"It Looks Like You're Making Very Healthy Choices": Attending to the Lifeworld and Medicine in Photo-Based Talk in Primary Care.

Addressing patient-clinician communication barriers to improve multiple chronic disease care is a public health priority. While significant research exists about the patient-clinician encounter, less is known about how to support patient-clinician communication about lifestyle changes that includes the context of people's lives. Data come from a larger photo-based primary care study collected from 13 participants who were adults 60 or older with at least two chronic conditions, in English, Chinese (Cantonese or Mandarin), or Spanish. We use discourse analysis of three examples as anchor points demonstrating different interactional pathways for the photo-based communication. Patients and clinicians can move smoothly through a pathway in which photos are shared, clinicians acknowledge and align with the patient's explanation, and clinicians frame their medical evaluations of food choices, nutrition suggestions, and shared goal-setting by invoking the voice of lifeworld (VOL). On the other hand, when clinicians solely press the voice of medicine (VOM) in their evaluations of patients' pictures with little attention to patients' presentations, it can lead to patient resistance and difficulty moving to the next activity. Because photo-sharing is still relatively novel, it offers unique interactional spaces for both clinicians and patients. Photo-sharing offers a sanctioned moment for a primary care visit to operate in the VOL and promote goal-setting that both parties can agree upon, even if clinicians and patients framed the activity as one in which patients' lifeworld choices should be assessed as medically healthy or unhealthy based on the ultimate judgment of clinicians operating from the VOM.

Mapping Uncharted Terrain: A Systematic Review of Complementary and Integrative Health Communication Using Observational Data in Biomedical Settings.

Complementary and integrative health (CIH) use is diverse and highly prevalent worldwide. Prior research of CIH communication in biomedical encounters address safety, efficacy, symptom management, and overall wellness. Observational methods are rarely used to study CIH communication and avoid recall bias, preserve ecological validity, and contextualize situated clinical communication. Following PRISMA guidelines, we systematically reviewed studies at the intersection of social scientific observational research and findings about CIH communication between clinicians, patients, and caregivers in biomedical settings. We identified international, peer-reviewed publications from seven databases between January 2010 and December 2020. Titles and abstracts were first screened for inclusion, then full studies were coded using explicit criteria. We used a standard checklist was modified to assess article quality. Ten of 11,793 studies examined CIH communication using observational methods for CIH communication in biomedical settings. Studies used a range of observational techniques, including participant and non-participant observation, which includes digital audio or video recordings. Results generated two broad sets of findings, one focused on methodological insights and another on CIH communication. Despite methodological and topic similarities, included studies addressed CIH communication as a process and as proximal and intermediate health outcomes. We recommend how observational studies of CIH communication can better highlight relationships between communication processes and health outcomes. Current research using observational methods offers an incomplete picture of CIH communication in biomedical settings. Future studies should standardize how observational techniques are reported to enhance consistency and comparability within and across biomedical settings to improve comparability.

A Communication Perspective on What Patient Advisory Boards Do: Action-Implicative Discourse Analysis and Negotiating Advice.

Stakeholder advisory boards are recognized as an essential and useful part of patient-centered research. However, such engagement can involve exchanges of diverse individual experiences, multiple opinions, and strong feelings in the face of researchers' limitations, deadlines, and agendas. Yet, little work examines how these potential tensions occur and are resolved in actual advisory board meetings. This perspective article describes and employs a communication framework for analyzing a patient advisory council (PAC) for a comparative effectiveness study on acupuncture and pain counseling for inpatients with cancer. The framework, Action-Implicative Discourse Analysis (AIDA), is an observational method that examines challenges through recorded and transcribed, naturally occurring interaction. Our analysis focused on two short excerpts from the first PAC meeting to demonstrate members' navigation of advice-giving and advice-receiving-one in which advice was ultimately implemented by the study team and another in which it was deemed unfeasible. Although advice is inherent to the work of all PACs, it often emerges unannounced as negotiated moments, made up of seemingly minor conversation moves. As a recurring event, advice can and should be analyzed and discussed within PACs to improve communication and team dynamics.

Burnout and sources of stress among medical residents at Hamad Medical Corporation, Qatar.

This study aimed to describe the experiences of stress and burnout and sociodemographic factors associated with dimensions of stress among medical residents at Hamad Medical Corporation, Qatar. Medical residents participating in a stress management course were asked to complete an anonymous survey. The survey included demographic questions, the Abbreviated Maslach Inventory, and 4 open-ended questions on experiences with stress. Of the 150 residents participating in the stress management course, 142 responded to the survey, listing an average of 2.2 types of stressors, with workload and workplace relationships as the most frequent. They listed an average of 3.1 coping strategies, most frequently seeking out social support and entertainment. Responses indicated low depersonalization, high personal accomplishment, high satisfaction with medicine and high emotional exhaustion. Training to improve coping and reduce burnout is recommended.

A Case Study of the Neti Pot's Rise, Americanization, and Rupture as Integrative Medicine in U.S. Media Discourse.

In a period of only one decade in the United States, the neti pot shifted from obscure Ayurvedic health device to mainstream complementary and integrative medicine (CIM), touted by celebrities and sold widely in drug stores. We examine the neti pot as a case study for understanding how a foreign health practice became mainstreamed, and what that process reveals about more general discourses of health in the United States. Using discourse analysis of U.S. popular press and new media news (1999-2012) about the neti pot, we trace the development of discourses from neti's first introduction in mainstream news, through the hype following Dr. Oz's presentation on Oprah, to 2011 when two adults tragically died after using Naegleria fowleri amoeba-infested tap water in their neti pots. Neti pot discourses are an important site for communicative analysis because of the pot's complexity as an intercultural artifact: Neti pots and their use are enfolded into the biomedical practice of nasal irrigation and simultaneously Orientalized as exotic/magical and suspect/dangerous. This dual positioning as normal and exotic creates inequitable access for using the neti pot as a resource for increasing cultural health capital (CHC). This article contributes to work that critically theorizes the transnationalism of CIM, as the neti pot became successfully Americanized. These results have implications for understanding global health practices' incorporation or co-optation in new contexts, and the important role that popularly mediated health communication can play in framing what health care products and practices mean for consumers.

Assessing the cultural in culturally sensitive printed patient-education materials for Chinese Americans with type 2 diabetes.

Type 2 diabetes affects Chinese Americans at an alarming rate. To address this health disparity, research in the area of cultural sensitivity and health literacy provides useful guidelines for creating culturally appropriate health education. In this article, we use discourse analysis to examine a group of locally available, Chinese- and English-language diabetes print documents from a surface level and deep structure level of culture. First, we compared these documents to research findings about printed health information to determine whether and how these documents apply current best practices for health literacy and culturally appropriate health communication. Second, we examined how diabetes as a disease and diabetes management is being constructed. The printed materials addressed surface level culture through the use of Chinese language, pictures, foods, and exercises. From a deeper cultural level, the materials constructed diabetes management as a matter of measurement and control that contrasted with previous research suggesting an alternative construction of balance. A nuanced assessment of both surface and deeper levels of culture is essential for creating health education materials that are more culturally appropriate and can lead to increased health literacy and improved health outcomes.

Using Chinese medicine in a Western way': Negotiating integrative Chinese medicine treatment for Type 2 Diabetes.

Type 2 diabetes affects Chinese Americans at an alarming rate and many Chinese Americans use Chinese medicine principles to deal with their diabetes. In this article, we examine interviews with Chinese medicine practitioners about the best ways to treat diabetes and xiaoke (Chinese medicine's closest equivalent to diabetes). These interviews were conducted to examine how practitioners would promote a particular form of integrative medicine ­ in this case, using Chinese medicinal principles to suggest food treatments for diabetes or xiaoke. Our research expands understandings of integrative medicine and Chinese medicine recognizing that in practice, the static categories of Chinese and Western diagnosis and treatment are not very useful for understanding how integration occurs. Instead, Chinese medicine practitioners negotiate between the poles of individual and standardized on one dimension and physical and energetic on another dimension as a way of practicing Chinese medicine and enregistering their professional identities here in the U.S. Examining these interviews from a language and social interaction perspective, we present integration as a performance and enactment of social personae rather than a product. We highlight the need to attend to differences in what oftentimes is treated as a monolithic community of Chinese medicine in the U.S.

"How's your mood": Recorded physician mental health conversations with Chinese and Latino patients in routine primary care visits.

OBJECTIVE: Patient-physician communication patterns may influence discussions around depressive symptoms and contribute to engagement in depression care among racial/ethnic minority adults. We examined patient-physician communication about depressive symptoms during routine primary care visits with Chinese and Latino patients with and without language barriers. METHODS: We examined 17 audio-recorded conversations between primary care physicians and Chinese (N = 7) and Latino (N = 10) patients who discussed mental health during their visit and reported depressive symptoms on a post-visit survey. Conversations (in English, Cantonese, Mandarin, Hoisan-wa, Spanish) were transcribed and translated by bilingual/bicultural research assistants and analyzed using inductive and deductive thematic and discourse analysis. RESULTS: Patients initiated mental health discussion in eleven visits. Physicians demonstrated care in word choice and sometimes avoided openly mentioning depression; this could contribute to miscommunication around symptoms and treatment goals. Interpreters had difficulty finding single words to convey terms used by either patients or physicians. CONCLUSION: Patients and doctors appeared willing to discuss mental health; however, variability in terminology presented challenges in mental health discussions in this culturally and linguistically diverse sample. PRACTICE IMPLICATIONS: Further understanding patient preferred terminology about mental health symptoms and interpreter training in these terms could improve patient-physician communication about depressive symptoms and treatment preferences.

Complementary and integrative healthcare communication in Chinese American patient / primary care visits: An observational discourse analysis.

Objective: Chinese-American patients use CIH at high rates but disclosure of CIH use to clinicians is low. Further, the content of CIH talk between patients and their clinicians is not well described. We aimed to characterize CIH talk between Chinese-American patients and their primary care clinicians. Methods: Discourse analysis of 70 audio-recordings of language concordant and discordant-interpreted visits. Results: Nearly half of all visits (48.6%) had some form of CIH communication. 'Simple CIH talk' focused on a single CIH topic resulting in a positive, neutral, or negative response by clinicians. 'CIH-furthering talk' was characterized by clinicians and patients addressing more than one CIH topic or including a combination of orientations to CIH by both clinicians and patients. CIH-furthering talk characterized by clinician humility could enhance rapport, cultural understanding, and open communication. CIH-furthering talk also led to miscommunication and retreat toward biomedicine. Conclusion: CIH communication occurred frequently during language concordant and discordant-interpreted visits with Chinese-American patients. Both patients and clinicians used CIH-furthering talk as a conversational resource for managing care. Innovation: This discourse analysis of visits between Chinese-American patients and their clinicians advances understanding of CIH communication beyond disclosure, illustrating the complexity of linguistic and cultural nuances that affect patient care.

Cultural resources for health participation: examining biomedicine, acupuncture, and massage therapy for HIV-related peripheral neuropathy.

In this article we use a culture-centered approach to understand people's experiences of treatment options for human immunodeficiency virus (HIV)-related peripheral neuropathy. We present from often unheard and marginalized voices the stories of how people live with this chronic illness and negotiate treatment options. Based on individual and group interviews, participants reported that biomedical pills were an important context for understanding decision making regarding neuropathy treatment. While most people spoke of the necessity of these drugs for their survival, they also expressed deep resentment and frustration with biomedically prescribed pills. Complaints about the pills worked to frame the holistic alternatives of acupuncture and massage therapy as better options for neuropathy and to establish a foundation for understanding how participants made particular health treatment decisions. Through strategically refusing certain drugs and choosing holistic treatments instead, participants asserted agency and control over their health decision making. By choosing holistic therapies, these clients were able to make choices about their neuropathy treatment in light of the many issues surrounding drug toxicity and treatment efficacy.

Heart-Healthy Integrative Nutritional Counseling Group Education Sessions Among Chinese Americans With Cardiovascular Risk Factors or Disease: A Primary Care Quality Improvement Pilot.

PURPOSE: Current biomedical cardiovascular disease nutrition counseling does not incorporate Chinese medicine principles. METHODS: A heart-healthy integrative nutritional counseling (H2INC) curriculum consistent with Chinese medicine principles and biomedical nutrition guidelines was taught to Chinese Americans in group education sessions. Chinese-speaking patients with cardiovascular disease or risk factors from an urban general medicine practice were recruited to attend a 90-minute group session. Participants completed pre-post surveys to assess the impact of H2INC on their perceived heart-healthy nutrition knowledge and empowerment, as well as the cultural relevance of H2INC. RESULTS: A total of 47 participants (mean age: 74 years; 63.8% female) attended a session. In response to the statement "I am able to choose heart-healthy Chinese foods to eat," on a 5-point Likert scale for which "strongly disagree" = 1 and "strongly agree" = 5, the presession survey mean response was 3.87 ± 0.69 and the postsession survey mean response was 4.13 ± 0.58 (P=0.05). Postsession, 87% of participants agreed or strongly agreed that they felt confident using what they learned and 94% agreed or strongly agreed that H2INC fit their culture. CONCLUSIONS: H2INC had a positive impact on perceived heart-healthy nutrition knowledge and empowerment and rated high in cultural relevance. Culturally relevant education sessions like H2INC could be a promising primary care health education intervention.

"I didn't know you were such a good cook": Photos as a tool for primary care clinician-patient communication.

OBJECTIVES: To examine audio-recorded primary care interactions with patient-initiated photo sharing around food and diet choices. METHODS: Data were 13 audio recordings of primary care visits with English-, Chinese-, or Spanish-speaking patients 60+ with two or more chronic conditions. Patients and clinicians completed pre-intervention surveys and some training on photo-taking / photo-sharing discussion. Data were analyzed using discourse analysis. RESULTS: Photo-based communication interactions lasted 3:34-28:37 min and averaged one-third of the visit. Clinicians and patients both initiated the photo-based talk and transition to other topics occurred smoothly. In eight of 13 interactions, the photo-based communication task was raised, but conversation did not occur at that moment. When discussed, the photos raised opportunities to talk about patient's decision-making which led to dietary suggestions including clinical nutrition suggestions and referrals to other specialty clinics. CONCLUSION: Photo-based communication in primary care can be used to promote patient activation and facilitate collaborative decision making that accounts for the patients' lived experiences and lifeworld. PRACTICE IMPLICATIONS: By setting the agenda early, clinicians or patients can designate the photo-sharing as a relevant part of the visit. Photos may be most relevant as part of the problem presentation, diagnosis, or treatment recommendation sections of the visit.

Adaptations to Acupuncture and Pain Counseling Implementation in a Multisite Pragmatic Randomized Clinical Trial.

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

A systematic review of communication about Complementary and Integrative Health (CIH) in global biomedical settings.

OBJECTIVES: A systematic review to analyze communication rates of complementary and integrative health (CIH) and analyze how communication terms, such as "disclosure," are measured and operationalized. METHODS: We searched seven databases for studies published between 2010 and 2018 with quantitative measurements of patients' communication of CIH to a biomedical clinician. We analyzed communication terms used to describe patients reporting CIH usage. We also examined the conceptual and operational definitions of CIH provided and whether those terms were explicitly operationalized. We aggregated the percentage, rate, or ratio of CIH users that communicated about CIH with their clinicians by disease type and geographical region. RESULTS: 7882 studies were screened and 89 included in the review. Studies used a wide range of conceptual and operational definitions for CIH, as well as 23 different terms to report communication related to reporting CIH usage. Usage varied by disease type and geographical region. CONCLUSIONS: Studies of CIH and CIH communication may measure different kinds of social and communicative phenomena, which makes comparison across international studies challenging. PRACTICE IMPLICATIONS: Future studies should employ standardized, replicable measures for defining CIH and for reporting CIH communication. Clinicians can incorporate questions about prior, current, and future CIH use during the medical visit.

Integrative Nutritional Counseling Combining Chinese Medicine and Biomedicine for Chinese Americans with Type 2 Diabetes: A Mixed-Methods Feasibility Study.

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

Pilot Cluster Randomized Controlled Trial of Integrative Nutritional Counseling Versus Standard Diabetes Self-Management Education for Chinese Americans with Type 2 Diabetes.

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

Models of health and models of interaction in the practitioner-client relationship in acupuncture.

The doctor-patient relationship has been widely studied in biomedicine. However, little research has focused on similar provider-client relationships in holistic healthcare forms. Based on ethnographic research with acupuncture clients and practitioners, the authors found that participants used specific models of health to understand and develop subsequent models of interaction, and in doing so, provided a clear critique of biomedicine. This article offers a brief overview of major models of healthcare, including biomedical, biopsychosocial, and holistic. The authors present current models of interaction that have been used to understand the biomedical doctor-patient relationship, and discuss the utility of both sets of models as they relate to the ethnographic observations. Although a particular model of health (biomedical or holistic) does not necessitate a particular model of health interaction (paternalism, consumerism, or collaboration), participants' attempts to tie these 2 realms together are important to understanding practitioner-patient relationships in all healthcare situations.

Can We Talk About It Now? Recognizing the Optimal Time to Initiate End-of-Life Care Discussions with Older Chinese Americans and Their Families.

INTRODUCTION: Older Chinese Americans often defer end-of-life care discussions. Researchers sought to explore how to engage older Chinese Americans and their families in end-of-life care discussions and to understand the optimal timing to initiate such discussions. METHODS: Individual, semistructured interviews were conducted with 14 community-dwelling older Chinese Americans, 9 adult children, and 7 clinicians. The data were collected and analyzed using focused ethnographic methodology. RESULTS: Older Chinese Americans and their families would discuss end-of-life care when introduced at "optimal times," which included after-triggering events (e.g., death of loved ones, fall accidents), changes in health status, or advanced age. DISCUSSION: Adult children are not expected to initiate end-of-life care discussions with their parents. Thus, culturally congruent health care that could better engage Chinese Americans in such discussions would be optimized by having clinicians proactively assess their patients' readiness and initiate such discussion at optimal times.

Please Ask Gently: Using Culturally Targeted Communication Strategies to Initiate End-of-Life Care Discussions With Older Chinese Americans.

BACKGROUND: Health-care providers (HCPs) find facilitating end-of-life (EOL) care discussions challenging, especially with patients whose ethnicities differ from their own. Currently, there is little guidance on how to initiate and facilitate such discussions with older Chinese Americans (≥55 years) and their families. OBJECTIVE: To explore communication strategies for HCPs to initiate EOL care discussions with older Chinese Americans in the San Francisco Bay Area. DESIGN: This qualitative (focused) ethnographic study included field observations and individual semistructured interviews with 14 community-dwelling older Chinese Americans who lived independently at home, 9 adult children, and 7 HCPs. Responses were analyzed using open coding, memos, and comparison across participants. RESULTS: The study participants emphasized the importance of assessing readiness for early EOL care discussions. All recommended using indirect communication approaches to determine older Chinese Americans' readiness. Indirect communication can be culturally targeted and applied at both system-wide (ie, health-care system) and individual (ie, HCP) levels. To institutionalize the practice, health-care facilities should implement EOL care discussion inquiries as part of routine during check-in or intake questionnaires. In individual practice, using depersonalized communication strategies to initiate the discussion was recommended to determine older Chinese Americans' readiness. CONCLUSION: Assessing readiness should be an essential and necessary action for early EOL care discussions. Culturally targeted assessment of older Chinese Americans includes using indirect communication approaches to initiate an EOL care discussion to determine their readiness. In addition to health-care system integration, providers should implement and evaluate proposed EOL discussion initiation prompts with their older Chinese American patients.