Experiences and meanings of integration of TCAM (Traditional, Complementary and Alternative Medical) providers in three Indian states: results from a cross-sectional, qualitative implementation research study

Objectives Efforts to engage Traditional, Complementary and Alternative Medical (TCAM) practitioners in the public health workforce have growing relevance for India's path to universal health coverage. We used an action-centred framework to understand how policy prescriptions related to integration were being implemented in three distinct Indian states. Setting Health departments and district-level primary care facilities in the states of Kerala, Meghalaya and Delhi. Participants In each state, two or three districts were chosen that represented a variation in accessibility and distribution across TCAM providers (eg, small or large proportions of local health practitioners, Homoeopaths, Ayurvedic and/or Unani practitioners). Per district, two blocks or geographical units were selected. TCAM and allopathic practitioners, administrators and representatives of the community at the district and state levels were chosen based on publicly available records from state and municipal authorities. A total of 196 interviews were carried out: 74 in Kerala, and 61 each in Delhi and Meghalaya. Primary and secondary outcome measures We sought to understand experiences and meanings associated with integration across stakeholders, as well as barriers and facilitators to implementing policies related to integration of Traditional, Complementary and Alternative (TCA) providers at the systems level. Results We found that individual and interpersonal attributes tended to facilitate integration, while system features and processes tended to hinder it. Collegiality, recognition of stature, as well as exercise of individual personal initiative among TCA practitioners and of personal experience of TCAM among allopaths enabled integration. The system, on the other hand, was characterised by the fragmentation of jurisdiction and facilities, intersystem isolation, lack of trust in and awareness of TCA systems, and inadequate infrastructure and resources for TCA service delivery. Conclusions State-tailored strategies that routinise interaction, reward individual and system-level individual integrative efforts, and are fostered by high-level political will are recommended.

3rd paragraph: Use more quotes from respondents or state how the respondents' perspectives are being relayed. This paragraph reads more like background than findings. • 5th paragraph/3rd and 4th sentences: Elaborate on what is meant by "little something." Group or system-linked experiences and meanings-distrust and fragmentation: • 1st paragraph/last sentence: This sentence seems contrary to the section heading. Consider adding a section on differences observed across ages if you have enough data to do so. • 3rd paragraph/2nd sentence: Rather than describing what you observed, use quotes or summaries of what the respondents said. For example "non-allopathic practitioners talked about the room assignments…" If you want to talk about your own observations, this should be added to the methods section as a data source and the methods of observation should be described.

Conclusion
The conclusion would be more salient if one or two examples were provided of an individually tailored strategy that would aid in integration. General comment The manuscript needs copy editing.

VERSION 1 -AUTHOR RESPONSE
-Reviewer(s) Reports: Reviewer: 1 Reviewer Name Eran Ben-Arye Institution and Country Integrative Oncology Program, The Oncology Service and Lin Medical center, Clalit Health Services, Haifa and Western Galilee District, Israel; and Complementary and Traditional Medicine Unit, Department of Family Medicine, Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel Please state any competing interests or state 'None declared': None declared This is an important large-scale study performed in the field of integrative medicine. There is some discrepancy between the high standard of writing in the introduction and methods sections compared with the results section. I would recommend focusing the results section by presenting the findings on several theme axis (e.g. integrative vs. alternative conceptualization, patient-centered care vs. disease-oriented approach). The need to present findings on theme axes is well taken. We have done this in the body of the manuscript and also provided a summary table for clarity. In the discussion section, I recommend adding point-to-point recommendations for further integration based on each of the findings indicated in the results section. It is advisable to generalize your recommendations so that other scholars who promote integration worldwide will benefit from your experience. Reviewer 2 asked for state-tailored recommendations, but we tend to agree with this reviewer that the lessons may be relevant in other country contexts. We have presented them in relation to our findings and further argued for their customization in each state. In addition, please add a small map indicating the 3 research areas for those readers who are not acquainted with the geography of India. We have found an open-source map and indicated the three areas as Figure 1. We have reproduced this image below.  Explain, "utilizing criteria of proximity from district headquarters" (i.e. did you use districts close by or did you vary the proximity?) If the former is true, this should be discussed in limitations. Of the two administrative regions chosen within district, the nearest and farthest regions from district headquarters were selected for interviewing the participants. We have indicated this on page 7.

Methods
First paragraph: Is the larger research study published? If so, cite it. If not, provide a brief background on it. The larger research study is reported, but not published. We have provided a brief background on page 6, as follows. "This analysis draws from a larger mixed methods implementation research study aimed at understanding operational and ethical challenges in integration of TCA providers for delivery of essential health services in three Indian states. The study looked at the contents and implementation of TCA provider integration policies in 3 states and at national level examining the understanding and interpretations of integration from the perspectives of different health systems actors. These coupled with their experiences in the actual processes of integration of TCA providers were studied using qualitative interview methods to help identify systemic and ethical challenges. Based on this, the study sought to derive strategies to augment the integration of TCA providers in the delivery of essential health services." 3rd paragraph: • suggest providing number in parentheses after each category of respondent to show how many interviews were conducted with each. This has been indicated as follows on pages 6-7: "Our methods comprised semi-structured, in-depth face-to-face interviews with policymakers (N-12), administrators (N=43), TCAM practitioners, (N=59) and allopathic practitioners (N=37), traditional healers (N=7), as well as health workers and community representatives (N=38) in three diverse Indian states: Kerala, where a number of systems have strong historical and systemic roots (N=74), Meghalaya, where local health traditions hold sway (N=61), and Delhi, where national, state, and municipal jurisdictions interface with multiple systems of medicine (N=61).
• State the length or range of length of each interview. This has been indicated on page 7 of the paper, as follows: "Interviews, ranging from 20 to 90 minutes in length were undertaken, only with prior informed consent, and separate consent to record interviews." • State mode of interviews (e.g., face-to-face, telephone). The modality was face-to-face interviewing, which has been indicated on page 6 (please see quote above) 4th paragraph: • State how respondents were approached and if you experienced hesitance in participating on the part of the respondent. If so, how did you counteract this hesitance? This information has been added into Page 7 as follows: "We would typically contact providers via cell phone, share information about the study verbally or via email, and set up a time to interview them. In some cases, we would arrive during out-patient clinic hours to the chosen facility, share our participant information sheet and seek an appointment time with eligible participants. In most cases, we found that participants were keen to participate once they were aware of the nature of the study and, in some cases, the assurance of confidentiality. We had no refusals, although some allopathic practitioners had to be persuaded to participate by emphasizing that this study was not "pro-TCAM integration" per se, but merely seeking to understand state policy implementation." • Provide the interviewing protocol as an appendix or describe it in the methods section. The interviewing protocol is being submitted as an appendix. 5th paragraph: • 2nd sentence: Provide information about the a priori codes and how they were developed. A priori codes were derived directly from our research questions. This is indicated on page 8 as follows: "A priori codes were based on our research questions, reflecting experiences, interpretations and meanings of integration (eg. Tc_Ap_El_Adm refers to a TCAM providers' explanation of experience of interactions with administration in the facility or the health care system). Emergent codes were used to describe the content or categories of these experiences, interpretations and meanings (eg. Em_El_IndInit refers to personal initiative as a determinant of integration)" • 3rd sentence: what percent of datasets were double coded? Double-coding was done for 20% of the state datasets. This is indicated on page 8.

Results
Individual experiences and meaningscollaboration and trust: • 2nd paragraph/1st sentence: spell out what MSV stands for. We had put in an acronym, but in order to protect confidentiality, are replacing this with • 3rd paragraph: Use more quotes from respondents or state how the respondents' perspectives are being relayed. This paragraph reads more like background than findings. Agreed. We were telling, more than showing here. We have revised the paragraph to include a quote from respondents, then using that to elaborate a larger point, on pages 9-10: "Across states, we heard of individual practitioners exercising personal initiative to hasten improvements in infrastructure and service delivery. Following is an excerpt of an interview with an Ayurvedic doctor from a Delhi hospital: "there is a lack of storage space so the diagnosis room is being used for some storage. But I have been treating people in the Public Works Department and then it is getting resolved!" Many of the participants we spoke to in many states were familiar with each otherthese personal relationships and interactions, more often than official platforms, were the basis for interaction, crossreferral, collective planning and advocacy, and in rarer cases, collaborative research." • 5th paragraph/3rd and 4th sentences: Elaborate on what is meant by "little something." We have gone on to show further what the participant meant by a little somethinga demand for regular systematic, meetings. This is indicated on page 10, as follows: As an Ayurvedic practitioner in Delhi put it, "if one takes a personal interest, there can be a little something. But everyone is busy in their own work. If it is done officiallylike in a month, every 2nd Saturday …Then it will happen more systematically." Group or system-linked experiences and meanings-distrust and fragmentation: • 1st paragraph/last sentence: This sentence seems contrary to the section heading. Consider adding a section on differences observed across ages if you have enough data to do so.
Based on comments from Reviewer 1, we have flipped the section heading to talk about fragmentation first, and then distrust. We have indicated this drawing directly from the data on page 11:" More junior practitioners noted that even with respect to TCAM systems: "We three [Ayurveda, Unani, and Homeopathy] are together here, but cross-reference is very, very less…We don't know what is the strong point of Ayurveda, Unani. Allopath will not know the strong point of homeopathy, Ayurveda. They just say 'skin!' -that's all they know!" • 3rd paragraph/2nd sentence: Rather than describing what you observed, use quotes or summaries of what the respondents said. For example "non-allopathic practitioners talked about the room assignments…" If you want to talk about your own observations, this should be added to the methods section as a data source and the methods of observation should be described. This finding was based on both observations and remarks made by practitioners. We have included observations in our methods section, on page 8, cited them in the relevant section on page 13 ("We observed in many dispensaries and hospitals in Delhi that non-allopathic practitioners were assigned rooms on the top floor of the facility (Fieldnotes June 11th, 20th, 21st, 22nd, and 27th 2012)"), and included direct quotations from participants to this effect:

Conclusion
The conclusion would be more salient if one or two examples were provided of an individually tailored strategy that would aid in integration. This is a great idea! Based on comments from both Reviewer 1 and 2, we have proposed recommendations strategies and indicated them in Table 2.

General comment
The manuscript needs copy editing. The manuscript has been carefully copy edited and revised to correct typographical errors, repeated words, and other mistakes.

REVIEWER
Eran Ben-Arye Lin Medical Center, Faculty of Medicine, Technion-Israel Institute of Technology, Israel REVIEW RETURNED 06-Jun-2014

GENERAL COMMENTS
This is an important large-scale study performed in the field of integrative medicine. Results Table 2:

REVIEWER
• The tables are a helpful addition to the findings. Table 2 is confusing because the plus signs refer to both promoting positive findings and mitigating negative findings. Suggest modifying column titles to reflect this (i.e. Strategies to increase facilitators/Strategies to decrease barriers).
Authors can be trusted to review these minor suggestions and make changes. The manuscript needs proofreading for duplicate words, spacing, and fragments.

VERSION 2 -AUTHOR RESPONSE
-Editors Comments to Authors: Please include a statement regarding ethics and any competing interests the authors may have.

We had included the following text on page 6 of our manuscript. "The research protocol was approved by the Institutional Ethics Committee of the Public Health Foundation of India."
We have no competing interests; the declaration is made on Page 2 and in the submission form.
-Reviewer(s) Reports This is an important large-scale study performed in the field of integrative medicine. There is some discrepancy between the high standard of writing in the introduction and methods sections compared with the results section. I would recommend focusing the results section by presenting the findings on several theme axis (e.g. integrative vs. alternative conceptualization, patient-centered care vs. disease-oriented approach).
The need to present findings on theme axes is well taken. We have done this in the body of the manuscript and also provided a summary table for clarity. In the discussion section, I recommend adding point-to-point recommendations for further integration based on each of the findings indicated in the results section. It is advisable to generalize your recommendations so that other scholars who promote integration worldwide will benefit from your experience.
Reviewer 2 asked for state-tailored recommendations, but we tend to agree with this reviewer that the lessons may be relevant in other country contexts. We have presented them in relation to our findings and further argued for their customization in each state.
In addition, please add a small map indicating the 3 research areas for those readers who are not acquainted with the geography of India.
We have found an open-source map and indicated the three areas as Figure 1. We have reproduced this image below. Figure 1 Explain, "utilizing criteria of proximity from district headquarters" (i.e. did you use districts close by or did you vary the proximity?) If the former is true, this should be discussed in limitations.
Of the two administrative regions chosen within district, the nearest and farthest regions from district headquarters were selected for interviewing the participants. We have indicated this on page 7.

Methods
First paragraph: Is the larger research study published? If so, cite it. If not, provide a brief background on it.
The larger research study is reported, but not published. We have provided a brief background on page 6, as follows. "This analysis draws from a larger mixed methods implementation research study aimed at understanding operational and ethical challenges in integration of TCA providers for delivery of essential health services in three Indian states. The study looked at the contents and implementation of TCA provider integration policies in 3 states and at national level examining the understanding and interpretations of integration from the perspectives of different health systems actors. These coupled with their experiences in the actual processes of integration of TCA providers were studied using qualitative interview methods to help identify systemic and ethical challenges. Based on this, the study sought to derive strategies to augment the integration of TCA providers in the delivery of essential health services." 3rd paragraph: · suggest providing number in parentheses after each category of respondent to show how many interviews were conducted with each.
This has been indicated as follows on pages 6-7: "Our methods comprised semi-structured, in-depth face-to-face interviews with policymakers (N-12), administrators (N=43), TCAM practitioners,(N=59) and allopathic practitioners (N=37) This has been indicated on page 7 of the paper, as follows: "Interviews, ranging from 20 to 90 minutes in length were undertaken, only with prior informed consent, and separate consent to record interviews." · State mode of interviews (e.g., face-to-face, telephone).
The modality was face-to-face interviewing, which has been indicated on page 6 (please see quote above) 4th paragraph: · State how respondents were approached and if you experienced hesitance in participating on the part of the respondent. If so, how did you counteract this hesitance?
This information has been added into Page 7 as follows: "We would typically contact providers via cell phone, share information about the study verbally or via email, and set up a time to interview them. In some cases, we would arrive during out-patient clinic hours to the chosen facility, share our participant information sheet and seek an appointment time with eligible participants. In most cases, we found that participants were keen to participate once they were aware of the nature of the study and, in some cases, the assurance of confidentiality. We had no refusals, although some allopathic practitioners had to be persuaded to participate by emphasizing that this study was not "pro-TCAM integration" per se, but merely seeking to understand state policy implementation." · Provide the interviewing protocol as an appendix or describe it in the methods section.
The interviewing protocol is being submitted as an appendix.
5th paragraph: · 2nd sentence: Provide information about the a priori codes and how they were developed.
A priori codes were derived directly from our research questions. This is indicated on page 8 as follows: "A priori codes were based on our research questions, reflecting experiences, interpretations and meanings of integration (eg. Tc_Ap_El_Adm refers to a TCAM providers' explanation of experience of interactions with administration in the facility or the health care system). Emergent codes were used to describe the content or categories of these experiences, interpretations and meanings (eg. Em_El_IndInit refers to personal initiative as a determinant of integration)" · 3rd sentence: what percent of datasets were double coded?
Double-coding was done for 20% of the state datasets. This is indicated on page 8.

Results
Individual experiences and meaningscollaboration and trust: · 2nd paragraph/1st sentence: spell out what MSV stands for.
We had put in an acronym, but in order to protect confidentiality, are replacing this with <Name of Well Known Ayurvedic Physician from Kerala> · 3rd paragraph: Use more quotes from respondents or state how the respondents' perspectives are being relayed. This paragraph reads more like background than findings. Agreed. We were telling, more than showing here. We have revised the paragraph to include a quote from respondents, then using that to elaborate a larger point, on pages 9-10: "Across states, we heard of individual practitioners exercising personal initiative to hasten improvements in infrastructure and service delivery. Following is an excerpt of an interview with an Ayurvedic doctor from a Delhi hospital: "there is a lack of storage space so the diagnosis room is being used for some storage. But I have been treating people in the Public Works Department and then it is getting resolved!" Many of the participants we spoke to in many states were familiar with each otherthese personal relationships and interactions, more often than official platforms, were the basis for interaction, crossreferral, collective planning and advocacy, and in rarer cases, collaborative research." · 5th paragraph/3rd and 4th sentences: Elaborate on what is meant by "little something." We have gone on to show further what the participant meant by a little somethinga demand for regular systematic, meetings. This is indicated on page 10, as follows: As an Ayurvedic practitioner in Delhi put it, "if one takes a personal interest, there can be a little something. But everyone is busy in their own work. If it is done officiallylike in a month, every 2nd Saturday …Then it will happen more systematically." Group or system-linked experiences and meanings-distrust and fragmentation: · 1st paragraph/last sentence: This sentence seems contrary to the section heading. Consider adding a section on differences observed across ages if you have enough data to do so.
Based on comments from Reviewer 1, we have flipped the section heading to talk about fragmentation first, and then distrust. We have indicated this drawing directly from the data on page 11:" More junior practitioners noted that even with respect to TCAM systems: "We three [Ayurveda, Unani, and Homeopathy]

Conclusion
The conclusion would be more salient if one or two examples were provided of an individually tailored strategy that would aid in integration.
This is a great idea! Based on comments from both Reviewer 1 and 2, we have proposed recommendations strategies and indicated them in Table 2.

General comment
The manuscript needs copy editing.
The manuscript has been carefully copy edited and revised to correct typographical errors, repeated words, and other mistakes.