Australian Naturopaths' Approach to Caring for People with Cardiovascular Disease and Associated Risk Factors: A Qualitative Study of the Providers' Perspective

Abstract

Objectives:

To date, no formal research has evaluated how naturopathic practitioners approach the care of people living with CVD and associated CVD risk factors. The primary aim of this research was to collect qualitative data from Australian Naturopathic practitioners about their clinical practices for CVD.

Design:

Semi-structured interviews were conducted, recorded, transcribed, and ultimately coded by three independent researchers using the Framework Approach.

Subjects:

10 Australian Naturopathic practitioners.

Results:

The key emergent themes from the responses of naturopathic practitioners embodied the elements of patient-centered care (PCC). Numerous factors, including regulation, barriers to service access, and interprofessional communication, were cited as hurdles to additional effectiveness as PCC practitioners.

Conclusion:

Future research should assess whether the principles of PCC are reported directly from the patients who utilize naturopathy for CVD to determine if their experience mirrors the reports by practitioners.

Introduction

An estimated 4.8% or 1.2 million Australian adults were affected by cardiovascular disease (CVD) in 2017–2018 (Ref.¹) accounting for 11% of all hospitalizations and more than 1 in 4 deaths.^2,3 CVD costs the Australian health care system AUD10.4 billion in 2015, contributing to 14% of Australia's total burden of disease.^2,3 In December 2019, The Australian government announced an investment of AUD220 million over the next decade to bring together key stakeholders to make “transformative improvements” in cardiovascular health.⁴

The Australian Heart Foundation endorses not smoking, maintaining normal blood pressure, cholesterol levels, and weight, adherence to a healthy diet and adequate physical activity as important factors in reducing CVD risk.⁵ However, behavior change is known to be multifaceted and complex, including social, demographic, and psychologic elements.⁵ The complexity of health behavior change requires health care professionals (HCPs) with a range of skill sets to provide patient-centered care (PCC) that meets individuals' needs. Such an approach focusing on a partnership between patients and HCPs is encouraged by the World Health Organization as a key component of quality health care.⁶

Australians consult both conventional HCPs who practice within the dominant health care system and traditional and complementary medicine (T&CM) HCP.⁷ Despite this, interprofessional communication between conventional and T&CM HCP in Australia is suboptimal.⁸ T&CM utilization is particularly prevalent by Australians who are one of the largest users of T&CM products and practitioner services in the Western world.⁹ An estimated 50% of Australians use CM products,⁹ and 36% consult at least one CM practitioner within a 12-month period.⁷ Naturopathy is a distinct profession under the umbrella of T&CM practices recognized by the World Health Organization as a global traditional medical system.¹⁰ Naturopaths are consulted by 6% of Australians in a given 12-month period primarily for chronic conditions, including CVD and associated risk factors.¹¹

Although the whole systems approach of naturopathic medicine in CVD care has not been evaluated in Australia, there is some evidence to support varying degrees of efficacy and safety of specific nutritional and herbal supplements prescribed in naturopathic practice for hypertension^12
–14 and hyperlipidemia,^15,16 and the management of heart failure.^17
–19 Furthermore, the results of a randomized controlled trial suggested improvement in primary risk factors for CVD from Naturopathic Doctor care in the United States and Canada,²⁰ but it is not known if these findings can be extended to Australian practitioners. A recent review exploring the use and characteristics of CM use in Australia identified that “individuals with chronic diseases or co-morbidities, and a lowered quality of life, have a higher reported CM health service utilization when compared with non-CM users.”²¹

The increasing use of CM services by the general population has been the subject of discussion among both primary HCP and policy makers prompting Australia's National Health and Medical Research Council to publish a guide to talking to patients about complementary medicines for HCP.²² Although there are well-established guidelines for conventional health care practitioners regarding the management of risk factors and the treatment of CVD, and evidence that naturopaths contribute to the care of individuals with CVD with potentially beneficial outcomes, there are no reports about how T&CM practitioners such as naturopaths are approaching patient care in this important area. Thus, the singular aim of this study was to explore how Naturopathic practitioners in Australia are approaching the care of people living with CVD and associated risk factors.

Methodology

Study instrument and design

An interview guide was developed based on the existing literature and expertise of the research team. The questions were designed to prompt participants to share their experience of managing clients with medically diagnosed CVD and/or known CVD risk factors. The interview guide was independently reviewed by two researchers considered “experts” in this field and piloted with a naturopath known to J.E.H. This process assisted in revising and targeting the interview questions to be more specific in preparation for the in-depth phone interviews, resulting in a final interview guide (Supplementary Appendix S1).

Qualitative research methods applying semistructured individual in-depth telephone interviews were undertaken to generate formative data to better understand the naturopathic practices and their approach to managing patients with medically diagnosed CVD and/or known CVD risk factors.^23
–25 Ethical approval for the study was obtained from the University of Sydney Human Research Ethics Committee and the Practice-Based Research Network (PBRN) of the Practitioner Research and Collaboration Initiative (PRACI) Steering Committee.²⁶

Recruitment and participants

Naturopaths registered with the PBRN PRACI (n = 281) were sent an e-mail invitation by the PRACI administration service to participate in the study. Participants were required to be 18 years of age and over, accredited members of a professional association and involved in the clinical management of people with medically diagnosed CVD and/or CVD risk factors. The interviewer had e-mail or phone contact with participants before the interview to organize a suitable interview time. Before being asked to consent to participate, potential participants were provided with information about the study and notified that the interviewer was a qualified naturopath.

Interview procedures

Interviews of between 45 and 60 min were conducted by one of the researchers who is a qualified naturopath (J.E.H.), with a second researcher (C.R.) present to take notes, suggest expansion on comments that could be valuable and provide additional insights relevant to the study. At the start of each interview, participants were asked to provide verbal consent that was recorded. Although a semistructured approach was employed, the interviews were also designed to remain sensitive to participants' own telling and concerns, and participants were encouraged to respond in their own terms and to introduce new and additional issues, as they deemed appropriate.

Data analysis

Interviews were recorded through a digital recorder and then transcribed through professional transcription service. The interviewer and the observer took field notes regarding key comments made by participants and to ensure important points warranting further exploration were not overlooked. It was found that thematic saturation (whereby no new or relevant material was produced from subsequent fieldwork) was attained with eight participants; however, all interested practitioners were interviewed to ensure any differences between practitioners were captured.

The Framework Approach^27,28 was employed to analyze the data as it enabled flexibility between inductive and deductive analysis.²⁹ Data were coded to open nodes by the two researchers present during the interviews [J.E.H. and C.R. (Supplementary Appendix S2)]. These identified nodes were reviewed by A.S. after immersion in the raw data by listening to recorded interviews and reading transcripts. After this review and immersion, the potential alignment between the identified nodes and contemporary models of PCC was proposed by A.S. and discussed with the research team. After agreement between all researchers involved in the analysis, a deductive analytic framework was developed, which utilized nodes based on PCC domains (Supplementary Appendix S3). The original nodes were coded to the framework by A.S. using NVivo 12. The analysis was then checked by J.E.H. and C.R. for alignment with their initial analysis. Any differences were resolved by consensus. Quotes were selected based on representativeness of the theme.

Results

Twelve interested CM practitioners in current clinical practice in Australia responded to the recruitment drive of which 10 were included in the study (Table 1). The two nonparticipants did not respond to the call at the prearranged time for the interview and did not reply to subsequent attempts to reschedule. The interviews took place between May and August 2017.

Table 1.

Characteristics of Naturopath Participants

Characteristic	n = 10
Gender
Male	4
Female	6
Age, years
30–39	2
40–49	2
50–59	3
60–69	2
70–79	1
Years in practice
<5	1
5–9	3
15–19	4
20+	2
Number of patients consulted with medically diagnosed CVD consulted per week
1–3	3
4–6	7
Number of patients consulted with a known cardiovascular risk factor per week
1–3	5
4–6	3
7–10	1
10+	1

CVD, cardiovascular disease.

In line with the framework approach, the research team identified key issues, concepts, and themes from the data. These initial themes were found to align with the domains of PCC.³⁰ The framework of PCC was then systematically applied to the data. The following results are organized by common principles considered reflective of PCC, including Coordination and integration of care; Access to care; Continuity and transition; Information and education; Respect for patients' values, preferences and expressed needs; and Involvement of family and friends.³⁰

Coordination and integration of care

The most dominant domain of PCC reflected in participants' account of their practice was coordination and integration of clinical care. Participants' described attempts to coordinate with other care providers, primarily general practitioners (GPs) who were also involved in providing care to the patient. The most common reason provided in support of the need for integration with others in the patients' care team was to ensure patient safety and to communicate respect for the role of all health professionals involved with the patient, as described by this participant:

“Keeping really open communication and making sure the GP is really kept up to date with what I might be doing with their patients… just demonstrating to them that we are really mindful of the medication they are taking,…of potential interactions and what the focus is, so that they are very clear what my role is.”—N10

Despite the importance of coordinated care being acknowledged by almost all participants, many also described difficulties in enacting effective interprofessional communication. Those who said they wrote letters to GPs often also expressed frustration at not receiving any response, whereas others indicated that they delegated patients to carry information between care providers.

“Overall, I find a lot of GPs don't interact too much with me, as a naturopath. There are a couple, they are probably a handful over the years, that are open to receiving letters or receiving emails about mutual clients.”—N7

“I don't communicate directly with the medical professional. I use the treatment plan that I give to the patient. And I usually say when you next see your GP tell them this is what you're doing.”—N3

Another challenge to coordinating care with GPs, although expressed by participants less frequently, was patient resistance toward consulting with medical doctors. In most instances, participants described encouraging those patients to continue consulting their GP where the participant felt the patient needed care that fell outside of the naturopathic scope of practice:

“Quite often I'll hear ‘I hate doctors, I'm not going to a Doctor, I don't want to go to a doctor, I'm not taking medications'…I would always try and get all my clients go to a doctor or at least speak to someone about concerns that I am worried about”—N1

Another common reason for participants to refer their patient to a GP was to facilitate coordination of other ancillary services such as pathology testing. However, participants described a lack of cooperation with GPs not agreeing to refer the patient for the testing considered necessary by the naturopath. This participant explained that they now send the patient to access the pathology service directly and pay out of pocket rather than involve the GP in the process:

“I have found in the last few years if we have needed to get additional blood tests and their GP isn't happy to do that, I'm finding that people are more open to using functional testing—the commercial side of pathology—more openly and they're willing to pay lots of additional money as a result.”—N7

Other ancillary or support services indicated by participants as referred to or collaborated with in CVD patient care include counselors (N2, N5, N6), psychologists (N2, N5, N6), physiotherapists (N2, N5, N6), specialist doctors (e.g., cardiologists) (N1), exercise physiologists (N2, N5), podiatrists (N5), massage therapists (N5), council library (N6), acupuncturist (N6), and social worker (N6).

Access to care

The second principle that was prominent among the participant interview data was access to care, particularly as it related to participant perceptions of patient challenges to accessing naturopathic care for CVD. A common reason raised by participants was poor awareness in the community of the potential role and contribution of naturopathic practitioners to managing CVD.

“It's just a lack of understanding of exactly what the role of a naturopath is, and how it can support somebody's journey as well being monitored through the primary health provision”—N10

“I guess there's some that are prejudiced but I think that prejudice is largely based on the fact that [the community] don't really completely understand a naturopathic approach to healthcare.”—N5

Further to this point, some participants described poor GP understanding of the risks of naturopathic treatments being used alongside pharmaceutical medication as a barrier to GPs referring CVD patients to naturopaths for support. This participant describes this point and also expresses sympathy for GPs who are not aware of naturopathic treatments and may have concerns for patient safety:

“They're just scared. With my stuff there isn't gonna be an interaction, but doctors don't know that. They haven't had the time to read the section, they haven't had the education. And the interaction between drugs is of much significance and damaging. But I think if I was a GP and I didn't understand naturopathy I would be very concerned if someone was taking a herbal mixture because with regards to the herbs, I [the GP] don't know what they do.”—N2

One of the most dominant reasons described by participants underlying GP reticence to refer patients to naturopaths for management of CVD was the GP perception that the training of naturopaths is insufficient for naturopaths to deliver safe and effective care. This participant expresses this view and further comments that the perception that naturopaths are not trained to assist patients with CVD is in direct contrast with the actual strengths of naturopathic care:

“I think it could be a bit of the stigma around…naturopaths and what they actually do. Perhaps it's the [perception that the] quality of education isn't warranted to be asking for or helping people with these types of chronic conditions. Even though I think that's where naturopathy…shines.”—N10

Participants further expanded on the impact of perceived GP concerns regarding naturopathic training by suggesting that statutory registration of the naturopathic profession may address this challenge, thereby improving patient access to naturopathic care for CVD.

“There is still that potential for people to have done a 20-hour course on the internet and call themselves a naturopath. And I have come across people who question me and ask, ‘How much training have you had?’. I think [statutory] registration would possibly help with that.”—N3

A final barrier to individuals with CVD accessing naturopathic care, mentioned by participants, was cost of care. All participants who raised this as an issue also expressed attempts to consider the financial burden to patients by prioritizing treatments and referring to low-cost alternatives.

“When you do get elderly clients who you would like to put on maintenance, support for all their medications and their cardiovascular disease, it can be really expensive and I try to be very mindful of that for my clients”—N1

Continuity and transition

Consistent with additional principles of PCC, the naturopaths described practice behaviors aimed to support continuity of care and appropriate care transition for individuals accessing their services. One such behavior was communicating understandable detailed information regarding their treatments.

“Well, it is always my responsibility to make sure their health literacy is pretty good, but with all the instructions that I [give] them on the product I ask them to call me within a week or so if they are having any problems with the instructions and I generally find some would follow up.”—N10

Participants also described providing information to patients regarding how best to access other services. This naturopath explains particularly how to engage with medical doctors about accessing pathology testing services when the GP is reticent to accept a referral from a naturopath:

“[I] just send them back to the doctor if I think that there's something that the doctor is gonna pick up…I counsel patients on how to speak to their doctors to get blood tests done…I don't get them to lie or anything … the doctor needs proof … that the test is warranted. [I avoid] having the patient go in and say ‘my naturopath said that you should test me for this thing’. It doesn't go down very well”—N2

Continuity of care was also demonstrated by the participants who described providing clear instructions to their patients on how to self-monitor changes in their condition in response to treatment:

“If you are working with blood pressure and encourage the client and say “you know what, we might improve your blood pressure. If you get headaches, you might need to go back to the doctor and reassess your dose and medication”—N1

As reflected in the aforementioned example, participants also described attempts to facilitate effective transition to care from other health professionals, particularly medical doctors. Sometimes, as seen in the statement by another participant, this extended to providing opportunities to medical doctors to modify their treatments in response to changes to the patient's condition:

“I guess just trying to get their cardiologist of GPs to look at the bigger picture and ask if they are being well managed; is there a way we can manage the diet and lifestyle as well? And you know trying to encourage that path.”—N9

However, a number of participants also described poor interprofessional collaborations with other health professionals. This participant, for example, described very poor communication channels with allied and medical practitioners:

“Very little, we don't communicate. Maybe with the practice nurse, but then it would be limited as well.”—N8

Information and education

Another prominent theme consistent with PCC identified through the analysis is the naturopaths' provision of information and education of their patients. Most commonly, this centered on providing patients with information to facilitate autonomy, self-care, and health promotion. This naturopath describes their process of making change achievable for patients and educating patients about their condition as a pathway to motivate them to change:

“I help motivate them to undergo changes required to get them out of the place that they are in at the moment. It's the motivation factor and that motivation comes by giving them the knowledge of why they have to change. What sort of areas they have to change. They have to break it down into little steps so they can find it is attainable to eventually get them to where you want them to get to.”—N4

Another participant describes identifying CVD risk factors in patients presenting for other health concerns and their approach to educating patients about the impact those risk factors have on their long-term health:

“I think often they know if they lose the weight that would help their blood pressure or it'll be like:… they're most concerned about their weight but then I explain how that puts them at greater risk for these other complaints; and, their blood pressure is high so if we address their diet and get them exercising it's quite likely that their blood pressure will come down.”—N2

Participants also described giving patients' information on their clinical status, progress, and prognosis. This may include, as is the case in the following examples, educating patients about the link between health risks, family history, and the patients' CVD:

“Quite often the conversation goes around stress in their life and what could be their cause of their hypertension. Sometimes they talk about a family member who has had a CV incident…if there is something in their family, they are a little bit more aware and thoughtful about it. If there is nothing in their family, they don't tie in [that] if you don't get your blood pressure fixed or you don't bring your blood pressure down your risk of a heart attack or other CV risks is increased.”—N3

This same participant also described identifying CVD risks such as hypertension and educating patients about the issues associated with leaving these health problems untreated:

“If they had hypertension that was not being treated in any way and other things going on I would say: I know you have come because of this [other health concern] but we really need to address this because it is urgent, because you can't walk around with blood pressure that high without doing anything.”—N3

Less common, but still reported by participants, was the education of patients about processes of medical care, particularly as it relates to accessing conventional medical services from doctors:

“Then it's about me helping them to talk to their doctor in a way that they get what they want or that they get what they need really. And explain to them that you can't walk in and demand stuff from the doctor because they have to see a need for it”—N2

Conversely, some participants described their practice of educating patients about the naturopathic approach to care. In the following example, this naturopath explains to patients that the difference between naturopaths and GPs is that naturopaths apply a more comprehensive view to understanding a patient's health status:

“If they haven't [been to a naturopath before] I talk to them about what we do and draw an analogy: if you go to a GP with a sore throat they will talk to you about the sore throat. If you come to me with a sore throat we will talk about everything in your life to why you had that sore throat.”—N3

Respect for patients' values, preferences, and expressed needs

Participants commonly described an approach to care for patients with CVD that respected patients' values, preferences, and expressed needs. This included recognizing the patient as an individual with their own unique values and preferences, most clearly demonstrated in this quote from a participant when asked to identify specific motivators for the lifestyle changes needed in patients with CVD:

Interviewer: Do you see that there are some motivators [for lifestyle change] that are more effective than others?

Participant: “No because that's very much up to the individual.”—N4

As another example, this practitioner tells of their approach to designing a treatment plan that is appropriate to the patient's lifestyle and skills:

“Because I say I give them small steps. I don't expect them to go to the market and buy fresh fruit, I just don't. Because around here that's setting people up for failure. I do say I want you to buy two bags of frozen vegetables when you next do the groceries.”—N6

A number of participants also expressed views that indicate an approach to care that treats patients with dignity, respect, and sensitivity to cultural values and autonomy. This is exemplified in a range of ways, including the amount of time allocated to the consultation and scope of naturopathic case taking permitted by this additional consultation time:

“As naturopaths, we allow ourselves to spend more time with the client, so they are able to speak about their whole wellbeing, their family life, how they are eating, how they feel they are eating, you know, everything about their treatment and ask them questions about very many things in their lives for which the doctors do not have time.”—N1

Respect and sensitivity to patient cultural values and autonomy may also be seen in the consideration reflected by naturopaths' descriptions of their approach to developing treatment plans for their patients with CVD:

“It's unfair to say I want you to go out and buy all brown rice, no bread, fresh foods and I want you to have salmon three times a week. That's never going to happen. It is only because they don't know how to cook salmon or fresh vegetables and they are not going to eat brown rice. … Coming from this area you have to look at what changes you can make that are actually going to stick…I have to set them up to succeed, if I set them up to fail they will fail.”—N6

The participant naturopaths stated various expectations of patients as it related to following the proposed treatment plan. At the minimum, the participants commonly described expecting the patient to follow the guidelines or treatment that were prescribed by the naturopath:

“I don't want to waste people's time and so I want people to get value for their money so if I give them some guidelines and some goals I want them to try and achieve those things. I guess the expectation is that they actually follow those guidelines because I don't want to keep taking their money if things aren't improving.”—N5

Some participants described tailoring the treatment to suit the patient's values and preferences, such as this naturopath who expressed taking into consideration the patient's motivation to change their health behaviors when developing a treatment plan:

“…it's like climbing a mountain you get there one step at a time, so therefore we make a program suited to their motivation to get them to where they want to be.”—N4

Involvement of family and friends

A smaller number of participants mentioned the role of family and friends in the successful treatment of CVD patients. In most of these cases, the focus was on the naturopath accounting for the impact of changes in the patients' health behaviors on their social networks, and vice versa. This naturopath explained the challenges associated with supporting their patients to improve their health choices while also being responsible for the household food preparation:

“You have to keep in mind I mostly see women and they tend to be the primary carers and the primary cooks in families….I would like you to introduce some colourful vegetables to [the patient's] meals every day, unfortunately their families have to suck it up if they want to eat pizzas and hot dogs everyday then that's not going to happen. They will end up eating what the mum eats, and I want her to eat well, so by extension the family eats well. Now sometimes that is a good thing where it is met by support. Sometimes it is not, sometimes its met with ‘we don't want to eat this', and after a week or two it all falls down. And I do hear, ‘’I tried to eat more vegetables but my kids wouldn't eat them and husband didn't like them’ and now we are back to where we started. So family support is very important. Very, very important; and sometimes it comes down to ‘this is important to health and needs to happen and it does happen’ and other times that family pressure is more than what they can manage [sic].”—N6

Discussion

The results of this exploratory study indicate that the clinical practice approach by naturopaths to the management of CVD aligns with the principles of PCC—particularly those principles relating to coordination and integration of care, access to care, continuity and transition of care, information and education of patients, respect for patients' values, preferences and needs, and involvement of family and friends. Previous research has found a PCC approach to CVD treatment or management can reduce length of hospital stay while better preserving activities of daily living,⁶ reduce patient uncertainty about CVD,³¹ and encourage patient self-efficacy in symptom management.³² Existing literature also describes shared characteristics between the principles of PCC and naturopathy both in theory^33,34 and in practice.^35

–38 Importantly, leading national and international organizations, including the Australian government³⁹ and the World Health Organisation,⁴⁰ acknowledge the need for health services targeting patients with noncommunicable diseases such as CVD to employ a patient-centered approach. Given the high socioeconomic burden of CVD in many countries, including Australia,³ the degree to which these findings are generalizable to the broader naturopathic community and meet the health and psychosocial needs of patients requires urgent researcher attention.

Despite the alignment with patient-centered principles in the general approach described by the participants, the degree to which this fully manifests as PCC may not be consistent. For example, naturopaths in this study describe somewhat unsuccessful attempts to coordinate and integrate the care they provide with the other medical professionals providing health care to the same patient. Poor integration is a known barrier to quality health care⁴¹ and a substantial contributor to the unmet health needs of individuals with CVD.⁴² Although this is a challenge experienced in many areas of health care, particularly as it relates to chronic illness, it is likely amplified in circumstances where naturopaths are part of the care team due to the structural, physical, and ideological gaps between naturopaths and conventional health care providers within the Australian health system.⁴³

A recent review of communication between medical doctors or pharmacists and T&CM practitioners has identified issues such as medical dominance, poor clarity of health care provider roles, misalignment in vision for patient care, and gaps in education and training as all affecting interprofessional communication.⁸ When interprofessional communication is limited, patient disclosure of treatments prescribed by other health professionals becomes crucial; yet two thirds of individuals using ingested complementary medicines do not disclose this use to their medical doctor.⁴⁴ The difficulties reported by study participants regarding coordination of care is likely detrimentally affecting patient safety and outcomes, which underpins the rationale for improved integration and coordination within the context of both complementary medicine¹⁰ and chronic illness, including CVD.^39,42 Based on these study findings, the evolving Australian research exploring appropriate integration models,^45,46 communication tools,⁸ and government policy^47
–49 to improve coordination between naturopathic and other health services need to be further expanded and implemented throughout the health system for the benefit of cardiovascular patients accessing diverse health care options.⁵⁰

This study also suggests that naturopaths may not be fully applying key patient-centered principles related to patient and family involvement in clinical decision making. In some instances, participants described considering the impact of prescribed lifestyle changes on the patient's family and modifying their treatment or providing additional advice and resources to patients to support them in implementing the required changes within the context of their family circumstances. However, this was not consistently reported by all participants. Family involvement in managing chronic illness such as CVD can be critical due to the extent to which lifestyle factors influence disease onset, progression, and prognosis.⁵¹

Cardiovascular patients who do not have strong support from their social network are commonly less successful in implementing and sustaining such changes.⁵² For this reason, shared decision making is a characteristic of successful lifestyle change interventions in cardiovascular populations.⁵³ The reason this appears less consistently applied in this study population, compared with other patient-centered principles, may be due to the individualized nature of naturopathic care.⁵⁴ It may also be that the alignment between patient-centered and naturopathic principles has occurred through convergent evolution whereby the naturopathic approach has been defined and employed as a traditional system of medicine,⁵⁴ whereas patient-centered principles have evolved out of the work of Carl Rogers in the 1940s and the Balints in the 1970s (Ref.⁵⁵). As such, the naturopathic profession may benefit from explicitly engaging with patient-centered literature and consciously adopting additional practices that have not historically been reflected in naturopathic practice.

The findings from this study should be considered within the context of its limitations. The study relied on self-reporting and although this is appropriate to answer the research question, the findings can only be viewed as perspectives and experiences, rather than behaviors. Selection bias is also a study limitation since naturopaths outside of the PRACI PBRN were not included in the study, whereas PRACI members self-selected for participation. As responders and nonresponders may have a very different experience, establishing the degree of transferability of findings to other groups and settings requires further research. The framework employed in the analysis was applied post hoc and as such participants were not asked specifically about PCC nor were interview questions structured to directly explore PCC approaches. As such some perceptions and experiences of providing PCC may have been omitted by participants in their responses. Finally, the study drew on a small sample.

However, all interested individuals who met the eligibility criteria were interviewed and data saturation was achieved, which meets accepted qualitative health research methods,⁵⁶ providing both richness and thickness of data. The validity of the findings is also strengthened by the approach to data analysis, which involved three researchers who independently examined raw data and identified themes by consensus. Despite these limitations, this study presents novel findings that warrant further exploration to inform improved cardiovascular care.

Conclusions

The results from this exploratory study conducted in Australia mirror qualitative research performed in the United States, which also identified themes consistent with PCC.^37,38

The results suggest naturopathic practice in Australia is an example of implementing the PCC approach to practice, although several physical, societal, and political barriers may limit the effectiveness of the model of care. The naturopathic profession in Australia and internationally may benefit from directly engaging with the PCC movement. Equally, health policy makers and health service managers seeking to facilitate the provision of PCC to individuals with CVD could explore the opportunities afforded by including naturopathic clinicians within the existing health services. Further research should determine whether this orientation toward PCC leads to differential patient outcomes.

Footnotes

Author Disclosure Statement

The authors have no conflicts of interest to declare.

Funding Information

No funding was received for this article.

Supplementary Material

Supplementary Appendix S1

Supplementary Appendix S2

Supplementary Appendix S3

References

Australian Bureau of Statistics. National Health Survey: First results, 2014–15, ABS cat. no. 4364.0.55.001, March 2019.

The Australian Department of Health and Welfare. Cardiovascular Disease. Canberra, Australia: The Australian Department of Health and Welfare, 2019.

Australian Institute of Health and Welfare. Australian Burden of Disease Study: Impact and Causes of Illness and Death in Australia 2015. Australian Burden of Disease series. Canberra, Australia: Australian Institute of Health and Welfare, 2019.

Australian Government. Cardiovascular Health Mission. Canberra, Australia: The Australian Health Department, 2019. Online document at: https://www.health.gov.au/initiatives-and-programs/cardiovascular-health-mission, accessed December 14, 2019 .

The National Heart Foundation. Heart Disease Statistics. Online document at: https://www.heartfoundation.org.au/search/%22heart-disease-statistics%22, accessed May 5, 2020 .

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