Lu M, et al.

, J Altern Complement Integr Med 2024, 10: 510

DOI: 10.24966/ACIM-7562/100510

HSOA Journal of
Alternative, Complementary & Integrative Medicine
Research Article

Alberta Complementary Health tional healthcare system that aimed to address the pain and mental
health care needs of the aforementioned vulnerable groups.

Integration Project (ABCHIP): Design: We present the plan for the implementation of the ABCHIP
program to facilitate access to nonpharmacologic care options,
Meeting the Pain and Mental which focuses on two populations in Alberta who deal with pain,
mental health, and addiction: children and adolescents (aged 24 and

Health Care Needs under under), and the elderly (aged 55 and above). ABCHIP is an interven-
tional study spanning one year which involved 606 patients in total.
The last measure for the study was taken in October 2022 and the
COVID-19 for Vulnerable study followed the patients for a year. For each patient, a nonphar-
macologic treatment protocol is added based on the patient’s major
Populations health condition (sciatica, depression, knee pain, etc.). The treat-
ment modalities include acupuncture therapy and one or both of the
Mingshan Lu1,2,3,4*, Yong Tao5, Xin Xia2,3,4,5, Gongliang Yang2,3, following: Qigong classes and dietary supplements. Furthermore, a
Max Jajszczok6, Yingying Cong3,4, Sumaiya Sharmin1, Jing Ji- wide range of well-validated instruments were employed to assess
ang7, Yun Xiao2, Laura Peng2, Joshua Quan2 and Bentong Xu3,4 patients’ outcomes on pain relief, depression and anxiety reduction,
sleep quality improvement, fatigue and anger management, and
Department of Economics, University of Calgary, 2500 University Drive NW,
1
quality of care, using: the Brief Pain Inventory (BPI), Patient Health
Calgary, Alberta, Canada T2N 1N4 Questionnaire 9 (PHQ-9), Pittsburgh Sleep Quality Index (PSQI),
Department of Community Health Sciences, University of Calgary, 3330
2 PROMIS Short Form v1.0 Fatigue 8a & PROMIS Pediatric Short
Hospital Drive NW, Calgary, Alberta, Canada T2N 1N4 Form v2.0 Fatigue 10a, EQ-5D-5L, PROMIS Short Form v1.1 An-
ger 5a & PROMIS SF v2.0 5a. Participants were evaluated regularly
3
Alberta College of Acupuncture and Traditional Chinese Medicine, 500, 628
throughout the treatment: at baseline, and once every three visits.
– 12 Ave SW Calgary, Alberta, Canada T2R 0H6
Conclusion: We offered additional services to high-risk, high-need
4
Huatuo Clinic, 300, 628 – 12 Ave SW Calgary, Alberta, Canada T2R 0H6
groups by integrating effective community-based nonpharmacologic
Healing Point Acupuncture Clinic / Classic Acupuncture & Herbal Clinic, 949
5
therapies with conventional medical procedures to improve popula-
Sherwood Ave, Ste 100, Los Altos, CA 94022, USA tion health.
Island Health, Vancouver Island Health Authority, 1900 Fort St, Victoria, BC,
6
Keywords: Acupuncture; Community Intervention; Integrative Medi-
Canada V8R 1J8 cine; Mental Health; Pain; Populations; Vulnerable
Department of Forest and Conservation Sciences, Faculty of Forestry,
7

University of British Columbia, 3041-2424 Main Mall, Vancouver, BC, Canada

V6T 1Z4
Introduction
The psychosocial consequences of pandemics may affect some
Abstract populations more than others. Elderly populations with pre-existing
medical, psychiatric or substance use issues may be more vulnerable
Background: The combined effect of COVID-19 and economic re-
cession has worsened the health of disadvantaged and vulnerable
to the psychosocial impacts of contracting COVID-19 [1,2]. These
groups, particularly the young and the elderly who have been ex- individuals are at heightened risk if they have compromised immune
periencing pain and/or mental health issues. We report the Alberta systems, which may further deteriorate due to residing in communal
Complementary Health Integration Project (ABCHIP) design which living environments such as aged care facilities or due to receiving
integrated evidence-based nonpharmacologic care into the conven- treatment in communal settings where effective infection control
measures may be more difficult to implement [1,2]. For those with
*Corresponding author: Mingshan Lu, Department of Economics, University of already weakened immune systems, their risks may increase when
Calgary, 2500 University Drive NW, Calgary, Alberta, Canada T2N 1N4, Tel: +1 living in a communal setting [1,2]. On the other hand, the pandemic
4032205488; E-mail: lu@ucalgary.ca has taken a toll on the mental and physical well-being of children,
adolescents, and youth. Children and adolescents have experienced
Citation: Lu M, Tao Y, Xia X, Yang G, Jajszczok M, et al. (2024) Alberta Com-
plementary Health Integration Project (ABCHIP): Meeting the Pain and Mental stress and anxiety due to school closures and being separated from
Health Care Needs under COVID-19 for Vulnerable Populations. J Altern Com- peers. Exposure to crisis event coverage in the media and incorrect
plement Integr Med 10: 510. information being shared on social media has made this worse [3,4].
Again, with mental health issues, the negative impacts of pain, be it
Received: August 13, 2024; Accepted: August 23, 2024; Published: August 30,
2024
acute or chronic, are more severe because of the pandemic. The joint
effect of the fear of contracting COVID-19 on the patient side, and
Copyright: © 2024 Lu M, et al. This is an open-access article distributed under the lack of capacity in our overburdened healthcare system leads to
the terms of the Creative Commons Attribution License, which permits unrestrict- under-treatment of pain [5], which subsequently could lead to many
ed use, distribution, and reproduction in any medium, provided the original author
and source are credited.
health consequences, including worsening quality of sleep and mental
Citation: Lu M, Tao Y, Xia X, Yang G, Jajszczok M, et al. (2024) Alberta Complementary Health Integration Project (ABCHIP): Meeting the Pain and Mental Health Care
Needs under COVID-19 for Vulnerable Populations. J Altern Complement Integr Med 10: 510.

• Page 2 of 6 •

health in general. Healthcare policy wise, not enough attention has Objectives
been given to the specific consequence of the COVID-19 pandemic
on people living with chronic pain, despite the efforts of several pain • To assess improvements in the psychosocial well-being of partic-
physicians and researchers raising the alarm about the vulnerabili- ipants;
ties of these patients and the necessity to maintain the continuity of • To examine the reduction in the usage of the patient’s habit-form-
care during the pandemic [6,7]. Leaving these pain and mental health ing pharmaceuticals;
needs unmet can lead to an increase in health care utilization, loss of
productivity, learning loss, reductions in quality of life, and even loss • To measure pain during and after the course of care;
of life; all of which impose huge costs on individuals, families, and • To measure changes in pain interference and physical function
communities as a whole [8,9].
Recruitment
Acupuncture’s effectiveness in addressing pain and mental health
issues has been thoroughly investigated by researchers and clinicians The study was conducted in the Alberta College of Acupuncture
from all over the world, including major institutions such as Har- & Traditional Chinese Medicine (ACATCM) - Huatuo Clinic and
vard University and the University of York. Acupuncture has been participants were recruited through public outreach efforts, Alberta
shown to be effective in treating chronic pain, mental stress, anxiety, Health Services (AHS) mail-out services, and recommendations from
depression, and substance dependence [10-16]. Recent studies show primary care physicians. To reach those who require mental health
that acupuncture users have a wide socio-demographic profile, and it care among these two vulnerable categories, we collaborated with
can play a role in managing the health needs of marginalized commu- primary care doctors as additional patient referral sources, building
nities. Specifically, when barriers such as knowledge, accessibility, on the already existing primary care network connection. We also
and affordability to access acupuncture treatments are removed, some used the AHS mail-out service in collaboration with the AHS/SPOR
group at the Center for Health Informatics (CHI) at the University of
disadvantaged populations are open to engaging in acupuncture treat-
Calgary to broaden our patient outreach. The Enterprise Data Ware-
ments. In addition, research reports that group treatment models and house (EDW), located within Alberta Health Services, was used to
integrative health settings may increase acupuncture availability and locate potential participants who are seniors and children/adolescents
uptake among marginalized people [17-20]. with mental health issues. Additionally, advertisements were used to
find candidates and fill positions, with participants having the option
Other evidence-based nonpharmacologic therapies, such as di- of self-referral or recommendation by a medical professional. The
etary supplements, physical activity, and mindfulness have been study’s website, http://www.abchip.ca, was made available and up-
shown to be effective for patients with depression or anxiety across dated as required for recruitment and informational purposes. Addi-
age groups and cognitive skills [21-23]. Specifically, in a systematic tionally, participants were recruited via social media, including Face-
review, magnesium was confirmed as a therapeutic supplementation book. To draw in potential patients, project flyers and curbside posters
for patients with depression and anxiety [24]. Another systematic re- in English, Chinese, and Korean were also put up in various Calgary
view with meta-analysis found that vitamin B intake (containing B6, neighborhoods.
B8, and B12) reduced psychiatric symptoms significantly [25]. Medi-
Inclusion and Exclusion Criteria
tative movement practices like Qigong have been studied for treating
chronic pain and symptoms associated with mental stress [26]. More Our study group included children and adolescents (aged 24 and
specifically, Qigong has been found to be beneficial in improving below) and elderly (aged 55 and above) who are Alberta residents
quality of life, sleep quality, balance, handgrip strength, trunk flex- with chronic pain or pain management, substance use, and mental
ibility, alleviating musculoskeletal pain, and improving overall sleep health issues. These populations are particularly vulnerable under the
quality for people with chronic illness [26]. Noticeably, Qigong has impacts of the COVID-19 pandemic. The inclusion criteria of the AB-
been found to significantly improve mental health for youth, college CHIP study are listed as follows:
students, and the elderly [27- 32].
• Aged 24 or below, and aged 55 or above;
Alberta’s economic outlook and budgetary constraints require pol-
icymakers to look into cost-effective ways to provide patient-centered • Those who have any of the following concerns or conditions:
services for our vulnerable populations. In the Alberta Complemen- mental health concerns and/or conditions (e.g., sleep disorders,
tary Health Integration Project (ABCHIP), an innovative approach anxiety, depression, oppositional defiant disorder, developmental
is taken to integrate evidence-based nonpharmacologic options with disorders, eating disorders, cognitive impairment and dementia,
conventional medicine to improve conditions related to pain, mental digestive complaints, etc.);
health and addiction. For the two vulnerable disadvantaged popula- • Chronic pain or pain management issues;
tions in Alberta: children and adolescents and seniors, the objective
of ABCHIP was to promote evidence-based nonpharmacologic care • Addiction (drugs and others).
integration in the treatment and prevention of COVID-related pain
The exclusion criteria are:
and mental health-related issues.
• Patients who do not give their consent;
Methodology
• Children whose parents or guardians do not give their consent;
Hypothesis
• Patients who withdrew their consent;
Patients who receive acupuncture and one or both of dietary sup-
plements and meditative movement therapy will have improved men- • Patients who are not available or comfortable receiving the treat-
tal and physical well-being, as well as a higher quality of life. ment.
J Altern Complement Integr Med ISSN: 2470-7562, Open Access Journal Volume 10 • Issue 6 • 100510
DOI: 10.24966/ACIM-7562/100510
Citation: Lu M, Tao Y, Xia X, Yang G, Jajszczok M, et al. (2024) Alberta Complementary Health Integration Project (ABCHIP): Meeting the Pain and Mental Health Care
Needs under COVID-19 for Vulnerable Populations. J Altern Complement Integr Med 10: 510.

• Page 3 of 6 •

Data collection method Qigong: If the patient is interested in practicing this exercise, the
patient was offered the opportunity to join in person and/or online
With participants’ consent, we collected basic demographic infor- interactive Qigong learning sessions with a Qigong master to learn.
mation to help us establish a better understanding of what factors con- Other online learning tools such as recorded Qigong videos were also
tribute to their willingness to use nonpharmacologic care services. In- provided.
formation on conventional health care utilization, pain, mental health,
quality of life, and healthcare utilization was also collected. This data Outcome Measures
was collected via and stored on REDCap (Research Electronic Data
Capture), a secure web application for building and managing online All outcome measures are listed in table 1.
surveys and databases. We also launched a public campaign program
to showcase ABCHIP projects to promote education and awareness Measure Instrument Description
of the benefits of evidence-based nonpharmacologic care options and
ABCHIP among both healthcare providers and patients. Calculated from the mean of four pain sever-
ity questions: pain at its “worst” in the past
Our survey questionnaires included various well-validated and week, “least” in the past week, “average” pain
Pain Brief Pain Inventory
widely used instruments to measure pain conditions and levels of severity (BPI)
in the past week, and pain “now.” The answer
pain, depression, anxiety, sleep quality, fatigue, work status, addic- to each of the four questions ranged from zero
to 10, where zero indicates no pain and 10 in-
tion, and overall quality of life (see “Outcome Indicators”). Baseline dicates the worst pain imaginable.
questionnaires also included demographic questions (patients’ age,
gender, race/ethnicity, income, etc.).
Calculated from the mean of seven pain inter-
ference questions, which asks how much pain
Additionally, patients who finished their course of treatment in
interferes with seven daily activities: general
ABCHIP were also invited to participate in patient interviews. With activity, mood, walking ability, normal work
patient consent, a semi-structured guided interview was conducted. Pain inter- Brief Pain Inventory (at home and outside home), relationships,
Participants were asked to share their experience with ABCHIP, iden- ference (BPI) sleep, and enjoyment of life. The answer to
each question ranges from zero to 10, where
tifying strengths as well as areas for future improvement.
zero indicates no interference with function
Interventions and 10 indicates that pain completely inhib-
ited function.
Licensed practitioners with 5-15 years of expertise provided pa-
tients with complimentary and proven nonpharmacologic treatment,
The PHQ-9 score is generated from the sum
with modalities including acupuncture, dietary therapy, and medita- of answers to nine questions that ask for the
tive movement therapy (Qigong). Practitioners proposed an individ- frequency by which patients experienced nine
Patient Health
ualized treatment plan for the patient, using the established treatment Depres- symptoms of depression, including feelings of
Questionnaire 9
protocols as guidelines. The number of treatments depended on the sion
(PHQ-9)
hopelessness, decreased interest in activity,
and loss of appetite. The PHQ-9 score ranges
condition being treated and its severity. A common treatment plan
from zero to 27, and a higher score indicates
for a single complaint typically lasted one to three months, involving more severe depression.
three modalities: a minimum of two acupuncture treatments a week;
dietary therapy with a dietary supplement if needed; and regular Qi-
gong exercise on a voluntary basis. Since this is a community service Patient Reported Out-
project, we aimed to serve as many participants as possible while comes Measurement The sum of answers to eight questions focus-
Information System ing on fear, anxiety, misery, and hyperarousal
keeping a reasonable level of treatment outcome. We chose a mini-
Anxiety (PROMIS) Anxiety 8a was used to generate an overall score ranging
mum of 6 acupuncture sessions and a maximum of 12 sessions, at the for adults & PROMIS from 8 to 40. A higher score indicates more
frequency of twice a week. This treatment frequency has been shown Anxiety- Pediatric for severe anxiety.
to be necessary to reach optimal treatment results, especially for those minors.
with chronic pain and mental health issues [32-40]. In addition, there
were patients with varied health concerns, and some were less critical Nineteen questions are used to generate sev-
than others. If the patients felt they had reached their treatment goals, en component scores in accordance with the
they were allowed to leave after their sixth treatment session. scoring instructions: subjective sleep quality,
sleep latency, sleep duration, sleep efficiency,
Acupuncture intervention: All ABCHIP patients received acupunc- Sleep Pittsburgh Sleep sleep disturbances, use of sleep medication,
ture, which was done by inserting very thin needles into the body Quality Quality Index (PSQI) and daytime dysfunction. A global sleep qual-
ity score ranging from zero to 21, generated
surface at certain points to obtain De Qi. A minimum of six and a from the sum of the seven component scores,
maximum of 12 acupuncture treatments, at least twice a week, were was reported. Overall, a higher PSQI score in-
included in every treatment plan. dicates worse sleep.

Dietary Therapy: Following Health Canada Guidelines, ABCHIP

PROMIS Short Form
health professionals provided recommendations on dietary supple- v1.0 Fatigue 8a for The sum of answers to questions in these
ments (magnesium, vitamin B supplementation including B6, inosi- adults & PROMIS questionnaires generated a fatigue score up
Fatigue
tol, and B12), which have been shown to be beneficial for patients Pediatric Short Form to 40, where a higher score indicates greater
with depression or anxiety. This was an optional need-based inter- v2.0 Fatigue 10a for fatigue.
minors
vention and was provided only if the health professionals deemed it
necessary.
J Altern Complement Integr Med ISSN: 2470-7562, Open Access Journal Volume 10 • Issue 6 • 100510
DOI: 10.24966/ACIM-7562/100510
Citation: Lu M, Tao Y, Xia X, Yang G, Jajszczok M, et al. (2024) Alberta Complementary Health Integration Project (ABCHIP): Meeting the Pain and Mental Health Care
Needs under COVID-19 for Vulnerable Populations. J Altern Complement Integr Med 10: 510.

• Page 4 of 6 •

from baseline to post-treatment are reported (clinical outcomes of

Asks questions about patients’ mobility, self- ABCHIP are reported in [48]).
care, usual activities, pain/discomfort, and
anxiety/depression. The answers to the five Economic evaluation, including cost-effectiveness and cost-ben-
Overall
questions was used to generate a health util- efit analyses, are performed. We translate the observed impacts into
ity score in accordance with the instrument
Quality of EQ-5D-5L cost savings by looking at healthcare utilization and by measuring
instructions. This score ranges from slightly
Life
less than zero, indicating a health state that both reduction in direct cost (i.e., hospital, physicians, drugs, re-
is worse than death, to one, which indicates search, and other institutional care expenditures) and indirect costs
full health. The higher the score, the better the (i.e., reduction of quality of life, lost productivity due to disability
patient’s state of health. and premature mortality). Comparing the costs and benefits of the
ABCHIP program will inform policy makers whether there is po-
PROMIS Short Form The sum of answers to all five questions was tential cost savings from integrating conventional medicine and ev-
v1.1 Anger 5a for used to generate a score ranging from 5 to 25,
Anger idence-based nonpharmacologic options into the health care system
adults & PROMIS SF where a higher score indicates more severe
v2.0 5a for minors anger. (economic evaluation outcomes of ABCHP are reported in [49]).

Accommodation
Patients self-report the number of doses of
non-prescription substances taken in the past To fulfill the objective of the study, ABCHIP employed 11 outcome
year (Baseline) or in the past week (Fol-
measures in total. It can be challenging to strike a balance between the
low-up) as well as the type of substance used.
The number of patients who did not use sub-
comprehensiveness of outcome measurements and the length of the
stances, who used 1-35 doses per week, 36- survey data collection. We incorporated the following elements into
Substance Self-reporting
use mechanism
70 doses per week, 71-140 doses per week, our project. First, we recruited a social worker in our study team who
and >140 doses per week were tabulated. A works on-site with patients who have mental health conditions, sub-
comparison was made between the number of
patients in each dosage category at baseline
stance use problems, or other challenges. ABCHIP participants were
and at their final treatment. The total number encouraged to have an initial one-hour visit with the social worker, as
of doses of each type of substance will also be well as following 30-minute visits during their project participation,
compared from baseline to the final treatment. whenever they felt they needed help from the social worker. Second,
our data collectors received extensive training from the social worker
Patients’ self-reported employment statuses
on both survey items and communication skills with individuals who
were collected and categorized as one of the
following: not employed, part time employed, suffer from mental health and addiction concerns. Such training is
full time employed, part time employed and to guarantee that the survey is carried out in the most efficient and
Self-reporting
Work
mechanism
not working, or full time employed and not patient-centered manner. Third, we ensured that all participants were
working. The number of patients between the
properly educated and prepared for the survey, as well as aware of the
ages of 14 and 65 in each category at baseline
and after the final treatment will be used for
support available from our project team throughout data collection
economic analysis. in case they felt uncomfortable or stressed at any moment. This is
explicitly stated in the patient consent form, which is given to par-
Patients self-reported the number of times ticipants when they sign up for the research. Members of our project
they visit the emergency department as well
team also interacted with participants to ensure they were aware of it.
Health as the number of inpatient days at a hospital in
care utili-
Self-reporting
the past year (Baseline) or the past week (Fol-
Finally, we have tested the survey instruments with five participants
zation
mechanism
low-up). The average number of ER visits and at the initial stage of the study. The average length of the survey was
the estimated number of hospital admissions around 30 minutes, and all participants found the survey manageable.
will be used for economic analysis.
In summary, we feel that the survey instruments we selected for
Table 1: Measure, Instrument and Description. this study are appropriate for our participants. We have taken every
precaution to ensure that the extra time required for data collection
Data analysis does not burden or stress the participants. Most significantly, this en-
abled us to develop comprehensive outcome measures, allowing us
Immediately after each 3 treatment sessions, the participants were to undertake a complete outcome and economic evaluation of this
asked to answer questions about all the outcome measures listed in intervention.
an online questionnaire on REDCap. The short-term outcome of the
study are assessed from this information, whereas long-term effects Discussion
are projected using short-term outcome indicators and the economic
burden of illnesses estimations in the existing literature [41-47]. Managing pain and mental health conditions presents several dif-
ficulties. Many of these concerns are based on diseases that are al-
Our primary outcome indicators are changes in pain severity and ready challenging to treat in a general practitioner institution, such as
pain interference, quality of sleep, mental health conditions, quality chronic pain, stress-related mental health issues, and preventing and/
of life, and healthcare utilization, and are constructed by comparing or treating addictions. With the ABCHIP approach, a treatment plan
admission and discharge patient conditions. Descriptive statistics are can be designed specifically for each patient in order to meet their
employed to report the proportion/mean for each demographic vari- unique needs and guarantee the greatest results.
able, as well as the baseline health status. Distributions of outcome se-
verity and mean outcome scores at baseline and post-treatment, mean The community initiative that has been presented is based on the
individual differences and percent changes in treatment outcomes ability of Alberta’s healthcare system to handle the historical surge of
J Altern Complement Integr Med ISSN: 2470-7562, Open Access Journal Volume 10 • Issue 6 • 100510
DOI: 10.24966/ACIM-7562/100510
Citation: Lu M, Tao Y, Xia X, Yang G, Jajszczok M, et al. (2024) Alberta Complementary Health Integration Project (ABCHIP): Meeting the Pain and Mental Health Care
Needs under COVID-19 for Vulnerable Populations. J Altern Complement Integr Med 10: 510.

• Page 5 of 6 •

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