Understanding the role of context in health policy implementation: a qualitative study of factors influencing traditional medicine integration in the Indian public healthcare system.

India's public health system aims to foster pluralism by integrating AYUSH (Ayurveda, Yoga & Naturopathy, Unani, Siddha, and Homeopathy) with mainstream biomedical care. This policy change provides an opportunity to explore the complexity of health system innovation, addressing the relationship between biomedicine and complementary or alternative medicine. Implementing health policy depends on local, societal, and political contexts that shape intervention in practice. This qualitative case study explores contextual features that have influenced AYUSH integration and examines the extent to which practitioners are able to exercise agency in these contexts. Health system stakeholders were interviewed (n = 37) and integration activities observed. The analysis identifies contextual factors in health administration, health facilities, community, and wider society which influence the integration process. In the administrative and facility spheres, pre-existing administrative measures, resource and capacity deficits limit access to AYUSH medicines and opportunities to build relationships between biomedical and AYUSH doctors. At the community and society levels, rural AYUSH acceptance facilitates integration into formal healthcare, while professional organisations and media support integrative processes by holding health services accountable. The findings also demonstrate how, amid these contextual influences, AYUSH doctors navigate the health system hierarchies, despite issues with system knowledge against a background of medical dominance.

'First in family' experiences in a Canadian medical school: A critically reflexive study.

BACKGROUND: Medical students from affluent and highly educated backgrounds remain overrepresented in Canadian medical schools despite widespread efforts to improve diversity. Little is known of the medical school experiences of students who are first in their family (FiF) to attend university. Drawing on Bourdieu and a critically reflexive lens, this study explored the experiences of FiF students in a Canadian medical school to better understand the ways in which the medical school environment can be exclusive and inequitable to underrepresented students. METHODS: We interviewed 17 medical students who self-identified as being FiF to attend university. Utilising theoretical sampling, we also interviewed five students who identified as being from medical families to test our emerging theoretical framework. Participants were asked to discuss what 'first in family' meant to them, their journey into medical school and their experiences at medical school. Bourdieu's theories and concepts were used as sensitising concepts to explore the data. RESULTS: FiF students discussed the implicit messages they received about who belongs in medical school, challenges in shifting from their pre-medical lives to a medical identity and competing with peers for residency programmes. They reflected on the advantages they perceived they had over their fellow students due to their less 'typical' social backgrounds. CONCLUSION: While medical schools continue to make strides when it comes to increasing diversity, inclusivity and equity require increased attention. Our findings highlight the ongoing need for structural and cultural change at admissions and beyond-change that recognises the much-needed presence and perspectives that underrepresented medical students, including those who are FiF, bring to medical education and healthcare. Engaging in critical reflexivity represents a key way that medical schools can continue to address issues of equity, diversity and inclusion.

The salutogenic gaze: Theorising the practitioner role in complementary and alternative medicine consultations.

Research on why people use complementary and alternative medicine (CAM) shows clients value the CAM consultation, where they feel listened to and empowered to control their own health. Such 'empowerment' through CAM use is often theorised as reflecting wider neoliberal imperatives of self-responsibility. CAM users' perspectives are well studied, but there has been little sociological analysis of interactions within the CAM consultation. Specifically, it is unclear how user empowerment/self-knowledge relates to the CAM practitioner's power and expert knowledge. We address this using audio-recorded consultations and interviews with CAM practitioners to explore knowledge use in client-practitioner interactions and its meaning for practitioners. Based on our analysis and drawing on Foucault (1973), The Birth of the Clinic: an archaeology of medical perception and Antonovsky (1979), Health, Stress and Coping, we theorise the operation of power/knowledge in the CAM practitioner-client dyad by introducing the concept of the 'salutogenic gaze'. This gaze operates in the CAM consultation with disciplining and productive effects that are oriented towards health promotion. Practitioners listen to and value clients' stories, but their gaze also incorporates surveillance and normalisation, aided by technologies that may or may not be shared with clients. Because the salutogenic gaze is ultimately transferred from practitioner to client, it empowers CAM users while simultaneously reinforcing the practitioner's power as a health expert.

"Another tool in our toolbox": a scoping review of the use of eHealth technologies in health social work practice.

There is increasing recognition of the salience of eHealth technologies in enhancing health service capacity. Yet social work remains "behind the curve" in progressing digital practices. As the demand for digital health care increases, particularly following COVID-19, it is becoming increasingly urgent to understand how social workers engage with eHealth technologies, and how technological engagement impacts on social work practice. In this scoping review, we sought to examine eHealth use in health social work practice. Our findings suggest that, while social workers recognize the strengths and opportunities to broaden the scope of their practice, they remain concerned that eHealth may not be congruent with the values and approaches of the profession. This review provides a broad overview of health social workers' engagement with eHealth technologies and considers implications for future research that examines the nuanced and complex nature of professional values, risk, and assessment in the digital space.

Classifying knowledge used in complementary medicine consultations: a qualitative systematic review.

BACKGROUND: Complementary Medicine (CM) is widely used internationally but there is limited understanding of the forms of knowledge CM practitioners use in their clinical practice and how they use this knowledge in interactions with patients. This review aims to synthesise the existing evidence on the forms of knowledge that are mobilised, and the role of this knowledge in the interactions between practitioners and patients during CM consultations. It considered a diverse range of CM practice areas to develop a classification of CM practitioners' knowledge use in consultations. METHODS: Systematic searches of health and sociology databases were conducted using core concepts, including complementary and alternative medicine, practitioners, and knowledge. Articles were included where they reported on data from recorded CM practitioner and patient consultations and offered insights into the types and applications of knowledge used in these consultations. 16 unique studies were included in the review. Data were extracted, coded and analysed thematically. RESULTS: Results demonstrate that diverse sources of knowledge were mobilised by practitioners, predominantly derived from the patients themselves -their bodies and their narratives. This reflected principles of patient-centredness. The use of discipline specific forms of knowledge and references to biomedical sources illustrated ongoing efforts towards legitimacy for CM practice. CONCLUSION: CM practitioners are navigating tensions between what some might see as competing, others as complementary, forms of knowledge. The classification system provides a useful tool for promoting critically reflective practice by CM practitioners, particularly in relation to self-assessment of knowledge translation and patient interactions.

The dynamics of TCAM integration in the Indian public health system: Medical dominance, countervailing power and co-optation.

Hierarchies of power among healthcare professionals are well documented, nonetheless, power remains neglected, understudied and under-theorised in health systems analysis and policy discussions, especially in the domain of Traditional, Complementary and Alternative Medicine (TCAM). Sociological and public health scholarship has documented the persistence of medical dominance in the health system, theorised as the limitation, subordination, exclusion and incorporation of other professions. This paper explores how interprofessional power dynamics shape the integration of TCAM into Indian primary healthcare centres, as part of a nationwide policy of TCAM integration and medical pluralism implemented since 2005. We conducted interviews (n = 37) with health system administrators, nurses, pharmacists, TCAM and biomedicine doctors, and observed day-to-day activities of primary healthcare centres for six months in Odisha state, India. Thematic analysis enabled the identification of themes and exploration of sub-themes. The analysis revealed multilayered forms of medical dominance within the primary healthcare system and identified multiple sites where everyday power is mobilised. Biomedicine practitioners exercised authoritative power and restricted TCAM doctors' access to facility-level resources, i.e. financial and workforce support, which inhibited the integration policy implementation. Significantly, TCAM doctors were 'ordered' to practice biomedicine at primary healthcare centres, which was beyond the scope of the integration policy. However, TCAM doctors were also able to exercise countervailing power in their day-to-day activities in the primary healthcare centres and sought to assist patients' health behaviour change through their authoritative knowledge about 'how to live a healthy life'. The health system actors involved in policy implementation hold a range of forms of power specific to the circumstances, influencing the integration processes. We explain these dynamics in relation to existing theories of medical dominance and countervailing power, while introducing a previously unreported dimension of dominance: 'co-optation', which enrols TCAM practitioners in the practice of biomedicine.

Naturopaths' mobilisation of knowledge and information in clinical practice: an international cross-sectional survey.

BACKGROUND: The contemporary evidence-based practice model acknowledges the importance of patient preferences and clinician experience when applying evidence within a clinical setting. Knowledge mobilisation (KM) acknowledges the complexities of knowledge translation by recognising and respecting diversity in types of knowledge and how such diversity can influence health care and health care choices. While there has been considerable discussion on KM in health care, it has received little attention in the field of naturopathy. Despite naturopathy's widespread international use, it is unclear how naturopathic practitioners (NPs) use and share knowledge and information in clinical practice. This study examines the mobilisation of knowledge amongst NPs internationally. METHODS: Online, international, cross-sectional survey of a self-selected sample of NPs from any country, that were either currently in clinical practice or had been in practice within the previous 12 months. The survey was administered in five languages (English, French, Portuguese, Spanish, German). Descriptive statistics were prepared for all survey items. RESULTS: The survey was completed by 478 NPs who reported using an average of seven (median = 7, SD = 2.6) information sources to inform patient care. NPs also drew on knowledge gained through patients sharing their perspectives of living with their health condition (Always/Most of the time: 89.3%). They mostly sought knowledge about how a treatment might benefit a patient, as well as knowledge about treatment safety and a better understanding of a patient's health condition. NPs frequently reported sharing knowledge developed through consideration of the patient's unique needs (83.3%), and primarily shared knowledge by producing information for the public (72.6%) and for patients (72.2%). CONCLUSIONS: Based on these findings, it may be argued that NPs practice knowledge mobilisation; employing multiple forms and sources of knowledge, and mobilising knowledge to - as well as from - others. Due to their active engagement in patient and community education, NPs also may be considered knowledge brokers. In the context of the growing understanding of the complexities of knowledge translation and mobilisation in contemporary health care - and particularly within the context of implementation science - this study provides novel insights into an under-researched element of health services accessed by the community.

Transitional journeys into, and through medical education for First-in-Family (FiF) students: a qualitative interview study.

BACKGROUND: There has been much interest in the transitions along the medical education continuum. However, little is known about how students from non-traditional backgrounds experience both the move to, and through Medical School, and their ambitions post-graduation. This research sought to understand the transitional journey into, and through undergraduate medical education, and future career aspirations for first-in-family (FiF) medical students. METHODS: Based on a interpretivist epistemological perspective, 20 FiF students from one English Medical School participated in semi-structured interviews. Participants were identified according to purposive inclusion criteria and were contacted by email via the student association at the Medical School and academic year leaders. The team approach to the thematic analysis enhanced the findings credibility. This research was part of an international collaboration. RESULTS: In the first transition, 'The Road to Medical School', a passion for science with an interest in people was a motivator to study medicine. Participants' parents' shared the elation of acceptance into Medical School, however, the support from school/college teachers was a mixed experience. In 'The Medical School Journey' transition, knowledge about the medical curriculum was variable. 'Fitting' in at Medical School was a problem for some, but studying for an elite degree elevated social status for many study participants. A source of support derived from senior medical student peers, but a medical degree could sacrifice students' own health. In the final transition, 'Future Plans', a medical career was perceived to have intrinsic value. Clarity about future aspirations was related to clinical experience. For some, career trajectories were related to a work-life balance and future NHS working conditions for Junior Doctors. CONCLUSIONS: The transitions highlighted in this article have important implications for those educators interested in a life cycle approach to widening participation in medical education. Future research should explore the post-graduation transitions for doctors from first-in-family University backgrounds.

Registered Nurses' communication about patients' use of complementary therapies: A national survey.

OBJECTIVE: To identify communication patterns of Registered Nurses regarding patients' use of complementary therapies. METHODS: A cross-sectional online survey conducted in 2017 recruited Australian Registered Nurses working in any area of nursing. RESULTS: Responses of 614 Registered Nurses were analysed. Patient-initiated discussion of complementary therapies were common for 77% of nurses; nurse-initiated discussions were perceived by 73% (sometimes/almost always/always). Nurses' personal use of complementary therapies predicted discussion with patients and education-based, oncology, or aged care/rehabilitation nurses were most likely to initiate dialogue. Many (55%) did not 'recommend' a particular therapy, although 12% 'almost always/always' did so. Four out of five nurses (84%) documented patients' use and communicated with medical/nursing colleagues about this use. Conversely, 61% 'never' or 'almost never' communicated with a complementary therapy practitioner. CONCLUSION: Nurses working in Australia often discuss complementary therapies, however they rarely specifically recommend their use. Their workplace environment and clinical context influenced nurses' willingness to communicate about complementary therapy use. PRACTICE IMPLICATIONS EVIDENCE: suggests the need for policy development to promote communication between mainstream healthcare providers and complementary therapy practitioners to support the delivery of safe, high quality patient care.

Nurses' attitudes and behaviour towards patients' use of complementary therapies: A mixed methods study.

AIM: To explore Registered Nurses' attitudes and behaviour towards patients' use of complementary therapies. BACKGROUND: Despite high rates of use of complementary therapies by the general population, little is known of how nurses respond to patients' use of these therapies. DESIGN: A two-phase sequential exploratory mixed methods design. METHODS: Nineteen Registered Nurses working in Australia participated in a semi-structured interview in 2015-2016 and emerging themes informed the development of a quantitative survey instrument administered online nationwide in 2016. FINDINGS: Emerging key themes "Promoting safe care"; "Seeking complementary therapies knowledge";" Supporting holistic health care"; and "Integrating complementary therapies in practice" were reflected in survey results. Survey responses (N = 614) revealed >90% agreement that complementary therapies align with a holistic view of health and that patients have the right to use them. Most nurses (77.5%) discussed complementary therapies with patients and 91.8% believed nurses should have some understanding of the area. One-third did not recommend complementary therapies and there was a lack of overall consensus as to whether these therapies should be integrated into nursing practice. Nurses with training in complementary therapies held more positive views than those without. CONCLUSION: Nurses were generally supportive of patients' interest in complementary therapies, although their primary concern was safety of the patient. Despite broad acceptance that nurses should have a basic understanding of complementary therapies, there was a lack of consensus about recommendation, integration into nursing practice and referral. Further research should explore how nurses can maintain safe, patient-centred care in the evolving pluralistic healthcare system.

Alternative futures: Fields, boundaries, and divergent professionalisation strategies within the Chiropractic profession.

Sociological studies of the complementary and alternative medicine (CAM) occupations have documented the professionalisation strategies these groups use to establish boundaries between themselves and their competitors, including seeking educational accreditation and statutory regulation/licensure. Chiropractic has been particularly successful at professionalising and in Australia and the UK it is taught within public universities. Recent events have threatened chiropractic's university foothold, however, showing that professionalisation needs to be understood as an ongoing process of negotiation. Based on interviews with chiropractors in Australia and the UK, this paper examines the professionalisation strategies deployed by chiropractors within and outside of the university. Highly divergent strategies are identified across different sectors of the profession, relating to defining the chiropractic paradigm, directing education and constructing professional identity. In each domain, chiropractic academics tended to prioritise building the evidence base and becoming more aligned with medicine and other allied health professions. Although some practitioners supported this agenda, others strove to preserve chiropractic's vitalistic philosophy and professional distinction. Following Bourdieu, these intra-professional struggles are interpreted as occurring within a field in which chiropractors compete for different forms of capital, pulled by two opposing poles. The differing orientations and strategies pursued at the two poles of the field point to a number of possible futures for this CAM profession, including a potential split within the profession itself.

Nurses' attitudes towards complementary therapies: A systematic review and meta-synthesis.

BACKGROUND: The use of complementary therapies is becoming increasingly prevalent. This has important implications for nurses in terms of patient care and safety. OBJECTIVE: The aim of this meta-synthesis is to review critically, appraise and synthesize the existing qualitative research to develop a new, more substantial interpretation of nurses' attitudes regarding the, use of complementary therapies by patients. DATA SOURCES: A search of relevant articles published in English between, January 2000 and December 2015 was conducted using the following, electronic databases; MEDLINE, CINAHL and AMED. Reference lists of selected papers and grey literature were also interrogated for pertinent, studies. DESIGN: This review is reported according to the Enhancing Transparency in Reporting the Synthesis of Qualitative Research (ENTREQ) guidelines. Data were extracted and analysed using a thematic synthesis process. RESULTS: Fifteen articles were included in this review. Five analytical themes emerged from the data relating to nurses' attitude towards complementary therapies: the strengths and weaknesses of conventional medicine; Complementary therapies as a way to enhance nursing practice; patient empowerment and patient-centeredness; cultural barriers and enablers to integration; and structural barriers and enablers to integration. DISCUSSION: Nurses' support for complementary therapies is not an attempt to challenge mainstream medicine but rather an endeavour to improve the quality of care available to patients. There are, however, a number of barriers to nurses' support including institutional culture and clinical context, as well as time and knowledge limitations. CONCLUSION: Some nurses promote complementary therapies as an opportunity to personalise care and practice in a humanistic way. Yet, nurses have very limited education in this field and a lack of professional frameworks to assist them. The nursing profession needs to consider how to address current deficiencies in meeting the growing use of complementary therapies by patients.

Experiences of medical students who are first in family to attend university.

CONTEXT: Students from backgrounds of low socio-economic status (SES) or who are first in family to attend university (FiF) are under-represented in medicine. Research has focused on these students' pre-admission perceptions of medicine, rather than on their lived experience as medical students. Such research is necessary to monitor and understand the potential perpetuation of disadvantage within medical schools. OBJECTIVES: This study drew on the theory of Bourdieu to explore FiF students' experiences at one Australian medical school, aiming to identify any barriers faced and inform strategies for equity. METHODS: Twenty-two FiF students were interviewed about their backgrounds, expectations and experiences of medical school. Interviews were recorded, transcribed and analysed thematically. Findings illustrate the influence and interaction of Bourdieu's principal forms of capital (social, economic and cultural) in FiF students' experiences. RESULTS: The absence of health professionals within participants' networks (social capital) was experienced as a barrier to connecting with fellow students and accessing placements. Financial concerns were common among interviewees who juggled paid work with study and worried about expenses associated with the medical programme. Finally, participants' 'medical student' status provided access to new forms of cultural capital, a transition that was received with some ambivalence by participants themselves and their existing social networks. CONCLUSIONS: This study revealed the gaps between the forms of capital valued in medical education and those accessible to FiF students. Admitting more students from diverse backgrounds is only one part of the solution; widening participation strategies need to address challenges for FiF students during medical school and should enable students to retain, rather than subdue, their existing, diverse forms of social and cultural capital. Embracing the diversity sought in admissions is likely to benefit student learning, as well as the communities graduates will serve. Change must ideally go beyond medical programmes to address medical culture itself.

Regional Influences on Chinese Medicine Education: Comparing Australia and Hong Kong.

High quality education programs are essential for preparing the next generation of Chinese medicine (CM) practitioners. Currently, training in CM occurs within differing health and education policy contexts. There has been little analysis of the factors influencing the form and status of CM education in different regions. Such a task is important for understanding how CM is evolving internationally and predicting future workforce characteristics. This paper compares the status of CM education in Australia and Hong Kong across a range of dimensions: historical and current positions in the national higher education system, regulatory context and relationship to the health system, and public and professional legitimacy. The analysis highlights the different ways in which CM education is developing in these settings, with Hong Kong providing somewhat greater access to clinical training opportunities for CM students. However, common trends and challenges shape CM education in both regions, including marginalisation from mainstream health professions, a small but established presence in universities, and an emphasis on biomedical research. Three factors stand out as significant for the evolution of CM education in Australia and Hong Kong and may have international implications: continuing biomedical dominance, increased competition between universities, and strengthened links with mainland China.

Epistemic cultures in complementary medicine: knowledge-making in university departments of osteopathy and Chinese medicine.

There is increasing pressure on complementary and alternative medicine (CAM) to follow the evidence-based approach promoted in allied health and medicine, in which the randomised control trial represents the evidence gold standard. However, many CAM advocates see these methods as undermining the holism of CAM practice. This paper explores how such tensions are managed in CAM university departments - settings in which particular forms of knowledge and evidence are given 'official' imprimatur by CAM educators and researchers. By comparing two types of CAM, the paper also unpacks differences within this broad category, asking whether CAM academic disciplines comprise different 'epistemic cultures' (Knorr-Cetina, K. (1999). Epistemic cultures: How the sciences make knowledge. Cambridge, MA: Harvard University Press). Interviews were conducted with 20 lecturers in Chinese medicine and osteopathy, across five Australian universities, and augmented with observation in two degree programs. Findings reveal contrasting ontological and epistemological perspectives between the two academic fields. Chinese medicine lecturers had largely adopted bioscientific models of research, typically conducting laboratory work and trials, although teaching included traditional theories. Osteopathy academics were more critical of dominant approaches and were focused on reframing notions of evidence to account for experiences, with some advocating qualitative research. The study illustrates CAM's 'epistemic disunity' while also highlighting the particular challenges facing academic CAM.

Between the bench, the bedside and the office: The need to build bridges between working neuroscientists and ethicists.

This paper presents findings from an empirical study that explored the meaning of ethics in the everyday work of neuroscientists. Observation and interviews were carried out in one neuroscience research group that was involved in bench-to-bedside translational research. We focus here specifically on the scientists' perceptions of bioethics. Interviewees were often unfamiliar with bioethics as a discipline, particularly the more junior members of the group. Those who were aware of its existence largely viewed it as something distant from them, and as either too abstract, not relevant or an alien imposition on their work. Some interviewees themselves pointed to the need for better 'bridge building' between ethical principles and real-world examples drawn from scientific practice, and we argue that this space is where a more empirically grounded ethics may be useful in terms of actually engaging scientists at both the bench and the bedside.

Enacting the 'neuro' in practice: translational research, adhesion and the promise of porosity.

This article attends to the processes through which neuroscience and the neuro are enacted in a specific context: a translational neuroscience research group that was the setting of an ethnographic study. The article therefore provides a close-up perspective on the intersection of neuroscience and translational research. In the scientific setting we studied, the neuro was multiple and irreducible to any particular entity or set of practices across a laboratory and clinical divide. Despite this multiplicity, the group's work was held together through the 'promise of porosity'--that one day there would be translation of lab findings into clinically effective intervention. This promise was embodied in the figure of the Group Leader whose expertise spanned clinical and basic neurosciences. This is theorized in terms of a contrast between cohesion and adhesion in interdisciplinary groupings. We end by speculating on the role of 'vivification'--in our case mediated by the Group Leader--in rendering 'alive' the expectations of interdisciplinary collaboration.

Neuroscientists' everyday experiences of ethics: the interplay of regulatory, professional, personal and tangible ethical spheres.

The ethical issues neuroscience raises are subject to increasing attention, exemplified in the emergence of the discipline neuroethics. While the moral implications of neurotechnological developments are often discussed, less is known about how ethics intersects with everyday work in neuroscience and how scientists themselves perceive the ethics of their research. Drawing on observation and interviews with members of one UK group conducting neuroscience research at both the laboratory bench and in the clinic, this article examines what ethics meant to these researchers and delineates four specific types of ethics that shaped their day-to-day work: regulatory, professional, personal and tangible. While the first three categories are similar to those identified elsewhere in sociological work on scientific and clinical ethics, the notion of 'tangible ethics' emerged by attending to everyday practice, in which these scientists' discursive distinctions between right and wrong were sometimes challenged. The findings shed light on how ethical positions produce and are, in turn, produced by scientific practice. Informing sociological understandings of neuroscience, they also throw the category of neuroscience and its ethical specificity into question, given that members of this group did not experience their work as raising issues that were distinctly neuro-ethical.

The consequences of authentic early experience for medical students: creation of metis.

CONTEXT: Authentic early experience (AEE) describes experiences provided to new medical students to undertake 'human contact' to enhance learning. Although the concept of AEE is not new, and was commonplace prior to the Flexner Report of 1910, little is known about how or why meaning and knowledge are constructed through early student placements in medical, social and voluntary workplaces. Variance among settings means AEE is a collection of non-uniform, complex educational interventions which require students to make repeated transitions between different workplaces and their university institution. The purpose of this paper is to develop theory in this context. METHODS: We report on a study undertaken in a UK medical school using interviews and discussion groups to generate data from students, workplace supervisors and school faculty staff. We used narrative analysis to access knowledge and meaning construction, in combination with analytic tools drawn from thematic and interpretative approaches to phenomena. We sought to refine theoretical understanding through the application of metis, a socio-cultural theory novel to the field of medical education. RESULTS: Scott's concept of metis provides a useful theoretical framework for understanding how AEE works for students in terms of their creation of meaning and how they choose to use it in relation to formally recognised knowledge. Knowledge and meaning, generated as a consequence of AEE, contained dichotomies and paradoxes. Students improvised, in the face of unpredictability and uncertainty, to create a form of metis that allowed them to handle the perceived competing demands of AEE settings and the medical school. DISCUSSION: We demonstrate how meaning making can be conceived of as student metis arising from social processes in students' learning interactions. We suggest that the development of collaborative working with students could potentiate positive forms of student metis, thereby maximising desirable educational consequences. Further work is required to establish effective ways to do this.