Integrative oncology in cancer care – implementation factors: mixed-methods systematic review

Abstract

BackgroundIntegrative oncology (IO) appears to be beneficial to patients with cancer, but its implementation remains a challenge. Guided by the Theoretical Domains Framework (TDF) and the Capability–Opportunity–Motivation–Behaviour (COM-B) model, this systematic review identified the barriers to and facilitators of IO implementation in conventional cancer care settings.MethodsWe searched eight electronic databases from their inception until February 2022 for qualitative, quantitative or mixed-methods empirical studies reporting the implementation outcomes for IO services. Critical appraisal approach was tailored according to study types. The identified implementation barriers and facilitators were mapped onto TDF domains and the COM-B model, and subsequently onto the behavioural change wheel (BCW) for formulating behavioural change interventions.ResultsWe included 28 studies (11 qualitative, 6 quantitative, 9 mixed-methods and 2 Delphi studies) of satisfied methodological quality. The main implementation barriers were the lack of IO knowledge, the absence of funding and healthcare professionals’ low level of IO receptiveness. The key implementation facilitators were the dissemination of evidence on IO clinical benefits, the equipping of professionals with IO service delivery skills and the provision of a supportive organisational climate.ConclusionMultifaceted implementation strategies are needed to address the determinants influencing IO service delivery. Based on our BCW-based analysis of the included studies, the keybehavioural change techniquesare: (1) educating healthcare professionals about the value and application of traditional and complementary medicine; (2) ensuring access to actionable clinical evidence on IO effectiveness and safety and (3) designing guidelines on communicating traditional and complementary medicine interventions with patients and caregivers for biomedically trained doctors and nurses.

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

“…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 identi ed 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).…”

“…Lack of recognition among healthcare professionals, patients, and caregivers of the evidence supporting safety and effectiveness of IO 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' con dence 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 .…”

“…Potential implementation strategies -Local authorities can develop a shared electronic health record system for collaborative IO service delivery. This provides an e cient 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 are effective in consolidating connectivity and fostering trust between professionals 41 .…”

“…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 e cient interprofessional communication is deemed indispensable as expected 22 .…”

“…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.…”