on self-reported stress mood, in healthy, predominantly Latino adolescents. Study Design 111 adolescent participants (94% Latino), a subset from a large, randomized controlled lifestyle intervention to improve obesity-related health behaviors, received either 4 weekly lifestyle education sessions (Lifestyle group; LS) or the same weekly lifestyle education sessions plus an additional weekly stress-reduction guided imagery session delivered in group format (Guided imagery group; GI). Salivary cortisol, salivary amylase, and self-reported stress moods were assessed before and after sessions on intervention weeks 3 and 4. Statistics: Linear mixed effects models examined within- and between-session and group differences in pre- to post-session changes. Results Both groups showed decreases in salivary cortisol, 5% decrease in LS group and 32% in GI group (within-group differences all P < .05), with between-group difference in salivary cortisol of moderate size ( P = .05; Cohen’s d = .44). Within the GI group alone, salivary cortisol decrease was similar following either the lifestyle or GI sessions ( P = .64). There were no statistically significant amylase changes within or between groups. All 5 individual stress moods declined by 27% to 46% in the GI group (all P < .05), while only 1 of the 5 declined in LS group. Conclusions Group stress-reduction guided imagery reduces the stress biomarker salivary cortisol, as well as reducing subjective stress mood states, making it a viable modality for large scale stress-reduction interventions.
Background Individuals with posttraumatic stress disorder (PTSD) and chronic pain evince different presentations, coping strategies, and treatment utilization patterns than individuals with chronic pain alone. Theorists have suggested that comorbid PTSD may complicate chronic pain treatment, and that integrated pain and PTSD treatment may be preferable to pain treatment alone. Objective Assess whether comorbid PTSD moderates Veterans’ response to yoga and/or cognitive behavioral therapy (CBT) for pain. Methods Veterans with Gulf War illness (n = 75) were assessed using the Brief Pain Inventory at baseline and posttreatment as part of a randomized clinical trial. PTSD status was abstracted from participants’ medical records. Results PTSD+ participants (n = 41) reported more pain at baseline than PTSD− participants (n = 34; d = .66, p < .01). PTSD+ participants experienced more improvement in pain from baseline to posttreatment than PTSD− participants by a small to moderate, marginally statistically significant amount ( d = .39, p = .07). The relationship between PTSD and treatment outcome was not moderated by treatment type (yoga vs CBT; p = .99). Observation of treatment responses across PTSD status (+ vs −) and treatment (yoga vs CBT) revealed that PTSD+ participants responded well to yoga. Conclusion PTSD is not associated with reduced effectiveness of behavioral chronic pain treatment among Veterans with Gulf War illness. Therefore behavioral pain treatment should be made readily available to Veterans with pain and PTSD. Yoga deserves further consideration as a treatment for pain among individuals with PTSD.
Background Chronic low back pain (cLBP) and chronic neck pain (cNP) are highly prevalent conditions and common reasons for disability among military personnel. Yoga and other mind-body interventions have been shown to safely decrease pain and disability in persons with cLBP and/or cNP but have not been adequately studied in active duty military personnel. The objective of this study was to examine the feasibility and acceptability of delivering 2 types of yoga (hatha and restorative) to a sample of active-duty military personnel with cLBP/cNP. Methods Military personnel with cLBP and/or cNP (n = 49; 59% men) were randomized to either hatha or restorative yoga interventions. Interventions consisted of in-person yoga 1-2x weekly for 12 weeks. Feasibility and acceptability were measured by rates of recruitment, intervention attendance, attrition, adverse events, and satisfaction ratings. Health outcomes including pain and disability were measured at baseline, 12 weeks, and 6 months. Means and effect sizes are presented. Results Recruitment was completed ahead of projections. Over 90% of participants agreed or strongly agreed that they enjoyed participation, liked the instructor, and would like to continue yoga. Retention rates were 86% and 80% at 12 week and 6 month assessments, respectively. Intervention attendance was adequate but lower than expected. There were small to moderate reductions in back-pain related disability, pain severity and pain interference, and improvements in quality of life, grip strength, and balance. In general, effects were larger for those who attended at least 50% of intervention classes. Participants with cNP tended to have smaller outcome improvements, but conclusions remain tentative given small sample sizes. Conclusions Results demonstrate feasibility for conducting a randomized controlled comparative effectiveness trial of yoga for cLBP and cNP among active duty military personnel. Acceptability was also established. Ongoing work will enhance the intervention for cNP and establish feasibility at another military facility in preparation for a fully-powered comparative effectiveness trial. ClinicalTrials #NCT03504085; registered April 20, 2018.
Background:The Veterans Health Administration is rolling out a Whole Health system of care as part of an enhanced focus on proactive, person-centered healthcare.Objective:Our program evaluation seeks to characterize what Veterans use Whole Health services, for what diagnoses they are seeking Whole Health services, and to examine "high utilizers" of Whole Health services.Methods:Data were collected on 174 Veterans using Whole Health services from December 2018 through March 2020 and consisted of chart review and self-report data.Results:Women were more likely than men Veterans to use individual only Whole Health services. High utilizers (the top 30% of the sample in Whole Health services used) were more likely to attend groups than the remainder of the sample.Conclusion:Future work should examine the community-building aspects of Whole Health and ways to create group programming tailored to women Veterans.
Introduction The Veterans Health Administration (VHA) initiated a system-wide redesign in 2011 toward a patient-centered approach called the Whole Health System (WHS) of care. Education of VHA clinical staff in WHS-informed care, Whole Health Clinical Care (WHCC), is one critical element of this redesign effort. At a minimum, WHCC education should address core competencies for clinicians and be considered satisfactory for learners. This is the first study to evaluate learner satisfaction and perceived achievement of course objectives in WHCC that incorporated active learning strategies. Method A large VA Healthcare System developed an in-person workshop focused on WHCC that used multiple active learning activities. These activities included case presentations, role playing, experiential learning, and group discussion. Results Sixty-two interprofessional staff attended the workshop in November 2019. Forty (64.50%) participants completed post-workshop surveys within 30 days. Data suggest participants were highly satisfied with the workshop and that they successfully met stated learning objectives. Conclusions We call on VHA and private-sector hospitals to train clinical staff in WHCC that incorporates use of active learning strategies.
Background:Poor sleep is common during pregnancy and is associated with increased risk of negative health outcomes. Research indicates that physical discomfort and having an active mind are primary factors for prenatal sleep disturbances. Mindfulness-based interventions have the potential for addressing these factors, but have yet to be optimized for this purpose in this population.Objective:The objective of this study was to gather input from pregnant and postpartum individuals about the value of a mindfulness-based program for improving prenatal sleep and their preferred content and delivery format.Methods:We conducted 2 focus groups with 12 pregnant people experiencing poor sleep quality and 3 individual interviews with postpartum people. Interviews were thematically analyzed.Results:The majority of participants expressed strong interest in a mindfulness program for improving prenatal sleep. Participants reported that pregnancy-specific physical discomfort and worry (both general and pregnancy-specific) affected their sleep. Participants wanted sleep education, and strategies for calming the mind, reducing physical discomfort, reducing impact of bedtime partners on sleep, and tips for improving sleep schedule and quality. Participants recognized the convenience of an online intervention and the social benefits of an in-person intervention and favored a hybrid delivery model.Conclusion:Addressing prenatal sleep problems is an unmet need. Given the challenges and discomfort women face during pregnancy, and the importance of adequate sleep for promoting mental and physical health during pregnancy, sleep difficulties are critical to address. A mindfulness-based intervention for improving prenatal sleep was deemed of high interest to this perinatal population.
The field of mindfulness-based research and practice is expanding fast. This development calls for a careful evaluation of the merits and scientific underpinnings of newly developed mindfulness-based programs (MBP's). In this viewpoint, we describe a process initiated by two professional mindfulness teacher training organisations (the Dutch Vereniging Mindfulness-based Trainers Nederland, VMBN, and the British Association of Mindfulness-based Approaches, BAMBA) to develop a framework for evaluating the integrity of newly developed MBP's. The framework aims to articulate criteria describing the elements and processes required to ensure that a new MBP meets good practice, adheres to evidenced-based practice, and is attending to the challenge of implementation and scalability. The development and implementation of the criteria are still a 'work in progress'. We hope that this initiative offers a foundation for supporting the MBP field to balance innovation and grassroot community development with aligning to the principles of evidence-based practice.
Background Accounting professionals experience a stressful working environment with previous studies demonstrating a high prevalence of burnout. Meditation-based interventions have a potential role in decreasing burnout and improving satisfaction with life. However, the benefits of Heartfulness meditation intervention have not been demonstrated among accounting professionals. Objective To evaluate the effects of an 8-week Heartfulness Meditation program on burnout and satisfaction with life in chartered accountants. Methods The study was a prospective cohort analysis comparing burnout and satisfaction with life outcomes among accounting professionals who either self-selected to participate in the Heartfulness Meditation Program (intervention group) or with no particular intervention (control group). Maslach Burnout Inventory (MBI) and Satisfaction with Life Scale (SWLS) scores were collected at baseline and at the end of the study period. Results Two hundred and six participants completed the study. Participants in the intervention group (n = 107) experienced statistically significant improvement in MBI emotional exhaustion from 2.17 to 1.75 ( P = .00) and overall MBI score decreased from 2.99 to 2.83 ( P = .020). Participants in the control group (n = 99) experienced statistically significant improvement for emotional exhaustion only, from 1.82 to 1.52 ( P = .009). Further, participants in the intervention group demonstrated statistically significant improvement with SWLS from 4.90 to 5.17 ( P = .005). While participants in the intervention group experienced higher levels of decline (19.55%) compared to the control group (16.41%) for emotional exhaustion, it was not statistically significant. Conclusion The current study is one of the first attempts of a Heartfulness meditation intervention to reduce burnout and improve satisfaction with life among accounting professionals. Both the intervention group and the control group showed an improvement of emotional exhaustion. The statistically significant improvements observed in the overall MBI and SWLS outcomes in the intervention group suggest an online Heartfulness meditation program could serve as a potential tool for reducing burnout and improving satisfaction among accounting professionals.
Background Cancer treatments, such as chemotherapy, may adversely affect gastrointestinal (GI), physical and mental health in survivors of cancer. Objective This study investigated associations between GI, mental and physical health outcomes, and cancer treatment-related variables, such as chemotherapy, in adult cancer survivors. Methods A one-time cross-sectional survey with patient-reported outcomes was used. Cancer survivors (N = 317) aged ≥18 years, living in Canada, who completed cancer treatments were included. Descriptive statistics, correlation, and linear regression analyses are reported. Results Mean age at diagnosis was 40.90 ± 15.40 years. Most survivors received chemotherapy (86.1%). Persistent GI symptoms include constipation (53.6%), diarrhea (50.5%), and bloating/pain (54.9%). Mean GI symptom duration was 30.53 ± 33.42 months. Severity of GI symptom interference was moderate to extreme for 51.9% of survivors. Compared to normative values of 50 in healthy people, survivors scored poorer for mental health (M = 42.72 ± 8.16) and physical health (M = 45.55 ± 7.93), and reported more belly pain (M = 56.10 ± 8.58), constipation (M = 54.38 ± 6.81), diarrhea (M = 55.69 ± 6.77), and gas/bloating (M = 56.08 ± 8.12). Greater GI symptom severity was associated with poorer mental and physical health ( P < .01). Chemotherapy was associated with increased belly pain ( B = 4.83, SE = 1.65, P < .01) and gas/bloating ( B = 3.06, SE = 1.45, P = .04). Conclusion We provide novel evidence that many cancer survivors experience chronic, moderate to severe GI symptoms lasting for years after cancer treatment, which are associated with worse mental and physical health. Chemotherapy is associated with specific GI symptoms. Integrative therapies are needed to address GI symptoms in cancer survivors.
Background There is a knowledge gap in the physiological effects of short-term yoga exercise interventions. Objective To evaluate the feasibility of a randomized controlled trial (RCT) assessing the acute effects of a yoga exercise protocol practiced at 2 intensities (high or moderate) on temporal responses of a battery of systemic circulatory cytokines in healthy yoga-naïve adults. Methods This study was a three-arm, pre-post pilot-RCT employing a single bout of yoga exercise intervention. Groups were high-intensity yoga (HY, n = 10), moderate-intensity yoga (MY, n = 10), and a sedentary, no-intervention control group (CON, n = 10). Blood samples were collected at baseline and post-intervention at 6 timepoints (0-, 30-, 60-, 120-, 180-minutes, and 24-hours post-intervention) and were processed with a pre-defined inflammatory panel of 13 cytokines. Heart rate (HR) was assessed with a Polar H10® device. The PROMIS Pain intensity Questionnaire was used to assess body soreness. Results We demonstrate feasibility of recruitment, randomization, and retention of participants based upon predetermined metrics, including: proportion of eligible to enrolled participants (55%); recruitment period (11-months); participant retention (97%); completion rate for questionnaires (99%); completion of physiological measures (98%); and adherence to the yoga exercise protocol (88%). Cytokine levels over time were heterogeneous within and between groups. Responses of a subset of cytokines were positively correlated with 1 another in high- and moderate-intensity yoga exercise groups but not in the control group. Median values for HR were 91 (IQR: 71–95) in the HY, 95 (IQR: 88–100) in the MY, and 73 (IQR: 72–75) in the CON. Pre-post changes in body soreness after the yoga exercise intervention were most evident in the HY group. Conclusion Along with observed trends in select cytokines, findings encourage a more definitive trial aimed at understanding the short-term effects of yoga exercise on inflammatory immune markers and pain in sedentary healthy adults. Clinicaltrials.gov ID# NCT04444102.
