Developing Implementation Strategies for Promoting Integrative Oncology Outpatient Service Delivery and Utilisation: A Qualitative Study in Hong Kong

doi:10.21203/rs.3.rs-3444900/v1

Download PDF

Research Article

Developing Implementation Strategies for Promoting Integrative Oncology Outpatient Service Delivery and Utilisation: A Qualitative Study in Hong Kong

https://doi.org/10.21203/rs.3.rs-3444900/v1

This work is licensed under a CC BY 4.0 License

Version 1

posted

You are reading this latest preprint version

Purpose: Current evidence supports the use of integrative oncology (IO) interventions in cancer supportive care. The demand for outpatient IO services in Hong Kong is expected to soar following the surge in cancer incidence in an ageing population. This study identified the implementation determinants of delivering and utilising outpatient IO from local stakeholders’ perspectives and developed corresponding implementation strategies.

Methods: This study involved two sequential stages. First, with individual semi-structured interviews guided by the Theoretical Domains Framework (TDF), we explored stakeholders’ views on the barriers to and facilitators for implementing IO. Second, guided by a TDF-based qualitative data analysis of interview transcripts, we performed intervention mapping to develop Behaviour Change Wheel-based implementation strategies that may overcome the barriers and strengthen the facilitators.

Results: We interviewed 31 stakeholders, including traditional Chinese medicine (TCM) practitioners (n=8), biomedically-trained doctors (n=7), nurses (n=6), administrators (n=4), caregivers (n=4), and pharmacists (n=2). The common local implementation determinants of IO are (1) lacking nursing and administrative manpower supporting IO service delivery, (2) lacking awareness of IO services among healthcare professionals, administrators, patients, and caregivers, and (3) lacking knowledge among healthcare professionals of herb–drug interaction and herbal toxicities.

Conclusion: We recommended a multi-faceted implementation strategies package that included arranging additional funding to train, recruit, and retain experienced nursing and administrative staff, devolving resources into demonstrating successful interprofessional collaborations and clinical evidence on IO effectiveness and safety, integrating evidence on herb–drug interactions and herbal toxicities into automated electronic health record systems monitored by pharmacists with dual qualifications in TCM and conventional pharmacy.

Cancer

Integrative Medicine

Implementation Science

Delivery of Health Care

Qualitative Research

Many healthcare organisations worldwide have started providing integrative oncology (IO) services as part of their routine cancer care ¹. As a sub-field in integrative medicine, IO is a patient-centred, evidence-informed approach that utilises traditional and complementary medicine (T&CM) alongside conventional cancer treatments ², aiming to optimise the health, quality of life, and clinical outcomes of cancer patients, in addition to empowering them to become active participants in their care before, during, and beyond cancer treatment ². Traditional Chinese medicine (TCM) is one of the major modalities of T&CM popular amongst Chinese populations worldwide. It is a comprehensive system that originated in ancient China that involves the study of life, health and diseases and is applied to health preservation and disease prevention, diagnosis, and treatment, as well as rehabilitation ³. Chinese herbal medicine and acupuncture are the most common TCM interventions. The former refers to the usage of natural medicinal ingredients (i.e., plants, animals, and minerals) and their processed products for therapeutic purposes ⁴, and the latter refers to using stainless-steel filiform needles to puncture specific “acupoints” on the body to trigger specific therapeutic effects ⁵. Evidence supporting the effectiveness and safety of TCM in IO has been systematically synthesised. For instance, overviews of reviews found that Chinese herbal medicine can improve the quality of life among patients receiving cancer palliative care ^6–8. Acupuncture may also alleviate cancer-related fatigue, chemotherapy-induced nausea and vomiting, and leukopenia ^9,10.

TCM has been playing a pivotal role in filling the effectiveness gaps of conventional medicine ¹¹, providing a substantial portion of chronic disease management services in Hong Kong outpatient settings ¹². The private sector is the main provider of TCM services. In the public sector, the government established 18 Chinese Medicine Centres for Training and Research (CMCTRs) to provide a relatively small volume of service. Aiming to facilitate training placements for local TCM graduates, each of these CMCTRs is operated through a tripartite collaboration between the Hospital Authority (the statutory body providing most tax-funded healthcare services in Hong Kong), a non-governmental organisation, and a local university ¹³. Some non-governmental organisations and registered charities are also providers of TCM outpatient services.

In Hong Kong, TCM was not introduced into inpatient settings until 2014 when the Hospital Authority initiated the “Integrated Chinese–Western Medicine” (ICWM) pilot programme, providing stroke rehabilitation, musculoskeletal pain management, and cancer palliative care services in public hospitals ¹⁴. The programme aims to offer affordable IO services to patients in inpatient settings and encourage collaborations between TCM practitioners (TCMPs) and biomedically-trained doctors (BMDs) through co-formulating and executing evidence-based patient management plans¹⁵. However, ICWM services are mainly confined to inpatient care, and their collaboration experience may not be directly transferable outside the wards. The demand for outpatient IO services in Hong Kong is expected to soar following the projected increase in annual cancer incidence to more than 42,000 in 2030 ¹⁶. In response to patients’ demand for IO ¹⁷ and an international trend of providing cancer supportive care in outpatient settings ¹⁸, outpatient IO services emerged in the private sector. In Hong Kong, interprofessional collaborations must rely on the personal networks between private TCMPs and BMDs as there is no established interprofessional collaboration platform ¹⁹. Also, without formal implementation strategies to support shared care, collaboration between TCMPs and BMDs remains challenging, despite the availability of evidence supporting the benefits of IO ²⁰.

Empirical models have been proposed to streamline outpatient IO service delivery with central coordinators ²¹, but how such models work for bringing together TCM and conventional medicine service is unclear. International experience regarding IO implementation determinants (barriers and facilitators) might inform outpatient IO service development ²², but how these lessons learnt should be translated to implementation strategies relevant to the Hong Kong healthcare system context is uncertain. To be comprehensive, the determinants of outpatient IO service delivery and utilisation among potential stakeholders must be investigated based on established implementation science theories, models, or frameworks. Such studies would allow theory-guided assessment of implementation determinants across service providers (e.g., BMDs, TCMPs, nurses, administrators, and pharmacists) and caregivers to inform the formulation of theory-informed implementation strategies to support implementation. These strategies would then assist policy-makers and authorities in promoting outpatient IO service implementation in the future. Implementation strategies constitute the “how to” of integrating evidence-based interventions, programmes, and other practices into routine use in healthcare and other settings ²³. An implementation strategy has been defined as “a systematic intervention process to adopt and integrate” evidence-based practices into usual care ²⁴.

Conducted within the Hong Kong healthcare system context, this study aims to (1) identify the implementation determinants of delivering and utilising outpatient IO services from the perspectives of service providers and caregivers; and (2) develop theory-informed implementation strategies for promoting the delivery and utilisation of outpatient IO services, addressing identified implementation determinants at behavioural, organisation, and policy levels.

The study consists of two sequential stages. In stage 1, we explored the views of different stakeholders on the potential implementation determinants of delivering and utilising outpatient IO services. Guided by the Theoretical Domains Framework (TDF) ²⁵ and the Behaviour Change Wheel (BCW) ²⁶, qualitative data collected from the semi-structured virtual interviews provided insights into stakeholders’ perspectives on capacities, opportunities, and motivations for delivering and utilising outpatient IO services. In stage 2, we performed intervention-mapping to establish theory-informed implementation strategies that address implementation determinants we identified in stage 1. Figure 1 provides an overview of this two-stage study. We obtained ethical approval from the Survey and Behavioural Research Ethics Committee of the Chinese University of Hong Kong before the commencement of interviews (Reference number: SBRE-21-0164).

Stage 1. Identification of implementation determinants of outpatient IO service delivery and utilisation

Participant sampling

The semi-structured individual virtual interviews involved two groups of potential stakeholders of outpatient IO services. We planned to include at least 15 healthcare professionals (e.g., BMDs, TCMPs, nurses, and healthcare administrators) and caregivers in the first group. Those healthcare professionals must have at least five years of experience delivering IO services (e.g., via the ICWM programme) in Hong Kong, while the caregivers must have experience caring for cancer patients who utilised local IO or ICWM services. We planned to involve in the second group with at least ten healthcare professionals without previous experience delivering IO services. The purposive sampling of participants with or without IO experience allowed us to investigate implementation challenges during the scaling up or maintenance of existing services, or during the establishment of new services, respectively. We sampled more interviewees in the experienced group as they are supposed to be richer informants. The target sample size of 25 (at least 15 with IO experience plus at least 10 without IO experience) fulfilled the number of participants expected to achieve saturation in implementation research (n = 16 to 24) ^27,28.

Data collection

For the two groups of interviewees, we prepared separate interview guides based on the TDF (Supplementary Boxes S1 to S4) ²⁵. This framework contains 14 theoretical domains generated from 128 constructs based on 33 health and social psychology theories on behaviour change ²⁵. These domains provided comprehensive coverage of the complex determinants of behaviours that influence the implementation of outpatient IO services at the individual, organisational, and societal levels.

We first asked the healthcare professionals to describe: (1) the activities to promote IO service delivery that had been useful (for those with experience) or were expected to be useful (for those without experience) and (2) the specific incidences when they delivered IO services but found that the experience was not satisfactory (for those with experience) or where the experience was expected to be unsatisfactory (for those without experience). These two questions were followed by specific prompts relating to the possible influences of implementing outpatient IO services, covering all TDF domains. For caregivers, we inquired about their expectations or experience of assisting patients in accessing outpatient IO services.

The interviews were hosted by authors with expertise in qualitative interview methods (MHK and ASCL) and IO in Hong Kong (VCHC and LH). Each interview took approximately one hour and was conducted on virtual meeting platforms between February 2022 and July 2022. Each interview was audio-recorded after receiving written informed consent from the participant.

Data analysis

For stage 1, we performed interviews, transcription, and data analysis concurrently to track emerging themes, which enabled timely follow-up of questions for the next interview or clarifications with the interviewees. We transcribed the audio recordings verbatim and imported the transcripts into NVivo for data analysis in three phases as follows:

Phase 1: Coding of transcripts

The responses from the first 12 participants were coded independently by two authors (ASCL, MHK or LH). Specifically, the coding involved (1) reading the participants’ responses in the transcripts, (2) considering their relevance to the definitions of the TDF domains or constructs, and (3) assigning these responses to one or more domains via directed content analysis ²⁹. The coders then compared their coding results and developed a consensus-based coding scheme. This approach ensured coding consistency as this consensus-based coding scheme guided subsequent coding.

The authors coded the remaining interviews and met frequently (after completing the coding of every five interviews) to assess consistency and seek consensus. When the authors could not reach a consensus on coding, they would discuss with a senior author (VCHC) and an experienced academic familiar with the TDF (PN) on text interpretation. If the authors could not reach an agreement on assigning a code to a single domain, they would assign the code to all the domains they identified.

Phase 2: Generating themes on the implementation determinants of outpatient IO service delivery

Following current guidelines ³⁰, after coding the data into theoretical domains, one author was responsible for generating themes attributable to outpatient IO service delivery and utilisation inductively from the codes via thematic analysis. Another author cross-checked and confirmed the themes and the codes. When they could not reach a consensus, the discrepancy was resolved via discussion among the authors or by arbitration of senior researchers (VCHC or LH). We counted each theme once within each interview to create a frequency count across all interviews.

Then, we selected the top three themes that were (i) most frequently mentioned by the participants, and (ii) also found to be important implementation determinants identified in our previous systematic review of international experiences for further discussion (denoted as common international themes) ²². Meanwhile, the top three themes that were (i) most frequently mentioned by the participants, but (ii) were not mentioned in the previous systematic review were also chosen for further discussion (denoted as common local themes). We reported the proportion of participants with or without experience mentioning each theme separately.

Stage 2. Designing theory-informed implementation strategies to facilitate outpatient IO service implementation

With the results generated from stage 1, we developed theory-informed implementation strategies comprising complex behaviour change techniques (BCTs), aiming at overcoming barriers to and strengthening facilitators for delivering or utilising IO services at individual, organisational, and policy levels. We designed the implementation strategies via the intervention-mapping approach, a systematic, formal process for tailoring strategies according to identified implementation determinants ³¹. In this process, we selected BCTs to target themes mapped to TDF domains identified in stage 1 using the BCW Matrix ²⁶. The BCW Matrix contains 53 effective BCTs mapped across the TDF domains and facilitates the application of a comprehensive range of BCTs for generating empirically supported implementation strategies ³². Thus, the mapping process ensured the logic of the intervention choice by explicitly linking a given BCT with participants’ stated implementation determinants, with concomitant consideration of organisational and policy contexts.

Specifically, we applied our stage 1 TDF-based findings to the three core components of the BCW necessary to induce a target behaviour: (1) capability, (2) opportunity, and (3) motivation (COM–B). Using the COM–B model and the TDF, we performed a behaviour diagnosis to determine what needs to be changed to enable IO service delivery or utilisation. Having identified the relevant COM-B components, we explored how to address each implementation determinant by focusing on specific intervention functions. After developing the intervention functions, we considered the policy categories most applicable to supporting the identified intervention functions. After selecting the intervention functions and policy categories that might aid IO service delivery and utilisation, we identified those BCTs for inclusion. BCTs refer to the active components of strategies designed to promote behaviour that enable implementation ²⁶.

The formulation of implementation strategies was performed by authors with expertise in qualitative research methods (MHK) and IO in Hong Kong (VCHC and LH). The team met regularly to perform mapping and discuss possible BCTs relevant to the Hong Kong healthcare system context. After the completion of data analysis for every two to three interviews, we would design and amend the implementation strategies based on the findings at that time point and adjust the content iteratively until the completion of all interview data analysis.

Participants

We were able to interview a total of 31 participants in this qualitative study, exceeding the number of participants needed to achieve saturation. The first group (with IO experience) consisted of 16 healthcare professionals (i.e., BMDs (n = 4), TCMPs (n = 4), nurses (n = 4), and healthcare administrators (n = 4)) and four caregivers. The second group (without IO experience) comprised another 11 healthcare professionals (i.e., BMDs (n = 3), TCMPs (n = 4), nurses (n = 2), and pharmacists (n = 2, of which one is dual qualified in Chinese herbal and conventional pharmacy)). We invited the two pharmacists after completing the first few interviews, where participants expressed that it was essential to consider the views of local pharmacists as they are likely to play a role in IO service delivery. Table 1 presents participants’ professional and demographic characteristics.

Table 1

Basic professional and demographic characteristics of participants
Participant characteristics and demographics	Frequency (%)
Female	15 (48.4)
Age group (years)
< 30	7 (22.6)
31 to 45	18 (58.1)
46 to 60	4 (12.9)
> 61	2 (6.5)
Role
Traditional Chinese medicine practitioner	8 (25.8)
Biomedically-trained doctor	7 (22.6)
Nurse	6 (19.4)
Healthcare administrator	4 (12.9)
Caregiver	4 (12.9)
Pharmacist	2 (6.5)
Years of practice or caregiving experience
< 5	10 (32.3)
6 to 10	6 (19.4)
11 to 15	9 (29.0)
16 to 20	4 (12.9)
> 21	2 (6.5)
Years of integrative oncology experience as service provider or caregiver (n = 20)
≥ 5 to 10	18 (90.0)
11 to 15	1 (5.0)
16 to 20	0 (0.0)
> 21	1 (5.0)

Stage 1. Implementation determinants of outpatient Integrative Oncology service delivery in Hong Kong

Qualitative data analysis generated 19 themes of implementation determinants, and we mapped all identified themes to at least one of the three components of the COM-B system, as well as ten of the 14 TDF domains. The three common international themes identified from the 31 interviews were:

lack of recognition among healthcare professionals, patients, and caregivers on the evidence supporting the safety and effectiveness of IO interventions (mentioned in 31 interviews);
lack of knowledge among healthcare professionals and healthcare administrators regarding IO (mentioned in 27 interviews); and
inefficient interprofessional communication and collaboration system (mentioned in 16 interviews)

The three common local themes identified were:

lack of nursing and administrative manpower supporting IO service delivery (mentioned in 30 interviews);
lack of awareness of IO services among healthcare professionals, healthcare administrators, patients, and caregivers (mentioned in 29 interviews); and
lack of knowledge among healthcare professionals regarding herb–drug interaction and herbal toxicities (mentioned in 28 interviews)

Table 2 illustrates all implementation determinants summarised from the interviews. For substantiating further discussion, we asterisked (*) these six important themes listed above and described them in-depth with relevant quotes extracted from the transcripts below.

Table 2

Implementation determinants of outpatient integrative oncology services in Hong Kong classified by the Theoretical Domains Framework
COM–B System	TDF Domain	Implementation determinants identified from interviews (Themes)	Frequency
COM–B System	TDF Domain		Total	% in participants with IO experience	% in participants without IO experience
Psychological Capability	Knowledge	• Lack of awareness of IO services among healthcare professionals, healthcare administrators, patients, and caregivers^#	29	90.0	100.0
		• Lack of knowledge among healthcare professionals regarding herb–drug interactions and herbal toxicities^#	28	100.0	72.7
		• Lack of knowledge among healthcare professionals, healthcare administrators, and the public regarding IO services^*	27	100.0	63.6
		• Lack of content regarding interprofessional collaboration between TCM, conventional medicine, and nursing in undergraduate education	24	80.0	72.7
	Memory, attention, and decision processes	• Difficulties in decision-making among patients and caregivers on IO service utilisation	16	45.0	63.6
Physical Capability	Skills	• Lack of skills among healthcare professionals in delivering IO services	25	80.0	81.8
Reflective Motivation	Beliefs about consequences	• Lack of recognition among healthcare professionals, patients, and caregivers of clinical evidence supporting safety and effectiveness of IO interventions^*	31	100.0	100.0
	Beliefs about consequences	• Lack of knowledge among healthcare professionals about the potential ethical or legal consequences of collaborative IO service delivery	25	80.0	81.8
	Social/professional role and identity	• Failure among BMDs and nurses to recognise the compatibility of IO service delivery with their duties and responsibilities	26	80.0	90.9
	Intention	• Lack of career prospects for TCMPs and nurses involved in IO service delivery	20	60.0	72.7
Automatic Motivation	Reinforcement	• Lack of motivation among healthcare professionals in delivering IO service	25	85.0	72.7
	Emotion	• Negative feelings among BMDs and nurses towards TCM and TCMPs	17	60.0	45.5
		• Feelings of being excluded by the conventional medicine-dominated healthcare system among TCMPs	17	60.0	54.5
		• Lack of emotional understanding among BMDs and nurses towards patients’ requests for IO referral	13	40.0	45.5
Physical Opportunity	Environment and resources	• Lack of nursing and administrative manpower supporting IO service delivery^#	30	85.0	81.8
		• Lack of structured referral mechanisms and clear operation procedures for IO service delivery	27	100.0	63.6
		• Unaffordability of IO services	14	50.0	36.4
Social Opportunity	Social influences	• Inefficient interprofessional communication and collaboration system^*	16	65.0	27.3
Keys: BMD: Biomedically-trained doctor; COM–B: Capability, Opportunity, Motivation, and Behaviour; IO: Integrative oncology; TCM: Traditional Chinese medicine; TCMP: Traditional Chinese medicine practitioner; TDF: Theoretical Domains Framework.
^*Common key themes also identified in a previous systematic review [BMJ Support Palliat Care 2023 May 12;spcare-2022-004150] of international literature on IO service implementation determinants
^#Local key themes frequently mentioned by the participants

Capability (COM-B component)

Overall, six themes were relevant to the capability component of the COM-B system, covering three TDF domains (knowledge; memory, attention, and decision process; and skills) [Table 3]. This component included one common international theme and two common local themes.

Table 3

Recommended behaviour change interventions for addressing implementation issues related to capability
Implementation issues identified from interviews (Themes)	COM–B (TDF domain)	Intervention function	Policy category	Behaviour change technique	Behaviour change intervention
• Lack of awareness of IO services among healthcare professionals, healthcare administrators, patients, and caregivers^#	Psychological Capability (Knowledge)	Education	Communication/ marketing	Information about health consequences	• Promoting IO services (including information on safety and effectiveness) to the public and elucidating progress of TCM modern development • Explaining the regulatory and complaint mechanisms on TCM practice to the public • Explaining the fees of IO services, as well as relevant subsidy schemes to patients and caregivers
• Lack of knowledge among healthcare professionals regarding herb–drug interactions and herbal toxicities^#		Enablement	Environmental/social planning	Restructuring the physical environment	• Developing an online information platform for herb–drug interactions and Chinese herbal medicine safety for all healthcare professionals • Integrate safety information into existing electronic health record systems which will enable automated alert when contra-indication appears
		Enablement	Fiscal measures	Problem solving	• Allocating additional resources to improve the research capacity on TCM and IO safety and effectiveness
		Enablement	Service provision	Social support (practical)	• Recruiting pharmacists with dual qualifications in TCM and Conventional pharmacy to update the online information platforms for herb–drug interactions and Chinese herbal medicine safety • Recruiting pharmacists with dual qualifications in TCM and Conventional pharmacy to provide relevant consultation services on the co-administration of TCM herbs and Conventional drugs
• Lack of knowledge among healthcare professionals and healthcare administrators regarding IO^*		Education	Communication/ marketing	Information about health consequences	• Organising continuing professional development programmes on IO services and encouraging all healthcare professionals to participate
		Enablement	Fiscal measures	Problem solving	• Allocating additional resources to improve the research capacity on TCM and IO safety and effectiveness
• Lack of content regarding interprofessional collaboration between TCM, conventional medicine, and nursing in undergraduate education		Education	Guidelines	Feedback on behaviour	• Incorporating BMD–TCMP–nurse interprofessional communication skills training into undergraduate education
• Difficulties in decision-making among patients and caregivers on IO utilisation	Psychological Capability (Memory, attention, and decision processes	Education	Communication/ marketing	Information about health consequences	• Promoting details of IO services (including information on safety and effectiveness) to the public
		Enablement	Regulation	Social support (practical)	• Drafting accreditation criteria for the providers (TCMPs and BMDs) of IO services • Developing the list of accredited providers (TCMPs and BMDs) of IO services
• Lack of skills among healthcare professionals in delivering IO services	Physical Capability (Skills)	Training	Guidelines	Instruction on how to perform a behaviour	• Planning and delivering sustainable clinical training programmes for IO services with a medium term aim of improving local training capacity and capability
	Physical Capability (Skills)	Training	Service provision	Demonstration of the behaviour	• Inviting Chinese Mainland TCM experts to participate in the development of outpatient IO service. Their expertise is expected to enhance practice skills of IO delivery for all healthcare professionals
Keys: BMD: Biomedically-trained doctor; COM–B: Capability, Opportunity, Motivation, and Behaviour; IO: Integrative oncology; TCM: Traditional Chinese Medicine; TCMP: Traditional Chinese Medicine practitioner; TDF: Theoretical Domains Framework.
^*Common key themes also identified in a previous systematic review [BMJ Support Palliat Care 2023 May 12;spcare-2022-004150] of international literature on IO service implementation determinants
^#Local key themes frequently mentioned by the participants

Knowledge

*Common local theme: lack of awareness of IO services among healthcare professionals, healthcare administrators, patients, and caregivers. In Hong Kong, lacking awareness of IO services was highlighted as one of the key reasons explaining why healthcare professionals and administrators do not deliver or adopt IO services in their daily practice. It might also explain why patients and caregivers do not use or recommend IO services. The common cultural practice of consuming Chinese herbal soups and consulting TCMPs for health maintenance does not necessarily contribute to the establishment or usage of IO services. We found that as many as 90.0% of participants with; and 100% without IO experience mentioned this particular issue.

“When we consulted BMDs for the first time, there was no information about IO posted in the oncology clinics, nor there was information provided by the nurses. It is always better to have advertisements or promotion leaflets available for patients because they might think: “Oh, TCM and TCMPs may help!” Perhaps many patients and caregivers are frustrated about not having authoritative information about IO services.” – a caregiver with IO experience.

“While TCM culture heavily influences our dietary habits like the regular consumption of Chinese herbal soups, its’ influence on healthcare service choice is unclear. When it comes to cancer management, I think both healthcare professionals, caregivers or patients have no idea about what exactly constitutes integrative oncology and how we can provide or use such services.” – a nurse without IO experience.

*Common local theme: lack of knowledge among healthcare professionals regarding herb–drug interactions and herbal toxicities. From the interviews, we identified that 100% of participants with; and 72.7% without IO experience expressed that lack of knowledge among healthcare professionals (BMDs in particular) regarding herb–drug interactions and herbal toxicities is a significant implementation barrier. Healthcare professionals are worried about the potential harms incurred to patients during the concurrent use of Chinese herbs and conventional cancer treatments like chemotherapies. However, patients and caregivers are less concerned, and they may not disclose their concurrent use of Chinese herbal medicine to avoid opposition from their BMDs.

“In Clinical Oncology settings, most, if not all, oncologists oppose the oral administration of Chinese herbal medicine during anticancer treatments. There is a lack of safety data regarding the potentially harmful interactions between concurrent oncology and herbal treatments. – a BDM with IO experience.

“The patient must have a certain level of white blood cells to continue chemotherapies. Also, we may need to rely on granulocyte colony-stimulating factors (G-CSFs) to boost the white blood cell level. Many patients expressed that the side effects of G-CSFs, including bone pain and fever, are unbearable and this may affect chemotherapy adherence. I think Chinese herbal medicine helps us strengthen our immune functions by elevating the white blood cell level with little to no side effects. Meanwhile, I am worried about BMDs’ disapproval of using Chinese herbs during chemotherapies due to the limited evidence on harmful interactions. Or else, I would have to lie to the BMD by not telling them that the patient consumed Chinese herbs.” – a caregiver without IO experience.

*Common international theme: lack of knowledge among healthcare professionals and healthcare administrators regarding IO. The knowledge among healthcare professionals (BMDs and nurses in particular) about IO is essential for its implementation, given their dominant roles in the Hong Kong healthcare system. Since nurses are expected to play a pivotal role in coordinating BMDs and TCMPs collaboration, and performing the instructions placed by the two parties, having specialised knowledge in TCM and IO is paramount for them to carry out these tasks with confidence. It is even expected that they will be able to spot potential herb–drug interactions by examining both conventional medicine and Chinese herbal medicine prescriptions. In Hong Kong, healthcare professionals’ scepticism towards IO due to the lack of relevant knowledge reduced BMDs’ and nurses’ willingness to participate in IO service delivery.

“As you call it “integrative oncology”, all parties [nurses, BMDs and TCMPs] must have a common language of communication. In Hong Kong, nursing students receive training in conventional medicine only, and nurses know nothing about TCM. If they do not receive relevant training on TCM or IO, they are unable to understand what TCMPs are doing to the patients. If we want to make nurses the coordinators between BMDs and TCMPs in IO service delivery, and the implementors of IO nursing procedures, we must provide them with adequate training and ensure that they at least understand Chinese herbal prescriptions.” – a nurse without IO experience.

Theme: lack of content regarding interprofessional collaboration between TCM, conventional medicine, and nursing in undergraduate education. 80.0% of participants with; and 72.7% without IO experience expressed that lacking credit-bearing modules on interprofessional collaboration skills in undergraduate TCM, medical, and nursing curriculums hindered interprofessional collaboration in IO service delivery.

Memory, attention, and decision processes

Theme: difficulties in decision-making among patients and caregivers on IO utilisation. 45.0% of participants with; and 63.6% without IO experience thought that having inadequate information or knowledge to support medical decision-making is a barrier to IO service utilisation among patients and caregivers.

Skills

Theme: lack of skills among healthcare professionals in delivering IO services. 80.0% of participants with; and 81.8% without IO experience reported that lacking skill in IO can demotivate TCMPs, BMDs, and nurses in IO service delivery.

Motivation (COM-B component)

Overall, eight themes were relevant to the motivation component of the COM-B system, covering five TDF domains (beliefs about consequences; social/professional role and identity; intention; reinforcement; and emotion) [Table 4]. This component included one common international theme.

Table 4

Recommended behaviour change interventions for addressing implementation issues related to motivation
Implementation issues identified from interviews (Themes)	COM–B (TDF domain)	Intervention function	Policy category	Behaviour change technique	Behaviour change intervention
• Lack of recognition among healthcare professionals, patients, and caregivers of the evidence supporting safety and effectiveness of IO interventions^*	Reflective Motivation (Beliefs about consequences)	Education	Communication/ marketing	Information about health consequences	• Providing all healthcare professionals with updated research evidence on IO safety and effectiveness • Promoting IO services (including information on safety and effectiveness) to the public and elucidating progress of TCM modern development
• Lack of knowledge among healthcare professionals about the potential ethical or legal consequences of IO service delivery	Reflective Motivation (Beliefs about consequences)	Persuasion	Regulation	Information about social and environmental consequences	• Developing regulations to clarify the duties and legal responsibilities of different healthcare professionals involved in IO services
• Failure among BMDs and nurses to recognise the compatibility of IO service delivery with their duties and responsibilities	Reflective Motivation (Social/professional role and identity)	Persuasion	Communication/ marketing	Framing/reframing	• Organising campaigns to promote IO services as a key government policy with substantial public demand to all healthcare professionals
• Lack of career prospects for TCMPs and nurses involved in IO service delivery	Reflective Motivation (Intention)	Incentivisation	Legislation	Material reward	• Establishing IO specialty training schemes for TCMPs and nurses, and improve their remuneration packages upon completion of training and satisfactory job performance
• Lack of motivation among healthcare professionals in delivering IO service	Automatic Motivation (Reinforcement)	Coercion	Regulation	Feedback on behaviour	• Setting performance indicators to monitor and evaluate the number of referrals between district health centres, TCM clinics, and BMD clinics
		Coercion	Regulation	Feedback on outcome(s) of behaviour	• Establishing assessment criteria to appraise the clinical effectiveness of, and patient satisfaction towards, IO services
		Incentivisation	Service provision	Feedback on outcome(s) of behaviour	• Providing reports on clinical effectiveness and patient satisfaction to healthcare professionals involved in IO services
• Negative feelings among BMDs and nurses towards TCM and TCMPs	Automatic Motivation (Emotion)	Persuasion	Communication/ marketing	Information about social and environmental consequences	• Elucidating TCM modern development to all conventional healthcare professionals with an aim to change their negative impressions towards TCM and TCMPs
• Feelings of being excluded by the conventional medicine-dominated healthcare system among TCMPs		Environmental restructuring	Environmental/social planning	Restructuring the physical environment	• Establishing a TCM and integrative medicine clinical governance centre supported with a multidisciplinary team of experts to advise on TCM and IO development
• Lack of emotional understanding among BMDs and nurses towards patients’ requests for IO referral		Persuasion	Communication/ marketing	Credible source	• Inviting patients and caregivers who used IO services to share their experience with conventional healthcare professionals
Keys: BMD: Biomedically-trained doctor; COM–B: Capability, Opportunity, Motivation, and Behaviour; IO: Integrative oncology; TCM: Traditional Chinese Medicine; TCMP: Traditional Chinese Medicine practitioner; TDF: Theoretical Domains Framework.
^*Common key themes also identified in a previous systematic review [BMJ Support Palliat Care 2023 May 12;spcare-2022-004150] of international literature on IO service implementation determinants

Beliefs about consequences

*Common international theme: lack of recognition among healthcare professionals, patients, and caregivers on the evidence supporting safety and effectiveness of IO interventions. TCM has not been studied using modern research methodologies until recent decades. BMDs and nurses in Hong Kong may not oppose the adoption of IO, but they always expect IO interventions to be supported by robust clinical evidence, especially on safety and effectiveness. Meanwhile, patients and caregivers, who are interested in IO, also want to gather evidence to convince their BMDs to collaborate with TCMPs, with the expectation that partnership between their BMDs and TCMPs would optimise outcomes.

“We collaborated with University X [a university in Hong Kong] on a clinical trial for assessing the effectiveness of TCM in cancer management. After several years of follow-up, we submitted the results to the oncologists in Hospital Y [a hospital in Hong Kong] for their reference. When they saw the results, they were like: “Oh! The evidence is objective.” They then started believing in TCM and initiated collaboration with us. Therefore, I think we need to go through a process of generating and promoting TCM clinical evidence, to let BMDs understand TCM and IO better. It is not only about TCMPs advocating “integration” and then BMDs will be happy to team up with us. We need to build trust.” – a healthcare administrator with IO experience.

Theme: lack of knowledge among healthcare professionals about the potential ethical or legal consequences of IO service delivery. 80.0% of participants with; and 81.8% without IO experience believed that TCMPs’, BMDs’, and nurses’ intention of delivering IO services might be affected by the lack of clear guidelines detailing ethical or legal consequences of IO service delivery.

Social/professional role and identity

Theme: failure among BMDs and nurses to recognise the compatibility of IO service delivery with their duties and responsibilities. 80.0% of participants with; and 90.9% without IO experience expressed that if BMDs and nurses do not recognise IO service delivery as one of their job duties and responsibilities, they found no reason to be proactive in carrying out such tasks.

Intention

Theme: lack of career prospects for TCMPs and nurses involved in IO service delivery. 60.0% of participants with; and 72.7% without IO experience thought that lacking a well-designed career progress roadmap is discouraging TCM and nurses from performing tasks in IO service delivery, as such efforts will not be recognised for promotion or pay rise.

Reinforcement

Theme: lack of motivation among healthcare professionals in delivering IO services. 85.0% of participants with and 72.7% without IO experience reported that lacking motivation, in general, might influence TCMPs’, BMDs’, and nurses’ attitudes towards playing an active role in delivering IO services.

Emotion

Theme: negative feelings among BMDs and nurses towards TCM and TCMPs. 60.0% of participants with; and 45.5% without IO experience believed that BMDs’ and nurses’ negative feelings, or even hostility, towards TCM and TCMPs is jeopardising interprofessional trust, hence discouraging them from delivering IO services.

Theme: feelings of being excluded by the conventional medicine-dominated healthcare system among TCMPs. 60.0% of participants with; and 54.5% without IO experience expressed that TCMPs’ feelings of being unwelcomed by the healthcare system dominated by conventional medicine might make them reluctant to participate in IO service delivery.

Theme: lack of emotional understanding among BMDs and nurses towards patients’ requests for IO referral. 40.0% of participants with; and 45.5% without IO experience thought that the lack of emotional understanding or empathy towards patients’ requests for referral to IO services amongst BMDs and nurses can discourage their recommendation of IO services to patients and caregivers.

Opportunity (COM-B component)

Overall, five themes were relevant to the motivation component of the COM-B system, covering two TDF domains (environment and resources; and social influences) [Table 5]. This component included one common international theme and one common local theme.

Table 5

Recommended behaviour change interventions for addressing implementation issues related to opportunity
Implementation issues identified from interviews (Themes)	COM–B (TDF domain)	Intervention function	Policy category	Behaviour change technique	Behaviour change intervention
• Lack of nursing and administrative manpower supporting IO service delivery^#	Physical Opportunity (Environment and resources)	Enablement	Environmental/social planning	Restructuring the physical environment	• Recruiting specialist nurses to coordinate care in IO services • Recruiting administrative staff to assist in the operation of IO services
• Lack of structured referral mechanisms and clear operation procedures for IO service delivery		Enablement	Environmental/social planning	Restructuring the physical environment	• Using district health centres to coordinate IO services among TCM clinics and BMD clinics • Developing formal referral mechanisms between district health centres, TCM clinics, and BMD clinics • Developing clinical pathways and streamlined service processes for healthcare professionals involved in IO services • Setting performance indicators to evaluate the compliance with clinical pathways and service process compliance • Promoting implementation by integrating clinical pathways and service processes into existing electronic health record systems
• Unaffordability of IO services		Enablement	Fiscal measures	Social support (practical)	• Formulating various patient subsidy schemes for IO services to improve access • Expanding the coverage on IO services in the health insurance plans
• Inefficient interprofessional communication and collaboration system^*	Social Opportunity (Social influences)	Enablement	Environmental/social planning	Restructuring the physical environment	• Developing a shared electronic health record system for all healthcare professionals involved in IO services • Organising team-building activities for all healthcare professionals involved in IO services
Keys: BMD: Biomedically-trained doctor; COM–B: Capability, Opportunity, Motivation, and Behaviour; IO: Integrative oncology; TCM: Traditional Chinese Medicine; TCMP: Traditional Chinese Medicine practitioner; TDF: Theoretical Domains Framework.
^*Common key themes also identified in a previous systematic review [BMJ Support Palliat Care 2023 May 12;spcare-2022-004150] of international literature on IO service implementation determinants
^#Local key themes frequently mentioned by the participants

Environment and resources

*Common local theme: lack of nursing and administrative manpower supporting IO service delivery. A total of 85.0% of participants with; and 81.8% without IO experience agreed that lacking nursing and administrative manpower is a major implementation barrier for IO. Echoing the key theme of the need of training specialised IO nurses, some expressed that the availability of nurses and administrative assistants with IO knowledge and skills will be a critical factor for the successful launch or scaling up of IO services.

“Of course, we need some more nurses for IO service delivery. However, most of the nurses in Hong Kong are only familiar with conventional medicine. You must provide them with specialised TCM training to equip them with IO knowledge and skills. Is there a role for TCM nurses? I am not sure. There is a need to find out what their competencies should be. Also, these specialised nurses should be more confident in triaging patients to IO services and introducing the details to patients. Without extra human resources, we must use our existing nurses who have already been occupied by heavy clinical and administrative tasks. If it is the case [i.e. no extra human resources], I think it is not ideal.” – a BMD with IO experience.

“Sometimes, giving us extra funding is not as useful as one imagines. All they [healthcare administrators] want is trained human resources. After all, they are going to hire people with the funding to help share nurses’ clinical tasks. There are also many administrative tasks required for a single IO referral. I know it is difficult to rely on those without medical backgrounds to perform clinical tasks, yet at least you can give them some administrative assistants to handle routine non-clinical tasks. I am not sure if BMDs would be happy to deliver IO services with an increased salary. However, I know they will be happy if you provide extra human resources.” – a healthcare administrator without IO experience

Theme: lack of structured referral mechanisms and clear operation procedures for IO service delivery. All the participants with; and 63.6% without IO experience reported that the lack of well-structured referral mechanisms to streamline patient referrals between BMDs and TCMPs presented as a major implementation barrier. Similarly, lacking detailed operation procedures that guide the collaborations between BMDs, TCMPs, and nurses decreased their motivation in IO service delivery.

Theme: unaffordability of IO services. 50.0% of the participants with and 36.4% without IO experience expressed that the cost of IO services might be one of the reasons why patients and caregivers choose not to use or recommend IO services.

Social influences

*Common international theme: inefficient interprofessional communication and collaboration system. Well-organised interprofessional communications help blur the borders between healthcare professionals and facilitate their collaborations. For instance, BMDs, TCMPs, and nurses may discuss whether the patient is eligible for IO services and whether they should be aware of any special concerns during IO treatment provision. Such communications may be realised by interdisciplinary meetings in specific and protected timeslots. However, when meetings are infeasible, shared electronic health record systems, are key to improving IO service quality as all parties would at least have access to records of all the treatments the patients are receiving.

“Whenever patients and caregivers visit our TCMP, we need to carry around a big binder containing all records of all the conventional treatments the patient is receiving currently, and in the past. Also, we need to jot down everything the oncologist said in every consultation for our TCMP’s reference. It will be much better for all parties if the BMDs and TCMPs have some kind of an online collaboration platform for interprofessional communications.” – a caregiver with IO experience

Stage 2. Implementation strategies addressing the common implementation determinants

The intervention functions, policy categories, BCTs, and implementation strategies for addressing the common implementation determinants identified from the interviews (i.e., common international themes and common local themes) are presented in Tables 3 to 5. Below, we will discuss the respective potential implementation strategies targeting the determinants.

Common international implementation determinants

Lack of recognition among healthcare professionals, patients, and caregivers of the evidence supporting safety and effectiveness of IO interventions

Potential implementation strategies – It is vital to provide the most up-to-date clinical evidence, preferably generated using rigour clinical research methodologies, to support interprofessional decision-making and improve stakeholders’ confidence in IO service delivery ^33,34. Clinical evidence may also be incorporated into electronic health record systems with assisted decision-making functions to enhance the appropriateness and adherence ²². Similarly, clinical evidence on IO safety and effectiveness should be given to the general audience in plain language to help patients, caregivers, and the public make informed decisions on IO service utilisation ³⁵. Appropriate dissemination of evidence will also empower them to have constructive discussions with their BMDs and TCMPs regarding their decisions to use IO services.

Lack of knowledge among healthcare professionals and healthcare administrators regarding IO

Potential implementation strategies – Healthcare professionals, especially BMDs and nurses, and healthcare administrators may not be willing to deliver IO services if they are not familiar with relevant interventions ^36,37. Therefore, local authorities can arrange practical training programmes for them on a regular basis, to provide them with updated, actionable knowledge in the format of locally relevant clinical guidelines ³⁸. Funding bodies, like the Hong Kong Chinese Medicine Development Fund ³⁹, have been providing funding schemes to support TCM and IO research and development. Additional funding should be allocated to strengthen the creation and dissemination of IO clinical practice guidelines as this is considered to be key for evidence uptake and translation into real-world practice ⁴⁰.

Inefficient interprofessional communication and collaboration system

Potential implementation strategies – Local authorities can develop a shared electronic health record system for collaborative IO service delivery. This provides an efficient communication platform for BMDs, TCMPs, and nurses to exchange and update patients’ information, and spares patients and caregivers from passing information back and forth between BMDs and TCMPs ^22,41. Evidence suggests that both formal and informal bridge-building activities are effective in consolidating connectivity and fostering trust between professionals ⁴¹. Such activities may include journal clubs and mutual practice observations ⁴². With better professional relationships, BMD, TCMP and nurses are expected to be more willing to refer patients mutually and maintain efficient interprofessional communications ^43,44.

Common local implementation determinants

Lack of nursing and administrative manpower supporting IO service delivery

Potential implementation strategies – Care coordination is critical to the day-to-day operation of IO services because BMDs and TCMPs may not be capable of keeping track of administrative arrangements, or triaging patients for appropriate IO interventions ^45,46. To streamline IO service delivery and facilitate interprofessional collaborations, relevant local authorities can arrange additional funding to train, recruit, and retain nurses who are experienced in coordinating IO services. Besides nursing staff, administrative assistants should also be recruited or retained to handle administrative work incurred by patient referrals and triage.

Lack of awareness of IO services among healthcare professionals, healthcare administrators, patients, and caregivers

Potential implementation strategies – To build confidence among conventional healthcare professionals on the value of adding TCM to conventional care, a demonstration of how interprofessional collaboration works and how IO actually benefit patients with real-world data is essential. The public may not be familiar with current regulatory systems on TCMPs, and the malpractice complaint mechanisms in TCM practice. Such unfamiliarity may undermine the public’s confidence in TCM and IO services ^43,47. Local authorities can devolve resources into educating the public on these regulatory measures via different media. Monitoring the price transparency of TCM and IO services is also necessary if patient subsidy schemes are available in the future to facilitate access among the needy ⁴¹.

Lack of knowledge among healthcare professionals regarding herb–drug interactions and herbal toxicities

Potential implementation strategies – local authorities can develop a publicly accessible online platform containing up-to-date knowledge on herb–drug interactions and herbal toxicities. To facilitate avoidance of negative herb–drug interactions and adverse effects, relevant evidence should be integrated into existing electronic health record systems and provide automated alerts when contra-indications or potential toxicities are detected. Pharmacists with dual qualifications in Chinese medicine and conventional pharmacy should also be recruited to help develop and update these clinical information systems regularly. They can also provide consultation services on the co-administration of Chinese herbal medicine and conventional treatment if deemed necessary in the management of complex patient cases. Real-world outcomes of co-administering Chinese herbal medicine and conventional treatment among cancer patients should also be investigated using existing data from electronic health records of the public healthcare system.

Implications for local practice

Compared to those without IO experience, a much higher proportion of experienced interviewees (at least 30%) emphasised the importance of addressing three implementation barriers: (i) lack of knowledge among healthcare professionals, administrators, and the public regarding IO services; (ii) lack of structured referral mechanisms; and (iii) insufficient interprofessional communications. The hands-on experience in delivering IO services made the participants understand more about the importance of combining conventional and TCM knowledge in a coordinated manner ^48–50. Such coordination will require formalising the IO service referral pathway, specifying how clinical care responsibility is delegated from one party to another at appropriate time-points ^41,51. Bi-directional referral between conventional and TCM practitioners is the norm rather than an exception in IO service delivery, and therefore efficient interprofessional communication is deemed indispensable as expected ²². When launching or scaling up outpatient IO services, local policy-makers and authorities should endeavour to tackle these fundamental implementation issues as the first step.

Implications for international practice

We have located many similarities between international experiences ³¹ and local findings regarding IO service implementation. The IO implementation strategies we developed for the Hong Kong context may provide policy ideas to other conventional medicine-dominated healthcare systems. From the same intervention functions and policy categories we identified, policy-makers and managers may tailor the BCTs according to their healthcare system and organisational context. For instance, a key implementation issue we identified is inefficient interprofessional communication and collaboration workflow. On top of adopting the BCT of “reconstructing the physical environment” to develop a shared information system and organise team-building activities, overseas policy-makers may also choose “goal setting (behaviour)” as an additional strategy, which may entail a minimum number of protected interprofessional meetings per month. Also, they may consider “social support (practical)” as a complementary strategy to facilitate such meetings by providing administrative assistance.

Strengths and limitations of this study

The main strength of this qualitative study is our adherence to established implementation theories in the design, analysis, and generation of implementation strategies ⁵². Our findings are generated from a multi-stakeholder perspective, ensuring that implementation determinants were assessed comprehensively. We also contrasted views from stakeholders with and without IO delivery or usage experience, allowing us to pinpoint key implementation determinants relevant to launching or scaling up IO services.

This study also has two key limitations. First, we did not include policy-makers in the interviews, and therefore our implementation strategies did not consider issues from a top-down perspective. Second, we did not evaluate the proposed implementation strategies against the APEASE (affordability, practicability, effectiveness and cost-effectiveness, acceptability, side-effects and safety, equity) criteria. Future research is needed to refine and assess our proposed strategies in the Hong Kong healthcare system context by widening our perspectives.

In this study, we identified three common implementation determinants of outpatient IO service delivery and utilisation unique to the conventional-dominant healthcare system in Hong Kong: (1) the lack of nursing and administrative manpower in supporting IO service delivery, (2) the lack of awareness of IO services among healthcare professionals, administrators, patients, and caregivers, and (3) the lack of knowledge among healthcare professionals of herb–drug interaction and herbal toxicities. Implementation strategies addressing these local determinants, as well as other issues identified in our study, will allow the formation of implementation strategies packages that promote the implementation of outpatient IO services in Hong Kong.

Funding

This study was funded by the Chinese Medicine Development Fund of the Hong Kong Special Administrative Region Government (Reference number: 20B2/031A).The funders had no role in study design, data collection and analysis, decision to publish or preparation of the manuscript.

Authors’ contributions

LH, MHK: Data curation; investigation; formal analysis; writing—original draft; visualisation. ASCL: Data curation; investigation; writing—review and editing. PN: Conceptualisation; investigation; writing—review and editing. FFH, CCWZ: Investigation; writing—review and editing. CHLW, LWL: writing—review and editing; VCHC: Conceptualisation; writing—review and editing; funding acquisition; supervision. All authors read and approved the final manuscript. VCHC is responsible for the overall content as the guarantor.

Ethics approval

The study received ethics approval from the Survey and Behavioural Research Ethics Committee of the Chinese University of Hong Kong (Reference number: SBRE-21-0164). All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.

Consent to participate

Informed consent was obtained from all individual participants included in the study.

Consent for publication

All authors confirm that human research participants provided informed consent for publications.

Competing interests

All authors declare no competing interests.

Hui D, Bruera E. Models of integration of oncology and palliative care. Ann Palliat Med. 2015;4(3):89-98.
Witt CM, Balneaves LG, Cardoso MJ, Cohen L, Greenlee H, Johnstone P, et al. A Comprehensive Definition for Integrative Oncology. J Natl Cancer Inst Monogr. 2017;2017(52).
World Health Organization. WHO international standard terminologies on traditional Chinese medicine: Manila: WHO Regional Office for the Western Pacific; 2022.
Xi S, Gong Y. Essentials of Chinese Materia Medica and Medical Formulas: New Century Traditional Chinese Medicine. 1 ed. Cambridge, Massachusetts: Academic Press; 2017.
Zhang J, Shang H, Gao X, Ernst E. Acupuncture-related adverse events: a systematic review of the Chinese literature. Bull World Health Organ. 2010;88(12):915-21c.
Chung VC, Wu X, Hui EP, Ziea ET, Ng BF, Ho RS, et al. Effectiveness of Chinese herbal medicine for cancer palliative care: overview of systematic reviews with meta-analyses. Sci Rep. 2015;5:18111.
Wu X, Chung VCH, Lu P, Poon SK, Hui EP, Lau AYL, et al. Chinese Herbal Medicine for Improving Quality of Life Among Nonsmall Cell Lung Cancer Patients: Overview of Systematic Reviews and Network Meta-Analysis. Medicine (Baltimore). 2016;95(1):e2410.
Chung VCH, Wu X, Lu P, Hui EP, Zhang Y, Zhang AL, et al. Chinese Herbal Medicine for Symptom Management in Cancer Palliative Care: Systematic Review And Meta-analysis. Medicine (Baltimore). 2016;95(7):e2793.
Wu X, Chung VC, Hui EP, Ziea ET, Ng BF, Ho RS, et al. Effectiveness of acupuncture and related therapies for palliative care of cancer: overview of systematic reviews. Sci Rep. 2015;5:16776.
Lau CH, Wu X, Chung VC, Liu X, Hui EP, Cramer H, et al. Acupuncture and Related Therapies for Symptom Management in Palliative Cancer Care: Systematic Review and Meta-Analysis. Medicine (Baltimore). 2016;95(9):e2901.
Chinese Medicine Council of Hong Kong. Development of Chinese Medicine in Hong Kong. Hong Kong: Chinese Medicine Council of Hong Kong; 2023 [accessed Jun 24 2023]. Available from: https://www.cmchk.org.hk/pcm/eng/#../../eng/main_deve.htm.
Wong W, Lam CLK, Bian XZ, Zhang ZJ, Ng ST, Tung S. Morbidity pattern of traditional Chinese medicine primary care in the Hong Kong population. Sci Rep. 2017;7(1):7513.
Hong Kong Hospital Authority. Introduction to Chinese Medicine. Hong Kong: Hong Kong Hospital Authority; 2022 [accessed Jun 24 2023]. Available from: https://www.ha.org.hk/chinesemedicine/intro.asp?lan=en.
Hong Kong Hospital Authority. The Hospital Authority launches the Integrated Chinese-Western Medicine Pilot Programme. Hong Kong: Hong Kong Hospital Authority; 2014.
Hong Kong Legislative Council. Administration's paper on the progress of the Integrated Chinese-Western Medicine Pilot Programme. Hong Kong: Hong Kong Legislative Council; 2015.
Hong Kong Department of Health, Hong Kong Food and Health Bureau, Hong Kong Hospital Authority. Hong Kong Cancer Strategy 2019. Hong Kong; 2019.
Chung VCH, Ma PHX, Lau CH, Wong SYS, Yeoh EK, Griffiths SM. Views on traditional Chinese medicine amongst Chinese population: a systematic review of qualitative and quantitative studies. Health Expect. 2014;17(5):622-36.
Hui D. Palliative Cancer Care in the Outpatient Setting: Which Model Works Best? Curr Treat Options Oncol. 2019;20(2):17.
Chung VC, Ma PH, Lau CH, Griffiths SM. Developing policy for integrating biomedicine and traditional chinese medical practice using focus groups and the delphi technique. Evid Based Complement Alternat Med. 2012;2012:149512.
Wong CHL, Wu IXY, Adams J, Steel A, Wardle J, Wu JCY, et al. Development of Evidence-Based Chinese Medicine Clinical Service Recommendations for Cancer Palliative Care Using Delphi Approach Based on the Evidence to Decision Framework. Integr Cancer Ther. 2020;19:1534735420940418.
Hui D, Hoge G, Bruera E. Models of supportive care in oncology. Curr Opin Oncol. 2021;33(4):259-66.
Kwong MH, Ho L, Li ASC, Nilsen P, Ho FF, Zhong CCW, et al. Integrative oncology in cancer care - implementation factors: mixed-methods systematic review. BMJ Support Palliat Care. 2023:spcare-2022-004150.
Proctor EK, Powell BJ, McMillen JC. Implementation strategies: recommendations for specifying and reporting. Implement Sci. 2013;8:139.
Powell BJ, McMillen JC, Proctor EK, Carpenter CR, Griffey RT, Bunger AC, et al. A compilation of strategies for implementing clinical innovations in health and mental health. Med Care Res Rev. 2012;69(2):123-57.
Cane J, O'Connor D, Michie S. Validation of the theoretical domains framework for use in behaviour change and implementation research. Implement Sci. 2012;7:37.
Michie S, van Stralen MM, West R. The behaviour change wheel: a new method for characterising and designing behaviour change interventions. Implement Sci. 2011;6:42.
Hennink MM, Kaiser BN, Marconi VC. Code Saturation Versus Meaning Saturation: How Many Interviews Are Enough? Qual Health Res. 2017;27(4):591-608.
Atkins L, Francis J, Islam R, O'Connor D, Patey A, Ivers N, et al. A guide to using the Theoretical Domains Framework of behaviour change to investigate implementation problems. Implement Sci. 2017;12(1):77.
Hsieh HF, Shannon SE. Three approaches to qualitative content analysis. Qual Health Res. 2005;15(9):1277-88.
Nowell LS, Norris JM, White DE, Moules NJ. Thematic Analysis: Striving to Meet the Trustworthiness Criteria. Int J Qual Methods. 2017;16(1):1609406917733847.
Mangurian C, Niu GC, Schillinger D, Newcomer JW, Dilley J, Handley MA. Utilization of the Behavior Change Wheel framework to develop a model to improve cardiometabolic screening for people with severe mental illness. Implement Sci. 2017;12(1):134.
Michie S, Johnston M, Francis J, Hardeman W, Eccles M. From Theory to Intervention: Mapping Theoretically Derived Behavioural Determinants to Behaviour Change Techniques. Appl Psychol. 2008;57(4):660-80.
Hack CC, Wasner S, Meyer J, Häberle L, Jud S, Hein A, et al. Analysis of Oncological Second Opinions in a Certified University Breast and Gynecological Cancer Center in Relation to Complementary and Alternative Medicine. Complement Med Res. 2020;27(6):431-9.
Kweku Sey A, Hunter J. Finding the value in oncology massage: A mixed-method study of cancer services and survivors in Australia. Adv Integr Med. 2020;7(3):126-34.
Rogge AA, Helmer SM, King R, Canella C, Icke K, Pach D, et al. Effects of training oncology physicians advising patients on complementary and integrative therapies on patient-reported outcomes: A multicenter, cluster-randomized trial. Cancer. 2021;127(15):2683-92.
Koenig CJ, Ho EY, Trupin L, Dohan D. An exploratory typology of provider responses that encourage and discourage conversation about complementary and integrative medicine during routine oncology visits. Patient Educ Couns. 2015;98(7):857-63.
Tröndle M, Stritter W, Odone V, Peron K, Ghelman R, Seifert G. Beyond the Standard of Care: An Exploratory Qualitative Study of an Implemented Integrative Therapeutic Care Program in a Brazilian Pediatric Oncology Unit. J Altern Complement Med. 2021;27(11):1002-10.
Neumann I, Alonso-Coello P, Vandvik PO, Agoritsas T, Mas G, Akl EA, et al. Do clinicians want recommendations? A multicenter study comparing evidence summaries with and without GRADE recommendations. J Clin Epidemiol. 2018;99:33-40.
Hong Kong Chinese Medicine Development Fund. Introduction. Hong Kong: Hong Kong Chinese Medicine Development Fund; 2023 [accessed Jun 22 2023]. Available from: https://www.cmdevfund.hk/content-en.php?mid=1#cont-7.
Neumann I, Schünemann HJ. Guideline groups should make recommendations even if the evidence is considered insufficient. CMAJ. 2020;192(2):E23-e4.
Chung VCH, Ho L, Leung TH, Wong CHL. Designing delivery models of traditional and complementary medicine services: a review of international experiences. Br Med Bull. 2021;137(1):70-81.
Grant SJ, Marthick M, Lacey J. Establishing an integrative oncology service in the Australian healthcare setting-the Chris O'Brien Lifehouse Hospital experience. Support Care Cancer. 2019;27(6):2069-76.
Lim E, Vardy JL, Oh B, Dhillon HM. Mixed Method Study to Investigate Models of Australian Integrative Oncology. J Altern Complement Med. 2017;23(12):980-8.
Mittring N, Pérard M, Witt CM. Corporate culture assessments in integrative oncology: a qualitative case study of two integrative oncology centers. Evid Based Complement Alternat Med. 2013;2013:316950.
Rutert B, Stritter W, Eggert A, Auge U, Laengler A, Seifert G, et al. Development of an Integrative Care Program in a Pediatric Oncology Unit. Complement Med Res. 2021;28(2):131-8.
Stritter W, Rutert B, Eggert A, Längler A, Holmberg C, Seifert G. Evaluation of an Integrative Care Program in Pediatric Oncology. Integr Cancer Ther. 2020;19:1534735420928393.
Halpin M. Coordinating integrated services: a pilot study with participants of a co-ordinators course. Complement Ther Clin Pract. 2006;12(2):156-62.
Witt CM, Balneaves LG, Carlson LE, Cohen M, Deng G, Fouladbakhsh JM, et al. Education Competencies for Integrative Oncology-Results of a Systematic Review and an International and Interprofessional Consensus Procedure. J Cancer Educ. 2022;37(3):499-507.
Broom A, Adams J. Oncology clinicians' accounts of discussing complementary and alternative medicine with their patients. Health (London). 2009;13(3):317-36.
Smith CA, Hunter J, Delaney GP, Ussher JM, Templeman K, Grant S, et al. Integrative oncology and complementary medicine cancer services in Australia: findings from a national cross-sectional survey. BMC Complement Altern Med. 2018;18(1):289.
Bodewes Wynand EJ. Formalization and innovation revisited. European Journal of Innovation Management. 2002;5(4):214-23.
Damschroder LJ. Clarity out of chaos: Use of theory in implementation research. Psychiatry Res. 2020;283:112461.

No competing interests reported.

IOQualiSupplLH210823.docx

Download PDF

Version 1

posted

You are reading this latest preprint version

Developing Implementation Strategies for Promoting Integrative Oncology Outpatient Service Delivery and Utilisation: A Qualitative Study in Hong Kong

Status:

Version 1

Abstract

Figures

INTRODUCTION

METHODS

Stage 1. Identification of implementation determinants of outpatient IO service delivery and utilisation

Participant sampling

Data collection

Data analysis

Stage 2. Designing theory-informed implementation strategies to facilitate outpatient IO service implementation

RESULTS

Participants

Stage 1. Implementation determinants of outpatient Integrative Oncology service delivery in Hong Kong

Knowledge

Memory, attention, and decision processes

Skills

Beliefs about consequences

Social/professional role and identity

Intention

Reinforcement

Emotion

Environment and resources

Social influences

Stage 2. Implementation strategies addressing the common implementation determinants

Lack of knowledge among healthcare professionals and healthcare administrators regarding IO

Inefficient interprofessional communication and collaboration system

Lack of nursing and administrative manpower supporting IO service delivery

Lack of awareness of IO services among healthcare professionals, healthcare administrators, patients, and caregivers

Lack of knowledge among healthcare professionals regarding herb–drug interactions and herbal toxicities

DISCUSSION

Implications for local practice

Implications for international practice

Strengths and limitations of this study

Conclusions

Declarations

References

Additional Declarations

Supplementary Files

Status:

Version 1