Person-centred care and naturopathy: patient beliefs and

values.

Introduction

This paper explores patient beliefs and values for those consulting

with a naturopath in Australia with relevance to person-centred care.

Understanding, respecting and honouring the patient as a person with

individual beliefs and values are important aspects in ensuring

person-centred care, and are an important component of naturopathic

practice development.

Patient-centred care is internationally recognised as a dimension

of the broader concept of high-quality health care. (1-3) It is

recognised that good patient health outcome must be defined by what is

meaningful and valuable to that individual patient. (1,2) Practitioner

mindfulness of the patient's beliefs and values, alongside their

own, is important in identifying possible areas of conflict that may

exert some influence on clinical decision making. (2) Being mindful of

what the patient considers important, as well as their beliefs and

values, is important for maintaining trust and open communication

channels. A general practitioner, reflecting on clinical practice,

highlighted this. (4) The practitioner noted that being open and

non-judgemental to her patients' beliefs and values allowed for

open dialogue which allowed the practitioner to provide differing

opinions and evidence in a non-threatening way. (4) This collaborative

approach provides the patient with empowerment to actively participate

in their health plan and health decisions. Ultimately this practitioner

found this approach allowed her patients to reach the best possible

health outcomes. (4) Shared decision making has also been shown to

support treatment adherence. (5)

Identifying the patient's beliefs and values helps to clarity

their treatment expectations, which benefits practitioner and patient.

On-going evaluation and readjusting of values, beliefs and expectations

is important, especially as some needs, beliefs and values may change as

a health condition moves from acute to chronic. This has been

demonstrated in patients with HIV/AIDS, as their values and beliefs in

using complementary medicine (CM) and consulting with CM practitioners

differed as their condition progressed. (6) Cultural background and

religious beliefs can also influence health beliefs and values. For

example, Islam prohibits the use of swine derived products, (7) which

may influence what medicines are deemed acceptable by the patient.

Evidence-based practice encompasses person-centred care. The

practitioner must consider the patient's individual needs,

including beliefs and values, and combine this with clinical experience,

knowledge, and scientific evidence for clinical decision-making. (1)

Practice development teachings advocate the use of 'CIP

principles', Collaboration, Inclusiveness and Participation, which

allow for authentic practitioner engagement with key stakeholders,

including patients and their significant others, such as family. (2)

Utilising CIP principles, the practitioner is able to ensure that the

beliefs and values of the patient are incorporated to collaboratively

create a shared vision of desired health outcomes. The practitioner

facilitates this by 'blend[ing] personal qualities and creative

imagination with practice skills and practice wisdom.'2 This

approach allows for the formation and fostering of healthy relationships

through a respectful approach to patients and their needs, beliefs and

values, and demonstrates respect for their individual right to

self-determination, empowerment and enablement so that they may be

involved in their own individual care plan. Ultimately this ensures a

well-grounded foundation for person-centred care. (2)

With at least 40% of the general Australian population using some

form of CM product, (8) CMs forms an important part of patient-centred

care. Concerns have been raised in relation to patients with serious but

treatable conditions, that they may substitute non-evidence-based CM in

the place of evidence-based treatments; (9) hence, research in this area

is needed to gain a greater understanding of this topic and ensure

informed public health, clinician, and patient decision making.

In some conditions, such as cancer, CM use is reported to be

The use of naturopathic practitioners for primary health care needs

differs between population groups, and is influenced by beliefs, values,

and specific cultural and health needs. For example, 78% of people

living in rural communities, with an average age of 66, indicated they

had taken a CM product, with 66% consulting with a CM practitioner and

15% with a naturopath. (21) Women are key drivers of this trend with

recent research finding that 22% of women consulted a naturopath in the

prior 12 months. (22) Older research found that a total of 10.9% of

mid-aged women consult a naturopath, increasing to 15% if they have

cancer. (23) In general, research has shown that 17.1% of people with

cancer consult a CM practitioner, with herbal medicine and naturopathy

being the most common therapies utilised. (24) In these cases, CM is

used as an adjunct, not a substitute, to conventional medicine (24) with

up to 94% of patients believing that CM enhances conventional medical

treatment. (25) This is consistent with HIV/AIDS patients, with 49%

stating they used CM to assist with the management of the HIV virus.

Only 5% indicated that they used solely CM for their HIV/AIDS treatment.

(26)

There are a number of themes emerging from research literature in

relation to patient beliefs and values in relation to naturopathic

practices. These include a desire for integrated medicine, health

promotion and disease prevention, personal empowerment, sharing of

beliefs and values with the practitioner including cultural and

post-modern values, naturopath as service provider of information and

tailored natural medicines.

1: Integrative Medicine: the best of both worlds

Patients with HIV/AIDS describe using CM to improve their health,

rather than as a result of dissatisfaction with conventional medicine.

(6,26,27) This demonstrates a desire for integrative medicine (IM) care;

a desire to continue to use conventional medicine and support this with

the use of CM.

To fulfil patient need, a number of IM clinics have been

established in Australia. These clinics are multi-disciplinary,

incorporating conventional medicine practitioners with allied health and

complementary medicine practitioners, such as naturopaths, all located

in the one premises. The aim of IM clinics is to be patient-centric,

holistic and to focus on health. (28-31) 3.8% of practicing Australian

naturopaths, herbalists or acupuncturists surveyed in research work with

a GP in an IM clinics. (31,32) There is evidence to support the idea

that an IM approach contributes to higher levels of patient satisfaction

and improves patient perceptions of health. (31) In this sense, the IM

approach supports person-centred care principles, although more research

is needed to establish if patient beliefs and values related to IM

clinical settings are being met. Limited research has established two

main IM models operating in IM clinics. (31) The 'equitable

partnerships' model puts patient preference, needs and values ahead

of practitioner needs, and is marked by all involved practitioners

adopting a shared and collaborative approach to patient care. (31) The

second model is more hierarchical, where the general practitioner acts

as gatekeeper, monitoring which CM practitioner and therapy is most

relevant for the patient. (31) Either approach may be person-centred

depending on the patient's preference, and the willingness of

practitioners to co-operate to ensure best patient outcomes in line with

the patient's vision of health. (31)

From the perspective of patients and practitioners IM: (1) provides

authentically patient-centred care; (2) fills the gaps in treatment

effectiveness, particularly for certain patient populations (those with

complex, chronic health conditions, those seeking an alternative to

pharmaceutical health care, and those seeking health promotion and

illness prevention); and (3) enhances the safety of primary health care

(due to IM retaining a general medical practitioner as the primary

contact practitioner and using strategies to increase disclosure of

treatments between practitioners). (28)

2: Health promotion and prevention of disease

Users of CM in the general population cited promotion of general

health and prevention of illness as the primary reasons for CM medicine

and therapy use. (19) Self-care, active coping and valuing self-reliance

were identified as primary motivators for using CM and consulting a CM

practitioner in older adults living in a rural location in Australia.

(21)

3: Personal empowerment

A clear theme of positive empowerment emerges from the research,

especially in relation to the use of CM for chronic conditions such as

HIV/AIDS and cancer. Patients describe gaining a sense of control from

the active involvement in their health care. (6,27) Aspects of personal

empowerment and self-reliance are also apparent in rural, aging

communities. (21)

4: Shared beliefs and values

a) Cultural:

Research within Australian rural communities indicate patients are

more inclined to consult a naturopath who was a local member of the

community. (21,33) Practitioners noted that it was only once they were

accepted as locals that their services were sort. (33) Patients valued

autonomy, self reliance and self-care. (21,33) Patients also valued

practitioners providing them with additional information and reading,

which encouraged shared decision making more hints and empowerment in their

personal health management. (5,21,33)

Cultural factors, values and beliefs inherent in immigrant

communities may influence the use of naturopaths and herbalists for

specific health needs. Ethnographic research found that Latin American

immigrants in Melbourne consulted traditional healers for specific

conditions, the knowledge of which was kept within the community. (34)

The research indicates that South American immigrant women living in

Australia, who would culturally consult traditional medicine healers,

consult naturopaths or herbalists in Australia, mainly for digestive

issues. (34) The traditional medicine healer, naturopath or herbalist

did not replace the need for a medical practitioner, especially in what

was considered more serious disease such as sexually transmitted

disease. (34) The shared beliefs and values, as well as the sharing of

common language was found to be the key influencers in the use of

traditional medicine healer, naturopath or herbalist. (34)

Some CM users believe the historical use of traditional medicine

validates its use in contemporary health care. (19) It is important to

note that not all cohorts found the traditional aspect or ideologies of

naturopathic practice of significance. For example, patients with

HIV/AIDS consulting with a naturopath placed more importance on what

they perceived as beneficial for their health and wellbeing (6) as

opposed to naturopathic philosophy. For these patients it was common to

be overwhelmed by the advice and possible impracticalities provided by

the CM practitioners, which resulted in the participants deciding to

limit their involvement. Therapy that was seen to be too onerous on a

daily basis was seen as having a detrimental effect on health, and hence

dropped. (6) This highlights the importance of establishing and

re-assessing patient values and beliefs to ensure patient needs are

being addressed, as well as understanding the reasons for poor

adherence. (5)

b) Post-modern values:

The rise in post-modern values is thought to play a role in the

attraction of individuals to CM and IM. (19,28,35) A range of beliefs

include concepts of holism, the importance of a medicine being

'natural', individual responsibility for health and wellness,

and consumerism. (19)

Research indicates that the rise in post-modern values is evident

in patients attending IM clinics: 1) Clients did not bring the

expectation of prescriptive treatment regimens, saw the practitioner as

one source of information or advice resource, and used the service to

monitor their health; 2) Practitioners also valued client knowledge and

judgement, and respected the client's right to choose and direct

their healthcare. Clients perceived themselves as the health

expert--this presented its own challenges to the practitioners in

relation to misinformed self-diagnosis or from heavily marketed

products. (28,35) There was no strong correlation between post-modern

values and CM therapy use in an older rural, community cohort, although

themes of 'natural', self-reliance and individual

responsibility were evident. (21)

5: Naturopathic service

a) Information provider:

Naturopathic practitioners are also seen as trusted sources of

information on CM by their patients. (19) Naturopaths were referred to

as highly reliable sources of information with a number of cohorts

valuing their information, and evaluation of CM (19), for example, in

breastfeeding mothers, where natural substances are preferred over

conventional medicine. (36) A total of 76% of breastfeeding mothers

wanted more information on safety and efficacy of herbs during

breastfeeding and referred to naturopaths as their preferred source of

information. (36)

The active information seeking from trusted sources also supported

the empowering, post-modern, self-reliant and individual responsibility

values discussed. The information provided a means to be actively

involved in determining their personal healthcare plan.

Interestingly, people who regularly consulted with a naturopath are

more active in seeking information, and use their naturopath as the

first and primary source of information. (19) The need to verify

information from other sources seemed to diminish after the consulting

with their naturopath. (19)

b) Individualised treatment:

High users of CM indicate the value of naturopathic practitioners

and herbalists formulating and providing a tailored medicine for their

individual health needs. (19) There was also the belief that the

practitioner-only supplied product, that is only available from the

practitioner, or the individualised herbal mixture especially made up

for the patient, was more efficacious than pre-formulated off-the-shelf

products. (19)

c) Natural medicines: perceptions of safety

There is a tendency for CM users to perceive CM products as being

safe. (6,19,36) This may affect the way users perceive dosage

(over-dosing) and interactions, (19) and may explain why up to 40% of

people with cancer do not disclose their CM use to their medical doctor.

(10) Interestingly, some research indicates that high CM users are more

likely to disclose CM use with their doctor (66% disclosing use),

compared to 48% of low CM users. (19) Conversely, research still

indicates that high CM users in a rural setting still only disclose CM

use in 40% of cases. (21)

Conclusion

Person-centred care emphasises collaboration, inclusion and

participation, the CIP principles of practice development, to help

understand patient (and other stakeholders) health goals, beliefs and

values. Patients have beliefs and values associated with their decision

to use CMs which need to be considered by all practitioners.

Naturopathic medicine philosophies of practitioner as teacher and

individualised care lend themselves to person-centred care. It is,

however, important to consider how the patient views or values the

practitioner's philosophies. Collaboratively involving the patient

in discussions of differing views/evidence and sharing decision making

helps support person-centred care, better patient adherence and

ultimately better patient outcomes. Practitioners need to also be

mindful of their own values and beliefs in supporting their patients to

ensure they do not negatively impact the patient's health views and

priorities. Further research is needed to understand more on the

patient-practitioner values and beliefs, and the effects on

person-centred care and patient outcomes.

Disclaimer

Despina Lord is a qualified naturopath currently employed by

Blackmores Ltd. The views and recommendations expressed in the article

are her own and do not necessarily reflect the views or assessments of

Blackmores Ltd.

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Despina Lord

Private practice, Sydney, New South Wales, Australia

Contact: DL757@uowmail.edu.au

https://www.thefreelibrary.com/Person-centredcareandnaturopathy:patientbeliefsandvalues-
-a0439109330