Long-Term Acupuncture Therapy for Low-Income Older Adults with Multimorbidity: A Qualitative Study of Patient Perceptions

Design and ethics

This was a qualitative study that used thematic content analysis of semistructured interviews. ²⁶ Study participants were recruited using purposive sampling. ²⁷ The study was approved by the institutional review board of Yo San University of Traditional Chinese Medicine, Los Angeles, California, and participants were guided through a written, informed consent process before being interviewed.

Study sample and site

Participants were recruited from a free acupuncture clinic for low-income older adults in Southern California. The clinic was operated jointly by a local acupuncture college and a local charitable organization. Acupuncture was performed by student interns from the college, under the supervision of licensed acupuncturists from the college faculty. There was no standard treatment style or protocol, and the interns were free to diagnose and treat based on principles of Traditional Chinese Medicine, Japanese, Five Element, and auricular acupuncture. All the participants continued to attend regular acupuncture therapy during the period in which interviews were conducted. The study population included 10 women and 5 men, of which fewer than half (n = 7) identified as non-Hispanic white. The mean age was 70.5 years, with a range of 62–83 years. Patients had attended the clinic for a mean of 5.3 years, with a range of 1–15 years (Table 1). The mean number of self-described comorbidities was 4.4, with a range of 2–11 (Table 2).

Recruitment and interviews

Patients were recruited directly from the clinic through verbal interaction while onsite. Inclusion criteria comprised being aged 60 years or older, self-reporting at least two chronic conditions, having attended regular acupuncture sessions (weekly or biweekly) for at least 12 months, and being conversationally fluent in English.

Interviews took place in a private room in the same building as the clinic. Most patients were interviewed following their acupuncture treatment, although in two cases, participants traveled to the site on a day they were not scheduled for treatment. The first author, who was trained in qualitative research methods, conducted all the interviews between March 2016 and July 2016. The interviewer was known to some of the participants as a former acupuncturist at the clinic, and had given acupuncture treatments to six of the participants at some time in the previous 5 years, most recently between May 2015 and August 2015. At the time of the study, she was a doctoral candidate at Yo San University and the participants were informed of this.

The interviews were semistructured, using an interview guide based on the purpose of the study, existing literature, and clinical experience. The initial guide was used for the first three interviews; after these were transcribed and read, it was modified with two additional questions and used for subsequent participants. The interviews were recorded and transcribed verbatim by a professional transcriptionist and then checked for accuracy by the first author. All personal identifying details were removed before data analysis.

Statistical analysis

Thematic content analysis was used to order data and identify emergent concepts and themes. ²⁶ The coding began with structural coding and later expanded to include descriptive coding. In structural coding, codes are developed from the interview questions themselves; as the structural codes did not allow all of the salient content to emerge, descriptive coding, which was based on the content of the participants' answers, was added. ²⁸

In the initial coding process, R.P. and J.L.L. independently coded the same three interviews, selected for depth and richness of content. These codes were compared and discussed to resolve differences between the readers. Ultimately, a total of seven interviews were read and coded by both researchers. Two of these transcripts were recoded a second time by both researchers and compared again to establish inter-rater reliability; eventually all the transcripts were recoded by R.P. with the final codes. The data analysis was ongoing, such that early transcripts were coded before interviewing was complete; thus, as further transcripts were analyzed, codes were further refined as new content emerged, in an iterative process. The lead author kept reflective memos to record initial impressions and thought development and possible emotional or intellectual biases throughout the process.

All coding was done without software, using the comment feature of Microsoft Word to highlight data and label codes as they were identified from the transcripts. The codes were next organized in an Excel spreadsheet, with corresponding excerpts from the text ordered alongside each code, allowing comparison between and within categories as the coding process evolved. In addition, SimpleMind Desktop (SimpleApps, xpt Software & Consulting B.V. and ModelMaker Tools, The Netherlands) was used to help visualize the relationships of content to codes and codes to themes, both within and across interviews.

Themes

Notably, although during the interview, the majority of participants said their initial reason for coming to the clinic was pain, patients listed “anxiety” as equally prevalent and “depression” nearly as prevalent, as chronic pain.

While we found the positive benefits experienced by these patients were similar to those described in earlier studies of younger populations, ^{19 –23,25} the unique characteristics of this group and the clinic resulted in a particular impact on their lives. The codes coalesced into five themes: (1) mind-body effects, (2) the enhanced therapeutic alliance, (3) what they liked best, (4) the conventional healthcare system, and (5) importance of regular schedule. All five themes share the core concept of reasons to continue.

Mind-body effects

Mind-body effects comprised quantifiable or symptom changes, such as pain reduction; subtle effects, for example, increased energy; and the treatment experience itself.

The most cited type of symptom relief was from pain, but patients also described improvements in conditions such as digestive disorders, nocturia, and skin rashes. Others believed acupuncture had lowered or stabilized their blood pressure. Reduction in pain medication was often noted. One-third of participants reported cutting back or eliminating prescription drugs, in some cases dramatically:

I have been treated for depression and all that through my, through my other plan, [a name] plan, and for almost three and a half years I was heavily sedated – medicated. I was taking 22 different kinds of pills…That was before I started acupuncture. And after I started acupuncture, I told my doctor I'm feeling better, I've tried it all and I want to stop my medication, she says ‘Don't just stop one day to the next. Please, I'll wean you off of it.’ And took her a long time to wean me off of it, but I'm now med-free. (P12, M, 65 years old)

Subtle effects were noticed as a change in feeling, or a perceived increase in abilities. Patients remarked on increased energy, more motivation, and mood lift. An example of the almost ineffable nature of such changes came from one participant who said that after acupuncture, she was “able to actually feel like myself.”

The treatment experience

Most patients said they felt deeply relaxed and calm while undergoing treatment; two women likened the experience to meditation. Other feelings noted while lying on the table were “comfortable,” “cheerful and happy,” “like floating,” and “in balance.” However, not all experience was positive; one participant said he felt “nothing different” after the needles were inserted, while another spoke of being “anxious and uncomfortable,” and still another found it drained her energy. Despite these experiences, all three of these patients felt they benefited from their treatments.

The enhanced therapeutic alliance

The therapeutic alliance—a close, personal working relationship between patient and practitioner—is an important component of acupuncture in the Western world. ^21,22 Our study sample, due to its long relationship with the clinic, experienced benefits that went beyond the established patient-practitioner alliance. Patients formed relationships not only with their acupuncturists but also with the clinic supervisors and their fellow patients. As to the acupuncturists, some participants spoke of how they generally enjoyed the company of young people, who they described as “ambitious” and “just getting started in life,” or even “fun.” Three people noted their attentiveness, saying they “treat you like you're the only one,” and “I don't get that attention from anybody.” Nonetheless, several people said that having the same acupuncturist treat them consistently was not important.

Relationships with the supervisors—which were more longstanding than with the student acupuncturists—were described in more intimate terms. Three participants used the same words to portray this relationship: “I love them.” Others described the supervisors as “welcoming,” “caring,” and “compassionate,” and said they felt “very attached” and “connected” to them. Supervisors were valued for practical as well as emotional support: many patients said they had been given dietary, lifestyle, and medical advice. Such close personal attention was an important part of the treatment experience.

Due to the long-term nature of treatment, patients also developed relationships with one another. These ranged from minimal to intimate. One participant expressed irritation with other patients; others, however, spoke of a “special bond,” or “friendship.” Several people expressed empathy, compassion, or tolerance:

And the people here, you know they're looking for well-being and you feel their pain and you want to…you know. I became good friends with [a name], who has so many – poor guy, went through so much. (P8, F, 66 years old)

Liked best

There was also a distinction in how patients described what they liked best about acupuncture from their other portrayal of its benefits. When asked what they liked best, only three participants mentioned symptom improvement. Most people, instead, used the word “feeling”: “feeling on top of the world,” “feeling in control of my health,” “feeling relaxed and calm,” and “feeling optimistic and motivated.”

For the most part, these feelings were separate from the transient euphoric feelings experienced during and immediately after treatment. They represented an increased capacity for coping that could be carried into the days following treatment.

Context of the conventional healthcare system

Although this was a study focused on acupuncture and no questions were asked regarding how participants felt about conventional medical care, they provided numerous comments on it. Conventional medical treatment was the background, which seemed to illuminate their perceptions of acupuncture therapy.

Two-thirds of participants expressed a strong desire to avoid medication or invasive medical procedures. For several, the aversion was based on experience with side-effects:

Gosh, I don't remember, there were so many, they were trying different medications but they were making me so nauseated…I just remember counting them, I go ‘no way am I going to keep doing this.’ (P15, F, 62 years old)

I've had arthritis for very long, long, long - it's chronic. And the pills, Celebrex, and all the hundred pills, that make your stomach worse. So I take a pill for one thing, and it worsens another thing. So now I have indigestion, a stomach pain, and that's the worst. (P5, F, 72 years old)

While there were a few positive or neutral comments about the conventional healthcare system, the overwhelming majority (81%) were negative. One-fifth of participants complained about being treated, as one man put it, as “just another number.” People related tales of ineffective or inadequate care, poor communication, unsatisfactory diagnosis and treatment, and unnecessary or unsuccessful surgery. Several patients decried the emphasis on drugs and contrasted that to acupuncture:

I often wonder why this is not included in health care. I think that, I don't know, maybe, maybe it's the pharmaceutical company that keeps it out. Because if you don't need the medication, if acupuncture keeps you feeling wonderful and helps your pain wherever it is, why would you have to take medication? (P4, F, 83)

The overall feeling for the conventional healthcare system may have been most succinctly expressed by one woman who said, “Doctors are just, something. But they're not healers.”

The importance of regular schedule

Responses to the question of how long treatment effects lasted varied from 2 h to 2 weeks. Two participants said their pain relief typically lasted only hours, although both of these women also mentioned conditions that had improved over time. One participant spoke critically of the short-term effect of acupuncture:

My complaint is that, that it's just, it doesn't seem to last. It seems to, you know, you have to do it every week. (P11, F, 75 years old)

On the other hand, several people seemed to cognitively group the observation that their symptom relief was relatively short with the anticipation of returning to the clinic each week, and did not see the need to return as a problem:

And I feel, I feel on top of the world usually after a treatment for like five days straight. And then, then you know, it's time to come back again. (P9, F, 67 years old)

Reasons to continue treatment

The themes discussed above are all subsumed under the core concept of reasons to continue. The reasons can be described further as social need, subtle need, and urgent need. Social needs included the caring atmosphere, social connections, and habit. Subtle needs ranged from feeling better to maintaining health. The urgent needs included hope of improving illness as well as a strongly expressed desire to retain physical and mental faculties:

Because I take this as a matter of life and death because my heart is out of whack, you know, and sometimes I feel depressed, so I have to come here, because I feel like dying sometimes. So I have to come here. (P6, M, 65 years old)

Several participants described their acupuncture treatments as a way to maintain their health; they seemed to view the clinic as a means to prevent minor conditions from becoming major issues—in other words, to prevent subtle needs from becoming urgent needs. In addition, older adults with chronic pain are more likely to experience isolation and loneliness. ⁸ The clinic in this study may have provided needed social support, in the form of bonds formed with acupuncturists, supervisors, and other patients. Thus, the strongly expressed desire to continue treatment was a natural response by this group to the benefits they perceived from acupuncture.

Comparison with existing literature

The mind-body effects of long-term acupuncture treatment described by patients in this study are similar to those reported in previous qualitative research of shorter term acupuncture therapy in the United States and the United Kingdom ^{19 –23,25} : symptomatic relief and psychologic benefits such as stress reduction, increased energy, and more motivation. However, while many previous qualitative studies have looked at populations with an average age of 45–56 years, ^{19 –22} our study sample had a mean age of 70.5 years. To our knowledge, this is the first qualitative acupuncture research to concentrate exclusively on an older population, as well as on one with multimorbidity, highlighting how long-term acupuncture therapy addresses characteristics and needs that are unique to this demographic.

Unique characteristics and needs

The prevalence of anxiety, depression, and chronic pain was an important feature of this study. As previously mentioned, chronic pain and depression are especially problematic among older adults with multimorbidity. ^6,7 That participants described improvements in both mood and pain suggests that long-term acupuncture has particular benefit for this group. Moreover, older people with chronic pain are especially vulnerable to loneliness and isolation. ⁸ While not a benefit specific to acupuncture, social contact and the sense of belonging and being cared for were important aspects of the holistic experience in this study. Against the backdrop of anxiety, depression, pain, and dissatisfaction with doctors' care, there was a significant benefit related to the enhanced therapeutic alliance: the communal/social aspect of care, involving acupuncturists and supervisors. While the therapeutic alliance between patient and practitioner played an important role in this study, so did the relationship between patient and clinic supervisor; many patients came to depend on the supervisors for both practical and emotional support. Practical support included other health and lifestyle advice, as well as outside referrals. In effect, the clinic acted as a central hub that reviewed and coordinated the entirety of the participants' healthcare. In practice, the patients' experience had some key elements in common—a thorough initial assessment, plan of care, diagnosis and treatment, counseling and health education, and referrals to healthcare providers and social services—with the geriatric evaluation and management process described by Boult et al., ²⁹ a coordinated care model, which was found to reduce functional decline among high-risk older adults living at home.

Another benefit of the communal clinic was social interaction between patients, previously reported by Tippens et al. ³⁰ in community acupuncture clinics in the United States. While some patients had minimal contact with others, many formed friendships, leading to a sense of bonding between people with common needs and purpose. Some participants spoke of feeling an increased sense of empathy or compassion toward the others. This connection may be related to an observation made by Sofaer et al. ³¹ that helping others who were perceived as worse off than oneself was a coping mechanism for older people with chronic pain.

Implications for delivery of care

A notable point that arose from the data was the relatively short duration of treatment effect. The duration of pain relief demonstrated in quantitative acupuncture trials has varied, ^{13 –16} perhaps with some relationship to age. The duration of effect reported by our study population was generally <1 week. A variety of reasons could account for this. Because they knew they could return to the clinic weekly, patients may have conflated the expectation of the deeply relaxed feeling during treatment with symptom relief, such that the term treatment effect to them meant the full benefit of the entire experience; therefore, they did not credit incremental symptomatic improvements over time. It is possible that some patients overstated their weekly need for treatment so as to be able to keep coming to the clinic, which they also counted on for social and logistical support. It is equally conceivable that some patients felt relief for a few hours or days only.

These findings have strong implications for delivery of care to older adults with multiple chronic conditions. With a median treatment history of 3.5 years, the participants in this study were able to describe how their lives were affected by acupuncture over time. They experienced benefits that they believed decreased their dependence on conventional healthcare, while improving their day-to-day abilities, pain level, and mood: in other words, their quality of life. They depended on treatment not only for continued relief of symptoms but also to address new conditions as they arose, and for encouragement in maintaining a healthier lifestyle. A noteworthy effect was the reduction in medication reported by one-third of the patients in the study. Thus, there is an indication that an extended course of acupuncture therapy is appropriate for this demographic.

Strengths and limitations

The racial, ethnic, and cultural diversity of this study sample increase the scope of the study's findings. A limitation was that participants were self-selected for mobility; sicker people not ambulatory enough to travel to the clinic might respond differently to acupuncture. In addition, the data on health conditions were self-reported as we did not access medical records. However, some multimorbidity studies have also used self-reported conditions or symptoms. ^1,5 Moreover, there is no standardization of conditions applicable to multimorbidity, but using 12 or more conditions specific to the study population is advised. ³² Our study included 17.

As this was a qualitative study, its results reflected the participants' experiences and beliefs; it did not attempt to assess outcomes objectively, and it could not account for changes that might have occurred without acupuncture. More quantitative or mixed-method studies are needed to determine specific outcomes related to acupuncture in older adults, especially those with multimorbidity.

The first author's history as an acupuncturist at the clinic could be seen as both a limitation and a strength. Patients who knew her previously might have felt they needed to give more positive reviews of acupuncture, although in the analysis, no difference was found between the responses of those she had treated and those she had not. On the other hand, her close knowledge of the clinic gave her added insight into its dynamics. As the researcher is the data collection instrument in qualitative research, her relationship with the clinic could make her a more powerful tool, as long as she acknowledges and accounts for her own biases as she collects and interprets the data. ³³