Barriers to the Engagement of Complementary and Integrative Health Providers in Public Health Responses to COVID-19: Recommendations From a Multidisciplinary Expert Panel.

OBJECTIVE: The purpose of this project was to explore barriers to the involvement of complementary and integrative health (CIH) providers in the public health response to COVID-19 and potential solutions for future involvement in public health crises. METHODS: An expert panel of 10 people, which included doctors of chiropractic, naturopathic doctors, public health practitioners, and researchers from the United States, was convened for a day-long online panel discussion. Facilitators asked panelists how CIH practitioners could contribute and be mobilized. We summarized themes and recommendations from the discussion. RESULTS: Despite their skills and resources, few CIH providers participated in public health efforts like testing and contact tracing during the COVID-19 pandemic. Panelists described that CIH professionals may not have participated in those efforts due to the CIH providers possibly not having sufficient public health training and limited contact with public health professionals, as well as policy and financial challenges during the pandemic. Panelists proposed solutions to these barriers, including more public health training, stronger formal relationships between CIH and public health organizations, and improved financial support for both CIH care and public health efforts. CONCLUSION: Through an expert panel discussion, we identified barriers that hindered the involvement of CIH providers in the public health response to the COVID-19 pandemic. During future pandemics in the United States, public health planners should recognize CIH providers as part of the existing labor resource, with clinical expertise and community-level connections that can be called upon in a crisis. During future events, CIH professional leaders should be more proactive in seeking out a supportive role and sharing their knowledge, skills, and expertise.

Income as a Predictor of Self-Efficacy for Managing Pain and for Coping With Symptoms Among Patients With Chronic Low Back Pain.

OBJECTIVES: The purpose of this study was to evaluate pain self-efficacy (PSE) and coping self-efficacy (CSE) for people with chronic low back pain (CLBP), and to assess whether lower income may be associated with less PSE and CSE in the United States. METHODS: We conducted a cross-sectional study using survey data collected between June 2016 and February 2017 from n = 1364 patients with CLBP from chiropractic clinics in the United States to measure the relationship between income and both types of self-efficacy. We created 4 multivariate models predicting PSE and CSE scores. We used both a parsimonious set of covariates (age, sex) and a full set (age, sex, education, neck pain comorbidity, catastrophizing, and insurance). We also calculated effect sizes (Cohen's d) for unadjusted differences in PSE and CSE score by income. RESULTS: Lower income was associated with lower PSE and CSE scores across all 4 models. In the full models, the highest-income group had an average of 1 point (1-10 scale) higher PSE score and CSE score compared to the lowest income group. Effect sizes for the unadjusted differences in PSE and CSE scores between the highest and lowest income groups were 0.94 and 0.84, respectively. CONCLUSIONS: Our findings indicate that people with lower income perceive themselves as less able to manage their pain, and that this relationship exists even after taking into account factors like health insurance and educational attainment. There is a need to further investigate how practitioners and policymakers can best support low-income patients with chronic pain.

Clinical Scenarios for Which Spinal Mobilization and Manipulation Are Considered by an Expert Panel to be Inappropriate (and Appropriate) for Patients With Chronic Low Back Pain.

BACKGROUND: Spinal mobilization and manipulation are 2 therapies found to be generally safe and effective for chronic low back pain (CLBP). However, the question remains whether they are appropriate for all CLBP patients. RESEARCH DESIGN: An expert panel used a well-validated approach, including an evidence synthesis and clinical acumen, to develop and then rate the appropriateness of the use of spinal mobilization and manipulation across an exhaustive list of clinical scenarios which could present for CLBP. Decision tree analysis (DTA) was used to identify the key patient characteristics that affected the ratings. RESULTS: Nine hundred clinical scenarios were defined and then rated by a 9-member expert panel as to the appropriateness of spinal mobilization and manipulation. Across clinical scenarios more were rated appropriate than inappropriate. However, the number patients presenting with each scenario is not yet known. Nevertheless, DTA indicates that all clinical scenarios that included major neurological findings, and some others involving imaging findings of central herniated nucleus pulposus, spinal stenosis, or free fragments, were rated as inappropriate for both spinal mobilization and manipulation. DTA also identified the absence of these imaging findings and no previous laminectomy as the most important patient characteristics in predicting ratings of appropriate. CONCLUSIONS: A well-validated expert panel-based approach was used to develop and then rate the appropriateness of the use of spinal mobilization and manipulation across the clinical scenarios which could present for CLBP. Information on the clinical scenarios for which these therapies are inappropriate should be added to clinical guidelines for CLBP.

Workplace breastfeeding support and job satisfaction among working mothers in the United States.

BACKGROUND: Job satisfaction is associated with health and productivity. Workplace support for breastfeeding may affect working mothers' job satisfaction. METHODS: We analyzed responses from 488 women from the Infant Feeding Practices Study II (2005-2007). Using logistic regression, we assessed whether workplace breastfeeding problems at 3 months postpartum were related to low job satisfaction concurrently and, for a subsample (n = 265), at 9 and 12 months postpartum. RESULTS: Compared with women reporting no problems, women reporting three or more problems had higher odds (odds ratio [OR] = 4.76; 95% confidence interval [CI]: 2.03-11.18) of low job satisfaction at 3 months, and at 12 months (OR = 6.88, 95% CI: 1.33-35.58) after controlling for baseline job satisfaction. Models isolating problems with break time and space to pump/nurse showed more modest results. CONCLUSIONS: Work-related breastfeeding problems at 3 months postpartum were associated with low job satisfaction concurrently and at follow-up. Improving workplace breastfeeding accommodations could improve mothers' job satisfaction.

The impact of patient preferences and costs on the appropriateness of spinal manipulation and mobilization for chronic low back pain and chronic neck pain.

BACKGROUND: Although the delivery of appropriate healthcare is an important goal, the definition of what constitutes appropriate care is not always agreed upon. The RAND/UCLA Appropriateness Method is one of the most well-known and used approaches to define care appropriateness from the clinical perspective-i.e., that the expected effectiveness of a treatment exceeds its expected risks. However, patient preferences (the patient perspective) and costs (the healthcare system perspective) are also important determinants of appropriateness and should be considered. METHODS: We examined the impact of including information on patient preferences and cost on expert panel ratings of clinical appropriateness for spinal mobilization and manipulation for chronic low back pain and chronic neck pain. RESULTS: The majority of panelists thought patient preferences were important to consider in determining appropriateness and that their inclusion could change ratings, and half thought the same about cost. However, few actually changed their appropriateness ratings based on the information presented on patient preferences regarding the use of these therapies and their costs. This could be because the panel received information on average patient preferences for spinal mobilization and manipulation whereas some panelists commented that appropriateness should be determined based on the preferences of individual patients. Also, because these therapies are not expensive, their ratings may not be cost sensitive. The panelists also generally agreed that preferences and costs would only impact their ratings if the therapies were considered clinically appropriate. CONCLUSIONS: This study found that the information presented on patient preferences and costs for spinal mobilization and manipulation had little impact on the rated appropriateness of these therapies for chronic low back pain and chronic neck pain. Although it was generally agreed that patient preferences and costs were important to the appropriateness of M/M for CLBP and CNP, it seems that what would be most important were the preferences of the individual patient, not patients in general, and large cost differentials.

Researching the Appropriateness of Care in the Complementary and Integrative Health Professions Part 3: Designing Instruments With Patient Input.

OBJECTIVES: The purpose of this article is to describe how we designed patient survey instruments to ensure that patient data about preferences and experience could be included in appropriateness decisions. These actions were part of a project that examined the appropriateness of spinal manipulation and mobilization for chronic low back pain and chronic neck pain. METHODS: We conducted focus groups, cognitive interviews, a literature review of measures in prior chiropractic and complementary and integrative health research, and a pilot study to develop questionnaires of patient preferences, experiences, values, and beliefs. RESULTS: Questionnaires were administered online to 2024 individuals from 125 chiropractic clinics. The survey included 3 long questionnaires and 5 shorter ones. All were administered online. The baseline items had 2 questionnaires that respondents could complete in different sittings. Respondents completed shorter biweekly follow-ups every 2 weeks and a final questionnaire at 3 months. The 2 initial questionnaires had 81 and 140 items, the 5 biweekly follow-up questionnaires had 37 items each, and the endline questionnaire contained 121 items. Participants generally responded positively to the survey items, and 91% of the patients who completed a baseline questionnaire completed the endpoint survey 3 months later. We used "legacy" measures, and we also adapted measures and developed new measures for this study. Preliminary assessment of reliability and validity for a newly developed scale about coping behaviors indicates that the items work well together in a scale. CONCLUSIONS: This article documents the challenges and the efforts involved in designing data collection tools to facilitate the inclusion of patient data into appropriateness decisions.

Coping and Management Techniques Used by Chronic Low Back Pain Patients Receiving Treatment From Chiropractors.

OBJECTIVES: The purpose of this study was to describe coping strategies (eg, mechanisms, including self-treatment) that a person uses to reduce pain and its impact on functioning as reported by patients with chronic low back pain who were seen by doctors of chiropractic and how these coping strategies vary by patient characteristics. METHODS: Data were collected from a national sample of US chiropractic patients recruited from chiropractic practices in 6 states from major geographical regions of the United States using a multistage stratified sampling strategy. Reports of coping behaviors used to manage pain during the past 6 months were used to create counts across 6 domains: cognitive, self-care, environmental, medical care, social activities, and work. Exploratory analyses examined counts in domains and frequencies of individual items by levels of patient characteristics. RESULTS: A total of 1677 respondents with chronic low back pain reported using an average of 9 coping behaviors in the prior 6 months. Use of more types of behaviors were reported among those with more severe back pain, who rated their health as fair or poor and who had daily occurrences of pain. Exercise was more frequent among the healthy and those with less pain. Female respondents tended to report using more coping behaviors than men, and Hispanics more than non-Hispanics. CONCLUSION: Persons with chronic back pain were proactive in their coping strategies and frequently used self-care coping strategies like those provided by chiropractors in patient education. In alignment with patients' beliefs that their condition was chronic and lifelong, many patients attempted a wide range of coping strategies to relieve their pain.

Researching the Appropriateness of Care in the Complementary and Integrative Health Professions Part 4: Putting Practice Back Into Evidence-based Practice by Recruiting Clinics and Patients.

OBJECTIVES: This paper focuses on the methods of a single study, incorporating data from chiropractic clinics into an evidenced-based investigation of the appropriateness of manipulation for chronic back pain. METHODS: A cluster sample of clinics (125) from 6 sites across the United States was chosen for this observation study. Patients with chronic low-back and neck pain were recruited using iPads, completed a series of online questionnaires, and gave permission for their patient records to be scanned. Patient records for a random sample were also obtained. The RAND staff and clinic personnel collected record data. RESULTS: We obtained survey data from 2024 patients with chronic low back pain, chronic neck pain, or both. We obtained patient record data from 114 of 125 clinics. These included the records of 1475 of the individuals who had completed surveys (prospective sample), and a random sample of 2128 patients. Across 114 clinics, 22% of clinics had patient records that were fully electronic, 32% had paper files, and 46% used a combination. Of the 114 clinics, about 47% scanned the records themselves with training from RAND. We obtained a total of 3603 scanned records. The patient survey data were collected from June 2016 to February 2017, the provider surveys from June 2016 to March 2017, and the chart pull from April 2017 to December 2017. CONCLUSIONS: Clinics can be successfully recruited for practice-based studies, and patients can be recruited using iPads. Obtaining patient records presents considerable challenges, and clinics varied in whether they had electronic files, nonelectronic records, or a mixture. Clinic staff can be trained to select and scan samples of charts to comply with randomization and data protection protocols in transferring records for research purposes.

Researching the Appropriateness of Care in the Complementary and Integrative Health Professions Part 2: What Every Researcher and Practitioner Should Know About the Health Insurance Portability and Accountability Act and Practice-based Research in the United States.

OBJECTIVE: This paper describes a process for ensuring and documenting Health Insurance Portability and Accountability Act (HIPAA) compliance in clinical practice-based research. METHODS: The Center of Excellence for Research in Complementary and Alternative Medicine was funded by National Center for Complementary and Integrative Health to develop the methods for researching the appropriateness of care in complementary and integrative health, which previously was known as complementary and alternative medicine. We recruited 125 participating chiropractic clinics for enrolling patients and gathering their data via the online surveys. Chiropractic clinics completed the following: (1) obtained the files of patients who provided prior consent (the prospective sample), (2) obtained the files of the patients selected randomly using specified randomization procedures (the retrospective sample), and (3) transferred all patient data to the RAND Corporation via an encrypted file. RESULTS: Most of the doctors of chiropractic from clinical practices had no concerns about obtaining and transferring the files of patients who provided informed consent. However, some doctors were uneasy about allowing the researchers to access the randomly selected files of patients who had not provided prior authorization. This led us to develop a set of forms to provide clinics about HIPAA compliance. CONCLUSION: For this study, we provided clinics with information about the rules under HIPAA, demonstrated how the study complied with those rules, explained the logic behind the necessity for collecting files from both the prospective and retrospective samples, and, if requested, provided clinics with a confidentiality agreement signed by the study principal investigator and an organizational contracts representative. The process we developed may assist other complementary and integrative health researchers and practitioners in future studies.

Researching the Appropriateness of Care in the Complementary and Integrative Health Professions: Part I.

OBJECTIVES: The purpose of this article is to report on the Center of Excellence for Research on Complementary and Alternative Medicine at RAND Corporation. The overall project examined the appropriateness of chiropractic spinal manipulation and mobilization for chronic low back pain and chronic cervical pain using the RAND and University of California Los Angeles Appropriateness Method, including patient preferences and costs, to acknowledge the importance of patient-centered care in clinical decision-making. METHODS: This article is a narrative summary of the overall project and its inter-related components (ie, 4 Research Project Grants and 2 centers), including the Data Collection Core, whose activities and learning will be the subject of a following series of methods articles. RESULTS: The project team faced many challenges in accomplishing data collection goals. The processes we developed to overcome barriers may be of use to other researchers and for practitioners who may want to participate in such studies in complementary and integrative health, which previously was known as complementary and alternative medicine. CONCLUSION: For this large, complex, successful project, we gathered online survey data, collected charts, and abstracted chart data from thousands of chiropractic patients. The present article delineates the challenges and lessons that were learned during this project so that others may gain from the authors' experience. This information may be of use to future research that collects data from independent practitioners and their patients because it provides what is needed to be successful in such studies and may encourage participation.

How Working Conditions in Civilian Jobs Can Affect Veterans' Health and Well-Being: Veterans' Issues in Focus.

Too often, policy discussions focus on employment rates over the quality of the jobs that are available to veterans. Ensuring safe and healthy working conditions for veterans should be a priority of policies and programs to improve employment opportunities for this population. Veterans have already put their lives and health on the line for their country, sometimes with long-term effects that make them vulnerable to additional hazards on the job. Understanding why veterans choose the occupations they do and the risks they are exposed to could lead to policies that improve veteran health and support for all workers.

Working Conditions and Racial and Ethnic Disparities in Self-rated Health.

OBJECTIVE: The aims of the study are to examine racial and ethnic differences in occupational physical demands, substantive complexity, time pressure, work hours, and establishment size and to assess whether working conditions contribute to racial and ethnic differences in self-rated health. METHODS: We used 2017 and 2019 Panel Study of Income Dynamics data for 8439 adults. Using path models, we examined working conditions among Black, Latino, and White workers and explored whether those conditions mediated racial and ethnic differences in incident poor self-rated health. RESULTS: Some working conditions disproportionately affected Black workers (high physical demands, low substantive complexity), Latino workers (low substantive complexity, small establishments), and White workers (time pressure). Time pressure predicted worse self-rated health; there was no evidence that the working conditions studied mediated racial/ethnic differences. CONCLUSIONS: Working conditions vary by racial and ethnic group; some predict worse health.

Modifying Text Messages from a Faith-Based Physical Activity Intervention with Latino Adults in Response to the COVID-19 Pandemic.

BACKGROUND: Text messages are useful for health promotion and can be modified during public health emergencies. PURPOSE: Describe how we developed and implemented a physical activity (PA) text messaging component within a faith-based intervention, modified the text message content in response to the COVID-19 pandemic and evaluated participants' perceptions of the modified text messages. RESEARCH DESIGN AND STUDY SAMPLE: PA promotion text messages were delivered to predominately Spanish-speaking, churchgoing Latino adults (n = 284) in Los Angeles, California. In 2020, we modified the messages to disseminate COVID-19-related information and support and share virtual PA resources. DATA COLLECTION AND ANALYSIS: We analyzed quantitative and qualitative survey data to gauge participants' experiences with the text messages. RESULTS: COVID-19 related text messages were a feasible, acceptable addition to a PA intervention for a sample of Latinos. CONCLUSIONS: Throughout the pandemic, the messages enabled continued communication and support for PA and protection from COVID-19 in a population at high-risk of health inequities.

Building Bridges Toward Common Goals - A Call for Greater Collaboration Between Public Health and Integrative, Complementary and Traditional Health Providers.

This commentary makes the case for greater collaboration between public health professionals and integrative, complementary and traditional health practitioners (ICTHP). Previous partnerships have been successful, and more such collaborative work is needed to help overcome division, enhance the health workforce, and move all involved toward shared goals. ICTHP providers may be uniquely able to work across ideological differences and engage individuals and communities who are less trusting of public health, including those who are vaccine hesitant. Diverse partnerships can be difficult to maintain, but the application of equitable processes may aid their success. In the face of highly complex public health challenges, partnerships with ICTHP are critical.

Low Job Control and Racial Disparities in Breastfeeding.

BACKGROUND: Low job control may predict shorter breastfeeding (BF) among working mothers and may contribute to racial disparities in BF. METHODS: We used demographic, employment, and health data for n = 631 observations from the Panel Study of Income Dynamics. Job control scores came from a job-exposure matrix.Using path analysis, we assessed whether job control predicted BF and mediated Black-White BF differences. We controlled for education, working hours, marital status, and low birthweight. RESULTS: Lower job control predicted decreased odds of BF for at least 6 months (odds ratio, 0.61; 95% confidence interval, 0.31-0.90; reference, no BF). Low job control explained 31% of the Black-White difference for both shorter-term and longer-term BF. CONCLUSIONS: Low job contributes to shorter BF and to BF disparities by race. Intervening to enhance job control could improve BF.

Incorporating Complementary and Integrative Health Providers in the Public Health Pandemic Response: Lessons from COVID-19 and Recommendations for the Future from a Multidisciplinary Expert Panel.

Complementary and integrative health (CIH) providers, such as chiropractors and naturopathic doctors, have been an underutilized public health asset in the response to the COVID-19 pandemic. This article seeks to inform how they can be better integrated into future responses to public health emergencies. The authors convened an expert panel of ten CIH and public health practitioners and researchers for a daylong discussion of how the CIH workforce could be better mobilized during future crises. In this article, the authors summarize the key barriers identified in the discussion and make recommendations on how they can be overcome.

Linking churches and parks to promote physical activity among Latinos: Rationale and design of the Parishes & Parks cluster randomized trial.

BACKGROUND: Regular physical activity (PA) contributes to positive health outcomes, but a minority of US adults meet minimum guidelines for moderate-to-vigorous PA (MVPA) and muscle-strengthening, and Latinos are less likely than whites to meet these guidelines. Public parks can be leveraged for community PA but tend to be underutilized, while churches have reach within Latino communities and can influence parishioners' health. METHODS: We are conducting a cluster randomized controlled trial to examine the impact of a multilevel, faith-based intervention linking Catholic parishes (n = 14) to their local parks on adult Latino parishioners' (n = 1204) MVPA and health-related outcomes. Our approach targets multiple levels (individual, group, church, and neighborhood-park) to promote health-enhancing PA through park-based exercise classes led by kinesiology students, peer leader-led walking groups, park-based church events, church-based PA support activities, and environmental advocacy. Data are collected at churches by trained bilingual/bicultural research assistants using accelerometry, surveys, and biometric procedures. We will implement a set of hierarchical repeated-measure linear models to examine effects on the primary outcome (MVPA) and secondary outcomes (self-reported PA, heart rate/fitness, waist circumference, waist-to-hip ratio, body fat, mental health, and perceived social support for PA). We will also conduct a process evaluation. CONCLUSION: To our knowledge, this will be the first study examining efficacy of an integrated church and park-based intervention on Latino adults' PA and represents a scalable model of PA programming for low-income communities. The intervention makes use of innovative partnerships within and across sectors - faith-based, local parks/city government, and local universities - further facilitating sustainability. CLINICALTRIALS: govID: NCT03858868.

Work, race and breastfeeding outcomes for mothers in the United States.

BACKGROUND: In the United States, mothers' employment status and occupation are related to breastfeeding. However, it is unclear whether not working leads to longer breastfeeding duration even when compared to professional/managerial jobs, which tend to accommodate breastfeeding better than service/manual labor jobs. Furthermore, occupation and breastfeeding are racially patterned, and it is possible that race could moderate the relationships between mother's work and breastfeeding. METHODS: Using data from the Panel Study of Income Dynamics, we modeled breastfeeding duration based on mother's employment/occupation (not working, professional/managerial work, or service/labor work) during the first 6 months postpartum, as well as mother's race (White, Black or other) and other potential confounders. We used zero-inflated negative binomial regression models and tested an interaction between employment/occupation type and race. Predictive margins were used to compare breastfeeding duration among subgroups. RESULTS: Mothers working in service/labor occupations had the shortest breastfeeding duration of the three employment/occupation groups, and there was no significant difference in duration between not working and professional/managerial occupation. White mothers had longer breastfeeding duration than Black mothers on average. When we included an interaction between employment/occupation and race, we found that among White mothers, non-working mothers breastfed the longest, while mothers in service/labor work breastfed for the shortest duration, but among Black mothers, mothers in professional/managerial work breastfed for longer than mothers in the other two work categories. DISCUSSION: Race moderated the relationship between employment status/occupation type and breastfeeding such that, for White mothers, not working was the most advantageous circumstance for breastfeeding, in line with traditional work-family conflict theory. In contrast, for Black mothers, professional/managerial work was the most advantageous circumstance. These findings support the idea of the Market-Family Matrix, which allows that different work scenarios may be more or less advantageous for parenting behaviors like breastfeeding, depending on mothers' circumstances.

Feasibility and acceptability of a mobile messaging program within a church-based healthy living intervention for African Americans and Latinos.

Church-based programs can act on multiple levels to improve dietary and physical activity behaviors among African Americans and Latinos. However, the effectiveness of these interventions may be limited due to challenges in reaching all congregants or influencing behavior outside of the church setting. To increase intervention impact, we sent mobile messages (text and email) in English or Spanish to congregants (n = 131) from predominantly African American or Latino churches participating in a multi-level, church-based program. To assess feasibility and acceptability, we collected feedback throughout the 4-month messaging intervention and conducted a process evaluation using the messaging platform. We found that the intervention was feasible to implement and acceptable to a racially ethnically diverse study sample with high obesity and overweight rates. While the process evaluation had some limitations (e.g. low response rate), we conclude that mobile messaging is a promising, feasible addition to church-based programs aiming to improve dietary and physical activity behaviors.

Clinical Scenarios for Which Cervical Mobilization and Manipulation Are Considered by an Expert Panel to Be Appropriate (and Inappropriate) for Patients With Chronic Neck Pain.

OBJECTIVES: Cervical mobilization and manipulation are 2 therapies commonly used for chronic neck pain (CNP). However, safety, especially of cervical manipulation, is controversial. This study identifies the clinical scenarios for which an expert panel rated cervical mobilization and manipulation as appropriate and inappropriate. METHODS: An expert panel, following a well-validated modified-Delphi approach, used an evidence synthesis and clinical acumen to develop and then rate the appropriateness of cervical mobilization and manipulation for each of an exhaustive list of clinical scenarios for CNP. Key patient characteristics were identified using decision tree analysis (DTA). RESULTS: Three hundred seventy-two clinical scenarios were defined and rated by an 11-member expert panel as to the appropriateness of cervical mobilization and manipulation. Across clinical scenarios more were rated inappropriate than appropriate for both therapies, and more scenarios were rated inappropriate for manipulation than mobilization. However, the number of patients presenting with each scenario is not yet known. Nevertheless, DTA indicates that all clinical scenarios that included red flags (eg, fever, cancer, inflammatory arthritides, or vasculitides), and some others involving major neurological findings, especially if previous manual therapy was unfavorable, were rated as inappropriate for both cervical mobilization and manipulation. DTA also identified the absence of cervical disk herniation, stenosis, or foraminal osteophytosis on additional testing as the most important patient characteristic in predicting ratings of appropriate. CONCLUSIONS: Clinical guidelines for CNP should include information on the clinical scenarios for which cervical mobilization and manipulation were found inappropriate, including those with red flags, and others involving major neurological findings if previous manual therapy was unfavorable.