NCA Inside & Out

Vinita Agarwal is an Associate Professor of Strategic Communication at Salisbury University. Dr. Agarwal is the author of numerous journal articles in the area of patient-provider communication in chronic pain management. Dr. Agarwal uses both qualitative and quantitative methods to understand how provider-patient communication in therapeutic and integrative medicine relationships can better address patient needs to further the goals of patient-centered care. Dr. Agarwal was a member of the National Communication Association’s Teaching and Learning Council (TLC) from 2016 to 2019 and just started serving as Chair-Elect of the TLC.

1. Some of your research focuses on how practitioners can use communication to further patient-centered care. What does patient-centered care mean?

Patient-centered care involves constructing a tailored understanding of the environment and relationships that impact a patient’s subjective experience of disease. Drawing upon findings from my research in long-term management of chronic conditions, patient-centered care is constituted by openness, connectedness, balance, and acceptance of the patient experience. This research advances understandings of patient-centered care as care that integrates diverse health knowledges and is inclusive in critiquing the validity of methodological perspectives from philosophically and ontologically distinct systems.

In recent projects drawing upon traditional (complementary and integrative medicine, CIM, or complementary and alternative medicine, CAM) medical systems, I’ve examined patient-centered care in the context of how local, culturally-based practices, and ethnic beliefs are connected with health within the historical-social context of their enactment. This conceptualization of a patient-centered care agenda advances the World Health Organization’s goal of being “people-centered rather than disease-centered.” While the biopsychosocial model has made tremendous advances in the diagnosis and treatment of chronic disease conditions and symptom alleviation, less attention has been paid to how care is conceptualized and communicated in ways that support the integration of the body, mind, and self. Notably, Communication scholars have, in recent scholarship, increasingly argued for approaches that go beyond disease diagnosis, treatment, and symptomology to understanding the experience of the disease in the context of the patient’s lifeworld.

In chronic pain contexts, the recognition that treatment-centered pharmacological approaches often offer a temporary solution with risk of drug dependency has prioritized the need for patient-centered approaches that support self-management of long-term conditions. Findings from my research suggest that patient-centered care involves provider openness to constructing a nuanced understanding of the relationship between the patient’s body, the subjective perception of pain, and the experience of balance, acceptance, and agency as constituted in their lived contexts and contributes to supporting patient empowerment.

One theme I have uncovered in my research within the chronic condition care context is the emphasis given by patients on being empowered and feeling in control, often by obtaining the knowledge they need to make their own decisions situated in their life context. Provider-patient communication that supports the patient’s sense of agency, facilitates their lived connection with the body and the environment, and supports body awareness is central to patient-centered care.

2. What can providers do to integrate patient-centered care into their practices?

My findings suggest that providers should be trained to cultivate self-reflexive awareness that helps them make sense of their own experiences in the context of the healthcare interaction and open up inclusive spaces for patient-centered care. Providers can communicate in ways that promote self-reflexivity by centering the body and supporting acceptance-based, self-reflective engagement using personalized approaches to address the whole patient.

Providers can recognize the patient-provider encounter as embodied through a self-reflexive lens. My research suggests that a central endeavor of the provider’s role is to integrate a self-reflexive awareness of their own experiences in an embodied patient-provider interaction. By centering self-reflexivity, the provider can provide insights that position the provider-patient relationship as an intersubjective site, where the meanings of disease and health are continually negotiated. Such awareness can expand the provider’s role beyond examination and diagnosis to relating with their patient in open, vulnerable, and intersubjective ways, and bringing to the patient-provider encounter a complex and empowering awareness of the connections of the body, mind, and self in the disease experience.

My work with integrative medicine (research in progress) and CAM providers suggests that provider awareness of their own embodied presence in the therapeutic relationship can support the management of chronic conditions in interdisciplinary teams. Specifically, providers can support patient-centered care in their practices by being cognizant of how their embodied presence contributes to shaping mutual understandings of the disease experience.

By being aware of their own body’s lived experiences and their presence in the relationship, the provider is better positioned to draw upon discursive, sensory, and experiential modes of knowing. My research suggests that centering the provider’s self-reflexive awareness of this process in the therapeutic relationship can support a healthcare interaction that is inclusive of diverse understandings of health and illness.

3. You have also done some research on mothers in India. What did your study reveal about discourses around motherhood in India?

My research on mothers in India was set in a temporary urban resettlement community (basti) in the first decade of the 21st century. At the time of my research, through understanding the women’s maternal practices, I wanted to understand how the mothers’ appropriation of knowledge production discourses shaped their subjectivity at the intersection of shifting socio-geographical migrations, economic constraints, and power relations. I found the women’s discourses of maternal practices speak to the contested ideological space represented by motherhood in developing world contexts globally.

When I conceptualized the research, I felt the site of the basti and the context of enactment of the motherhood discourses would be as important as the examination of the motherhood discourses constituted within those sites. Similar to the broader demographic pattern of increasing rural-urban population shifts in developing countries, the women were migrants who had moved from rural communities to an uncertain and over-burdened urban setting. Here, the basti was situated in as shifting a context as were their traditional practices and identity as women and mothers. The women’s negotiation of motherhood constitutes a struggle over agency, subjectivity, and ownership of the body set in the space of contested social, political, economic, and institutional relations. The multiplicity of these discursive and material relations constituted the basti as the site of the mothers’ meaning making, where they legitimize and enact knowledge claims.

The research reveals some ways the women overcome the challenges posed by displaced, temporary urban settings to create empowering contexts. In Western representation of non-Western cultures, the indigenous woman is often represented as the subjugated other. The study finds that the community of women in the basti successfully appropriated and contested the dominant medical discourses through constructing the language of our ways. Our ways describes a collective articulation of maternal practices in geographically displaced contexts. Such integrative maternal health discourses, enacted at the intersection of dominant power relations and institutional forms, hold transformative potential for the groups working with women globally to contest the gendered subject positions of marginalized communities.

The study finds that the women employed the strategies of challenging, co-opting, and judging to construct collective knowledge production discourses in enacting the language of our ways in maternal practices. To illustrate, the women challenged (i.e., questioned authority), co-opted (i.e., conditionally adopted), and judged (i.e., regulated practices) to define their own and their collective choices. This suggests how the marginalizing discourses of difference, other-ness, and social flux can be mobilized by those they constrain into local moments of resistance and transformation. The findings reveal that maternal discourses can be performed through gendered subject positions that challenge, co-opt, or judge in ways that constitute productive forms of power.

The study recommends that the dai (the Indian doula) be considered the focal point of maternal support groups to create collective ownership of decision making. This collective can coordinate with institutional pathways to integrate diverse knowledges equitably. The collective can also articulate narratives of our ways that define maternal experiences and a shared knowledge repository of birthing practices. Ultimately, the study reveals how motherhood can be an empowering space to articulate ways for (re)shaping meaning of women’s health practices in marginalized global contexts.

4. Your CV includes some health practitioner certifications. Could you tell us a bit about why you pursued those certifications and how they contribute to your research?

My pursuit of Ayurvedic certifications is an outcome of the coming together of my lived knowledge from childhood and my formal research agenda. My goal was to be formally introduced to the traditional medical framework of my Indian roots, to gain a rigorous understanding of the philosophies and medical ontologies of Ayurveda, and to be guided into an integrative awareness of the body-mind relationship in my own meditation practice.

The certifications provided formal training for my larger program of research inquiry to expand meanings of health beyond the health-disease binary. I come from a culture where Western biomedical systems are the dominant recognized institution for medical knowledge, yet one where the biomedical system co-exists alongside multiple traditional philosophies of medicine, ranging from homeopathy to Ayurveda, Siddha, and Unani systems. In this context, the foundations of health are defined through an expansive ontology that integrates human health with environment, nature, seasons, and chronicity in a framework of meaning-making that is equitable and sustainable.

I am currently engaged in analysis of semi-structured interview data gathered during my recent study conducted in India on protocols employed by Ayurvedic physicians in chronic pain management. In treating the chronic pain patient, Ayurvedic physicians use prescription as one arm of treatment. Treatment of the physiology is considered alongside multiple other aspects of human form, including lifestyle, diet, mental strength, spiritual energy, alignment with natural rhythms, and others. My certificate in Advanced Ayurvedic Diet and Nutrition gave me insight into how mind-body principles are understood and applied in Ayurvedic medicine in theory and action. Typologies such as the properties of food (carbohydrates, proteins, vitamins, minerals, etc.) in Western knowledge forms are understood distinctly through their qualities in Ayurveda. For example, Ayurveda considers a nuanced combination of specific tastes, states of digestive fire and vital energy (e.g., rasa—six tastes, guna, or qualities, veerya, or potency, and vipaka, post-digestive effect), which combine with the notion of time, evolution, individual genetics, and the subtle nature of elements to provide an individualized and holistic state of health and disease in the patient.

Earning these certifications provided me with the distinctive philosophical understandings needed to propose ways in which Communication scholarship can facilitate an integrative dialog in the United States between different medical knowledge systems. To illustrate, in my analysis of the research data gathered for the study with Ayurvedic physicians in India, I am exploring the integration of dinacharya/ ritucharya/ dosha/ panchabhuta (five elements)/ guna / veerya/ vipaka, role of time (kal), pragya (experience), jadi/buti (herbs), agni (digestive fire), habituation (satmya), ahar and manas (lifestyle and diet with mind), and desh (environment) in the Ayurvedic treatment protocol of patients with chronic pain.

5. You recently presented at the Career Center during the NCA Annual Convention in Baltimore. What advice would you give to graduate students looking to get academic jobs?

Communication graduates today are entering the academia at a rich socio-historic moment. They have an opportunity to push the boundaries of our discipline in pragmatically and theoretically relevant ways. Given the well-acknowledged pressures of positioning oneself for competitive academic positions, I will use this space to remind graduate students of the deeper reasons that make such work meaningful.

I would advise students to:

(a) Make a positive difference through your scholarship, focus on the meaningful nature of your work, and connect your research with personal, social, disciplinary, and larger institutional goals,

(b) Seek positions that are a good fit with these connections, enjoy the collegiality and mentorship of Communication colleagues, and nurture your mentorship network, both with the students you mentor and with those who mentor you, and, 

(c) Connect scholarship, pedagogy, and mentorship with your lived communities and the larger project of humanity to support and contribute in positive ways.