Volunteer Providers’ Experience Referring Guatemalan Patients for Acupuncture Care in a Pilot,Integrated,Health Care Clinic

Abstract

Purpose:

The aim of this qualitative study was to explore the experience of volunteer providers referring Guatemalan patients for acupuncture care during a 1-day, pilot, integrated, health care clinic.

Methods:

In a partnership among the University of Utah College of Nursing and Refuge International, the integrated, health care clinic occurred at hospital in San Raymundo. Before the clinic, nursing faculty offered providers an overview of acupuncture care. Providers referred 11 patients for acupuncture care. After the clinic, seven providers (one cardiologist, one certified nurse midwife, five student nurse midwives) were asked 10 questions in semi-structured interviews about their experience referring patients for acupuncture care. The interviews were audiotaped, transcribed, and analyzed to identify themes.

Results:

Five themes emerged from analysis of the semi-structured interviews. Providers accurately recognized primarily pain, among other reasons, to refer patients for acupuncture care. Providers stated they lacked a comprehensive understanding of acupuncture care and wanted a more thorough education. Providers did not encounter barriers to referring patients for acupuncture care, and referrals did not hinder clinic flow. Providers were enthusiastically receptive to acupuncture care and endorsed expansion of integrated, health care clinics. Providers felt acupuncture care offered an important and culturally acceptable alternative to biomedicine, particularly for Guatemalan patients who are frequently marginalized and lack consistent access to health care.

Discussion:

Results from this pilot study indicate promising potential for offering acupuncture care in an integrated, health care clinic, particularly for marginalized patients who lack consistent access to health care.

INTRODUCTION

Guatemala is a small Central American country, approximately the size of Kentucky with a population density similar to the state of New York.¹ The country, which is the most populated in Central America, has the unfortunate designation of sustaining the longest civil war in Central American history.^2,3 The 36-year civil war (1960–1996) impacted indigenous Mayans disproportionately more than Ladinos.^2,4 Of the 200,000 people killed during the war, >90% were indigenous Mayans, as they were considered enemies of the state.^2–4 No Guatemalans were immune from the destruction, suffering, and death from the war.^2–4 The impact of the war also has had a long-lasting effect on the health and organization of the country as it continues to mend and disperse health care allocations.⁵ Many barriers and disparities still exist that affect the health of indigenous Mayans, who make up 40% of the population, and live in extreme poverty.^5,6

Academic institutions across the U.S. from Marywood University in Pennsylvania to the University of Utah (UU) in the intermountain west have provided health care missions in Guatemala to offer essential health care for the past 2 decades.⁷ Nonprofit organizations also have increased the number of short-term, health care missions after the war ended as the country has tried to recover.⁵

Often, the chief complaint among Guatemalan patients when presenting for health care is pain along with other somatic symptoms of allostatic stress.^6–8 The civil war led to an economic shift, forcing many Guatemalans work in manual labor. Current estimations are that 38% of adults work in agriculture, and 14% work in industry.^6,9 The physical demands of manual labor, in conjunction with the trauma of the civil war, compound pain among Guatemalan patients.

Acupuncture is recommended by the American College of Physicians as a first-line intervention for acute, subacute, and chronic pain.¹⁰ Limitations are evident to the biomedical services that can be provided for symptoms, such as insomnia, chronic pain, anxiety, depression, and stress.⁷ Most indigenous Mayans still rely on and trust traditional medicine as their primary source of health care.¹¹ Thus, acupuncture and acupressure are evidence-based practices that offer an alternative to biomedicine for treating the aforementioned symptoms, particularly among marginalized indigenous Mayans.^10,11 Acupuncture has been a part of global health since 1995 in Guatemala and shares similar components with traditional Mayan medicine, which make the practice acceptable to Indigenous Mayans.^12,13

At present, we lack literature regarding provider perspectives and possible barriers to referring patients for acupuncture, particularly in developing countries, such as Guatemala, where adjunct care could offer promise to patients with limited access to health care. Lack of awareness or limited knowledge about acupuncture efficacy and safety among patients, providers, and support staff can pose a barrier to patients seeking or being offered the intervention.¹⁴ Acupuncture services, particularly in a country, such as Guatemala, with limited health care, are supportive and in alignment with Mayan traditional medicine, making it a culturally sensitive option to treat pain and disease symptom management.¹⁵ In summary, acupuncture and acupressure offer promising alternative care for pain and trauma that many Guatemalans have experienced as a result of the civil war and that manual laborers suffer in agricultural and industrial facilities.⁶

Understanding the level of provider buy-in for new care options, fostering a change in health care, and eliminating barriers is an essential first step.^16,17 More information is needed about facilitators and barriers to offering acupuncture in an integrated, health care clinic, particularly to patients who may lack access to health care. The purpose of this qualitative study was to explore the experience of volunteer providers referring patients for acupuncture care during a 1-day, pilot, integrated health care clinic to determine the usability, feasibility, and acceptability of the alternative care option.

METHODS

This qualitative pilot study used a semi-structured interview format with an interdisciplinary group of providers. This study assessed the feasibility, usability, and acceptability of providers referring patients for acupuncture care in an integrative, health care clinic. Insights gained from these interviews can be built upon to guide the design of future integrated, health care clinics offering acupuncture care in global health studies.

SETTING

The provider interviews occurred in a two-story hospital in Llano de La Virgen that was a Refuge International site in San Raymundo. San Raymundo is a municipality in the highlands, northwest of Guatemala City. Refuge International is a nonprofit U.S.-based organization in operation since 2001. Refuge International has maintained four clinics in Guatemala for 20 years and has a local board comprised of Guatemalans. Refuge International conducts a “jornada” (translated to “a day’s journey” in Spanish) that offers health care for a week, four times a year, as part of its commitment to providing culturally appropriate and responsive health care in Guatemala. The interviewed providers delivered health care during the week-long jornada. Provider acupuncture education occurred in a large room in the hospital in a group setting. The provider semi-structured interviews were conducted in a private room in the hospital. Translators were used for patient intake and communication.

SAMPLE

Inclusion criteria were providers who referred a patient for acupuncture during the clinic. Exclusion criteria were providers who did not refer patients for acupuncture during the clinic. The group consisted of seven providers, including a cardiologist, a certified nurse midwife (CNM), and five student nurse midwives (SNMs) from Case Western Reserve University. No providers were excluded as all seven providers referred patients for acupuncture.

PROCEDURE

The two primary investigators (PIs) included a nursing scientist in the UU College of Nursing with 22 years of experience practicing acupuncture and Chinese medicine, and a bilingual, Doctor of Nursing Practice (DNP) and CNM who has had a program of study with Guatemalan lay midwives since 2009 in partnership with Refuge International. The acupuncturist and nurse scientist trained another CNM to assist in the acupuncture room. The experienced and the novice acupuncturists provided acupuncture therapy to 11 patients. Before the clinic, the experienced acupuncturist and nurse researcher gave the Refuge International volunteers an educational overview of acupuncture therapy.

The experienced acupuncturist and nurse scientist explained that acupuncture is a safe, evidence-based care that has been used for more than 2,000 years. She explained the efficacy for acupuncture demonstrated in the literature is for pain and nausea during pregnancy. She welcomed providers to refer any patients who were interested in acupuncture for care, except patients with an acute abdomen or undiagnosed cardiac disease. She also mentioned she would be treating patients with diabetes using an ear seed protocol. The acupuncturist and nurse researcher then answered all questions the Refuge International health care team asked.

Refuge International provides a week-long clinic where patients frequently line up outside the facility before dawn. Patients are then called in for care based on assigned numbers. After intake, patients sit on benches along the clinic wall while waiting to receive primary care. Any patient who presented for primary care and had a complaint that could be addressed with acupuncture care was invited to go upstairs to receive acupuncture care while waiting the primary care for which the patient presented. After receiving acupuncture care upstairs, patients were escorted back downstairs and invited to wait on a bench in the line for care of their primary concern. The bilingual DNP and CNM provided primary care in the downstairs clinic and facilitated the flow of patients from the downstairs primary care clinic to the upstairs acupuncture clinic.

After the integrated, health care clinic, the CNM who assisted the experienced acupuncturist conducted the semi-structured interviews in English with providers. The providers were informed their participation was voluntary. The interviews included 10 questions about their experience referring patients for acupuncture care. Clinician type and clinical role data were collected during the interviews, which were conducted in English. No translation services were needed.

DATA COLLECTION AND ANALYSIS

The provider interviews were audiotaped for accuracy, and then transcribed and analyzed in the U.S. by the research team for common themes. The research team collaborated to read the manuscripts in totality, to identify categories and common themes. The bilingual DNP and CNM who was a co-PI in the study led this process. The data analysis process identified the common themes across all 10 semi-structured interviews. Supporting quotes from participants were selected to demonstrate the themes.

While the interview questions were novel and not a verified tool, study validity was supported by several members of the research team collaborating on designing questions based on a thorough literature review. Study reliability was ensured through the CNM, who assisted the acupuncturist during clinic, conducting all seven provider interviews and using a reference card (see Table 1) with the interview questions for consistency. Study reliability was further supported through audio recordings of the interviews and transcribing them verbatim.

Table 1.

Questions Volunteer, Primary Care Providers Were Asked during Semi-Structured Interviews

What was your role in clinic?

What symptoms are appropriate to refer patients for acupuncture care?

Did you refer any patients for acupuncture care?

For what symptoms did you refer patients to acupuncture care?

How did the referrals you made for acupuncture care go?

Did you see the patients you referred after acupuncture care?

Did acupuncture care slow down the flow of the primary care clinic?

Were barriers evident to referring patients for acupuncture care?

Do you have recommendations for improving referral to acupuncture care during an integrative, health care setting?

Do you have additional comments about referring patients for acupuncture care during an integrative, health care setting?

ETHICS

The UU Institutional Review Board deemed signed consent forms exempt for the present study. The study protocols and procedures were designed in alignment with Brocher Declaration’s six principles that included (1) bidirectional input and learning partnership, (2) needs and activities defined by the host community, (3) a focus on program sustainability and capacity growth, (4) accordance with compliance with relevant laws, ethical standards, and code of conduct, (5) cultural sensitivity, mutual respect, and humility, and (6) action accountability.¹⁸

RESULTS

Five themes emerged from the analysis of the semi-structured interviews. Providers accurately recognized primarily pain, among other reasons, as an appropriate condition for patient referral for acupuncture care. Providers stated they lacked a comprehensive understanding of acupuncture care and wanted a more thorough education. Providers did not encounter barriers for referring patients for acupuncture care, and acupuncture care referrals did not impede clinic flow. Providers were enthusiastically receptive to acupuncture care and endorsed expansion of integrated, health care clinics. Providers felt acupuncture care offered an important cultural alternative to traditional biomedicine, particularly for Guatemalan patients who are frequently marginalized and lack consistent access to health care.

CORRECT IDENTIFICATION OF REFERRAL REASONS

A cardiologist identified the following reasons to refer patients for acupuncture care, “From what I know it is mostly patients with musculoskeletal pain, joint pain, and headaches. I did learn while we were here that diabetics will benefit from it also.”

A CNM stated, “people with pain, diabetes, hypertension, depression, anxiety, gastrointestinal issues, and sleep issues” are candidates for acupuncture care.

DESIRE FOR COMPREHENSIVE KNOWLEDGE ABOUT ACUPUNCTURE

One SNM shared, “I did not know a lot about acupuncture. I knew a little bit. I personally would try to explain acupuncture to somebody. I understand it has to do with energy moving through the body. Trying to explain to somebody how it would help their pain when you don’t know a lot about it is difficult.”

The same student went on to say, “I would have loved an in-depth 10-min information (session) about what I should be telling my patients (that) acupuncture is and how it can help them.”

A second SNM stated, “I would like to know how to better educate the patients because I myself am not very familiar with exactly how acupuncture works.”

A cardiologist said, “I’m not as informed as to what all acupuncture can be used for, so maybe knowing that ahead of time would help, but I think they went over it briefly ahead of time, and I probably just don’t remember them all.”

CLINIC FLOW SUSTAINED

One SNM shared, “Yes, I didn’t have any problems once I made my referral. It seemed like my patient was able to get up there pretty easily.”

When asked if the integrative acupuncture clinic disrupted the primary care clinic, the cardiologist stated, “Not at all.”

A CNM added, “the other thing that was really helpful was because the acupuncturists did the evaluation after we did, I feel the overall evaluation and treatment was more thorough.”

ENTHUSIASTIC RECEPTION TO AN INTEGRATED CLINIC

A CNM stated, “I think it could be a really promising resource for patients who don’t have access to care.”

A SNM shared, “I think there would be no doubt patients (would) benefit from it a lot.”

IMPORTANT CULTURAL ALTERNATIVE

One SNM stated, “I think it’s pretty cool because it gets back to more indigenous and like native roots, and it’s a not too invasive, and it can really cause a lot of pain relief without giving a medicine.”

Another SNM said, “I think it’s a great option, considering cultural (issues) too. I think a lot of times it’s easy to just throw medication at a lot of things, and sometimes, I feel like the patient, at least the one patient I had, was really appreciative of having that option.”

DISCUSSION

This study used qualitative data to explore providers’ experience referring Guatemalan patients for acupuncture care in an integrated, health care clinic. The findings highlight that providers primarily recommend patients to acupuncture care for pain management. Pain is one of the primary health issues among Guatemalans and is one of the principal lingering symptoms of the impact of the 36-year civil war.⁹

As previously noted, more than half the Guatemalan population works in manual labor, which contributes to acute and chronic pain.^6,9 Additionally, acupuncture is an evidence-based intervention and a reasonable option for patients with chronic pain globally.^18–20 Consequently, the use of acupuncture is a beneficial approach to addressing the pain among Guatemalan patients.

Our analysis revealed positive attitudes from providers regarding the referral of patients for acupuncture care with no identified barriers for patient referrals or clinic flow. Providers’ enthusiasm supports the expansion of integrated, health care clinics. Notably, providers recognized acupuncture as a culturally significant alternative to biomedical care, particularly beneficial for Guatemalan patients facing marginalization and inconsistent health care access. This positive response suggests a need for further exploration and integration of acupuncture into health care clinics.

Despite the evident benefits of acupuncture and providers’ positive attitudes towards this alternative care, the providers indicated that more comprehensive information about acupuncture would enable them to refer more patients for acupuncture care. Their desire for a more comprehensive education underscores a recognized need for further training initiatives. Additional education is crucial to bridge the knowledge gap and empower providers with the requisite expertise to confidently recommend acupuncture as a practical therapeutic option for their patients. This finding highlights the results from Jackson et al., (2022) and Taylor-Swanson et al., (2023) who found that limited awareness or knowledge about acupuncture among patients and health care providers can hinder patients from seeking or being offered this intervention.^13,21

Incidentally, another acupuncturist from Kingstson, NY, offered care during a Refugee International health care clinic in Purulha, in the department of Baja Veracruz, shortly after our team provided an integrative clinic. The NY acupuncturist treated 75 patients for musculoskeletal complaints, headache, stress, depression, exhaustion, and gynecological symptoms. The acupuncturist reported similar findings as ours in that patients and providers did not initially know what acupuncture was. However, providers and patients, being Kek Chi and Pocomochi, were receptive and wanted more information. Many patients also were manual laborers and welcomed acupuncture care for musculoskeletal pain.

Strengths of our study were the proximity of the primary care clinic and the acupuncture care area. We also had a bilingual DNP and CNM with a long-standing relationship with Refuge International and extensive experience with acupuncture. This bilingual DNP and CNM worked in the primary care clinic, helping refer patients to acupuncture care and ensuring the clinic moved smoothly. Another strength was after receiving a training to assist the acupuncturist, a CNM provided acupuncture care assistance and conducted the provider interviews, which offered a level of knowledge and consistency regarding questions about acupuncture care.

CONCLUSION

Our analysis has several limitations. First, the research team spent only a week in Guatemala, preventing us from providing extensive acupuncture care to patients and education to providers, as well as follow-up assessment on the providers’ referral practices. Additionally, the study is constrained by a relatively small sample size, comprising seven providers. Moreover, one of the PIs, a nurse scientist with >22 years of experience in acupuncture and Chinese medicine, contracted COVID and could not continue to provide acupuncture for all 5 days of the clinic.

Finally, improvements could be made in collecting data. Most providers when asked, “Did acupuncture care slow down the flow of the primary care clinic,” answered, “No.” A more open-ended questions, such as, “How did acupuncture care impact the flow of the primary care clinic,” may have yielded more rich data. Further, the study team transcribed and analyzed the data; employing a more objective analytic tool, such as NVivo, could facilitate a more rigorous analysis of our data.

Future studies should build on our strengths of offering an integrated clinic where primary care and acupuncture care are in close proximity to one another. Designating someone to coordinate care and seek feedback from providers is also important. More comprehensive information about acupuncture care should be offered so a wider array of patients can be referred for acupuncture care to address pain and other health issues. Future studies should include a larger sample during a longer intervention interval.

AUTHOR DISCLOSURE STATEMENT

No competing financial interests exist.

FUNDING INFORMATION

No funding was received for this article.

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