Naturopathic Medicine for Endometriosis (NatME). Results of a pilot study

Naturopathic Medicine for Endometriosis (NatME). Results of a pilot study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Naturopathic Medicine for Endometriosis (NatME). Results of a pilot study Sophia Gerontakos, Amie Steel, Jon Wardle This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7396031/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 11 You are reading this latest preprint version Abstract Background Endometriosis is a chronic inflammatory condition characterised by pain and significant impacts on quality of life. Research shows women with endometriosis have unmet healthcare needs. Evidence also demonstrates naturopaths play an important role for women with endometriosis, and group visits are an effective model of care for chronic disease management. This study examines (a)the feasibility of a group visit model for delivering naturopathy to people with endometriosis, and (b)the preliminary effectiveness of the model. Methods a pilot feasibility study was delivered in four Australian locations. The intervention was a 12-week program comprising six visits, incorporating personalised naturopathic care and education within a supportive group environment. Outcomes were measured at baseline, end visit, and one-month follow-up. The study was registered February 2022 with Australian New Zealand Clinical Trials Registry (ACTRN12622000222741). Results Thirty-one participants were enrolled. High levels of satisfaction with the program structure, content, and facilitators were observed with high retention rates. Participants agreed (96.3%) or mostly agreed (3.7%) naturopathic group visits are a good way of receiving care for endometriosis. In clinical outcomes statistically significant improvements in pain-related items across all validated measures (Endometriosis Health Profile [EHP-5] pain baseline to follow-up p = 0.003; Health-related Quality of Life pain/work baseline to follow-up p = < 0.003), as well as in all five items of the EHP-5 and across all 13 items on the Pain Catastrophizing Scale. Conclusion A group naturopathic intervention program for endometriosis may result in clinical improvement of endometriosis, and has been seen to be feasible and well-accepted for women with endometriosis. Naturopathy complementary therapies endometriosis women’s health group visits shared medical appointments Figures Figure 1 Background Endometriosis is a complex, chronic inflammatory condition affecting women and persons assigned female at birth and characterized by endometrium-like tissue being present outside the endometrium( 1 ). Over 14% of Australian females of reproductive-aged are diagnosed with endometriosis( 2 ). The condition is often characterized by symptoms including chronic pain (pelvic and other pain), fatigue, painful urination and bowel movements, and painful sex along with other comorbidities including impacts on mental health, quality of life and financial wellbeing( 3 ). Endometriosis can affect trans men and non-binary people, yet the available research on the condition is overwhelmingly focused on cis women. Women 1 with endometriosis have reported negative healthcare experiences, unfeasible costs of endometriosis-related healthcare, unmet healthcare needs and a desire for increased access to allied health and complementary therapies (non-pharmaceutical and non-surgical treatments)( 4 ). Naturopathy is a traditional medicine system originating from Europe( 5 ) focused on supporting the body’s natural healing processes with key philosophical tenets including Tolle Causam (treat the cause) and Tolle Totum (treat the whole person)( 6 ). Use of naturopathic medicine is high among Australian women( 7 ) with women often consulting naturopaths for female-specific health concerns, such as menstrual disorders( 8 ), menopause-related symptoms, pregnancy-related complaints( 9 ) and polycystic ovary syndrome( 10 ) amongst other chronic conditions( 11 ). Evidence demonstrates naturopaths play a significant role in endometriosis with approximately 20% of Australian women with endometriosis reporting they consult with a naturopath( 12 ). Naturopathy services in Australia are mostly delivered in private practice settings, generally using a one-on-one long consultation model (i.e. an individual patient consulting with an individual practitioner). This model proffers the benefit of person-centered care and individualization( 13 ) but by its very nature, limits the number of patients any one clinician can reach, while adding a financial barrier for many patients. The cost burden of consultation fees and prescription are typically borne by the patient as an out-of-pocket expense( 14 ). Both of these features represent financial and social barriers to community access to naturopathic care( 15 ). Group visits (also known as shared medical appointments [SMAs], group medical visits [GMVs], or - when they incorporate integrative therapies such as acupuncture, mind-body therapies or others - integrative medicine group visits [IMGVs]), are models of care that have been shown to increase access to health care for diverse populations in Australia( 16 ), the United States (US)( 17 ) and other countries( 18 , 19 ). A group visit is a patient-centered model where multiple patients (usually sharing a similar medical condition or risk factors) consult with a health professional or team of health professionals within a group setting; the appointment can include medical consultation including measurement of vitals, medication reviews, patient education and other integrative medicine disciplines( 20 ). Group visits aim to improve patient outcomes by combining three important components – clinical care, patient education and peer support( 21 ). Evidence shows group visits are effective in managing chronic conditions such as diabetes( 22 , 23 ) and chronic pain( 24 , 25 ) and they have been found to be feasible and well accepted for women’s health conditions( 26 ). There is also a substantial body of evidence in support of group-delivered maternal and pregnancy care where group prenatal care has been found to be both feasible and more effective than individual care across a variety of settings and populations( 27 , 28 ). Although there is interest within the naturopathic profession to utilize the group visit model due to the model aligning well with naturopathic principles of practice( 29 ), to date evidence is lacking for feasibility and efficacy of delivering naturopathic care using a group visit model. However, evidence for the benefits of group visits for chronic disease management and women’s health provides a good basis for more research examining the model for women with endometriosis through a naturopathic lens. In summary, there is an issue of access to naturopathic medicine with the current mode of delivery using private consultations, and lack of access through health system pathways. Given that women with endometriosis are high users of naturopathy, have unmet healthcare needs and appear to demonstrate a desire for greater access to complementary therapies, research is needed into the feasibility and effectiveness of new models for delivering naturopathic care to women with endometriosis. Group visits have been seen to improve healthcare access, and be an effective healthcare model for chronic disease management. As such, this study – Naturopathic Medicine for Endometriosis (NatME) – used an uncontrolled pilot feasibility trial design to examine (a) the feasibility of a group visit model for delivering naturopathic care to people with endometriosis, and (b) the preliminary effectiveness of the group visit model in improving health outcomes of this population. Methods Study design and setting NatME was an uncontrolled pilot feasibility study, that took place in four different locations in Australia between April 2022 and August 2022, with four cohorts of patients. The intervention comprised four cohorts of participants, across three urban locations within the region and one online cohort. The four separate study locations and settings included: i) Coolangatta, Queensland, Australia, in a seminar room within Southern Cross University Gold Coast campus; ii) within a private practice natural therapies clinic in Brisbane, Queensland iii) in Lismore, NSW, Australia in a teaching room within Southern Cross University Lismore campus; and iv) online via the zoom conferencing platform. Each location had space for group activity, as well as an adjoining space for private one-on-one consultations between patient and practitioner (and equivalent “breakout rooms” for the online cohort). The intervention was delivered to each cohort of patients by a qualified naturopath practitioner with expertise in women’s health and endometriosis, alongside a co-facilitator who was trained in shared medical appointment facilitation. The co-facilitator in the program was the lead researcher in this study. The study was approved by the Southern Cross University Human Research Ethics Committee (approval no. 2021/117) and registered with Australian New Zealand Clinical Trials Registry (ANZCTR) (registration no. ACTRN12622000222741) on 8th February 2022. Participants Patient participants were recruited using purposive sampling. For example, the study was advertised using a flyer through endometriosis support groups and key endometriosis advocacy groups (Endometriosis Australia and QENDO). Recruitment information was widely disseminated on social media and via emailed newsletters (via Southern Cross University, other stakeholder organizations and expert clinicians in endometriosis with well-established public profiles and online engagement). Practitioner participants were recruited through professional naturopathic networks including the Naturopaths and Herbalists Association of Australia symposium and website, and naturopathic clinics identifying as having a clinical focus on women’s health and/or endometriosis. Practitioner participants were provided training in facilitating shared medical appointments through Australasian Society of Lifestyle Medicine and remuneration of $ 1000 at completion of the program, as well as counting their participation as continuing professional development (CPD). Snowball sampling was also used, where participants may have invited other prospective participants to the study. Participants who fulfilled the following inclusion criteria were included in the study: aged ≥ 18 years, female sex, had a diagnosis of endometriosis made by a medical doctor, were intending to seek naturopathic care for the primary purpose of managing endometriosis-related symptoms, spoke fluent English and were willing to commit to attending group visits (i.e. could not foresee a reason for missing two or more sessions). Participants were excluded if they were seeking naturopathic services solely or primarily for fertility issues, preconception care or pregnancy, were pregnant, were currently under the care of a naturopath and/or taking herbal or naturopathic medicines, had a medical diagnosis of serious mental illness (a clinically diagnosed disorder that significantly interferes with an individual’s cognitive, emotional and social abilities, e.g. bipolar disorder or schizophrenia) or were had an active medically diagnosed substance abuse disorder (i.e. alcohol, prescribed or illicit drugs). Four naturopath practitioners who fulfilled the following criteria were recruited to deliver the intervention: had a minimum of 5 years’ experience in naturopathic clinical practice, were currently working as a naturopath in part-time or full-time clinical practice (including casual or locum naturopaths who work at least one day per week), identified as experienced and having a clinical focus in the area of women’s health and/or endometriosis, were a member of an Australian professional association covering naturopaths, held a Bachelor degree or higher in naturopathy or an Advanced Diploma in Naturopathy completed prior to 2016, as their minimum qualification, held professional indemnity insurance that covered the practice of naturopathy, spoke fluent English and were female. All participants (including patients and practitioners) provided written, informed consent to participate in the study before any study procedures commenced. Interventions The NatME intervention was designed following an earlier suite of research comprising focus group studies involving people with endometriosis and naturopaths who specialize in endometriosis treatment. To inform the NatME intervention design, the previous qualitative research explored healthcare needs and experiences of people with endometriosis ( 4 ) and experiences and perspectives of patients and women’s health naturopaths on naturopathic treatment for endometriosis, alongside their views on prospective naturopathic group consultations. Program structure NatME used a group visit model to deliver six group naturopathic consultations consecutively to small groups of people with endometriosis over the course of three months which comprised of six fortnightly group visits lasting two hours per visit. Within the group naturopathic intervention, each patient received care in the presence of one another, that was reflective of general naturopathic practice including education on health topics relevant to the management of endometriosis (identified in prior research), self-care, and where appropriate, individualized prescription of herbal, nutritional or lifestyle medicine within the scope of naturopathic practice and according to individual patient needs. The intervention was administered by a qualified naturopath with clinical experience in the field of endometriosis and women’s health. The intervention reflected “usual naturopathic care” that would ordinarily be delivered in a one-on-one consultation but was delivered in the presence of other patients (i.e. as a group, where all patients had an opportunity to discuss the health topics collaboratively and to ask questions). Patients were permitted to speak from personal experience but were not permitted to provide advice to other participants. Only the naturopathic practitioner was permitted to provide expert advice. The naturopathic practitioner delivered the intervention collaboratively with the group facilitator. The group facilitator managed the group, including managing group dynamics, encouraging participation, keeping to topic, keeping to time, recording clinical notes, and ensuring all participants have been reviewed by the naturopath at every visit. The group facilitator was also able to deliver specific group activities, such as group shares, mindfulness, sharing recipe ideas and discussing health topics if required, but only where the naturopathic practitioner was unavailable (i.e. was required to conduct a brief one-on-one consultation with patients or attending to urgent medical needs, the latter which did not occur). The group facilitator was also a qualified naturopathic practitioner. Risk management The facilitator and naturopathic practitioner were trained clinicians who were sensitive to any signs of distress, discomfort or adverse reactions related to the intervention or treatments prescribed within the intervention. At every group session, each patient had an individual (within the group setting) review of progress and prescriptions. As such, prescriptions were closely monitored (reflecting one-on-one real-world clinical practice) and were adjusted, ceased or continued according to patient progress, symptoms and preferences, with record keeping of adherence or modification via clinical note-taking. Patients were also required to complete an intake form on the day of the group visit, prior to the group commencing on which they indicated if they would like a brief (approx. five minutes) private check-in with the practitioner to discuss any concerns they did not wish to discuss within the group. The facilitator reviewed these forms prior to commencing the group and scheduled any private check-ins into the proceedings for the session (either at the beginning or end of the group). The naturopathic practitioner used their expert clinical judgement to assess the need for referral to another service such as a medical practitioner or counsellor, if required (reflecting one-on-one real-world clinical practice). Outcomes measured Primary outcome – feasibility Feasibility was examined by measure the following six outcomes: i) acceptability, ii) demand, iii) compliance, iv) implementation, v) adaptation and vi) integration. A full description of the methods of measuring feasibility outcomes is presented in Table 1 . Table 1 Feasibility outcome measures Outcome Method of measurement Acceptability The reaction of patients and practitioners to the intervention (1) Patient questionnaire domains: experience of the intervention, satisfaction with the NatME curriculum, and perception of facilitator and practitioner performance (2) Practitioner questionnaire domain: experience and satisfaction with the intervention Demand The reaction to and likelihood that patients and practitioners would utilize the intervention again (1) Patient and practitioner questionnaire domains: likelihood of using the intervention again (2) Recruitment and retention rates Compliance The extent to which participants complied with the treatments (1) Observation and field notes documented by the facilitator Implementation The extent to which the intervention could be fully implemented as planned and proposed (1) Practitioner questionnaire domains: ease of implementation (2) Observation and field notes documented by the group facilitator Adaptation The extent to which the intervention was modified to be appropriate for the situation, or could be modified to address populations with different health conditions (1) Practitioner questionnaire domains: ease of adapting the intervention to other health conditions (2) Observation and field notes documented by the group facilitator Integration The extent to which the new model can fit within existing naturopathic practice (1) Patient questionnaire domains: Importance of the intervention, likelihood of recommending the program and using the program again or attending other naturopathic group visits (2) Practitioner questionnaire domains: satisfaction with the intervention, performance, and structure; likelihood of using the intervention again and recommending the intervention to other naturopaths (3) Observation and reflection on field notes documented by the group facilitator >>Please insert Table 1 here>> Secondary outcomes – clinical efficacy Secondary outcomes were measured at baseline, post-intervention (week 12) and one-month follow-up (week 16). Five patient-reported outcome measures were self-administered by participants. Health-related quality of life was measured using the 12-item Short Form survey (SF-12) and Endometriosis Health Profile-5 (EHP-5). Individual patient outcomes were measured using the Measure Yourself Medical Outcome Profile (MYMOP). Sexual health was measured using the Sexual health outcomes in women questionnaire (SHOW-Q). Participants pain experience was measured using the Pain Catastrophizing Scale (PCS). Maintenance, or the extent to which effects in individuals are maintained over time was measured with a week 16 follow-up of all patient reported outcome measures. Verification of primary and secondary outcome measures Feasibility and clinical outcomes via program evaluation and validated clinical questionnaires were verified with verbal feedback during the final 15–30 minutes of the final session (visit 6) for each cohort. The group facilitator facilitated the feedback sessions. A sample run sheet with questions asked during these sessions is presented in Appendix 1, Table A1. >Table A1. Session 6 week 12 NatME program verbal feedback run sheet> Sample size The study aimed to recruit four cohorts of 5–10 participants, which aligned with sample sizes reported in other pilot studies of group interventions( 30 – 32 ) as well as recommended sample sizes for pilot studies( 33 ). Statistical methods Data was either imported via Redcap, or entered manually (if derived from hard-copy documents). Data was then cleaned, coded and analyzed using SPSS v25. Due to the type of data collected, missing data were simply reported as missing. Data was analyzed using descriptive analysis for numerical data. Frequency distributions and percentages were used to describe categorical data. Means and standard deviations (or medians and interquartile ranges) were used for continuous data, depending on data distribution. The Friedman test was used to determine p values for ordinal variables, alongside the Wilcoxon test with Bonferroni correction. The Cochran Q test was used to determine p values for nominal variables alongside the McNemar test with Bonferroni correction. Statistical significance was set at p < 0.05. Results A total of 46 participants consented to participate of which 31 were enrolled into the study. Eleven of the 46 were placed on a waitlist because their requested location was already at capacity, and four participants withdrew consent prior to the baseline visit (enrolment). Of the 31 participants enrolled four participants were dropouts at visit two or earlier and their data was not included in analysis. A diagram of the flow of participants through the recruitment and enrolment processes is presented in Fig. 1 . Feasibility outcomes Feasibility results of the patient program evaluation questionnaire are presented in Table 2 . All participants agreed (96.3%) or mostly agreed (3.7%) that naturopathic group visits are a good way of receiving care for endometriosis. Demand and acceptability were high with an 87% (n = 27 of 31) retention rate and 96.3% reporting they would recommend NatME to other people with endometriosis while 100% of participants would participate in other naturopathic group visits. All participants were satisfied that their healthcare needs were met in the group visits and 100% were satisfied with the practitioner and facilitator. Over half of participants (51.9%) were satisfied with the program length (12 weeks), while 48.1% reported the program was too short. High levels of learning were also reported by majority of participants (74.1%). The extent to which participants were able to comply with the treatments were unable to be tracked due to the complexity of the intervention and heterogeneity of treatments prescribed. Compliance is discussed within the study limitations with recommendations for future studies of complex interventions. Verbal feedback was highly synonymous with questionnaire and clinical results. Verbal feedback reflected high levels of satisfaction with the overall program and with clinical results (e.g. reduced pain levels) as well as high levels of learning with increased knowledge leading to a sense of empowerment. One participant stated “ Seeing how you can take your health into your own hands ..that really is empowering ”; another stated “ I'm more empowered, because I now have a lot of knowledge ”. Verbal feedback also included satisfaction with the program structure, benefits of group support and feelings of safety within the group environment. For example, one participant stated “ Just knowing that you're in an environment where people actually understand and it's okay to be in pain, I didn't have to pretend to be someone else, I could just sit there and just get lifted up by everyone else ”; and others stated “ It's a very safe space ”. Some minor barriers and challenges to attending the program were reported verbally including motivation, traffic, and missing face-to-face sessions due to illness. A comprehensive list of participant quotes for each topic are included in Appendix 2, Table A2. Table 2 Patient program evaluation questionnaire responses Variable Response Frequency (%) n = 27 Expectations (How would you rate your experience of the NatME program?) 1 Exceeded expectations 21 (77.8%) 2 Met expectations 5 (18.5%) 3 Met most expectations 1 (3.7%) 4 Fell slightly short of expectations 0 (0%) 5 Fell extremely short of expectations 0 (0%) Satisfaction (How satisfied were you with the NatME program overall?) 1 Very satisfied 23 (88.5%) 2 Satisfied 2 (7.7%) 3 Neither satisfied nor dissatisfied 1 (3.8%) 4 Dissatisfied 0 (0%) 5 Very dissatisfied 0 (0%) Learning (How much did you learn in the NatME program?) 1 A great deal 20 (74.1%) 2 Quite a bit 6 (22.2%) 3 Adequate 1 (3.7%) 4 A little 0 (0%) 5 Nothing at all 0 (0%) Session length (How would you describe the length of each group session (e.g. approx. 2hours)?) 1 About right 17 (63%) 2 Slightly too long 5 (18.5%) 3 Slightly too short 5 (18.5%) 4 Much too short 0 (0%) 5 Much too long 0 (0%) Program length (How would you describe the length of the complete program (e.g. 3 months?)?) 1 About right 14 (51.9%) 2 Slightly too long 0 (0%) 3 Slightly too short 10 (37%) 4 Much too short 3 (11.1%) 5 Much too long 0 (0%) Group size (How would you describe the size of the group?) 1 About right 26 (96.3%) 2 Slightly too big 1 (3.7%) 3 Slightly too small 0 (0%) 4 Much too small 0 (0%) 5 Much too big 0 (0%) Facilitator satisfaction (How would you rate your satisfaction with the group facilitator?) 1 Very satisfied 25 (92.6%) 2 Satisfied 2 (7.4%) 3 Neither satisfied nor dissatisfied 0 (0%) 4 Dissatisfied 0 (0%) 5 Very dissatisfied 0 (0%) Practitioner satisfaction (How would you rate your satisfaction with the naturopath?) 1 Very satisfied 26 (96.3%) 2 Satisfied 1 (3.7%) 3 Neither satisfied nor dissatisfied 0 (0%) 4 Dissatisfied 0 (0%) 5 Very dissatisfied 0 (0%) Needs met (How satisfied were you that your individual healthcare needs were addressed in the group visits? 1 Very satisfied 20 (74.1%) 2 Satisfied 7 (25.9%) 3 Neither satisfied nor dissatisfied 0 (0%) 4 Dissatisfied 0 (0%) 5 Very dissatisfied 0 (0%) Importance (How important do you think the NatME program is for people with endometriosis? 1 Extremely important 25 (92.6%) 2 Very important 2 (7.4%) 3 Moderately important 0 (0%) 4 Slightly important 0 (0%) 5 Not at all important 0 (0%) Participation (Would you participate in other naturopathic group visits if available?) 1 Yes 27 (100%) 2 No 0 (0%) Recommendation (Would you recommend NatME to other people with endometriosis?) 1 Yes 26 ((96.3%) 2 No 0 (0%) Did not answer 1 (3.7%) Model (When considering your experience of the NatME program, please indicate your level of agreement with the following statement: Naturopathic group visits are a good way of receiving care for endometriosis) 1 Agree 26 (96.3%) 2 Mostly agree 1 (3.7%) 3 Undecided 0 (0%) 4 Slightly disagree 0 (0%) 5 Disagree 0 (0%) >Table A2. NatME participant quotes from verbal feedback during end visit> All practitioners (n = 4, 100%) reported high satisfaction with the program performance and ease of the potential for adapting the program for populations with other health conditions. 100% of practitioners would be likely to use the program again and recommend the program to other practitioners, while 75% found the program easy to implement. Results from the practitioner program evaluation questionnaire are presented in Table 3 . Table 3 Practitioner program evaluation questionnaire responses Variable Response Frequency (%) n = 4 Satisfaction (How satisfied are you with the NatME program overall?) 1 Very satisfied 4 (100%) 2 Satisfied 0 (0%) 3 Neither satisfied nor dissatisfied 0 (0%) 4 Slightly dissatisfied 0 (0%) 5 Not satisfied at all 0 (0%) Implementation (How easy was it to implement the program using the program manual?) 1 Very easy 2 (50%) 2 Easy 1 (25%) 3 So-so 1 (25%) 4 A little difficult 0 (0%) 5 Very difficult 0 (0%) Topics (How satisfied were you with the health topics included in the program, for treating endometriosis?) 1 Very satisfied 3 (75%) 2 Satisfied 1 (25%) 3 Neither satisfied nor dissatisfied 0 (0%) 4 Slightly dissatisfied 0 (0%) 5 Not satisfied at all 0 (0%) Performance (How satisfied were you with the performance of the program (thinking about the patient engagement, timing, compliance and behavior change)? 1 Very satisfied 4 (100%) 2 Satisfied 0 (0%) 3 Neither satisfied nor dissatisfied 0 (0%) 4 Slightly dissatisfied 0 (0%) 5 Not satisfied at all 0 (0%) Structure (How satisfied were you with the structure of the program (e.g. 3 months, fortnightly, 2-hour sessions, structured content)? 1 Very satisfied 2 (50%) 2 Satisfied 2 (50%) 3 Neither satisfied nor dissatisfied 0 (0%) 4 Slightly dissatisfied 0 (0%) 5 Not satisfied at all 0 (0%) Use (How likely would you be to use this program again if it was made available?) 1 Very likely 3 (75%) 2 Likely 1 (25%) 3 Unsure 0 (0%) 4 Unlikely 0 (0%) 5 Very unlikely 0 (0%) Recommend (How likely would you be to recommend this program to other naturopaths? 1 Very likely 3 (75%) 2 Likely 1 (25%) 3 Unsure 0 (0%) 4 Unlikely 0 (0%) 5 Very unlikely 0 (0%) Adaptation (To what degree do you think this program could be implemented in other populations (e.g. diabetes, PCOS, fibromyalgia, other health conditions) by altering the health topics?) 1 Very easily 3 (75%) 2 Easily 1 (25%) 3 So-so 0 (0%) 4 A little difficult 0 (0%) 5 Very difficult 0 (0%) >>Please insert Tables 2 – 3 here>> Clinical outcomes Statistically significant improvements were observed in a number of items across each individual assessment tool used and are represented by a p-value of < 0.05. In the SF-12 ordinal variables, reduced mean scores indicate improvement in items 1, 8, 9 and 10, and increased mean scores indicated improvement in items 2, 3, 11 and 12. In the SHOW-Q, increased mean scores indicate improvement in items 3, 4, 5 and 8 and reduced mean scores indicate improvement for the remaining items. In all other tools, reduced mean scores indicate improvement. EHP-5 scale scores are presented in Table 4 . Statistically significant improvements were observed as reduced mean scores across four of five categories of the EHP-5 from baseline to end visit and in all five categories from baseline to follow-up. Pain scores improved from baseline(M:2.81; SD:1.11) to end visit(M:2.44;SD:0.89;p = 0.025) with a further improvement(M:2.19;SD:1.03;p = 0.003) at follow-up. Mean control and powerlessness scores improved from baseline(M:3.44;SD:1.12) to end visit(M:2.63;SD:0.92;p = < 0.003) with a further improvement(M:2.48;SD:1.05;p = < 0.003) at follow-up. In emotional wellbeing no significant improvement was observed from baseline to end visit, however statistically significant improvement was observed in mean scores from baseline(M:3.59;SD:0.93) to follow up(M:3.04;SD:0.94;p = 0.036). Social support scores improved from baseline(M:3.81;SD:0.87) to end visit(M:2.81;SD:0.92;p = < 0.003) with a further improvement(M:2.85;SD:1.13;p = < 0.003) at follow-up. Self-image scores improved from baseline(M:4.07;SD:0.78) to end visit(M:3.30;SD:0.99;p = 0.009) with a further improvement at follow-up(M:3.33;SD:0.92;p = 0.006). SF-12 scale scores are presented in tables 5 and 6. Statistically significant improvements were observed across seven of the 12 items included in the SF-12 scale. Improvements in mean scores were observed from baseline(M:3.33;SD:0.92) to end visit(M:2.59;SD:1.08;p=0.015) in item eight (pain) with a further improvement(M:2.37;SD:1.04;p=<0.003) at follow-up. Improvements in mean scores were observed from baseline(M:4.26;SD:1.16) to end visit(M:3.44;SD:0.84;p=<0.003) in item nine (emotional wellbeing calm) with sustained improvement at follow up(M:3.63;SD:0.96;p=0.018). Improvement in mean scores were observed from baseline(M:4.74;SD:0.94) to end visit(M:3.96;SD:0.98;p=<0.003) in item ten (energy) with further improvement(M:3.70;SD:1.06;p=<0.003) at follow-up. In item 11 no significant improvement was observed from baseline to end visit, however significant improvement in mean scores were observed from baseline(M:3.81;SD:1.41) to follow-up(M:4.44;SD:1.12;p=0.021). In item 1 (general health) no significant improvement was observed from baseline to end visit, however significant improvement in mean scores was observed from baseline(M:3.52;SD:0.97) to follow-up(M:2.96;SD:0.64;p=0.024). In item 4 (physical health) no significant improvement was observed from baseline to end visit, however, significant improvement was observed from baseline to follow-up(p=0.024). In item 12 (social activities) significant improvement in mean scores was observed from baseline(M:3.30;SD:1.29) to end visit(M:4.15;SD:1.16;p=0.018) with improvement sustained at follow up(M4.11;SD:1.42;p=0.021). In the remaining items 2, 3, 5, 6, and 7 no significant improvements were observed at end visit or follow-up. PCS scale scores are presented in table 7. Statistically significant improvements were observed across all items in the PCS. In item one improvement was observed in mean scores from baseline(M:1.93;SD:1.20) to end visit(M:1.15;SD:0.98;p=0.006) with further improvement observed in mean scores at follow-up (1.07 (1.03), p=0.006). In item two no significant improvement in mean scores was observed from baseline to end visit, however significant improvement was observed in mean scores from baseline(M:1.15SD:1.19) to follow-up(M0.67SD:0.96;p=0.015). Item three significant improvement was observed in mean scores from baseline(M1.81SD:1.11) to end visit(M:0.85;SD:0.81;p=<0.03) with improvement sustained at follow-up(M:1.00;SD1.00;p=0.021. In item four significant improvement in mean scores was observed from baseline(M:1.93;SD:1.10) to end visit(M:1.22;SD:1.01;p=0.015) with further improvement observed at follow up(M:1.19;SD:1.00;p=0.006. In item five significant improvement was observed in mean scores from baseline(M:1.78;SD:1.39) to end visit(M:0.96;SD:1.25;p=0.006) and improvement was sustained at follow-up(M:1.00;SD:1.17;p=0.006). In item six no significant improvement was observed in mean scores from baseline to end visit, however significant improvement was observed from baseline(M:1.93;SD:1.32) to follow-up(M:1.26;SD:1.13;p=0.033). In item seven significant improvement was observed in mean scores from baseline(M:1.44;SD:1.18) to end visit(M:0.67;SD:0.92;p=0.006) and improvement was sustained at follow-up(M:0.81;SD:1.00;p=0.024. In item eight no significant improvement was observed from baseline to end visit, however significant improvement was observed in mean scores from baseline(M:1.93;SD:1.20) to follow-up(M:1.00;SD:1.10;p=<0.003). In item nine significant improvement was observed in mean scores from baseline(M:1.70;SD:1.13) to end visit(M:1.15;SD:1.19;p=0.018) with further improvement observed at follow-up(M:1.04;SD:1.19;p=0.015). In item ten significant improvement was observed in mean scores from baseline(M:1.70;SD:1.13) to end visit(M:1.04;SD:1.28;p=0.003), and improvement was sustained at follow-up(M:1.04;SD:1.16;p=0.006). In item 11 significant improvement was observed in mean scores from baseline(M:1.85;SD:1.23) to end visit(M:1.26;SD:1.40;p=0.042), with further improvement observed at follow-up(M:1.15;SD:1.23;p=0.012). In item 12 significant improvement was observed in mean scores from baseline(M:1.63;SD:1.14) to end visit(M:1.04;SD:0.94;p=0.012), with further improvement observed at follow-up(M:0.85;SD:0.94;p=<0.003). In item 13 significant improvement was observed in mean scores from baseline(M:1.70;SD:1.17) to end visit(M:1.22;SD:1.12;p=0.045), with further improvement observed at follow-up(M:1.11;SD:1.05;p=0.015). SHOW-Q results are presented in table 8. Statistically significant improvements were observed from baseline to end visit or follow-up in six of the 12 SHOW-Q items including satisfaction with frequency and enjoyment, satisfaction, and reduced interference of bleeding, pelvic pain and pelvic problems. In item one no significant improvement was observed from baseline to end visit, however significant improvement in mean scores from baseline(M:3.41;SD:1.36) to follow-up(M:2.70;SD:1.20;p=0.018). In item two, significant improvement was observed in mean scores from baseline(M:3.81;SD:1.27) to end visit(M:3.00;SD:1.33;p=0.003) with further improvement observed at follow-up(M:2.81;SD:1.41;p=0.006). In item four no significant improvement was observed from baseline to end visit, however significant improvement was observed in mean scores from baseline(M:3.56;SD:1.21) to follow-up(M:4.30;SD:1.17;p=0.030). In item 10 significant improvement was observed in mean scores from baseline(M:2.22;SD:1.28) to end visit(M:1.56;SD:0.97;p=0.042), however no significant improvement was observed from baseline to follow-up. In item 11 no significant improvement was observed from baseline to end visit, however significant improvement was observed in mean scores from baseline(M:3.41;SD:1.21) to follow-up(M:2.59;SD:1.15;p=<0.003). In item 12 no significant improvement was observed from baseline to end visit, however significant improvement was observed in mean scores from baseline(M:3.56;SD:1.18) to follow-up(M:2.56;SD:1.15;p=<0.003). In the remaining six items three, five, six, seven, eight and nine no significant improvement in mean scores was observed. MYMOP results are presented in table 9. Statistically significant improvements were seen from baseline to end visit in severity of both the primary and secondary complaints reported by participants as well as in how those problems impacted regular activities. In symptom one significant improvements in mean scores were observed from baseline(M:3.85;SD:1.35) to end visit(M:2.52;SD:1.42;p=0.006) with further improvement observed at follow-up(M:2.41;SD:1.30;p=0.006). In symptom two significant improvement in mean scores was observed from baseline(M:4.04;SD:1.45) to end visit(M:2.20;SD:1.44;p=<0.003) with sustained results at follow-up(M:2.28;SD:1.27;p=<0.003). In how those symptoms impacted regular activities, significant improvement in mean scores were observed from baseline(M:3.74;SD1.34) to end visit(M:2.74;SD:1.43;p=0.012) with further improvement observed at follow-up(M:2.41;SD:1.42;p=<0.003). In wellbeing significant improvement in mean scores was observed from baseline(M:4.00;SD:1.14) to end visit(M:2.44;SD:1.25;p=<0.003) with sustained results at follow-up(M:2.22;SD:1.18;p=>Please insert Tables 4-9 here (found in Additional file 1)>> Discussion This pilot feasibility study is the first study to examine a group-delivered naturopathic medicine intervention for women with endometriosis. In this study, a 12-week naturopathic group visit intervention for endometriosis was tested, where results show the intervention was feasible, well accepted and resulted in clinical improvement for women with endometriosis. Similar to other studies examining IMGVs for chronic illnesses( 26 , 34 ), high levels of satisfaction were observed across all aspects of the NatME program including those aspects that differed between cohorts (i.e. satisfaction with practitioners and group size). With such diversity of program aspects having met satisfaction and expectations among participants, the reasons for these findings cannot be attributed to any one component of the intervention (e.g. positive clinical outcomes). Rather, it is likely that feasibility and acceptability outcomes were associated with the unique combination of components of the intervention including the benefit of personalized and person-centered care that characterizes naturopathic medicine( 13 ), combined with the health enhancing effects of connection( 35 ) and group support( 36 ) with the addition of health education and in some cases natural medicines. However, it should also be noted that high levels of satisfaction often exist with complementary therapies due to their alignment with stated patient beliefs and values( 37 ). As such, the reasons behind the acceptability of this program are likely to be multifarious, and to reflect the composite nature of both the group visit model, and of naturopathic care. Further research work examining what additive role group visits play in enhancing positive non-specific effects in health is warranted. Further, in this study participants reported a sense of increased knowledge and empowerment resulting from the program. This knowledge and empowerment may also have contributed to their high satisfaction levels and experience of reduced pain, alongside efficacy of treatments prescribed. The group visit model proffers the opportunity to provide multifaceted healthcare, and lends itself well to pragmatic real-world interventions such as naturopathy that are rooted on principles of patient empowerment, education and person-centered care( 29 ). As prior research has identified, women with endometriosis have significant unmet healthcare needs and suboptimal healthcare experiences often based on disempowerment( 4 , 38 , 39 ). Patient empowerment has been identified as an important component in global chronic disease prevention, management and health promotion efforts( 40 , 41 ), and to date this does not appear to have translated to endometriosis-related healthcare( 4 , 38 ). Although specified tools measuring empowerment were not implemented in this study, the preliminary findings of patient empowerment reported here provide important insight to inform future endometriosis studies, which should use such tools measuring empowerment such as those used in other research( 40 , 42 ). In addition to good feasibility outcomes and patient empowerment, the findings of this study showed promising clinical outcomes and notably, improved pain outcomes. Chronic pelvic pain and other types of pain are core issues for people with endometriosis( 3 ). In this study, improvements were observed across all 13 items of the PCS. These findings have particular importance because pain catastrophizing has been shown to be associated with poor pain treatment outcomes in people with chronic pain( 43 ). As such, improvements in pain catastrophizing can lead to better pain treatment outcomes. Further, although no significant changes were seen on some SF-12 and SHOW-Q items, the items where statistically significant improvements were observed included the items relating to pain across all four of the validated scales used. While assessed within the context of the study’s limitations as a pilot feasibility study, these results suggest the NatME program has potential as a clinically effective intervention for reducing pain associated with endometriosis, and larger, more controlled studies are warranted. Moreover, while improvements in pain were seen consistently across outcome measures, positive clinical results were not limited to pain outcomes. A diverse range of clinical improvements were observed across domains including quality of life and emotional and physical wellbeing. As discussed in the context of participant satisfaction the clinical outcomes observed cannot be solely attributed to the treatments prescribed in the intervention, because as was characteristic of the program design and is of naturopathic medicine itself – only some participants in the study were prescribed ingestible medicines, as was appropriate to their individual clinical and financial circumstances. Therefore, again the diverse range of positive clinical outcomes observed may also reflect the complexity and multifaceted form of the naturopathic group visit program. As with all research, this study comes with limitations. Being a pilot feasibility study, the small sample size limits its generalizability and the study is also limited by a lack of control group. As such, while clinical outcomes were measured as secondary outcomes in this study, the study design limits its capacity to be used to interpret clinical efficacy. Despite this, the positive changes observed across clinical outcomes in this study were notable and exhibited in all four settings, however larger scale clinical trials are needed to further assess clinical efficacy. Results from this study may also inform the design of full-scale trials in future. Finally, measuring patient compliance in this study proved to be challenging due to the complex multifaceted form of intervention and as such compliance was unable to be reported among feasibility outcomes. For future studies on pragmatic real-world interventions, more specific data collection tools and strategies should be developed during the design phase to measure patient compliance. Overall the positive results of this study provide good rationale for future studies to provide a more thorough examination of clinical efficacy of the NatME intervention. Conclusion To date, endometriosis research has focused on medical and surgical treatments for endometriosis alongside some research examining the effects of dietary changes. However, recent research shows women with endometriosis do not believe they are getting the outcomes they need and want from standard medical approaches. Innovative new strategies for endometriosis management and treatment are needed, and a complex multi-systems condition with significant and diverse impacts on wellbeing and quality of life may warrant a complex multifaceted intervention to address those diverse impacts. The present study presents one such intervention and suggests the NatME program could benefit people with endometriosis by improving a wide range of symptoms while providing education, empowerment and connection, as well as making a treatment already actively sought out by women with endometriosis more accessible. The findings of this study indicate the NatME program is feasible and well-accepted. It has promising clinical outcomes and high levels of satisfaction across all elements of the program. Overall, these findings indicate a naturopathic group model of care may be an effective way to improve symptoms and healthcare experiences for people with endometriosis as well as address some of their unmet healthcare needs. Larger studies are needed to assess clinical efficacy of NatME, but this study indicates it may be an effective model of care for women with endometriosis, alongside available medical treatments. Declarations Acknowledgements The authors acknowledge the contribution from William Pinzon Perez for statistical support received through QCIF Biostatistics, QCIF Ltd, Brisbane, Queensland, Australia. Data availability Data will be made available upon request to the corresponding author. Disclosure statement The authors report there are no competing interests to declare. Funding This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Human ethics and consent to participate This study was approved by the Human Research Ethics Committee (HREC) at Southern Cross University (approval no. 2021/117) and registered with Australian New Zealand Clinical Trials Registry (ANZCTR) (registration no. ACTRN12622000222741). Written informed consent was provided by all participants. Authors contributions Sophia Gerontakos : Conceptualization, methodology, data curation, investigation, formal analysis, writing – original draft. Amie Steel : Conceptualization, writing – review and editing, supervision. Jon Wardle : Conceptualization, methodology, validation, writing – review and editing, supervision. All authors approved the final version of the manuscript. Biographical data Professor Jon Wardle is Foundation Director of the National Centre for Naturopathic Medicine (NCNM) and Maurice Blackmore Chair of Naturopathic Medicine at Southern Cross University. In addition to clinical qualifications in nursing and naturopathic medicine, Jon has postgraduate qualifications in public health, law and health economics and holds visiting positions at Boston University, University of Washington and University of Oxford. Amie Steel is an Associate Professor in the Australian Research Consortium in Complementary and Integrative Medicine (ARCCIM) at UTS. As an expert in women’s health - with a particular focus on pregnancy, fertility and preconception health – and complementary medicine, she is ranked as the #1 Traditional and Complementary Medicine Researcher in Australia (2021-present). Sophia Gerontakos is a PhD candidate at the National Centre for Naturopathic Medicine at Southern Cross University. Sophia’s PhD research focuses on endometriosis and a group-delivered naturopathic medicine approach to meeting unmet healthcare needs for people with endometriosis and improving their healthcare experiences and access to complementary therapies. In addition to her PhD research Sophia is also a research assistant at the Sydney Adventist Hospital in Wahroonga, Sydney where she manages the Sydney branch of a longitudinal multiple sclerosis cohort study. References Horne AW, Missmer SA. Pathophysiology, diagnosis, and management of endometriosis. BMJ. 2022;379:e070750. Australian Institute of Health and Welfare. 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Steel A, Schloss J, Leach M, Adams J. The naturopathic profession in Australia: A secondary analysis of the Practitioner Research and Collaboration Initiative (PRACI). Complement Ther Clin Pract. 2020;40:101220. Reid R, Steel A, Wardle J, Trubody A, Adams J. Complementary medicine use by the Australian population: A critical mixed studies systematic review of utilisation, perceptions and factors associated with use. BMC Complement Altern Med. 2016;16(1):176. Arentz S, Smith CA, Abbott J, Fahey P, Cheema BS, Bensoussan A. Combined lifestyle and herbal medicine in overweight women with polycystic ovary syndrome (PCOS): A randomized controlled trial. Phytother Res. 2017;31(9):1330–40. Myers S, Vigar V. The state of the evidence for whole-system, multi-modality naturopathic medicine: A systematic scoping review. J Altern Complement Med. 2019;25(2):141–68. Redmond R, Steel A, Wardle J, Adams J. Naturopathy utilisation by Australian women with diagnosed endometriosis: A cross-sectional survey. Complement Ther Clin Pract. 2022;46:101539. Foley H, Steel A, Adams J. Perceptions of person-centred care amongst individuals with chronic conditions who consult complementary medicine practitioners. Complement Ther Med. 2020;52:102518. Spinks J, Hollingsworth B. Policy implications of complementary and alternative medicine use in Australia: data from the National Health Survey. J Altern Complement Med. 2012;18(4):371–8. McIntyre E, Adams J, Foley H, Harnett J, Leach MJ, Reid R, et al. Consultations with naturopaths and Western herbalists: Prevalence of use and characteristics of users in Australia. J Altern Complement Med. 2019;25(2):181–8. Stevens J, Dixon J, Binns A, Morgan B, Richardson J, Egger G. Shared medical appointments for Aboriginal and Torres Strait Islander men. Aus Fam Physician. 2016;45:425–9. Cornelio-Flores O, Lestoquoy AS, Abdallah S, Deloureiro A, Lorente K, Pardo B, et al. The Latino integrative medical group visit as a model for pain reduction in underserved Spanish speakers. J Altern Complement Med. 2018;24(2):125–31. Andersson E, Christensson K, Hildingsson I. Parents' experiences and perceptions of group-based antenatal care in four clinics in Sweden. Midwifery. 2012;28(4):502–8. Sultana M, Ali N, Akram R, Jahir T, Mahumud RA, Sarker AR et al. Group prenatal care experiences among pregnant women in a Bangladeshi community. PLoS ONE. 2019;14(6). Parikh M, Rajendran I, D'Amico S, Luo M, Gardiner P. Characteristics and components of medical group visits for chronic health conditions: A systematic scoping review. J Altern Complement Med. 2019;25(7):683–98. Thompson-Lastad A. Group medical visits as participatory care in community health centers. Qual Health Res. 2018;28(7):1065–76. Baig AA, Staab EM, Benitez A, Hermans SP, Ham SA, Wan W, et al. Impact of diabetes group visits on patient clinical and self-reported outcomes in community health centers. BMC Endocr Disord. 2022;22(1):60. Menon K, Mousa A, de Courten MP, Soldatos G, Egger G, de Courten B. Shared medical appointments may be effective for improving clinical and behavioral outcomes in type 2 diabetes: A narrative review. Front Endocrinol. 2017;8:263. Dresner D, Gergen Barnett K, Resnick K, Laird LD, Gardiner P. Listening to their words: A qualitative analysis of integrative medicine group visits in an urban underserved medical setting. Pain Med. 2016;17(6):1183–91. Gardiner P, Luo M, D'Amico S, Gergen-Barnett K, White LF, Saper R et al. Effectiveness of integrative medicine group visits in chronic pain and depressive symptoms: A randomized controlled trial. PLoS ONE 2019;14(12). Gerontakos S, Leach M, Steel A, Wardle J. Feasibility and efficacy of implementing group visits for women's health conditions: a systematic review. BMC Health Serv Res. 2023;23(1):549. Picklesimer AH, Billings D, Hale N, Blackhurst D, Covington-Kolb S. The effect of CenteringPregnancy group prenatal care on preterm birth in a low-income population. Am J Obstet Gynecol. 2012;206(5):415. .e1-.e7 . Tubay AT, Mansalis KA, Simpson MJ, Armitage NH, Briscoe G, Potts V. The effects of group prenatal care on infant birthweight and maternal well-being: A randomized controlled trial. Mil Med. 2019;184(5/6):440–6. Solomonian L, Uraz Z, El-Hashemy S, Vu A, Hudson T. Naturopathic Medicine and Group Visits: A Natural Alignment. CAND J. 2022;29(2):9–17. Chao MT, Abercrombie PD, Santana T, Duncan LG. Applying the RE-AIM framework to evaluate integrative medicine group visits among diverse women with chronic pelvic pain. Pain Manage Nurs. 2015;16(6):920–9. Harrison E, Lach HW. Group visits for management of patients with PCOS: A pilot study. Women's Healthc. 2017;5(4):44–9. Schneeberger D, Golubíc M, Moore HCF, Weiss K, Abraham J, Montero A, et al. Lifestyle medicine-focused shared medical appointments to improve risk factors for chronic diseases and quality of life in breast cancer survivors. J Altern Complement Med. 2019;25(1):40–7. Whitehead AL, Julious SA, Cooper CL, Campbell MJ. Estimating the sample size for a pilot randomised trial to minimise the overall trial sample size for the external pilot and main trial for a continuous outcome variable. Stat Methods Med Res. 2016;25(3):1057–73. Gardiner P, Dresner D, Barnett KG, Sadikova E, Saper R. Medical group visits: A feasibility study to manage patients with chronic pain in an underserved urban clinic. Global Adv Health Med. 2014;3(4):20–6. Murthy VH, Together. New York, NY, USA: Harper Collins 2020. Maskell J. The community cure: Transforming health outcomes together. USA: Lioncrest; 2020. Bishop FL, Yardley L, Lewith GT. A systematic review of beliefs Involved in the use of complementary and alternative medicine. J Health Psychol. 2007;12(6):851–67. Evans S, Villegas V, Dowding C, Druitt M, O'Hara R, Mikocka-Walus A. Treatment use and satisfaction in Australian women with endometriosis: a mixed-methods study. Intern Med J. 2022;52(12):2096–106. Young K, Fisher J, Kirkman M. Women's experiences of endometriosis: a systematic review and synthesis of qualitative research. J Fam Plann Reprod Health Care. 2014;41(3):225–34. Stepanian N, Larsen MH, Mendelsohn JB, Mariussen KL, Heggdal K. Empowerment interventions designed for persons living with chronic disease - a systematic review and meta-analysis of the components and efficacy of format on patient-reported outcomes. BMC Health Serv Res. 2023;23(1):911. World Health Organization. Self-care for health and wellbeing Geneva, Switzerland2024 [Available from: https://www.who.int/news-room/fact-sheets/detail/self-care-health-interventions Foley H, Steel A. Patient perceptions of patient-centred care, empathy and empowerment in complementary medicine clinical practice: A cross-sectional study. Adv Integr Med. 2017;4(1):22–30. Darnall BD, Sturgeon JA, Cook KF, Taub CJ, Roy A, Burns JW, et al. Development and Validation of a Daily Pain Catastrophizing Scale. J Pain. 2017;18(9):1139–49. Footnotes The authors of this thesis recognise that not all people who experience menstruation and/or disorders of the menstrual cycle such as endometriosis identify as women. Trans men, intersex, non-binary and gender diverse people also experience menstruation and health conditions associated. They face both similar, and unique challenges to cis women. To date, the evidence on endometriosis overwhelmingly represents cis women’s experiences. Although trans men and gender diverse people were not excluded from this research, the participants who responded to recruitment notices identified as women. The word ‘women’ is used in this article to reflect the evidence drawn on throughout, and to reflect the women who participated in this research without misrepresenting the unique experiences and challenges of trans men, intersex, non-binary or gender diverse people. We note the gap in literature representing experiences of trans and gender diverse people, which should be built on in future. Additional Declarations No competing interests reported. Supplementary Files AdditionalFile1Tables4to9NatMEpilotstudy.docx Appendix1NatMEverbalfeedbackdiscussiontemplate.docx Appendix2NatMEfeedbackquotes.docx Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 24 Feb, 2026 Reviews received at journal 18 Feb, 2026 Reviewers agreed at journal 11 Feb, 2026 Reviews received at journal 06 Dec, 2025 Reviewers agreed at journal 05 Dec, 2025 Reviewers agreed at journal 12 Nov, 2025 Reviewers invited by journal 12 Oct, 2025 Editor invited by journal 08 Oct, 2025 Editor assigned by journal 02 Sep, 2025 Submission checks completed at journal 02 Sep, 2025 First submitted to journal 18 Aug, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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15:44:36","extension":"html","order_by":9,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":258218,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7396031/v1/2a0f000446f63d1fce02aa76.html"},{"id":94473508,"identity":"13270711-cd1f-423d-8ba0-3263d59db88a","added_by":"auto","created_at":"2025-10-27 15:44:41","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":72660,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eStudy flow diagram\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-7396031/v1/5ba24ea61beee59e2b05dc24.png"},{"id":94489729,"identity":"3a8ac331-d4e1-4f7a-8420-1054cb8d02af","added_by":"auto","created_at":"2025-10-27 17:05:48","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1026587,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7396031/v1/6c241007-7ae2-4c2e-af74-3bad13ee45d6.pdf"},{"id":94473362,"identity":"e9ab8d49-52d8-4371-8146-78712178f234","added_by":"auto","created_at":"2025-10-27 15:44:05","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":50433,"visible":true,"origin":"","legend":"","description":"","filename":"AdditionalFile1Tables4to9NatMEpilotstudy.docx","url":"https://assets-eu.researchsquare.com/files/rs-7396031/v1/08cacfd0ed2abc058a95179d.docx"},{"id":94473109,"identity":"6b34adae-820f-4821-89fc-7c934339d6fc","added_by":"auto","created_at":"2025-10-27 15:42:39","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":22122,"visible":true,"origin":"","legend":"","description":"","filename":"Appendix1NatMEverbalfeedbackdiscussiontemplate.docx","url":"https://assets-eu.researchsquare.com/files/rs-7396031/v1/356793d5684e5c53eefc912c.docx"},{"id":94473473,"identity":"f12a4484-ac6d-4e75-899e-740e8fdf5054","added_by":"auto","created_at":"2025-10-27 15:44:31","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":24008,"visible":true,"origin":"","legend":"","description":"","filename":"Appendix2NatMEfeedbackquotes.docx","url":"https://assets-eu.researchsquare.com/files/rs-7396031/v1/9202c865ff6266303a3cfd54.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Naturopathic Medicine for Endometriosis (NatME). Results of a pilot study","fulltext":[{"header":"Background","content":"\u003cp\u003eEndometriosis is a complex, chronic inflammatory condition affecting women and persons assigned female at birth and characterized by endometrium-like tissue being present outside the endometrium(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). Over 14% of Australian females of reproductive-aged are diagnosed with endometriosis(\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). The condition is often characterized by symptoms including chronic pain (pelvic and other pain), fatigue, painful urination and bowel movements, and painful sex along with other comorbidities including impacts on mental health, quality of life and financial wellbeing(\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Endometriosis can affect trans men and non-binary people, yet the available research on the condition is overwhelmingly focused on cis women. Women\u003csup\u003e1\u003c/sup\u003e with endometriosis have reported negative healthcare experiences, unfeasible costs of endometriosis-related healthcare, unmet healthcare needs and a desire for increased access to allied health and complementary therapies (non-pharmaceutical and non-surgical treatments)(\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eNaturopathy is a traditional medicine system originating from Europe(\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e) focused on supporting the body’s natural healing processes with key philosophical tenets including \u003cem\u003eTolle Causam\u003c/em\u003e (treat the cause) and \u003cem\u003eTolle Totum\u003c/em\u003e (treat the whole person)(\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). Use of naturopathic medicine is high among Australian women(\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e) with women often consulting naturopaths for female-specific health concerns, such as menstrual disorders(\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e), menopause-related symptoms, pregnancy-related complaints(\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e) and polycystic ovary syndrome(\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e) amongst other chronic conditions(\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). Evidence demonstrates naturopaths play a significant role in endometriosis with approximately 20% of Australian women with endometriosis reporting they consult with a naturopath(\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). Naturopathy services in Australia are mostly delivered in private practice settings, generally using a one-on-one long consultation model (i.e. an individual patient consulting with an individual practitioner). This model proffers the benefit of person-centered care and individualization(\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e) but by its very nature, limits the number of patients any one clinician can reach, while adding a financial barrier for many patients. The cost burden of consultation fees and prescription are typically borne by the patient as an out-of-pocket expense(\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). Both of these features represent financial and social barriers to community access to naturopathic care(\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eGroup visits (also known as shared medical appointments [SMAs], group medical visits [GMVs], or - when they incorporate integrative therapies such as acupuncture, mind-body therapies or others - integrative medicine group visits [IMGVs]), are models of care that have been shown to increase access to health care for diverse populations in Australia(\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e), the United States (US)(\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e) and other countries(\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). A group visit is a patient-centered model where multiple patients (usually sharing a similar medical condition or risk factors) consult with a health professional or team of health professionals within a group setting; the appointment can include medical consultation including measurement of vitals, medication reviews, patient education and other integrative medicine disciplines(\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). Group visits aim to improve patient outcomes by combining three important components – clinical care, patient education and peer support(\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). Evidence shows group visits are effective in managing chronic conditions such as diabetes(\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e) and chronic pain(\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e) and they have been found to be feasible and well accepted for women’s health conditions(\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). There is also a substantial body of evidence in support of group-delivered maternal and pregnancy care where group prenatal care has been found to be both feasible and more effective than individual care across a variety of settings and populations(\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). Although there is interest within the naturopathic profession to utilize the group visit model due to the model aligning well with naturopathic principles of practice(\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e), to date evidence is lacking for feasibility and efficacy of delivering naturopathic care using a group visit model. However, evidence for the benefits of group visits for chronic disease management and women’s health provides a good basis for more research examining the model for women with endometriosis through a naturopathic lens.\u003c/p\u003e\u003cp\u003eIn summary, there is an issue of access to naturopathic medicine with the current mode of delivery using private consultations, and lack of access through health system pathways. Given that women with endometriosis are high users of naturopathy, have unmet healthcare needs and appear to demonstrate a desire for greater access to complementary therapies, research is needed into the feasibility and effectiveness of new models for delivering naturopathic care to women with endometriosis. Group visits have been seen to improve healthcare access, and be an effective healthcare model for chronic disease management. As such, this study – Naturopathic Medicine for Endometriosis (NatME) – used an uncontrolled pilot feasibility trial design to examine (a) the feasibility of a group visit model for delivering naturopathic care to people with endometriosis, and (b) the preliminary effectiveness of the group visit model in improving health outcomes of this population.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eStudy design and setting\u003c/p\u003e\u003cp\u003eNatME was an uncontrolled pilot feasibility study, that took place in four different locations in Australia between April 2022 and August 2022, with four cohorts of patients. The intervention comprised four cohorts of participants, across three urban locations within the region and one online cohort. The four separate study locations and settings included: i) Coolangatta, Queensland, Australia, in a seminar room within Southern Cross University Gold Coast campus; ii) within a private practice natural therapies clinic in Brisbane, Queensland iii) in Lismore, NSW, Australia in a teaching room within Southern Cross University Lismore campus; and iv) online via the zoom conferencing platform. Each location had space for group activity, as well as an adjoining space for private one-on-one consultations between patient and practitioner (and equivalent “breakout rooms” for the online cohort). The intervention was delivered to each cohort of patients by a qualified naturopath practitioner with expertise in women’s health and endometriosis, alongside a co-facilitator who was trained in shared medical appointment facilitation. The co-facilitator in the program was the lead researcher in this study. The study was approved by the Southern Cross University Human Research Ethics Committee (approval no. 2021/117) and registered with Australian New Zealand Clinical Trials Registry (ANZCTR) (registration no. ACTRN12622000222741) on 8th February 2022.\u003c/p\u003e\u003cp\u003eParticipants\u003c/p\u003e\u003cp\u003ePatient participants were recruited using purposive sampling. For example, the study was advertised using a flyer through endometriosis support groups and key endometriosis advocacy groups (Endometriosis Australia and QENDO). Recruitment information was widely disseminated on social media and via emailed newsletters (via Southern Cross University, other stakeholder organizations and expert clinicians in endometriosis with well-established public profiles and online engagement).\u003c/p\u003e\u003cp\u003ePractitioner participants were recruited through professional naturopathic networks including the Naturopaths and Herbalists Association of Australia symposium and website, and naturopathic clinics identifying as having a clinical focus on women’s health and/or endometriosis. Practitioner participants were provided training in facilitating shared medical appointments through Australasian Society of Lifestyle Medicine and remuneration of \u003cspan\u003e$\u003c/span\u003e1000 at completion of the program, as well as counting their participation as continuing professional development (CPD). Snowball sampling was also used, where participants may have invited other prospective participants to the study.\u003c/p\u003e\u003cp\u003eParticipants who fulfilled the following inclusion criteria were included in the study: aged ≥ 18 years, female sex, had a diagnosis of endometriosis made by a medical doctor, were intending to seek naturopathic care for the primary purpose of managing endometriosis-related symptoms, spoke fluent English and were willing to commit to attending group visits (i.e. could not foresee a reason for missing two or more sessions). Participants were excluded if they were seeking naturopathic services solely or primarily for fertility issues, preconception care or pregnancy, were pregnant, were currently under the care of a naturopath and/or taking herbal or naturopathic medicines, had a medical diagnosis of serious mental illness (a clinically diagnosed disorder that significantly interferes with an individual’s cognitive, emotional and social abilities, e.g. bipolar disorder or schizophrenia) or were had an active medically diagnosed substance abuse disorder (i.e. alcohol, prescribed or illicit drugs).\u003c/p\u003e\u003cp\u003eFour naturopath practitioners who fulfilled the following criteria were recruited to deliver the intervention: had a minimum of 5 years’ experience in naturopathic clinical practice, were currently working as a naturopath in part-time or full-time clinical practice (including casual or locum naturopaths who work at least one day per week), identified as experienced and having a clinical focus in the area of women’s health and/or endometriosis, were a member of an Australian professional association covering naturopaths, held a Bachelor degree or higher in naturopathy or an Advanced Diploma in Naturopathy completed prior to 2016, as their minimum qualification, held professional indemnity insurance that covered the practice of naturopathy, spoke fluent English and were female. All participants (including patients and practitioners) provided written, informed consent to participate in the study before any study procedures commenced.\u003c/p\u003e\u003cp\u003eInterventions\u003c/p\u003e\u003cp\u003eThe NatME intervention was designed following an earlier suite of research comprising focus group studies involving people with endometriosis and naturopaths who specialize in endometriosis treatment. To inform the NatME intervention design, the previous qualitative research explored healthcare needs and experiences of people with endometriosis (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e) and experiences and perspectives of patients and women’s health naturopaths on naturopathic treatment for endometriosis, alongside their views on prospective naturopathic group consultations.\u003c/p\u003e\u003ch3\u003eProgram structure\u003c/h3\u003e\u003cp\u003eNatME used a group visit model to deliver six group naturopathic consultations consecutively to small groups of people with endometriosis over the course of three months which comprised of six fortnightly group visits lasting two hours per visit. Within the group naturopathic intervention, each patient received care in the presence of one another, that was reflective of general naturopathic practice including education on health topics relevant to the management of endometriosis (identified in prior research), self-care, and where appropriate, individualized prescription of herbal, nutritional or lifestyle medicine within the scope of naturopathic practice and according to individual patient needs. The intervention was administered by a qualified naturopath with clinical experience in the field of endometriosis and women’s health. The intervention reflected “usual naturopathic care” that would ordinarily be delivered in a one-on-one consultation but was delivered in the presence of other patients (i.e. as a group, where all patients had an opportunity to discuss the health topics collaboratively and to ask questions). Patients were permitted to speak from personal experience but were not permitted to provide advice to other participants. Only the naturopathic practitioner was permitted to provide expert advice. The naturopathic practitioner delivered the intervention collaboratively with the group facilitator.\u003c/p\u003e\u003cp\u003e The group facilitator managed the group, including managing group dynamics, encouraging participation, keeping to topic, keeping to time, recording clinical notes, and ensuring all participants have been reviewed by the naturopath at every visit. The group facilitator was also able to deliver specific group activities, such as group shares, mindfulness, sharing recipe ideas and discussing health topics if required, but only where the naturopathic practitioner was unavailable (i.e. was required to conduct a brief one-on-one consultation with patients or attending to urgent medical needs, the latter which did not occur). The group facilitator was also a qualified naturopathic practitioner.\u003c/p\u003e\u003ch2\u003eRisk management\u003c/h2\u003e\u003cp\u003eThe facilitator and naturopathic practitioner were trained clinicians who were sensitive to any signs of distress, discomfort or adverse reactions related to the intervention or treatments prescribed within the intervention. At every group session, each patient had an individual (within the group setting) review of progress and prescriptions. As such, prescriptions were closely monitored (reflecting one-on-one real-world clinical practice) and were adjusted, ceased or continued according to patient progress, symptoms and preferences, with record keeping of adherence or modification via clinical note-taking. Patients were also required to complete an intake form on the day of the group visit, prior to the group commencing on which they indicated if they would like a brief (approx. five minutes) private check-in with the practitioner to discuss any concerns they did not wish to discuss within the group. The facilitator reviewed these forms prior to commencing the group and scheduled any private check-ins into the proceedings for the session (either at the beginning or end of the group). The naturopathic practitioner used their expert clinical judgement to assess the need for referral to another service such as a medical practitioner or counsellor, if required (reflecting one-on-one real-world clinical practice).\u003c/p\u003e\u003cp\u003eOutcomes measured\u003c/p\u003e\u003ch3\u003ePrimary outcome – feasibility\u003c/h3\u003e\u003cp\u003eFeasibility was examined by measure the following six outcomes: i) acceptability, ii) demand, iii) compliance, iv) implementation, v) adaptation and vi) integration. A full description of the methods of measuring feasibility outcomes is presented in Table \u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e\u003cdiv class=\"gridtable\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eFeasibility outcome measures\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"2\"\u003e\u003c/colgroup\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOutcome\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMethod of measurement\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eAcceptability\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003eThe reaction of patients and practitioners to the intervention\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e(1) Patient questionnaire domains: experience of the intervention, satisfaction with the NatME curriculum, and perception of facilitator and practitioner performance\u003c/p\u003e\u003cp\u003e(2) Practitioner questionnaire domain: experience and satisfaction with the intervention\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eDemand\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003eThe reaction to and likelihood that patients and practitioners would utilize the intervention again\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e(1) Patient and practitioner questionnaire domains: likelihood of using the intervention again\u003c/p\u003e\u003cp\u003e(2) Recruitment and retention rates\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eCompliance\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003eThe extent to which participants complied with the treatments\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e(1) Observation and field notes documented by the facilitator\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eImplementation\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003eThe extent to which the intervention could be fully implemented as planned and proposed\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e(1) Practitioner questionnaire domains: ease of implementation\u003c/p\u003e\u003cp\u003e(2) Observation and field notes documented by the group facilitator\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eAdaptation\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003eThe extent to which the intervention was modified to be appropriate for the situation, or could be modified to address populations with different health conditions\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e(1) Practitioner questionnaire domains: ease of adapting the intervention to other health conditions\u003c/p\u003e\u003cp\u003e(2) Observation and field notes documented by the group facilitator\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eIntegration\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003eThe extent to which the new model can fit within existing naturopathic practice\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e(1) Patient questionnaire domains: Importance of the intervention, likelihood of recommending the program and using the program again or attending other naturopathic group visits\u003c/p\u003e\u003cp\u003e(2) Practitioner questionnaire domains: satisfaction with the intervention, performance, and structure; likelihood of using the intervention again and recommending the intervention to other naturopaths\u003c/p\u003e\u003cp\u003e(3) Observation and reflection on field notes documented by the group facilitator\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/table\u003e\u003c/div\u003e\u003cp\u003e\u0026gt;\u0026gt;Please insert Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e here\u0026gt;\u0026gt;\u003c/p\u003e\u003ch3\u003eSecondary outcomes – clinical efficacy\u003c/h3\u003e\u003cp\u003eSecondary outcomes were measured at baseline, post-intervention (week 12) and one-month follow-up (week 16). Five patient-reported outcome measures were self-administered by participants. Health-related quality of life was measured using the 12-item Short Form survey (SF-12) and Endometriosis Health Profile-5 (EHP-5). Individual patient outcomes were measured using the Measure Yourself Medical Outcome Profile (MYMOP). Sexual health was measured using the Sexual health outcomes in women questionnaire (SHOW-Q). Participants pain experience was measured using the Pain Catastrophizing Scale (PCS). Maintenance, or the extent to which effects in individuals are maintained over time was measured with a week 16 follow-up of all patient reported outcome measures.\u003c/p\u003e\u003ch3\u003eVerification of primary and secondary outcome measures\u003c/h3\u003e\u003cp\u003eFeasibility and clinical outcomes via program evaluation and validated clinical questionnaires were verified with verbal feedback during the final 15–30 minutes of the final session (visit 6) for each cohort. The group facilitator facilitated the feedback sessions. A sample run sheet with questions asked during these sessions is presented in Appendix 1, Table A1.\u003c/p\u003e\u003cp\u003e\u0026gt;Table A1. Session 6 week 12 NatME program verbal feedback run sheet\u0026gt;\u003c/p\u003e\u003cp\u003eSample size\u003c/p\u003e\u003cp\u003eThe study aimed to recruit four cohorts of 5–10 participants, which aligned with sample sizes reported in other pilot studies of group interventions(\u003cspan additionalcitationids=\"CR31\" citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e–\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e) as well as recommended sample sizes for pilot studies(\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eStatistical methods\u003c/p\u003e\u003cp\u003eData was either imported via Redcap, or entered manually (if derived from hard-copy documents). Data was then cleaned, coded and analyzed using SPSS v25. Due to the type of data collected, missing data were simply reported as missing.\u003c/p\u003e\u003cp\u003eData was analyzed using descriptive analysis for numerical data. Frequency distributions and percentages were used to describe categorical data. Means and standard deviations (or medians and interquartile ranges) were used for continuous data, depending on data distribution. The Friedman test was used to determine p values for ordinal variables, alongside the Wilcoxon test with Bonferroni correction. The Cochran Q test was used to determine p values for nominal variables alongside the McNemar test with Bonferroni correction. Statistical significance was set at p \u0026lt; 0.05.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 46 participants consented to participate of which 31 were enrolled into the study. Eleven of the 46 were placed on a waitlist because their requested location was already at capacity, and four participants withdrew consent prior to the baseline visit (enrolment). Of the 31 participants enrolled four participants were dropouts at visit two or earlier and their data was not included in analysis. A diagram of the flow of participants through the recruitment and enrolment processes is presented in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eFeasibility outcomes\u003c/p\u003e\u003cp\u003eFeasibility results of the patient program evaluation questionnaire are presented in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. All participants agreed (96.3%) or mostly agreed (3.7%) that naturopathic group visits are a good way of receiving care for endometriosis. Demand and acceptability were high with an 87% (n\u0026thinsp;=\u0026thinsp;27 of 31) retention rate and 96.3% reporting they would recommend NatME to other people with endometriosis while 100% of participants would participate in other naturopathic group visits. All participants were satisfied that their healthcare needs were met in the group visits and 100% were satisfied with the practitioner and facilitator. Over half of participants (51.9%) were satisfied with the program length (12 weeks), while 48.1% reported the program was too short. High levels of learning were also reported by majority of participants (74.1%). The extent to which participants were able to comply with the treatments were unable to be tracked due to the complexity of the intervention and heterogeneity of treatments prescribed. Compliance is discussed within the study limitations with recommendations for future studies of complex interventions. Verbal feedback was highly synonymous with questionnaire and clinical results. Verbal feedback reflected high levels of satisfaction with the overall program and with clinical results (e.g. reduced pain levels) as well as high levels of learning with increased knowledge leading to a sense of empowerment. One participant stated \u0026ldquo;\u003cem\u003eSeeing how you can take your health into your own hands ..that really is empowering\u003c/em\u003e\u0026rdquo;; another stated \u0026ldquo;\u003cem\u003eI'm more empowered, because I now have a lot of knowledge\u003c/em\u003e\u0026rdquo;. Verbal feedback also included satisfaction with the program structure, benefits of group support and feelings of safety within the group environment. For example, one participant stated \u0026ldquo;\u003cem\u003eJust knowing that you're in an environment where people actually understand and it's okay to be in pain, I didn't have to pretend to be someone else, I could just sit there and just get lifted up by everyone else\u003c/em\u003e\u0026rdquo;; and others stated \u0026ldquo;\u003cem\u003eIt's a very safe space\u003c/em\u003e\u0026rdquo;. Some minor barriers and challenges to attending the program were reported verbally including motivation, traffic, and missing face-to-face sessions due to illness. A comprehensive list of participant quotes for each topic are included in Appendix 2, Table A2.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003ePatient program evaluation questionnaire responses\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVariable\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eResponse\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eFrequency (%) n\u0026thinsp;=\u0026thinsp;27\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"4\" rowspan=\"5\"\u003e\u003cp\u003e\u003cb\u003eExpectations\u003c/b\u003e\u003c/p\u003e\u003cp\u003e(How would you rate your experience of the NatME program?)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1 Exceeded expectations\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e21 (77.8%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2 Met expectations\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5 (18.5%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3 Met most expectations\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1 (3.7%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4 Fell slightly short of expectations\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0 (0%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5 Fell extremely short of expectations\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0 (0%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"4\" rowspan=\"5\"\u003e\u003cp\u003e\u003cb\u003eSatisfaction\u003c/b\u003e\u003c/p\u003e\u003cp\u003e(How satisfied were you with the NatME program overall?)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1 Very satisfied\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e23 (88.5%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2 Satisfied\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2 (7.7%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3 Neither satisfied nor dissatisfied\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1 (3.8%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4 Dissatisfied\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0 (0%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5 Very dissatisfied\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0 (0%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"4\" rowspan=\"5\"\u003e\u003cp\u003e\u003cb\u003eLearning\u003c/b\u003e\u003c/p\u003e\u003cp\u003e(How much did you learn in the NatME program?)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1 A great deal\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e20 (74.1%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2 Quite a bit\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e6 (22.2%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3 Adequate\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1 (3.7%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4 A little\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0 (0%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5 Nothing at all\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0 (0%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"4\" rowspan=\"5\"\u003e\u003cp\u003e\u003cb\u003eSession length\u003c/b\u003e\u003c/p\u003e\u003cp\u003e(How would you describe the length of each group session (e.g. approx. 2hours)?)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1 About right\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e17 (63%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2 Slightly too long\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5 (18.5%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3 Slightly too short\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5 (18.5%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4 Much too short\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0 (0%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5 Much too long\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0 (0%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"4\" rowspan=\"5\"\u003e\u003cp\u003e\u003cb\u003eProgram length\u003c/b\u003e\u003c/p\u003e\u003cp\u003e(How would you describe the length of the complete program (e.g. 3 months?)?)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1 About right\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e14 (51.9%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2 Slightly too long\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0 (0%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3 Slightly too short\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e10 (37%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4 Much too short\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3 (11.1%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5 Much too long\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0 (0%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"4\" rowspan=\"5\"\u003e\u003cp\u003e\u003cb\u003eGroup size\u003c/b\u003e\u003c/p\u003e\u003cp\u003e(How would you describe the size of the group?)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1 About right\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e26 (96.3%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2 Slightly too big\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1 (3.7%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3 Slightly too small\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0 (0%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4 Much too small\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0 (0%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5 Much too big\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0 (0%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"4\" rowspan=\"5\"\u003e\u003cp\u003e\u003cb\u003eFacilitator satisfaction\u003c/b\u003e\u003c/p\u003e\u003cp\u003e(How would you rate your satisfaction with the group facilitator?)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1 Very satisfied\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e25 (92.6%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2 Satisfied\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2 (7.4%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3 Neither satisfied nor dissatisfied\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0 (0%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4 Dissatisfied\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0 (0%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5 Very dissatisfied\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0 (0%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"4\" rowspan=\"5\"\u003e\u003cp\u003e\u003cb\u003ePractitioner satisfaction\u003c/b\u003e\u003c/p\u003e\u003cp\u003e(How would you rate your satisfaction with the naturopath?)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1 Very satisfied\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e26 (96.3%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2 Satisfied\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1 (3.7%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3 Neither satisfied nor dissatisfied\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0 (0%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4 Dissatisfied\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0 (0%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5 Very dissatisfied\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0 (0%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"4\" rowspan=\"5\"\u003e\u003cp\u003e\u003cb\u003eNeeds met\u003c/b\u003e\u003c/p\u003e\u003cp\u003e(How satisfied were you that your individual healthcare needs were addressed in the group visits?\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1 Very satisfied\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e20 (74.1%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2 Satisfied\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e7 (25.9%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3 Neither satisfied nor dissatisfied\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0 (0%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4 Dissatisfied\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0 (0%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5 Very dissatisfied\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0 (0%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"4\" rowspan=\"5\"\u003e\u003cp\u003e\u003cb\u003eImportance\u003c/b\u003e\u003c/p\u003e\u003cp\u003e(How important do you think the NatME program is for people with endometriosis?\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1 Extremely important\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e25 (92.6%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2 Very important\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2 (7.4%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3 Moderately important\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0 (0%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4 Slightly important\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0 (0%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5 Not at all important\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0 (0%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u003cb\u003eParticipation\u003c/b\u003e\u003c/p\u003e\u003cp\u003e(Would you participate in other naturopathic group visits if available?)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1 Yes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e27 (100%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2 No\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0 (0%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e\u003cb\u003eRecommendation\u003c/b\u003e\u003c/p\u003e\u003cp\u003e(Would you recommend NatME to other people with endometriosis?)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1 Yes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e26 ((96.3%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2 No\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0 (0%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDid not answer\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1 (3.7%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"4\" rowspan=\"5\"\u003e\u003cp\u003e\u003cb\u003eModel\u003c/b\u003e\u003c/p\u003e\u003cp\u003e(When considering your experience of the NatME program, please indicate your level of agreement with the following statement:\u003c/p\u003e\u003cp\u003eNaturopathic group visits are a good way of receiving care for endometriosis)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1 Agree\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e26 (96.3%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2 Mostly agree\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1 (3.7%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3 Undecided\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0 (0%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4 Slightly disagree\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0 (0%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5 Disagree\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0 (0%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u0026gt;Table A2. NatME participant quotes from verbal feedback during end visit\u0026gt;\u003c/p\u003e\u003cp\u003eAll practitioners (n\u0026thinsp;=\u0026thinsp;4, 100%) reported high satisfaction with the program performance and ease of the potential for adapting the program for populations with other health conditions. 100% of practitioners would be likely to use the program again and recommend the program to other practitioners, while 75% found the program easy to implement. Results from the practitioner program evaluation questionnaire are presented in Table \u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003ePractitioner program evaluation questionnaire responses\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVariable\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eResponse\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eFrequency (%) n\u0026thinsp;=\u0026thinsp;4\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"4\" rowspan=\"5\"\u003e\u003cp\u003e\u003cb\u003eSatisfaction\u003c/b\u003e\u003c/p\u003e\u003cp\u003e(How satisfied are you with the NatME program overall?)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1 Very satisfied\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4 (100%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2 Satisfied\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0 (0%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3 Neither satisfied nor dissatisfied\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0 (0%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4 Slightly dissatisfied\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0 (0%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5 Not satisfied at all\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0 (0%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"4\" rowspan=\"5\"\u003e\u003cp\u003e\u003cb\u003eImplementation\u003c/b\u003e\u003c/p\u003e\u003cp\u003e(How easy was it to implement the program using the program manual?)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1 Very easy\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2 (50%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2 Easy\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1 (25%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3 So-so\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1 (25%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4 A little difficult\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0 (0%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5 Very difficult\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0 (0%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"4\" rowspan=\"5\"\u003e\u003cp\u003e\u003cb\u003eTopics\u003c/b\u003e\u003c/p\u003e\u003cp\u003e(How satisfied were you with the health topics included in the program, for treating endometriosis?)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1 Very satisfied\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3 (75%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2 Satisfied\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1 (25%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3 Neither satisfied nor dissatisfied\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0 (0%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4 Slightly dissatisfied\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0 (0%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5 Not satisfied at all\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0 (0%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"4\" rowspan=\"5\"\u003e\u003cp\u003e\u003cb\u003ePerformance\u003c/b\u003e\u003c/p\u003e\u003cp\u003e(How satisfied were you with the performance of the program (thinking about the patient engagement, timing, compliance and behavior change)?\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1 Very satisfied\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4 (100%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2 Satisfied\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0 (0%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3 Neither satisfied nor dissatisfied\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0 (0%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4 Slightly dissatisfied\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0 (0%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5 Not satisfied at all\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0 (0%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"4\" rowspan=\"5\"\u003e\u003cp\u003e\u003cb\u003eStructure\u003c/b\u003e\u003c/p\u003e\u003cp\u003e(How satisfied were you with the structure of the program (e.g. 3 months, fortnightly, 2-hour sessions, structured content)?\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1 Very satisfied\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2 (50%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2 Satisfied\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2 (50%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3 Neither satisfied nor dissatisfied\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0 (0%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4 Slightly dissatisfied\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0 (0%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5 Not satisfied at all\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0 (0%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"4\" rowspan=\"5\"\u003e\u003cp\u003e\u003cb\u003eUse\u003c/b\u003e\u003c/p\u003e\u003cp\u003e(How likely would you be to use this program again if it was made available?)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1 Very likely\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3 (75%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2 Likely\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1 (25%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3 Unsure\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0 (0%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4 Unlikely\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0 (0%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5 Very unlikely\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0 (0%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"4\" rowspan=\"5\"\u003e\u003cp\u003e\u003cb\u003eRecommend\u003c/b\u003e\u003c/p\u003e\u003cp\u003e(How likely would you be to recommend this program to other naturopaths?\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1 Very likely\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3 (75%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2 Likely\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1 (25%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3 Unsure\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0 (0%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4 Unlikely\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0 (0%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5 Very unlikely\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0 (0%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"4\" rowspan=\"5\"\u003e\u003cp\u003e\u003cb\u003eAdaptation\u003c/b\u003e\u003c/p\u003e\u003cp\u003e(To what degree do you think this program could be implemented in other populations (e.g. diabetes, PCOS, fibromyalgia, other health conditions) by altering the health topics?)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1 Very easily\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3 (75%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2 Easily\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1 (25%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3 So-so\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0 (0%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4 A little difficult\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0 (0%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5 Very difficult\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0 (0%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u0026gt;\u0026gt;Please insert Tables\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e here\u0026gt;\u0026gt;\u003c/p\u003e\u003cp\u003eClinical outcomes\u003c/p\u003e\u003cp\u003eStatistically significant improvements were observed in a number of items across each individual assessment tool used and are represented by a p-value of \u0026lt;\u0026thinsp;0.05. In the SF-12 ordinal variables, reduced mean scores indicate improvement in items 1, 8, 9 and 10, and increased mean scores indicated improvement in items 2, 3, 11 and 12. In the SHOW-Q, increased mean scores indicate improvement in items 3, 4, 5 and 8 and reduced mean scores indicate improvement for the remaining items. In all other tools, reduced mean scores indicate improvement.\u003c/p\u003e\u003cp\u003eEHP-5 scale scores are presented in Table \u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e. Statistically significant improvements were observed as reduced mean scores across four of five categories of the EHP-5 from baseline to end visit and in all five categories from baseline to follow-up. Pain scores improved from baseline(M:2.81; SD:1.11) to end visit(M:2.44;SD:0.89;p\u0026thinsp;=\u0026thinsp;0.025) with a further improvement(M:2.19;SD:1.03;p\u0026thinsp;=\u0026thinsp;0.003) at follow-up. Mean control and powerlessness scores improved from baseline(M:3.44;SD:1.12) to end visit(M:2.63;SD:0.92;p\u0026thinsp;=\u0026thinsp;\u0026lt;\u0026thinsp;0.003) with a further improvement(M:2.48;SD:1.05;p\u0026thinsp;=\u0026thinsp;\u0026lt;\u0026thinsp;0.003) at follow-up. In emotional wellbeing no significant improvement was observed from baseline to end visit, however statistically significant improvement was observed in mean scores from baseline(M:3.59;SD:0.93) to follow up(M:3.04;SD:0.94;p\u0026thinsp;=\u0026thinsp;0.036). Social support scores improved from baseline(M:3.81;SD:0.87) to end visit(M:2.81;SD:0.92;p\u0026thinsp;=\u0026thinsp;\u0026lt;\u0026thinsp;0.003) with a further improvement(M:2.85;SD:1.13;p\u0026thinsp;=\u0026thinsp;\u0026lt;\u0026thinsp;0.003) at follow-up. Self-image scores improved from baseline(M:4.07;SD:0.78) to end visit(M:3.30;SD:0.99;p\u0026thinsp;=\u0026thinsp;0.009) with a further improvement at follow-up(M:3.33;SD:0.92;p\u0026thinsp;=\u0026thinsp;0.006).\u003c/p\u003e\u003cp\u003eSF-12 scale scores are presented in tables 5 and 6. Statistically significant improvements were observed across seven of the 12 items included in the SF-12 scale. Improvements in mean scores were observed from baseline(M:3.33;SD:0.92) to end visit(M:2.59;SD:1.08;p=0.015) in item eight (pain) with a further improvement(M:2.37;SD:1.04;p=\u0026lt;0.003) at follow-up. Improvements in mean scores were observed from baseline(M:4.26;SD:1.16) to end visit(M:3.44;SD:0.84;p=\u0026lt;0.003) in item nine (emotional wellbeing calm) with sustained improvement at follow up(M:3.63;SD:0.96;p=0.018). Improvement in mean scores were observed from baseline(M:4.74;SD:0.94) to end visit(M:3.96;SD:0.98;p=\u0026lt;0.003) in item ten (energy) with further improvement(M:3.70;SD:1.06;p=\u0026lt;0.003) at follow-up. In item 11 no significant improvement was observed from baseline to end visit, however significant improvement in mean scores were observed from baseline(M:3.81;SD:1.41) to follow-up(M:4.44;SD:1.12;p=0.021). In item 1 (general health) no significant improvement was observed from baseline to end visit, however significant improvement in mean scores was observed from baseline(M:3.52;SD:0.97) to follow-up(M:2.96;SD:0.64;p=0.024). In item 4 (physical health) no significant improvement was observed from baseline to end visit, however, significant improvement was observed from baseline to follow-up(p=0.024). In item 12 (social activities) significant improvement in mean scores was observed from baseline(M:3.30;SD:1.29) to end visit(M:4.15;SD:1.16;p=0.018) with improvement sustained at follow up(M4.11;SD:1.42;p=0.021). In the remaining items 2, 3, 5, 6, and 7 no significant improvements were observed at end visit or follow-up.\u003c/p\u003e\n\u003cp\u003ePCS scale scores are presented in table 7. Statistically significant improvements were observed across all items in the PCS. In item one improvement was observed in mean scores from baseline(M:1.93;SD:1.20) to end visit(M:1.15;SD:0.98;p=0.006) with further improvement observed in mean scores at follow-up (1.07 (1.03), p=0.006). In item two no significant improvement in mean scores was observed from baseline to end visit, however significant improvement was observed in mean scores from baseline(M:1.15SD:1.19) to follow-up(M0.67SD:0.96;p=0.015). Item three significant improvement was observed in mean scores from baseline(M1.81SD:1.11) to end visit(M:0.85;SD:0.81;p=\u0026lt;0.03) with improvement sustained at follow-up(M:1.00;SD1.00;p=0.021. In item four significant improvement in mean scores was observed from baseline(M:1.93;SD:1.10) to end visit(M:1.22;SD:1.01;p=0.015) with further improvement observed at follow up(M:1.19;SD:1.00;p=0.006. In item five significant improvement was observed in mean scores from baseline(M:1.78;SD:1.39) to end visit(M:0.96;SD:1.25;p=0.006) and improvement was sustained at follow-up(M:1.00;SD:1.17;p=0.006). In item six no significant improvement was observed in mean scores from baseline to end visit, however significant improvement was observed from baseline(M:1.93;SD:1.32) to follow-up(M:1.26;SD:1.13;p=0.033). In item seven significant improvement was observed in mean scores from baseline(M:1.44;SD:1.18) to end visit(M:0.67;SD:0.92;p=0.006) and improvement was sustained at follow-up(M:0.81;SD:1.00;p=0.024. In item eight no significant improvement was observed from baseline to end visit, however significant improvement was observed in mean scores from baseline(M:1.93;SD:1.20) to follow-up(M:1.00;SD:1.10;p=\u0026lt;0.003). In item nine significant improvement was observed in mean scores from baseline(M:1.70;SD:1.13) to end visit(M:1.15;SD:1.19;p=0.018) with further improvement observed at follow-up(M:1.04;SD:1.19;p=0.015). In item ten significant improvement was observed in mean scores from baseline(M:1.70;SD:1.13) to end visit(M:1.04;SD:1.28;p=0.003), and improvement was sustained at follow-up(M:1.04;SD:1.16;p=0.006). In item 11 significant improvement was observed in mean scores from baseline(M:1.85;SD:1.23) to end visit(M:1.26;SD:1.40;p=0.042), with further improvement observed at follow-up(M:1.15;SD:1.23;p=0.012). In item 12 significant improvement was observed in mean scores from baseline(M:1.63;SD:1.14) to end visit(M:1.04;SD:0.94;p=0.012), with further improvement observed at follow-up(M:0.85;SD:0.94;p=\u0026lt;0.003). In item 13 significant improvement was observed in mean scores from baseline(M:1.70;SD:1.17) to end visit(M:1.22;SD:1.12;p=0.045), with further improvement observed at follow-up(M:1.11;SD:1.05;p=0.015).\u003c/p\u003e\n\u003cp\u003eSHOW-Q results are presented in table 8. Statistically significant improvements were observed from baseline to end visit or follow-up in six of the 12 SHOW-Q items including satisfaction with frequency and enjoyment, satisfaction, and reduced interference of bleeding, pelvic pain and pelvic problems. In item one no significant improvement was observed from baseline to end visit, however significant improvement in mean scores from baseline(M:3.41;SD:1.36) to follow-up(M:2.70;SD:1.20;p=0.018). In item two, significant improvement was observed in mean scores from baseline(M:3.81;SD:1.27) to end visit(M:3.00;SD:1.33;p=0.003) with further improvement observed at follow-up(M:2.81;SD:1.41;p=0.006). In item four no significant improvement was observed from baseline to end visit, however significant improvement was observed in mean scores from baseline(M:3.56;SD:1.21) to follow-up(M:4.30;SD:1.17;p=0.030). In item 10 significant improvement was observed in mean scores from baseline(M:2.22;SD:1.28) to end visit(M:1.56;SD:0.97;p=0.042), however no significant improvement was observed from baseline to follow-up. In item 11 no significant improvement was observed from baseline to end visit, however significant improvement was observed in mean scores from baseline(M:3.41;SD:1.21) to follow-up(M:2.59;SD:1.15;p=\u0026lt;0.003). In item 12 no significant improvement was observed from baseline to end visit, however significant improvement was observed in mean scores from baseline(M:3.56;SD:1.18) to follow-up(M:2.56;SD:1.15;p=\u0026lt;0.003). In the remaining six items three, five, six, seven, eight and nine no significant improvement in mean scores was observed.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMYMOP results are presented in table 9. Statistically significant improvements were seen from baseline to end visit in severity of both the primary and secondary complaints reported by participants as well as in how those problems impacted regular activities. In symptom one significant improvements in mean scores were observed from baseline(M:3.85;SD:1.35) to end visit(M:2.52;SD:1.42;p=0.006) with further improvement observed at follow-up(M:2.41;SD:1.30;p=0.006). In symptom two significant improvement in mean scores was observed from baseline(M:4.04;SD:1.45) to end visit(M:2.20;SD:1.44;p=\u0026lt;0.003) with sustained results at follow-up(M:2.28;SD:1.27;p=\u0026lt;0.003). In how those symptoms impacted regular activities, significant improvement in mean scores were observed from baseline(M:3.74;SD1.34) to end visit(M:2.74;SD:1.43;p=0.012) with further improvement observed at follow-up(M:2.41;SD:1.42;p=\u0026lt;0.003). In wellbeing significant improvement in mean scores was observed from baseline(M:4.00;SD:1.14) to end visit(M:2.44;SD:1.25;p=\u0026lt;0.003) with sustained results at follow-up(M:2.22;SD:1.18;p=\u0026lt;0.003).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026gt;\u0026gt;Please insert Tables 4-9 here (found in Additional file 1)\u0026gt;\u0026gt;\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis pilot feasibility study is the first study to examine a group-delivered naturopathic medicine intervention for women with endometriosis. In this study, a 12-week naturopathic group visit intervention for endometriosis was tested, where results show the intervention was feasible, well accepted and resulted in clinical improvement for women with endometriosis. Similar to other studies examining IMGVs for chronic illnesses(\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e), high levels of satisfaction were observed across all aspects of the NatME program including those aspects that differed between cohorts (i.e. satisfaction with practitioners and group size). With such diversity of program aspects having met satisfaction and expectations among participants, the reasons for these findings cannot be attributed to any one component of the intervention (e.g. positive clinical outcomes). Rather, it is likely that feasibility and acceptability outcomes were associated with the unique combination of components of the intervention including the benefit of personalized and person-centered care that characterizes naturopathic medicine(\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e), combined with the health enhancing effects of connection(\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e) and group support(\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e) with the addition of health education and in some cases natural medicines. However, it should also be noted that high levels of satisfaction often exist with complementary therapies due to their alignment with stated patient beliefs and values(\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e). As such, the reasons behind the acceptability of this program are likely to be multifarious, and to reflect the composite nature of both the group visit model, and of naturopathic care. Further research work examining what additive role group visits play in enhancing positive non-specific effects in health is warranted.\u003c/p\u003e\u003cp\u003eFurther, in this study participants reported a sense of increased knowledge and empowerment resulting from the program. This knowledge and empowerment may also have contributed to their high satisfaction levels and experience of reduced pain, alongside efficacy of treatments prescribed. The group visit model proffers the opportunity to provide multifaceted healthcare, and lends itself well to pragmatic real-world interventions such as naturopathy that are rooted on principles of patient empowerment, education and person-centered care(\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e). As prior research has identified, women with endometriosis have significant unmet healthcare needs and suboptimal healthcare experiences often based on disempowerment(\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e). Patient empowerment has been identified as an important component in global chronic disease prevention, management and health promotion efforts(\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e), and to date this does not appear to have translated to endometriosis-related healthcare(\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e). Although specified tools measuring empowerment were not implemented in this study, the preliminary findings of patient empowerment reported here provide important insight to inform future endometriosis studies, which should use such tools measuring empowerment such as those used in other research(\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eIn addition to good feasibility outcomes and patient empowerment, the findings of this study showed promising clinical outcomes and notably, improved pain outcomes. Chronic pelvic pain and other types of pain are core issues for people with endometriosis(\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). In this study, improvements were observed across all 13 items of the PCS. These findings have particular importance because pain catastrophizing has been shown to be associated with poor pain treatment outcomes in people with chronic pain(\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e). As such, improvements in pain catastrophizing can lead to better pain treatment outcomes. Further, although no significant changes were seen on some SF-12 and SHOW-Q items, the items where statistically significant improvements were observed included the items relating to pain across all four of the validated scales used. While assessed within the context of the study\u0026rsquo;s limitations as a pilot feasibility study, these results suggest the NatME program has potential as a clinically effective intervention for reducing pain associated with endometriosis, and larger, more controlled studies are warranted. Moreover, while improvements in pain were seen consistently across outcome measures, positive clinical results were not limited to pain outcomes. A diverse range of clinical improvements were observed across domains including quality of life and emotional and physical wellbeing. As discussed in the context of participant satisfaction the clinical outcomes observed cannot be solely attributed to the treatments prescribed in the intervention, because as was characteristic of the program design and is of naturopathic medicine itself \u0026ndash; only some participants in the study were prescribed ingestible medicines, as was appropriate to their individual clinical and financial circumstances. Therefore, again the diverse range of positive clinical outcomes observed may also reflect the complexity and multifaceted form of the naturopathic group visit program.\u003c/p\u003e\u003cp\u003eAs with all research, this study comes with limitations. Being a pilot feasibility study, the small sample size limits its generalizability and the study is also limited by a lack of control group. As such, while clinical outcomes were measured as secondary outcomes in this study, the study design limits its capacity to be used to interpret clinical efficacy. Despite this, the positive changes observed across clinical outcomes in this study were notable and exhibited in all four settings, however larger scale clinical trials are needed to further assess clinical efficacy. Results from this study may also inform the design of full-scale trials in future. Finally, measuring patient compliance in this study proved to be challenging due to the complex multifaceted form of intervention and as such compliance was unable to be reported among feasibility outcomes. For future studies on pragmatic real-world interventions, more specific data collection tools and strategies should be developed during the design phase to measure patient compliance. Overall the positive results of this study provide good rationale for future studies to provide a more thorough examination of clinical efficacy of the NatME intervention.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eTo date, endometriosis research has focused on medical and surgical treatments for endometriosis alongside some research examining the effects of dietary changes. However, recent research shows women with endometriosis do not believe they are getting the outcomes they need and want from standard medical approaches. Innovative new strategies for endometriosis management and treatment are needed, and a complex multi-systems condition with significant and diverse impacts on wellbeing and quality of life may warrant a complex multifaceted intervention to address those diverse impacts. The present study presents one such intervention and suggests the NatME program could benefit people with endometriosis by improving a wide range of symptoms while providing education, empowerment and connection, as well as making a treatment already actively sought out by women with endometriosis more accessible. The findings of this study indicate the NatME program is feasible and well-accepted. It has promising clinical outcomes and high levels of satisfaction across all elements of the program. Overall, these findings indicate a naturopathic group model of care may be an effective way to improve symptoms and healthcare experiences for people with endometriosis as well as address some of their unmet healthcare needs. Larger studies are needed to assess clinical efficacy of NatME, but this study indicates it may be an effective model of care for women with endometriosis, alongside available medical treatments.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eAcknowledgements\u0026nbsp;\u003c/h2\u003e\n\u003cp\u003eThe authors acknowledge the contribution from William Pinzon Perez for statistical support received through QCIF Biostatistics, QCIF Ltd, Brisbane, Queensland, Australia.\u003c/p\u003e\n\u003ch2\u003eData availability\u003c/h2\u003e\n\u003cp\u003eData will be made available upon request to the corresponding author.\u003c/p\u003e\n\u003ch2\u003eDisclosure statement\u003c/h2\u003e\n\u003cp\u003eThe authors report there are no competing interests to declare.\u003c/p\u003e\n\u003ch2\u003eFunding\u003c/h2\u003e\n\u003cp\u003eThis research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eHuman ethics and consent to participate\u003c/h2\u003e\n\u003cp\u003eThis study was approved by the Human Research Ethics Committee (HREC) at Southern Cross University (approval no. 2021/117) and registered with Australian New Zealand Clinical Trials Registry (ANZCTR) (registration no. ACTRN12622000222741). Written informed consent was provided by all participants.\u003c/p\u003e\n\u003ch2\u003eAuthors contributions\u003c/h2\u003e\n\u003cp\u003e\u003cstrong\u003eSophia Gerontakos\u003c/strong\u003e: Conceptualization, methodology, data curation, investigation, formal analysis, writing – original draft. \u003cstrong\u003eAmie Steel\u003c/strong\u003e: Conceptualization, writing – review and editing, supervision. \u003cstrong\u003eJon Wardle\u003c/strong\u003e: Conceptualization, methodology, validation, writing – review and editing, supervision. All authors approved the final version of the manuscript.\u003c/p\u003e\n\u003ch2\u003eBiographical data\u003c/h2\u003e\n\u003cp\u003eProfessor Jon Wardle is Foundation Director of the National Centre for Naturopathic Medicine (NCNM) and Maurice Blackmore Chair of Naturopathic Medicine at Southern Cross University. In addition to clinical qualifications in nursing and naturopathic medicine, Jon has postgraduate qualifications in public health, law and health economics and holds visiting positions at Boston University, University of Washington and University of Oxford.\u003c/p\u003e\n\u003cp\u003eAmie Steel is an Associate Professor in the Australian Research Consortium in Complementary and Integrative Medicine (ARCCIM) at UTS. As an expert in women’s health - with a particular focus on pregnancy, fertility and preconception health – and complementary medicine, she is ranked as the #1 Traditional and Complementary Medicine Researcher in Australia (2021-present).\u003c/p\u003e\n\u003cp\u003eSophia Gerontakos is a PhD candidate at the National Centre for Naturopathic Medicine at Southern Cross University. Sophia’s PhD research focuses on endometriosis and a group-delivered naturopathic medicine approach to meeting unmet healthcare needs for people with endometriosis and improving their healthcare experiences and access to complementary therapies. In addition to her PhD research Sophia is also a research assistant at the Sydney Adventist Hospital in Wahroonga, Sydney where she manages the Sydney branch of a longitudinal multiple sclerosis cohort study.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eHorne AW, Missmer SA. Pathophysiology, diagnosis, and management of endometriosis. BMJ. 2022;379:e070750.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAustralian Institute of Health and Welfare. 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New York, NY, USA: Harper Collins 2020.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMaskell J. The community cure: Transforming health outcomes together. USA: Lioncrest; 2020.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBishop FL, Yardley L, Lewith GT. A systematic review of beliefs Involved in the use of complementary and alternative medicine. J Health Psychol. 2007;12(6):851\u0026ndash;67.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eEvans S, Villegas V, Dowding C, Druitt M, O'Hara R, Mikocka-Walus A. Treatment use and satisfaction in Australian women with endometriosis: a mixed-methods study. Intern Med J. 2022;52(12):2096\u0026ndash;106.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eYoung K, Fisher J, Kirkman M. Women's experiences of endometriosis: a systematic review and synthesis of qualitative research. 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Self-care for health and wellbeing Geneva, Switzerland2024 [Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.who.int/news-room/fact-sheets/detail/self-care-health-interventions\u003c/span\u003e\u003cspan address=\"https://www.who.int/news-room/fact-sheets/detail/self-care-health-interventions\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eFoley H, Steel A. Patient perceptions of patient-centred care, empathy and empowerment in complementary medicine clinical practice: A cross-sectional study. Adv Integr Med. 2017;4(1):22\u0026ndash;30.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDarnall BD, Sturgeon JA, Cook KF, Taub CJ, Roy A, Burns JW, et al. Development and Validation of a Daily Pain Catastrophizing Scale. J Pain. 2017;18(9):1139\u0026ndash;49.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Footnotes","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003e The authors of this thesis recognise that not all people who experience menstruation and/or disorders of the menstrual cycle such as endometriosis identify as women. Trans men, intersex, non-binary and gender diverse people also experience menstruation and health conditions associated. They face both similar, and unique challenges to cis women. To date, the evidence on endometriosis overwhelmingly represents cis women\u0026rsquo;s experiences. Although trans men and gender diverse people were not excluded from this research, the participants who responded to recruitment notices identified as women. The word \u0026lsquo;women\u0026rsquo; is used in this article to reflect the evidence drawn on throughout, and to reflect the women who participated in this research without misrepresenting the unique experiences and challenges of trans men, intersex, non-binary or gender diverse people. We note the gap in literature representing experiences of trans and gender diverse people, which should be built on in future.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-complementary-medicine-and-therapies","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bcam","sideBox":"Learn more about [BMC Complementary Medicine and Therapies](https://bmccomplementmedtherapies.biomedcentral.com/)","snPcode":"","submissionUrl":"","title":"BMC Complementary Medicine and Therapies","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Naturopathy, complementary therapies, endometriosis, women’s health, group visits, shared medical appointments","lastPublishedDoi":"10.21203/rs.3.rs-7396031/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7396031/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eEndometriosis is a chronic inflammatory condition characterised by pain and significant impacts on quality of life. Research shows women with endometriosis have unmet healthcare needs. Evidence also demonstrates naturopaths play an important role for women with endometriosis, and group visits are an effective model of care for chronic disease management. This study examines (a)the feasibility of a group visit model for delivering naturopathy to people with endometriosis, and (b)the preliminary effectiveness of the model.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003ea pilot feasibility study was delivered in four Australian locations. The intervention was a 12-week program comprising six visits, incorporating personalised naturopathic care and education within a supportive group environment. Outcomes were measured at baseline, end visit, and one-month follow-up. The study was registered February 2022 with Australian New Zealand Clinical Trials Registry (ACTRN12622000222741).\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eThirty-one participants were enrolled. High levels of satisfaction with the program structure, content, and facilitators were observed with high retention rates. Participants agreed (96.3%) or mostly agreed (3.7%) naturopathic group visits are a good way of receiving care for endometriosis. In clinical outcomes statistically significant improvements in pain-related items across all validated measures (Endometriosis Health Profile [EHP-5] pain baseline to follow-up p\u0026thinsp;=\u0026thinsp;0.003; Health-related Quality of Life pain/work baseline to follow-up p\u0026thinsp;=\u0026thinsp;\u0026lt;\u0026thinsp;0.003), as well as in all five items of the EHP-5 and across all 13 items on the Pain Catastrophizing Scale.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e\u003cp\u003eA group naturopathic intervention program for endometriosis may result in clinical improvement of endometriosis, and has been seen to be feasible and well-accepted for women with endometriosis.\u003c/p\u003e","manuscriptTitle":"Naturopathic Medicine for Endometriosis (NatME). Results of a pilot study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-10-27 14:27:50","doi":"10.21203/rs.3.rs-7396031/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-02-24T12:32:16+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-19T00:18:05+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"272082317758739427725314556111275224172","date":"2026-02-12T00:15:33+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-12-06T09:59:45+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"201016996791141485103131195073193979846","date":"2025-12-06T04:46:07+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"205077193367865041116264021417875978729","date":"2025-11-13T00:48:16+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-10-12T21:32:50+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-10-08T15:24:55+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-09-02T14:11:25+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-09-02T14:10:35+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Complementary Medicine and Therapies","date":"2025-08-18T05:36:03+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-complementary-medicine-and-therapies","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bcam","sideBox":"Learn more about [BMC Complementary Medicine and Therapies](https://bmccomplementmedtherapies.biomedcentral.com/)","snPcode":"","submissionUrl":"","title":"BMC Complementary Medicine and Therapies","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"c2f7b119-5c7a-4785-810c-01ebae6257ce","owner":[],"postedDate":"October 27th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-27T20:53:16+00:00","versionOfRecord":[],"versionCreatedAt":"2025-10-27 14:27:50","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7396031","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7396031","identity":"rs-7396031","version":["v1"]},"buildId":"WvIrzKhiLBfengagbw6Ux","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}