Complementary Health Care Research Articles

To cut or not to cut …

There are not many people who would admit that, in their field, there should be cuts. I don't think I am brave or clever enough to be the odd one out. So here it is: I am against cuts in health care (the term ‘health care’, in my view, does not include management and administration — in these areas I would cut generously). Why? Because money is already short — sometimes too short even to meet the most basic needs of patients. But, come to think of it, in my particular field (complementary medicine), we seem to squander quite a lot of money on stuff that one cannot call ‘basic needs’. Take ‘The Prince of Wales' Foundation for Integrated Medicine’, for instance. They recently received £2 million (£1 million from the Department of Health) for facilitating the regulation of practitioners. In complementary medicine, that is an amount of money researchers can only dream of. And what did the ‘Foundation’ do with it? Search me — ah yes, they helped create the Complementary and Natural Healthcare Council — a resounding flop.1 And they facilitated the ‘Pittilo Report’.2 Apart from a gong for the lead author,3 this does not seem to go far either.4 If the Prince wants to ride farcical hobby horses, should he not use his own money? So there you are, I would cut expenditure for these and many other nonsensical activities,5 even in my very own field. So I might be brave. But clever? My research unit in Exeter might soon have to close because of lack of funds. This would surely not have happened had I aligned myself with the ‘right’ people and abstained from stubbornly insisting on good evidence and critically speaking out against bogus treatments. So, clever? Afraid not!

Abstracts from the Sixth IN-CAM Research Symposium: Complementary and Integrative Health Care: Methodological, Theoretical and Practical Issues

The following are abstracts of oral and poster presentations given at the sixth IN-CAM Research Symposium, Complementary and Integrative Healthcare: Methodological, Theoretical and Practical Issues, held November 19 to 21, 2010 at the Sutton Place Hotel, Vancouver, Canada. The Symposium was held in collaboration with IN-CAM partners PedCAM and HomeoNet. The abstracts are grouped under: IN-CAM, PedCAM, and HomeoNet. For more information, please visit: www.incamresearch.ca.

The Continuing Bias Against Complementary and Integrative Healthcare Education

The Continuing Bias Against Complementary and Integrative Healthcare Education

Perceived risks and benefits of the use of honey for infants

Question Traditional and complementary healthcare approaches (TCA) are widely used for children. Honey is one such TCA used for upper respiratory tract symptoms. A recent Cochrane review suggests honey has potential benefit for acute cough in children [1] . However, health officials advise limiting the use of honey due to the risk of contamination with Clostridium botulinum . As part of a larger study about TCA for children, parents’ and health professionals’ beliefs about the benefits and risks of honey were explored. Methods The study was conducted in a multi-ethnic community (London Boroughs of Brent and Harrow). Eleven parent focus groups ( n =92) and individual interviews with healthcare practitioners ( n =30) explored beliefs about TCA. Qualitative data was analysed using the Framework approach and validated with inter-rater coding. Data on the use of honey were extracted for detailed thematic analysis. Results Of the 92 parents interviewed, 27 (29%) reported use of honey for their children. Honey was believed to be culturally acceptable, easily accessible, natural and safe. Only 2 parents expressed concern over safety. Reported uses were for colds (11), coughs (10), sore throats (2), flu (2), fever (2) and loose motions (1). Modes of use included honey combined with lemon juice in hot water (19), or with ginger, lime, pepper, beetroot or hot milk, for its perceived healing properties and sometimes to improve taste. Almost half (40%) of practitioners mentioned the use of honey for children, but many believed that it ‘may not even be classed as healthcare’. One midwife and one GP cited honey and lemon as safe for infants. Only health visitors (9) stated the risk of infant botulism, 2 described a conflict with parents’ traditional beliefs. Some reported challenges in communicating risk to parents. Conclusion Honey is frequently used as a treatment for respiratory tract symptoms, Parents and some health practitioners are unaware of/choose to ignore safety advice. Healthcare professionals need to be attentive to the use of honey, and other TCA, according to belief systems. They must appreciate parental perception of risk and benefit and continue to raise awareness of contamination danger. Further research on the efficacy of honey for acute cough is needed as honey has potential as an inexpensive alternative to pharmacological intervention.

Evidence-based practice in British complementary and alternative medicine: Double standards?

The principles of evidence-based practice (EBP) are fundamental to medical ethics and seem essential for any form of health care. In 2000, a House of Lords Select Committee recommended that the ethos of EBP should extend to complementary and alternative medicine. The aim of this investigation was to determine whether EBP is incorporated in the codes of ethics of British complementary and alternative medicine organizations. We obtained the codes of the following bodies: Association of Naturopathic Practitioners, Association of Traditional Chinese Medicine (UK), Ayurvedic Practitioners Association, British Acupuncture Council, Complementary and Natural Healthcare Council, European Herbal Practitioners Association, General Chiropractic Council, General Osteopathic Council, General Regulatory Council for Complementary Therapies, National Institute of Medical Herbalists, Register of Chinese Herbal Medicine, Society of Homeopaths, UK Healers, Unified Register of Herbal Practitioners. We then extracted the statements referring to EBP and compared this with what the respective codes of British doctors and nurses proscribed. Only the General Chiropractic Council, the General Osteopathic Council and the General Regulatory Council for Complementary Therapies oblige their members to adopt EBP. This discloses double standards in UK health care which may compromise patient safety.

The Integrated Taxonomy of Health Care: classifying both complementary & biomedical practices using a uniform classification protocol

Since the late 1980s, several taxonomies have been developed to help map and describe the interrelationships of complementary and alternative medicine (CAM) modalities. In these taxonomies, several issues are often incompletely addressed: A simple categorization process that clearly isolates a modality to a single conceptual categoryClear delineation of verticality-that is, a differentiation of scale being observed from individually applied techniques, through modalities (therapies), to whole medical systemsRecognition of CAM as part of the general field of health care DEVELOPMENT OF THE INTEGRATED TAXONOMY OF HEALTH CARE (ITHC) INVOLVED THREE STAGES: Development of a precise, uniform health glossaryAnalysis of the extant taxonomiesUse of an iterative process of classifying modalities and medical systems into categories until a failure to singularly classify a modality occurred, requiring a return to the glossary and adjustment of the classifying protocol A full vertical taxonomy was developed that includes and clearly differentiates between techniques, modalities, domains (clusters of similar modalities), systems of health care (coordinated care system involving multiple modalities), and integrative health care. Domains are the classical primary focus of taxonomies. The ITHC has eleven domains: chemical/substance-based work, device-based work, soft tissue-focused manipulation, skeletal manipulation, fitness/movement instruction, mind-body integration/classical somatics work, mental/emotional-based work, bio-energy work based on physical manipulation, bio-energy modulation, spiritual-based work, unique assessments. Modalities are assigned to the domains based on the primary mode of interaction with the client, according the literature of the practitioners. THE ITHC HAS SEVERAL STRENGTHS: little interpretation is used while successfully assigning modalities to single domains; the issue of taxonomic verticality is fully resolved; and the design fully integrates the complementary health care fields of biomedicine and CAM.

Is Complementary and Alternative Healthcare Use Associated with Better Outcomes in Children with Juvenile Idiopathic Arthritis?

The objectives of this study were (1) to examine the association between the use of complementary and alternative healthcare (CAHC) and subsequent health outcomes; and (2) to explore the association between CAHC use and adherence to conventional treatments in children with juvenile idiopathic arthritis (JIA). A cohort of children with JIA (n = 182, mean age 10 yrs) who attended outpatient clinics were followed for one year. We evaluated the use of CAHC, health-related quality of life (HRQOL), global health, physical functioning, pain, and disease severity at 3-month intervals. We also evaluated perceived adherence to treatments. General estimating equations were performed to determine the association between use of CAHC and subsequent outcomes while controlling for possible confounders. CAHC was used by 36.4% of participants over the 12-month period. Use of CAHC was associated with subsequent lower global health and physical functioning despite higher adherence to prescribed medications as assessed by the rheumatologist (p < 0.05). Use of CAHC was not associated with subsequent improved HRQOL or decreased pain or disease severity. Children with JIA who use CAHC do not have improved outcomes, at least over the relatively short term. Nevertheless, they seem to be more adherent to conventional treatment according to the rheumatologist.

Longitudinal analysis of complementary and alternative health care use in children with juvenile idiopathic arthritis

The aims were to determine the frequency of use of different types of complementary and alternative health care (CAHC) in children with juvenile idiopathic arthritis (JIA), to evaluate their effectiveness from the parents' point of view and to explore the factors associated with utilization and with continued use. A cohort of children with JIA (n=182, mean age: 10 years) who attended out-patient clinics were followed for 1 year. Parents responded to questionnaires every 3 months. We used generalized estimating equations to analyze factors associated with CAHC use and polytomous regression to evaluate factors associated with continued use of CAHC. Use of CAHC ranged between 10% and 24% for the various 3-month intervals and 36.4% of participants used at least one type of CAHC over the 12-month period. Seventy-two percent of parents who used CAHC for their children felt that it was at least somewhat beneficial. Predictors of continued use of CAHC included previous use of CAHC by parents for their own health problems and lower perceived helpfulness of prescribed medications. Neither children's demographic and socioeconomic characteristics nor disease status were associated with CAHC use. CAHC use in children with JIA is common and considered to be moderately beneficial by most parents who used it. Lower parents' perceived helpfulness of medications and previous use of CAHC are associated with a longer use of CAHC by their child. These facts should be taken into account by health professionals involved in the care of these children.

Developing a decision-making model on traditional and complementary medicine use for children

Aim To explore why parents choose traditional and complementary approaches to health for their children, particularly the influence of cultural beliefs and norms, and develop a conceptual model based on Andersen's sociobehavioural model. Materials and methods Focus groups with 92 parents from at least 20 different countries living in London, UK, explored the influence of predisposing, enabling, need factors and healthcare experience on traditional and complementary healthcare use for children. Themes were identified using Framework Analysis. Results Traditional home remedies including herbs, spices, foods, prayer and rituals were used by most parents, often as a first choice of treatment. Parents were categorised into one of seven typologies depending on how these approaches were used: informed, routine, committed, pragmatic, open, last resort and nonbeliever. All three components of the sociobehavioural model (predisposing, enabling, need) were involved in parents’ decision-making when using traditional and complementary healthcare for children. Conclusions The sociobehavioural model can be used to conceptualise parental decision-making process for child use of traditional and complementary healthcare. This process is crucial in promoting shared decision-making between primary care practitioners and parents and could inform service provision, delivery and policy.

The practice and regulatory requirements of naturopathy and western herbal medicine in Australia

Australian health workforce regulation is premised on the need to protect public health and safety. Specific criteria are set out by governments to ascertain the degree of risk and the need for government intervention. A study was undertaken to understand the current state of usage and the practice of naturopathy and western herbal medicine, and to ascertain whether statutory regulation was warranted. We found increased use of these complementary therapies in the community, with risks arising from both the specific practices as well as consumers negotiating a parallel primary health care system. We also found highly variable standards of training, a myriad of professional associations, and a general failure of current systems of self-regulation to protect public health and safety. Statutory regulation was the preferred policy response for consumers, insurers, general practitioners, and most of the complementary therapists. While we found a case for statutory registration, we also argue that a minimalist regulatory response needs to be accompanied by other measures to educate the public, to improve the standards of practice, and to enhance our understanding of the interaction between complementary and mainstream health care.

Complementary and alternative health care use in young children with physical disabilities waiting for rehabilitation services in Canada

Purpose. We wished to determine the frequency of complementary and alternative health care (CAHC) use in preschool aged children with physical disabilities (PD) waiting for public rehabilitation services in the province of Quebec (Canada), to evaluate its effectiveness from the parents’ perspective and to explore factors associated with its utilisation.Method. Children with PD referred to rehabilitation centres from two Montreal hospitals were recruited. We evaluated the use of CAHC and its effectiveness from the parents’ perspective in a cross-sectional manner, using descriptive statistics. We explored factors associated with utilisation, using logistic regression models.Results. In this group of children widi PD(n = 206, mean age: 2.6 years), 31 (15%) used CAHC and 15 (48.4%) of those tried more than one type. CAHC was considered at least moderately beneficial by parents in 53% of the cases. The use of CAHC was higher among children with low health-related quality of life (HRQOL) and children whose mothers were more educated and considered themselves as Canadian (p < 0.05).Conclusions. Although the use of CAHC by young children with PD was low, use of CAHC was higher among children with lower HRQOL and whose mothers were highly educated and Canadian. CAHC use should be evaluated by health providers to better educate parents of children with PD, which may help them to make the best decisions regarding their child’s treatment while waiting for rehabilitation services.

Complementary and alternative health care use in young children with physical disabilities waiting for rehabilitation services in Canada

Complementary and alternative health care use in young children with physical disabilities waiting for rehabilitation services in Canada

Yoga and Mindfulness: Clinical Aspects of an Ancient Mind/Body Practice

The use of Yoga and other complementary healthcare interventions for both clinical and non-clinical populations has increased substantially in recent years. In this context, we describe the implementation of Hatha Yoga in the Mindfulness-Based Stress Reduction (MBSR) program of Kabat-Zinn and colleagues. This is embedded in a more general consideration of Yoga’s place in complementary healthcare. In providing this overview, we comment on the nature and quality of current research on Yoga, summarize current physiological and psychological explanations of its effects, and discuss practical issues related to teacher training and experience.

Developing health policy: The British perspective

Integrating regulation of practitioners: In the EU there are three main systems for regulating practitioners: Full legal framework (France and many southern European Countries). Only licensed health-care professionals may practice medicine, including complementary medicine (CM). Intermediate (Germany). CM practitioners have reduced registration requirements (Heilpraktiker). Liberal (UK, Netherlands, Ireland, some Nordic countries). The right to practice is not systematically regulated by law. In the UK many legally registered health professionals also integrate CM including homeopathy and acupuncture. The liberal system is associated with problems including public protection and professional discipline. In the UK there is a gradual process of regulation of CM practitioners: osteopaths and chiropractors became legally regulated in the early 1990s. In June 2008 an official report on the Regulation of Practitioners of Acupuncture, Herbal Medicine, Traditional Chinese Medicine and other Traditional Medicine Systems identified an urgent need for regulation. The main reason is to safeguard the public but also to permit the manufacture of herbal medicines for individual patients after full implementation of the European Traditional Herbal Medicinal Products Directive in 2011. The report recommends that these professions be regulated by Health Professions Council, which already regulates 13 health professions; this integrates the regulatory system for CM practitioners. In parallel the Complementary and Natural Healthcare Council has recently been launched. It will register other practitioners but is voluntary, and does not involve legal regulation. The governing council is independent and 100% lay; it will provide a more credible regulatory structure for other CM therapists. Public sector integration: The UK National Health Service (NHS) is being reformed from a classical socialist model to an ‘internal market’ of commissioners who purchase health services from providers. This aims to allow patients free choice, increases the autonomy of commissioners and providers and permits private sector involvement, although the entire system remains state-funded. In this context the integration of CM is very controversial. There are five NHS homeopathic hospitals, integrated with their respective local NHS providers and staffed by registered health professionals trained in CM. Despite their titles they provide a wide range of CM, homeopathy now forms less than 40% of the activity of the largest NHS homeopathic hospital, the Royal London Homoeopathic Hospital. There has been a high profile campaign to exclude the NHS homeopathic hospitals and CM from the NHS. Arguments against integration of CM include claimed lack of evidence and diversion of resources. Some commissioning bodies have restricted CM or stopped their contracts with the NHS homeopathic hospitals. This has met strong public and political opposition mostly on the grounds that it denies patients the choice which these reforms claim to increase. The private sector has shown increased interest in providing integrated services inside and outside the NHS.

The Spatial Pattern of Complementary and Alternative Medical Offices Across Ontario and Within Intermediate-Sized Metropolitan Areas

Complementary and alternative medical approaches such as chiropractic, massage, acupuncture, holistic, and naturopathic therapies act as complements to, and in some cases replacements for, conventional medical techniques. The growing acceptance of the benefits of "traditional" medicine in the Canadian province of Ontario continues to provide complementary and alternative medicine (CAM) practitioners with business opportunities, but to date little attention has been directed toward the spatial patterns exhibited by these operations. A province-wide database of 4,599 records, containing addresses and selected characteristics (e.g., sales, employment) of CAM offices, is utilized to describe the geographic pattern across Ontario. An additional database allows for the assessment of four intermediate-sized census metropolitan areas (CMAs) in Ontario (Kingston, Guelph, Thunder Bay, and Greater Sudbury), and it is determined (using a general nearest neighbor analysis and a nearest neighbor hierarchical clustering procedure) that CAM offices are significantly clustered in specific portions of each CMA. The results from a survey administered to CAM practitioners suggests that the benefits of urbanization economies are biasing location decisions within these CMAs, and that localization economies advantages appear to be influencing complementary and alternative healthcare specialists to share offices.

Knowledge and beliefs concerning evidence-based practice amongst complementary and alternative medicine health care practitioners and allied health care professionals: a questionnaire survey.

BackgroundEvidence-based practice (EBP) has become an important competency in many allied and complementary and alternative medicine (CAM) health care practitioners' professional standards of proficiency.MethodsTo compliment an EBP course for allied health care professionals and CAM practitioners, we undertook a questionnaire survey to assess learning needs. We developed a questionnaire to measure allied health care professionals and CAM practitioners' basic knowledge, skills and beliefs concerning the main principles of EBP. The questionnaires were administered to all attendees of one-day EBP workshops.ResultsDuring 2004–5 we surveyed 193 allied health care professionals and CAM practitioners who attended one-day EBP courses prior to commencement of teaching. Of the respondents 121 (62.7%) were allied health care professionals and 65 (33.7%) practitioners stated that they work in the CAM field Our survey found that the majority of the respondents had not previously attended a literature appraisal skills workshop (87.3%) or received formal training in research methods (69.9%), epidemiology (91.2%) or statistics (80.8%). Furthermore, 67.1% of practitioners specified that they felt that they had not had adequate training in EBM and they identified that they needed more training and education in the principles of EBM (86.7%). Differences in knowledge and beliefs concerning EBP amongst allied and CAM practitioners were found and length of time since qualification was also found to be an important factor in practitioner's beliefs. More CAM practitioners compared to allied health professionals accessed educational literature via the Internet (95.3% v 68.1%, p = 0.008). Whilst, practitioners with more than 11 years experience felt that original research papers were far more confusing (p = 0.02) than their less experienced colleagues.ConclusionThe results demonstrate that practitioner's learning needs do vary according to the type of profession, time since graduation and prior research experience. Our survey findings are exploratory and will benefit from further replication, however, we do believe that they warrant consideration by allied health care and CAM tutors and trainers when planning EBP teaching curricula as it is important to tailor teaching to meet the needs of specific subgroups of trainees to ensure that specific learning needs are met.

Gua sha research and the language of integrative medicine

This article is based on research findings published by Nielsen et al. [2007a. The effect of 'Gua sha' treatment on the microcirculation of surface tissue: a pilot study in healthy subjects. EXPLORE: The Journal of Science and Healing 3, 456-466]. The abstract was accepted for poster session at the conference on fascia (www.fascia2007.com) and appears in the conference text Fascia Research [Nielsen, A., Knoblauch, N., Dobos, G., Michalsen, A., Kaptchuk, T., 2007b. The effect of 'Gua sha' treatment on the microcirculation of surface tissue: a pilot study in healthy subjects. In: Findley, T.W., Schleip, R. (Eds.), Fascia Research: Basic Science and Implications for Conventional and Complementary Health Care. Elsevier, Munich, Germany, pp. 249-250]. Our Gua sha perfusion study, the abstract of which is reprinted in Box 1, was the first investigation into the physiology of Gua sha, a technique of traditional East Asian medicine used to treat conditions that have features of blood stasis, pain, and/or inflammation. Issues raised by our study are discussed here such as the significance of the terms used in Western medical literature to describe traditional indigenous therapies like Gua sha and the implication of our findings not only for future research but toward a shift in how the integrative medical community signifies its work.

Use of Complementary and Alternative Healthcare Practices Among Persons Served by a Remote Area Medical Clinic

Remote rural communities are often without adequate healthcare resources. To address the need in one area of Appalachia, an annual medical clinic is held to provide free healthcare services to residents of Appalachia. The Appalachian culture has a number of unique features that influence the healthcare practices of persons living in this region. Cultural values and beliefs about health and the use of complementary and alternative therapies among those attending the remote rural clinic are described, with faith healing, including prayer, and family-taught remedies being the most commonly used complementary and alternative medicine modalities.

It's a small world – paediatric CAM initiatives in the EU

With the recognition of increased paediatric use of CAM, there has been a growing need for specialised information and related networks to inform practice and facilitate communication. In Canada, the Pediatric CAM Research and Education Network (PedCAM) (http://www.pedcam.ca/) was created in 2004 in response to two national fora that each identified it as the number one priority to enable the field. As part of its mission to foster collaboration and advance paediatric CAM research, education, policy and decisionmaking, PedCAM hosted a series of meetings in 2006/07 to determine what role networks should play. As part of this initiative, PedCAM hosted an invitational meeting for Paediatric Integrative Medicine (PIM) leaders from conventional settings followed by a one-day research conference during the 14th Annual Symposium on Complementary Health Care in Exeter in December 2007. At both of these meetings, guided discussion focused on answering the question: ‘What can paediatric CAM networks do for you?’ A total of nine European leaders in paediatric CAM attended the invitational meeting, in addition to PedCAM representatives. These paediatric CAM leaders were identified through word of mouth from North American and European contacts and included representatives from paediatrics, surgery, oncology and psychology. The invitational meeting provided an opportunity for each leader to present on regional initiatives, plus time to discuss the roles of networks, and explore opportunities for collaboration. Attended by 49 individuals from a variety of conventional and CAM disciplines, the paediatric CAM research day consisted of two keynote speakers, presentations by seven of the leaders in paediatric CAM, scientific presentations, poster sessions, and an opportunity for breakout group discussion. The research presented has been published in Volume 12, Supplement 1 (2007) of FACT.

Medical Skepticism and the Use of Complementary and Alternative Health Care Providers by Patients Followed by Rheumatologists

Our understanding of the determinants of use of complementary and alternative (CAM) providers is limited, especially in regard to medical skepticism (ie, doubt in the ability of conventional medical care to appreciably alter health status). To determine whether medical skepticism was associated with CAM provider use in patients with arthritis and to explore the association between medical skepticism and demographic and health-related characteristics of persons with arthritis. A cross-sectional analysis of data from patients (N = 721) with osteoarthritis, rheumatoid arthritis, or fibromyalgia who completed a questionnaire about their health, health care use, and health-related attitudes/behaviors, including medical skepticism. Patients were recruited from 14 rheumatology practices in North Carolina. A multiple logistic regression analysis was conducted to examine the relationship between medical skepticism and the use of any CAM providers. Multiple linear regression analysis was conducted to examine relationships between medical skepticism and demographic and health-related measures. Fifteen percent of the sample used one or more CAM providers. Medical skepticism was positively associated with CAM provider use. A one point increase in skepticism increased the probability of CAM provider use by approximately 70% (odds ratios =1.70; 95% confidence intervals [1.13-2.56]). Individuals, who were younger, had better perceived health, and had a diagnosis of osteoarthritis or fibromyalgia had greater skepticism. By knowing more about medical skepticism and other determinants of CAM provider use, conventional practitioners can target patients to improve their uptake of appropriate conventional care, while also monitoring patients alternative therapy use.