Provider Support in Complementary and Alternative Medicine ...

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perceptions of provider support, patient-centered care, and empowerment as predictors of health ... of Perceived Provider Support and PCC with symptom relief.
THE JOURNAL OF ALTERNATIVE AND COMPLEMENTARY MEDICINE Volume 16, Number 7, 2010, pp. 745–752 ª Mary Ann Liebert, Inc. DOI: 10.1089/acm.2009.0381

Provider Support in Complementary and Alternative Medicine: Exploring the Role of Patient Empowerment Carla M. Bann, PhD,1 Fuschia M. Sirois, PhD,2 and Edith G. Walsh, PhD1

Abstract

Background: The quality of the patient–provider relationship is well-recognized as having a key role in therapeutic outcomes irrespective of treatment effects. Yet there is a lack of scales to assess aspects of complementary and alternative medicine (CAM) provider support. Objectives: The objectives of this study were to develop and psychometrically evaluate scales to measure patients’ perceptions of provider support, patient-centered care, and empowerment as predictors of health outcomes. Methods: Based on five focus groups with CAM clients, we developed the following three scales: Perceived Provider Support, Patient-Centered Care (PCC), and Empowerment. The scales were cognitively tested with 6 CAM users and then pilot-tested with 216 respondents. Confirmatory factor analyses, item response theory analyses, and Cronbach’s as were conducted to evaluate their psychometric properties. Bootstrapping techniques and structural equation modeling were used to evaluate Empowerment as a mediator of the relationship of Perceived Provider Support and PCC with symptom relief. Results: All three scales demonstrated high internal consistency with Cronbach’s alphas of 0.85 to 0.90 and confirmatory factor analyses supported a one-factor solution for each scale. Controlling for demographics, presenting problem, and main CAM provider used in the past 12 months, each of the scales had a positive and significant relationship with overall symptom relief for the patient’s primary presenting problem (p < .01). Bootstrapped Sobel tests were significant (p < .01), supporting the role of empowerment as a mediator of the impact of PCC and provider support on symptom relief. A structural equation model combining PCC and provider support into a single latent variable representing quality of patient–provider interactions and including empowerment as a mediator fit well. Conclusions: From a holistic perspective, CAM treatment effects can arise in part from sources related to the therapeutic relationship, as well as the philosophy of healing and specific techniques designed to reduce symptoms. This analysis provides conceptual support for this perspective, a means to evaluate aspects of the therapeutic relationship and to measure its impact on outcomes of CAM treatment across conditions and therapies.

Introduction and Background

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he quality of the patient–provider relationship is well recognized as having a key role in therapeutic outcomes irrespective of treatment effects.1–4 This may be especially true for complementary and alternative medicine (CAM) treatments delivered by a practitioner.5–7 Indeed, research to date suggests that a desire for a more patientcentered and supportive relationship is one reason why some people choose CAM,8,9 and that CAM patients value the caring and therapeutic relationship they have with their providers.6,10 Although aspects of the patient–provider relationship have been identified as key contextual components of

CAM care to be included when assessing outcomes,11,12 there is a lack of existing scales designed to measure specific aspects of CAM provider support. The purpose of this study was therefore to develop and psychometrically evaluate a set of scales designed to measure patients’ perceptions of provider support, patient-centered care, and empowerment they received as a part of their CAM treatments. Importance of Provider Support in CAM Outcomes In studies of both conventional medicine and CAM interventions, the therapeutic relationship is considered a key contextual factor that can aid in the process of healing. CAM

1

RTI International, Research Triangle Park, NC. Department of Psychology, Bishop’s University, Sherbrooke, Quebec, Canada.

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746 researchers have highlighted the need to examine CAM outcomes from a whole systems research approach, that is, one that includes a consideration of personal and contextual factors in the process and outcomes of healing.13 From this perspective, contextual factors such as aspects of the patient– provider relationship are proposed to play an influential role in treatment outcomes through their synergistic interaction with other system factors.14 Accordingly, researchers have developed a preliminary framework for organizing the possible components of CAM care, which presents several dimensions of the patient–provider relationship as important contextual factors.11 These include patient-centeredness of healing and the patient–practitioner relationship as distinct aspects of CAM provider support, which may be particularly relevant for CAM outcomes. In addition, empowerment has been identified as an intermediate outcome of the patient– practitioner relationship that can have important implications for healing.15 Patient-Centered Care Patient-centered care refers to building an empathetic relationship that considers the patient as a partner with the health care provider in the priorities, problems, and goals of treatment.16 The preference for a patient-centered approach to care has been linked to CAM use across several studies.8,9,17 The health benefits of patient-centered care are well documented in studies of conventional care,18 with patientcentered care associated with improved health outcomes,2 and disease self-management.19 In addition to better health outcomes, patient-centered care has been found to predict improved adherence to complex treatment regimens.3 With respect to CAM, the patient-centered approach is considered integral to the delivery of care, and is widely viewed as playing an important role in therapeutic outcomes by creating the context for healing.11,12,20 Empirical investigations of this type of provider support and its implications for treatment outcomes are limited, however, perhaps owing to a lack of adequate scales.5 Individualized treatment rather than administration of standardized protocols is another element of the patient-centered approach, a hallmark of some CAM treatments, and is oft-cited as a design and measurement challenge in CAM effectiveness research.21 One component of patient-centered care, empathy, has been examined as an important element of the therapeutic relationship. Mercer and colleagues developed the Consultation and Relational Empathy (CARE) measure22 to assess relational empathy as part of the process of care in general clinical settings. Both qualitative and quantitative methods were used to develop the CARE; however, the items were developed solely with patients from conventional practice. Tests of the 10-item CARE scale with CAM clients have found that empathy predicts positive outcomes in acupuncture23 and homeopathy24 clients. Nonetheless, empathy is considered to be only one aspect of patient-centered care, which is primarily focused on the shared management of illness between the patient and the practitioner.25 Provider Support Whereas patient-centered can be referred to as being seen and heard as a unique individual,3 provider support reflects perceptions of the patient–practitioner relationship as being

BANN ET AL. one that is emotionally supportive. Key characteristics of a supportive patient–practitioner relationship commonly mentioned by CAM clients include trust,7,26 acceptance,10,26 and feeling cared for.6,10 Apart from patient-centered care, provider support can be viewed as the overall quality of support received from the provider, and analogous to the term social support from the health psychology literature. Given the known links between the receipt of social support and health outcomes,27 it is not surprising that the quality of the relationship with the CAM provider is viewed as key for treatment success by CAM patients.6, 7 Empowerment One other aspect of a supportive and patient-centered relationship with the CAM provider is empowerment. Related to concepts such as self-efficacy and perceptions of control, empowerment is viewed as a key quality that distinguishes CAM from conventional biomedicine.28,29 In the context of CAM treatment, empowerment reflects a type of support that enables and motivates people to take the necessary steps to manage and improve their health in a selfdirected manner. Empowerment has been described as being characterized by responsibility and readiness for change.28 Although we are unaware of any existing scales to assess empowerment, Howie and colleagues30 have developed a measure of a related construct, enablement. The Patient Enablement Instrument (PEI) is a six-item scale that assesses immediate consultation outcomes related to coping and understanding one’s illness better. The PEI was developed with patients from conventional general practice and thus includes items that refer to illness as opposed to symptoms. Moreover, empowerment as we have defined it includes not just enablement, but also motivation to advocate for oneself with respect to health, not just illness. There is some evidence that empowerment may develop as a result of experience with CAM treatments and practitioners. For example, patients rate CAM providers higher on patient empowerment compared to medical doctors,31 and report that the empowering nature of CAM treatment facilitates gaining a sense of control over one’s health.32 Others have suggested that the holistic model of care that underlies many CAM therapies necessarily implies a participatory relationship between provider and client that creates a context that leads to empowerment.15 For example, Paterson and Britten 11 suggest that the therapeutic relationship is part of the dynamic process of healing which is inextricably linked with CAM treatment effects through reciprocal feedback loops. Relief of symptoms through CAM treatments is proposed to increase patients’ perceptions of control over symptoms, and enhance trust in the provider, which in turn motivates patients to continue treatment and other recommended self-care activities, resulting in further symptom reduction. Thus, the mutually reinforcing connections between the healing process and treatment outcomes are viewed as the basis for successful CAM outcomes. From this perspective we would argue that empowerment may be viewed as an intermediate outcome that arises from the unique context of holistic care, which in turn can have benefits for other salient outcomes such as symptom relief. Indeed, empowerment is posited as a type of CAM outcome in some models of CAM effects.11 Whether empowerment may

PROVIDER SUPPORT IN CAM link aspects of the patient–provider relationship to CAM outcomes such as symptom relief has yet to be investigated. The Current Study Despite the recognition of the importance of the patient– practitioner relationship for CAM outcomes, there are few available scales for assessing specific aspects of this relationship, and fewer still designed to measure CAM provider support that included CAM clients in their development. Although both the PEI 30 and the CARE22 assess patients’ perceptions of the therapeutic relationship and related outcomes, both were developed from consultation with general

747 practitioner patients, not CAM clients. Thus, elements unique to the CAM care experience are not addressed. CAM researchers have attempted to address this issue by adapting existing scales9 or using the best proxy scale available from extant measures.5 To address this gap, we developed and psychometrically evaluated three scales to measures specific aspects of CAM provider support that may be influential for CAM outcomes such as symptom relief. Given current theory on the possible role of empowerment in CAM outcomes, we also tested empowerment as a mediator between CAM patient–provider interactions (patient-centered care and provider support) and symptom relief. Methods Scale development process We used a systematic approach to scale development and refinement that incorporated patient input at each step in the process (Fig. 1). First, we conducted five focus groups in two geographic locations (North Carolina and Massachusetts), recruiting participants through CAM providers representing a wide array of CAM types and identified by local contacts as experienced and well-respected practitioners. Each group included 6 to 8 participants, resulting in a total of 36 focus group participants. Because we were interested in learning more about patients’ perceived benefits and positive outcomes Table 1. Demographic Characteristics of Pilot Study Participants Variable Demographics Gender Male Female Age 55 years or more 45–54 44 years or less Education Postgraduate or professional degree 4-year college graduate Some college or less Presenting problem Pain General wellness Other problem Type of therapist Acupuncturist Chiropractor Craniosacral therapist Other therapist Symptom relief Fewer symptoms Yes No Less severe symptoms Yes No Less frequent symptoms Yes No

FIG. 1.

Scale development process.

N ¼ 216.

N (%)

31 (14) 184 (85) 92 (43) 61 (28) 62 (29) 114 (53) 62 (29) 38 (18) 97 (45) 27 (13) 90 (42) 73 49 28 62

(34) (23) (13) (29)

103 (48) 113 (52) 135 (63) 81 (38) 73 (34) 143 (66)

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of CAM treatments, we recruited CAM users who felt the treatments they received were beneficial. We analyzed the focus group transcripts using the QSR NVivo33 program for qualitative analysis to identify common themes. One significant theme that emerged was the importance of the therapeutic relationship between patient and provider, including patient-centered care, provider support, and empowerment. The focus group findings are described in detail in Greene and colleagues.34 We drafted a pool of items to address the benefits participants described in the focus groups and asked experts in the field of CAM research to review the items for content and face validity. We then conducted one-on-one cognitive interviews35 with 6 of the focus group participants to identify any potential problems with item wording or interpretation and revised the items accordingly. Finally, we conducted a pilot study with a convenience sample of 216 current CAM consumers. Participants The analyses for this article utilized data from the 216 individuals who participated in the pilot survey; their demographic characteristics are shown in Table 1. Participants were recruited with the assistance of approximately 30 local CAM providers who provided a wide range of CAM services representing the five types of CAM services that have been defined by the National Center for Complementary and Alternative Medicine: whole medical systems (e.g., naturopathy, homeopathy, and Traditional Chinese Medicine),

biologically based practices (e.g., use of botanicals, specialized diets, and dietary supplements), manipulative and body-based practices (e.g., chiropractic, massage, Alexander Technique, Feldenkrais Method, and craniosacral therapy), mind–body interventions (e.g., yoga and hypnosis), and energy medicine (e.g., acupuncture, Reiki). We focused on CAM modalities that were provider-based rather than self-care practices. To encourage participation, providers were given flyers to post in reception areas, information cards for providers to distribute, and copies of the survey with prepaid envelopes attached to ensure confidentiality. Individuals were eligible for this study if they were 21 years of age or older, received treatments by one or more CAM providers for a health problem in the last year, and found their treatments to be beneficial. We considered this last requirement to be appropriate due to the exploratory nature of the study, in order to capture information about the types of benefits experienced and to identify the elements of effective provider interactions in analyzing the psychometric properties of the resultant scales. We discuss the implications of this sample restriction in the limitations section of the Discussion section. Measures Patient-centered care. The patient-centered care scale includes 10 statements, such as ‘‘The treatment is individualized for me at each session’’ and ‘‘My therapist receives feedback from my body that guides treatment’’ (Table 2). Respondents

Table 2. Factor Loadings and Participant Responses for Patient-Centered Care, Perceived Provider Support, and Empowerment Scales Item/scale Patient-centered care C1. I feel seen and heard as a unique individual by my therapist C2. My therapist has a full picture of me as a unique individual C3. My therapist is really interested in finding and addressing my health problems C4. The root causes of my problems are identified by my therapist C5. The root causes of my problems are being treated by my therapist C6. The treatment is individualized for me at each session C7. My therapist receives feedback from my body that guides treatment C8. My therapist asks me for feedback from my body that guides treatment C9. I know what to expect during treatment sessions C10. My therapist teaches me ways to relieve symptoms myself Perceived provider support S1. My therapist cares about me S2. I feel cared for during treatments S3. My therapist accepts me as I am S4. I receive personal attention during treatment S5. I can talk openly with my therapist S6. My therapist gives me hope S7. I trust my therapist Empowerment E1. Do you feel more in control of your health? E2. Do you know what to do to take care of your health problem? E3. Do you believe that your health problem will improve? E4. Do you advocate more for yourself? E5. Do you have techniques you can use when your symptoms get worse?

Strongly agree N (%)

Factor loading

152 (70) 114 (53) 153 (71)

0.51 0.69 0.68

87 (40) 98 (45) 151 (70) 152 (70) 126 (58) 128 (59) 82 (38) Strongly agree N (%) 145 (67) 154 (71) 145 (67) 171 (79) 151 (70) 124 (57) 166 (77) Yes, a lot N (%) 134 (62) 130 (60) 129 (60) 126 (58) 123 (57)

0.63 0.62 0.81 0.72 0.70 0.43 0.53 Factor loading 0.82 0.80 0.72 0.78 0.78 0.67 0.80 Factor loading 0.79 0.82 0.69 0.73 0.62

Factor loadings are based on one-factor confirmatory factor analyses for each scale: Patient-centered care (comparative fit index [CFI] ¼ 0.93, Tucker-Lewis fit index [TLI] ¼ 0.91, standardized root mean-square residual [SRMR] ¼ 0.05), perceived provider support (CFI ¼ 0.95, TLI ¼ 0.92, SRMR ¼ 0.04), and empowerment (CFI ¼ 0.96, TLI ¼ 0.91, SRMR ¼ 0.04).

PROVIDER SUPPORT IN CAM indicated their agreement with each statement using a 5-point scale from ‘‘strongly disagree’’ to ‘‘strongly agree.’’ Perceived provider support. The perceived provider support scale includes seven statements, addressing ways in which patients may feel supported by their CAM provider (Table 2). Similar to the patient-centered care scale, response options for this scale range from ‘‘strongly disagree’’ to ‘‘strongly agree.’’ Empowerment. The survey included five questions regarding possible ways in which the CAM therapies may have changed patients’ feelings of empowerment and/or control over their health problem (Table 2). Respondents answered each question using the following 3-point scale: ‘‘no,’’ ‘‘yes, a little,’’ or ‘‘yes, a lot.’’ Symptom relief. We asked participants whether they experienced fewer symptoms, less severe symptoms, or less frequent symptoms as a result of their CAM treatment. We added up these items to create an overall symptom relief scale with values of 0–3. Statistical analysis

749 their therapists taught them how to relieve symptoms themselves. On the provider support scale, they most often reported receiving personal attention, feeling cared for, and being able to talk openly. Slightly fewer reported that their therapist gave them hope. On the empowerment scale, levels of endorsement for the items ranged from 57% reporting they are a lot more likely to have techniques they can use when their symptoms get worse to 62% who reported feeling a lot more in control of their health. All three scales demonstrated high internal consistency based on Cronbach’s as: patient-centered care (a ¼ 0.87), perceived provider support (a ¼ 0.90), and empowerment (a ¼ 0.85). For each of the scales, confirmatory factor analyses indicated that the items on the scale are highly related and comprise one factor: patient-centered care (CFI ¼ 0.93, TLI ¼ 0.91, SRMR ¼ 0.05), perceived provider support (CFI ¼ 0.95, TLI ¼ 0.92, SRMR ¼ 0.04), and empowerment (CFI ¼ 0.96, TLI ¼ 0.91, SRMR ¼ 0.04); factor loadings are shown in Table 2. Respondents with CAM providers who practice patientcentered care and provide higher levels of support reported experiencing significantly greater overall symptom relief ( p < 0.01; Fig. 2). However, these effects were no longer significant after adding the indirect path through

First, we assessed the reliability and validity of the CAM patient-centered care, perceived provider support, and empowerment scales. Cronbach’s as were computed as a measure of internal consistency. To explore the factorial validity of the scales, we tested whether the items on each scale formed a single factor, using confirmatory factor analyses as implemented in the Mplus software program.36 We examined various fit indices, including the comparative fit index (CFI), Tucker-Lewis fit index (TLI), and standardized root mean-square residual (SRMR) to assess model fit. We then conducted a series of regression analyses to explore the relationship of patient-centered care and provider support with symptom relief and to determine whether empowerment serves as a mediator of this relationship, following the guidelines for establishing statistical mediation outlined by Baron and Kenny.37 We used the bootstrapping approach to estimate the Sobel test of indirect effects presented by Preacher and Hayes.38 The mediation analyses controlled for the following demographic variables: gender, age, education, presenting problem, and type of provider. Finally, we used structural equation modeling to test an overall model combining patient-centered care and perceived provider support into a single underlying latent variable representing quality of patient–provider interactions. Results Table 2 presents the item-level descriptive statistics for the two scales. Overall, participants reported high levels of patient-centered care, provider support, and empowerment, as would be expected given the focus of our study on satisfied CAM users. With respect to patient-centered care, respondents strongly endorsed items involving receiving individualized treatment, feeling seen and heard as a unique individual, and the therapist being interested in finding and addressing their health problems. Respondents were less likely to endorse items concerning whether the root causes of their problems are being identified and treated and whether

FIG. 2. Mediation analyses. **p < 0.01; ***p < 0.001.

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FIG. 3. Path diagram of empowerment as a mediator of relationship between patient–provider interactions and symptom relief. Note: Reference categories for sociodemographic variables are female, less than 45 years of age, high school of less education, other presenting problem, and acupuncturist. Model fit indices are: CFI ¼ 0.95, TLI ¼ 0.92, and SRMR ¼ 0.03. CFI, comparative fit index; TLI, Tucker-Lewis fit index; SRMR, standardized root mean-square residual. *p < 0.05; **p < 0.01; ***p < 0.001.

empowerment, suggesting that patient-centered care and provider support positively impact symptom relief by fostering patient empowerment. The bootstrapped Sobel tests of indirect effects were significant ( p < 0.01), confirming the role of empowerment as a mediator of this relationship. After establishing empowerment as a mediator between the individual scales and symptom relief, we then tested a structural equation model that includes patient-centered care and perceived provider support as indicators of a single latent variable representing quality of patient–provider interactions (Fig. 3). The model fit well (CFI ¼ 0.95, TLI ¼ 0.92, and SRMR ¼ 0.03). Those who were female and older reported more positive provider interactions, while those with a college education (versus high school or less) reported less positive interactions. Positive provider interactions were associated with greater feelings of empowerment, which in turn led to more overall symptom relief. We also tested the model with the individual components of symptom relief and found good model fit: fewer symptoms (CFI ¼ 0.97, TLI ¼ 0.96, and SRMR ¼ 0.03), less frequent symptoms (CFI ¼ 0.94, TLI ¼ 0.91, and SRMR ¼ 0.04), and less severe symptoms (CFI ¼ 0.97, TLI ¼ 0.95, and SRMR ¼ 0.03). Discussion The patient-centered care, perceived provider support, and empowerment measures all demonstrated good psy-

chometric properties with high Cronbach’s as and factor loadings. By building our measures upon the experiences of actual CAM users expressed through the focus groups and cognitive interviews, we were able to capture specific features of the relationship between CAM providers and patients important for fostering positive patient outcomes. Unlike measures of related constructs that were developed with general-practice patients,22,30 the new scales were developed with CAM clients and therefore do not refer to ‘‘illness’’ but to ‘‘health’’ or ‘‘health problems’’ or ‘‘symptoms,’’ terms that may be more relevant for those who seek CAM care. Consistent with holistic models of CAM care,11,12,20 we found evidence that aspects of the therapeutic relationship were associated with empowerment, which in turn was linked to symptom relief. The importance of measuring the nature of the relationship between the CAM practitioner and the patient has been noted by other researchers. For example, CAM outcomes are proposed to arise from several sources, including the patient–provider relationship.11,12 This relationship is viewed as a key contextual factor that shapes the healing experience.11,12 Rather than simply being longer time spent with patients, our findings suggest a more nuanced view of the beneficial dimensions of the CAM provider relationship and its potential outcomes. Indeed, we found that both patient-centered care and provider support were associated with a reduction in patient-reported symptoms, and that increases in empowerment explained this link.

PROVIDER SUPPORT IN CAM A couple of limitations of the study should be noted. The results reported here are based on a convenience sample of CAM users who were eligible for the pilot survey if they were over 21, current CAM users, and found CAM treatment to be beneficial. While these selection criteria are appropriate to the purpose of the study, the sample is clearly nonrepresentative, limiting the generalizability of the findings and likely creating a ceiling effect in regard to the findings. However, given the strength of the associations observed between the scale items within each scale, and between the scales and symptom relief in this sample, even more modest results are likely to reflect the same overall patterns. Still, it is important for the reader to understand that in a more representative sample of CAM users, statistics like the Cronbach’s as, the factor loadings and perhaps the impact of the measures on symptom relief would probably be lower. Also, we did not compare the characteristics of the measures in a non-CAM sample of health care users. Thus, while the literature suggests that patients experience more patient-centered care, more provider support, and feel more empowered through CAM use, we have not directly tested these propositions in this analysis. Indeed, using these measures to compare patient perceptions of CAM and conventional medical care providers is an interesting area for future research. These measures have various potential applications. In addition to investigating the relationships between these measures and clinical outcomes across conditions and therapies, the measures can be used to evaluate and improve the quality of the therapeutic relationship in both CAM and other types of care. Future research needs to include further evaluation of the scale properties in larger, more representative samples of CAM and conventional medical care patients to determine whether the properties remain consistent across treatment modality and/or condition. Longitudinal studies are also needed to explore the characteristics of the scales over time. For example, the ability of the measures to capture changes in provider support could be explored within the context of an intervention designed to enhance patient-centered care. The measures have recently been added to the PROCAIM Web-based data collection system, which will support comparisons of these measures to previously validated instruments of patient outcomes, such as the SF-36, the opportunity to evaluate their stability over time, and use as predictors or intervening variables in studies of commitment to CAM use and of clinical outcomes. Disclosure Statement No competing financial interests exist. References 1. Berry LL, Parish JT, Janakiraman R, et al. Patients’ commitment to their primary physician and why it matters. Ann Fam Med 2008;6:6–13. 2. Stewart M, Brown JB, Donner A, et al. The impact of patientcentered care on outcomes. J Fam Pract 2000;49:796–804. 3. Beach MC, Keruly J, Moore RD. Is the quality of the patient– provider relationship associated with better adherence and health outcomes for patients with HIV? J Gen Intern Med 2006;21:661–665. 4. Roberts C. ’Only connect’: The centrality of doctor–patient relationships in primary care. Fam Pract 2004;21:232–233.

751 5. So DW. Acupuncture outcomes, expectations, patient– provider relationship, and the placebo effect: Implications for health promotion. Am J Public Health 2002;92:1662–1667. 6. Luff D, Thomas KJ. ‘Getting somewhere’, feeling cared for: patients’ perspectives on complementary therapies in the NHS. Complement Ther Med 2000;8:253–259. 7. D’Crus A, Wilkinson JM. Reasons for choosing and complying with complementary health care: An in-house study on a South Australian clinic. J Altern Complement Med 2005; 11:1107–1112. 8. Richardson J. What patients expect from complementary therapy: A qualitative study. Am J Public Health 2004;94: 1049–1053. 9. Sirois FM, Purc-Stephenson R. Consumer decision factors for initial and long-term use of complementary and alternative medicine. Compl Health Pract Rev 2008;3:3–20. 10. Mercer SW, Reilly D. A qualitative study of patient’s views on the consultation at the Glasgow homoeopathic hospital, an NHS integrative complementary and orthodox medical care unit. Patient Educ Couns 2004;53:13–18. 11. Verhoef MJ, Vanderheyden LC, Dryden T, et al. Evaluating complementary and alternative medicine interventions: In search of appropriate patient-centered outcome measures. BMC Complement Altern Med 2006;6:38. 12. Long AF. Outcome measurement in complementary and alternative medicine: Unpicking the effects. J Altern Complement Med 2002;8:777–786. 13. Verhoef MJ, Vanderheyden LC, Fonnebo V. A whole systems research approach to cancer care: Why do we need it and how do we get started? Integr Cancer Ther 2006;5: 287–292. 14. Verhoef MJ, Lewith G, Ritenbaugh C, et al. Complementary and alternative medicine whole systems research: Beyond identification of inadequacies of the RCT. Complement Ther Med 2005;13:206–212. 15. Kaptchuk TJ, Edwards RA, Eisenberg DM. Efficacy beyond the placebo effect. In: Ernst E, ed. Complementary Medicine: An Objective Appraisal. Oxford: Butterworth, 1996:31–41. 16. Stewart M, Brown J, Weston W, et al. Patient-Centred Medicine Transforming the Clinical Method. Thousand Oaks, CA: Sage, 1995. 17. Swenson SL, Buell S, Zettler P, et al. Patient-centered communication: Do patients really prefer it? J Gen Intern Med 2004;19:1069–1079. 18. Stewart MA. Effective physician–patient communication and health outcomes: A review. Can Med Assoc J 1995;152: 1423–1433. 19. Naik AD, Kallen MA, Walder A, Street RL Jr. Improving hypertension control in diabetes mellitus: The effects of collaborative and proactive health communication. Circulation 2008;117:1361–1368. 20. Paterson C, Britten N. Acupuncture as a complex intervention: A holistic model. J Altern Complement Med 2004;10: 791–801. 21. Institute of Medicine of the National Academies. Complementary and Alternative Medicine in the United States. Washington, DC: National Academies Press, 2005. 22. Mercer SW, Maxwell M, Heaney D, Watt GCM. The consultation and relational empathy (CARE) measure: Development and preliminary validation and reliability of an empathy-based consultation process measure. Fam Pract 2004;21:699–705. 23. MacPherson H, Mercer SW, Scullion T, Thomas KJ. Empathy, enablement, and outcome: An exploratory study on

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Address correspondence to: Carla M. Bann, PhD RTI International 3040 Cornwallis Road P.O. Box 12194 Research Triangle Park, NC 27709 E-mail: [email protected]