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REVIEW ARTICLE
Year : 2019  |  Volume : 2  |  Issue : 2  |  Page : 71-76

The Establishment and Spread of Acupuncture Model Based on Different Cultures


Laboratory of Acupuncture and Moxibustion, Shanghai University of Traditional Chinese Medicine, Shanghai, China

Date of Web Publication19-Jun-2019

Correspondence Address:
Prof. Sheng Liu
Shanghai University of Traditional Chinese Medicine, 1200 Cailun Rd, Shanghai 201203
China
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/CMAC.CMAC_5_19

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  Abstract 


The Belt and Road (B and R) brings a historic opportunity for the Chinese medicine culture communication, especially the traditional acupuncture. The high rate of acupuncture cognitive barriers is one of the important factors among patients and service providers in “B and R” countries. The proposed project, to be conducted in “B and R” countries, has the following primary aims: (1) to assess acupuncture knowledge, attitudes, and perceptions; (2) to assess acupuncture knowledge, attitudes, and perceptions among clinic staff; and (3) to adapt, develop, and deliver acupuncture education programs for patients and clinic staff. The secondary aims are as follows: (4) to explore the barriers that impact acupuncture receiving intervention and medical service and (5) to explore ways to help service providers to provide acupuncture services to patients in acupuncture clinics based on different cultures. Through an iterative process of discussion and revision, we plan to develop a comprehensive acupuncture intervention program that is appropriate for the “B and R” countries setting and that can be tested for its effectiveness in a series of controlled trials in future research.

Keywords: Acupuncture, Chinese medicine, culture communication, the Belt and Road


How to cite this article:
Zhang Y, Liu S. The Establishment and Spread of Acupuncture Model Based on Different Cultures. Chin Med Cult 2019;2:71-6

How to cite this URL:
Zhang Y, Liu S. The Establishment and Spread of Acupuncture Model Based on Different Cultures. Chin Med Cult [serial online] 2019 [cited 2019 Nov 12];2:71-6. Available from: http://www.cmaconweb.org/text.asp?2019/2/2/71/260712






  Introduction Top


The Belt and Road (一带一路)[1] Initiative focuses on bringing together China, Central Asia, Russia, and Europe (the Baltic); linking China with the Persian Gulf and the Mediterranean Sea through Central Asia and West Asia; and connecting China with Southeast Asia, South Asia, and the Indian Ocean [Figure 1]. The construction of “B and R” brings a historic opportunity for the Chinese medicine culture communication, especially the traditional acupuncture.[2] Owing to the different cultures and races, traditional Chinese acupuncture is facing enormous barriers to establishment and dissemination in “B and R” countries.[3],[4] Disparities in acupuncture treatment across ethnic and class categories are widely documented and this represents an urgent problem for spread of acupuncture.[5] Causal explanations for disparities in acupuncture intervention, however, are still debated, especially with respect to the relative effects of class, culture, and gender, which affect the treatment of acupuncture.[6] This difference also hinders the depth and breadth of acupuncture spread in the “B and R.”
Figure 1: The 21st Century Maritime Silk Road(21世纪海上丝绸之路)

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Despite the great high demand on acupuncture treatment among patients and service providers in “B and R” countries, limited acupuncture intervention/prevention strategies are available in these countries [Figure 2]. The high rate of acupuncture cognitive barriers is one of important factors among patients and service providers in “B and R” countries. In fact, Chinese acupuncture clinics can provide an efficient platform to address issues among patients.[7] However, to our knowledge, not much study was conducted on the knowledge, attitudes, and perceptions of acupuncture among both patients and service providers in “B and R” countries.[8],[9] Many materials regarding acupuncture model have been developed in China, but research efforts are needed to integrate and adapt to different culture in other countries' settings and to empirically test the educational program to ensure that it is effective to increase knowledge services among patients in “B and R” countries.[2],[10],[11]
Figure 2: The acupuncture of different races

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For the establishment of acupuncture model, we first propose to investigate acupuncture knowledge, attitudes, and perceptions among patients and service providers in acupuncture clinics and further explore the barriers that impact acupuncture services and medical care. The proposed project, to be conducted in “B and R” countries, has the following primary aims: (1) to assess acupuncture knowledge, attitudes, and perceptions among patients; (2) to assess acupuncture knowledge, attitudes, and perceptions among clinic staff; and (3) to adapt, develop, and deliver acupuncture education programs for patients and clinic staff. The secondary aims are as follows: (4) to explore the barriers that impact acupuncture receiving intervention and medical service and (5) to explore ways to help service providers to provide acupuncture services to patients in acupuncture clinics based on different cultures. The program to be developed and the data collected in the proposed study will establish a basis for developing recommendations of a comprehensive acupuncture intervention program based on different cultures in order to be tested in future clinical trial. If proven effective, the intervention program can be widely used in “B and R” countries to reduce acupuncture cognitive barriers. Only overcoming these barriers acupuncture can spread more widely in “B and R” countries.


  Relevance Top


The study is unique and important because the establishment and spread of acupuncture model based on the culture in the background of “the B and R” acupuncture cognition are major problems, especially among the “B and R” countries, but there are few people who know about acupuncture, including acupuncture knowledge level and current barriers and intervention strategies for acupuncture among patients and staff in “B and R” countries. If related consequences cannot be controlled efficiently, it will result in much greater spreading obstacles for acupuncture.[12] This study will help the readers to understand and address this important problem in “B and R” countries [Figure 3].
Figure 3: Mind map

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Specific aims

Our program is devoted to solving the problem of acupuncture cognitive barriers in “B and R” countries. Through the investigation of acupuncture knowledge, attitude and awareness can develop appropriate solutions for different ethnic group patients and staffs. It will help for breaking the barriers of acupuncture cognitive in different races in “B and R” countries. Only overcoming these barriers acupuncture can spread more widely in “B and R” countries. Hence, we have to do the following:

Primary aims

  • Aim 1: To assess acupuncture knowledge, attitudes, and perceptions among patients
  • Aim 2: To assess acupuncture knowledge, attitudes, and perceptions among staff in acupuncture clinics.


Based on knowledge accumulated from studies 1 and 2, we will adopt and develop acupuncture educational programs appropriate for “B and R” countries' patients and service providers.

  • Aim 3: To adapt, develop, and deliver acupuncture education programs for clients and clinic staff and to assess acupuncture education outcome among the clients.


Secondary aims

  • Aim 4: To study the barriers that impact acupuncture intervention and medical service
  • Aim 5: To explore ways to help clinic staff to provide acupuncture services to patients.



  Innovations Top


Awareness of the impact of acupuncture raised in China, but in “B and R” countries, people know little about the importance of acupuncture. To our knowledge, this is the first comprehensive research which will use multiple instruments to measure acupuncture knowledge and behavior change in patients of different races who present in acupuncture clinic, as well as the acupuncture knowledge of acupuncture clinic staff. This is also the first trial which will test the effect of educational intervention. Acupuncture knowledge has had a science education among different races. However, for acupuncture education, this is the first time to collect “B and R-” related data and to develop acupuncture comprehensive intervention program. Based on this proposed study, some suggestion about promising directions for future research will be provided.

In addition, we use the contemplation ladder method to explore. This is an adapted version of the contemplation ladder.[13] It is a visual analog comprising 10 rungs and 5 anchor statements, representing stages of change. The instructions for the contemplation ladder are as follows: each rung on this ladder represents where a person might be in thinking about changing their risk behaviors and asking for acupuncture care. Select the number that best matches where you are now. Then, select the stage of change where you are. We can use this method to better understand the different acupuncture disorders in different races. To guide the proposed study, we intend to form a community advisory board (CAB) and an international expert panel (details please refer to 4).

In “B and R” countries, there were no empirical data related to acupuncture cognition barriers although it is a very critical public issue. The proposed research will add significantly to the acupuncture cognition among “B and R” countries, with potential implications for “B and R” countries' policies.


  Research Design and Methods Top


We propose to conduct three inter-related studies using both qualitative and quantitative research methods to address a series of research questions. First, we will begin by assessing acupuncture knowledge, attitudes, and perceptions, among acupuncture clinic in “B and R” countries (Study 1) and acupuncture knowledge, attitudes, and acupuncture services among acupuncture clinic staff (Study 2). Second, based on knowledge accumulated from Studies 1and 2, we will adapt and develop acupuncture education materials appropriate for “B and R” countries and acupuncture treatment service providers and then use the transtheoretical model of behavior change as a conceptual model to measure if our educational program will increase patients' readiness to consider getting acupuncture cognitive for patients (Study 3). Finally, by integrating findings of these three studies and by consulting with leading experts in acupuncture, we plan to develop acupuncture education program applicable in “B and R” countries, which can be tested in future formal experimental trials.

To guide the proposed study, we first plan to form a CAB [14] and an international expert panel. The CAB will consist of local experts: political leader, community leader, acupuncture providers, patients, a physician in a general hospital, and acupuncture physicians in acupuncture clinics. The CAB will provide guidance in the development of the education materials and provide feedback when the educational material is developed. The CAB will discuss the feasibility of the educational program and assure that the key issues related to acupuncture education are taken into consideration in the educational program. The CAB will also advise strategies for wider dissemination/implementation of the educational materials in acupuncture treatment settings or other related settings. An international expert panel will be established to guide the development of acupuncture educational program and intervention strategies that are evidence based. They will review and comment on educational materials as they are developed.

Study 1 – Assess acupuncture knowledge, attitudes, perceptions, and risk behaviors, among patients

Research questions

  1. What is the level of acupuncture knowledge, attitudes, and perceptions among patients in acupuncture clinics in “B and R” countries?
  2. Are there differences in acupuncture knowledge and attitudes among different ethnic groups?
  3. What are the barriers for patients to access acupuncture services?
  4. Are there differences in patients' knowledge and in their awareness and actual use of acupuncture services?


Study design

To address these research questions, we will conduct focus groups, review medical records, and survey patients in acupuncture clinics in “B and R” countries. Patients will be recruited from four clinics, and criteria for selecting acupuncture clinics are as follows:

  1. A minimum of 40 patients in the clinic
  2. Adequate space to accommodate research assistants and study protocol procedures including focus group discussions
  3. Able to provide complete data on individual patients regarding attendance and other laboratory test results, which will be shared upon patients' consent.


Participants

A total of 150 patients will be surveyed in this study. All patients in the acupuncture clinics will be invited to participate in the research. One hundred and twenty participants will be required to estimate a 95% confidence interval with a total width of 0.5 point. Hence, we propose to enlarge the sample to 150 to ensure reasonable power.

Instruments

  • The Medical Outcomes Study 36-item short-form health survey:[15] A 36-item short-form health survey (SF-36)profile was developed in 1988 Medical Outcomes Study, on the basis of health research and development and to Boston by the United States
  • Attitude scale of acupuncture: Attitude scale of acupuncture, psychometrics test scale of quality, and the general attitude test scale of acupuncture of patients
  • Acupuncture knowledge: We will produce a survey on acupuncture knowledge
  • Acupuncture cognitive barriers: We will ask some questions to test different racial perceptions of acupuncture
  • Organizational Culture Assessment Instrument:[16] It is taught by Prof. Robert E. Quinn of the University of Michigan Business School and Professor Kim S. Cameron, in the long-term research organization culture, based on the development of the measurement of organizational culture scale.


Study procedures

Recruitment

Based on the information from the pilot study, 70% of patients were male and 30% were female. At each selected clinic, the study will be explained to potential participants during the recruitment process. For those who decide to participate in this study, detailed informed consent procedures will outline the nature of participation, risks and benefits, and the schedule for data collection and compensation. Individuals will be reminded that they are free to decline or stop participation at any time.

Survey procedure

Individual and face-to-face interviews will be performed in a private room in the program. Audio Computer-Assisted Self-Interview (ACASI)[17],[18],[19] will be used to conduct the part of the interview dealing with sensitive questions such as sexual behavior. With ACASI, using headphones, respondents listen as the survey questions that appear on a computer monitor are read to them, and patients respond to these questions using a touchscreen monitor. Before responding to the survey, one of research staff will work with the patients individually using a variety of practice questions and help them become familiar with the use of ACASI. The research staff will remain nearby to answer any questions or deal with any problems in completing the instruments. All components of the interview will take a total of 0.5 h. We have successfully used this procedure in our previous studies.

Planned analysis

Establishment of the database, data entry, and data management.

  • Preliminary analysis: Frequencies will be run and examined for evidence of sparseness for categorical data and for nonnormality (using plots, examination of skewness, kurtosis, etc.) for continuous variables
  • Quantitative data analysis: These descriptive statistics may include means and standard deviations for continuous variables and frequencies or percentages for categorical variables
  • Qualitative data analysis: A flexible data analytical software package, the Analysis of Free Text for Ethnographic Research,[20] will be used for analysis of interview data.


Study 2 – Assess acupuncture knowledge and attitudes among service providers

Research questions

  1. What is the level of acupuncture knowledge, attitudes, and self-efficacy among acupuncture clinic staff?
  2. What kind of acupuncture services do they provide for patients?
  3. What is the relationship between their knowledge and their acupuncture-related services and practices?
  4. What are the barriers that prevent them from offering acupuncture care, and what can facilitate providers implementing acupuncture services?.


Study design

This study includes both quantitative and qualitative questionnaires to assess acupuncture knowledge, attitudes, self-efficacy, and current barriers and to explore the relationship between knowledge and practice among service providers.

Participants

About 70 acupuncture clinic staff will complete the acupuncture knowledge and attitude survey.

Instruments (refer to Instruments)

Study procedures

Recruitment

All acupuncture clinic staff have M. D. degrees. The questionnaire will be handed out to all staff during a routine meeting at each site.

Survey procedure

After obtained informed consent, participants will be asked to respond to questions about their acupuncture knowledge, attitudes, and acupuncture management practices; total survey time will be 0.5 h.

Focus group procedure

Same as described above for Study 1.

Planned analysis

Quantitative data analysis

Descriptive statistical methods will be utilized to describe the measures of acupuncture knowledge, attitude, self-efficacy, and barriers (Research Questions 1 and 2). These descriptive statistics will include means and standard deviations for continuous variables and frequencies or percentages for categorical variables. Bivariate analysis will be conducted to examine relationships among acupuncture knowledge, attitude, perception, and acupuncture services and practices (Research Question 3), and regression analysis (logistic regression for categorical outcomes and multiple regression for continuous outcomes) will be conducted to assess the association of acupuncture knowledge, attitude, and perception with acupuncture management practices. Qualitative data analysis (Research Question 4) has been described above (refer to planned analysis).

Study 3 – Develop and deliver education materials among patients and service providers

Based on knowledge accumulated from Studies 1 and 2, we will adopt and develop acupuncture educational material appropriate for “B and R” countries' patients and service providers. Study 3 will focus the following questions:

  1. Does the education program increase knowledge among acupuncture clinic staff?
  2. Does the education program improve knowledge and decrease acupuncture cognitive barriers among patients?
  3. Are acupuncture cognitive barriers reduced in association with increased acupuncture knowledge level among patients?


Study design

This study will include a developmental phase and an intervention phase. The developmental phase has the goal of developing educational materials for patients and service providers [Figure 4]. Input from focus groups, the CAB members, expert panel members, a physician will be solicited, incorporated, and integrated. Educational material will be delivered to acupuncture clinic staff via lectures. For patients, the education material will be given via eight 2-h sessions over 4 weeks.
Figure 4: The teaching model of human acupoints

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Developmental phase

Our preliminary plan is to include the following contents in our education programs (owing to the limited page, we did not explain training materials in detail).

  1. Acupuncture development background: We will introduce the history of acupuncture and the impact of patients
  2. Acupuncture knowledge
  3. Acupuncture treatment and how to deal with the disease
  4. Acupuncture tool.



  Summary Top


We will summarize the former topics and encourage patients to discuss what they have learned and address questions they have.

Intervention phase

Education for service providers

The training will be conducted in two half-day sessions on 2 consecutive days. The contents will be divided into individual modules based on a training manual.

Education for patients

A total of 160 patients were randomly selected from four clinics in different countries and divided into four groups. All participants will be given a twice weekly education session over 4 weeks based on intervention manual. We will use a variety of learning techniques, including lecture, brainstorming, small and large group activity, individual worksheets, role play, and video player. Each session will last 2 h. The 1st h will be used to deliver education, and the 2nd h will include discussion and testing via questionnaire survey. Patients will be encouraged to discuss issues related to each session's topic. The posttraining test will be conducted to evaluate the educational outcome.

Finalize education material

The CAB will review the intervention materials and provide guidance and suggestions to refine these materials after the intervention phase. The research staff will modify the drafts and then present it at the CAB meeting. This process will continue if the intervention materials are satisfactory.

Data collection instrument and measures

The acupuncture contemplation ladder which used to assess patients' readiness to consider getting acupuncture has been described above (refer to 3).

Other instruments to be administered at baseline and follow-up are described in previous section.

Developing recommendations for a comprehensive acupuncture intervention program in “Belt and Road” countries

Through an iterative process of discussion and revision, we plan to develop a comprehensive acupuncture intervention program that is appropriate for the “B and R” countries setting and that can be tested for its effectiveness in a series of controlled trials in future research.

Financial support and sponsorship

This study was financially supported by the National Natural Science Foundation of China Project(NSFC:81873379).

Conflicts of interest

There are no conflicts of interest.



 
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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