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| Journal of the New Zealand Medical Association,
25-July-2008, Vol 121 No 1278
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Inpatients’ use, understanding, and attitudes
towards traditional, complementary and alternative therapies at a provincial New
Zealand hospital
Amanda Evans, Bruce Duncan, Patrick McHugh, John Shaw, Craig
Wilson
Traditional, complementary and alternative medicines or
therapies (TCAM) are widely used by members of the
public.1,2 A growing body of evidence confirms
the widespread use of TCAM, although this evidence is largely gained from
questionnaire-based studies in larger centres or for specific groups (e.g.
cancer patients).3
There are few published studies, and none in New Zealand, of
TCAM use in an inpatient setting, or in a
provincial or rural population where over 45% of people identify as
Māori.4,5 In addition, relatively little
is known about reasons for use.6
It appears from recent studies that the majority of people
use TCAM as a complement to conventional medicine and not as an
alternative.7 Complementary and alternative
medicine has been defined as ‘a broad domain of healing resources that
encompasses all health systems, modalities, and practices and their accompanying
theories and beliefs, other than those intrinsic to the politically dominant
health system of a particular society or culture in a given historical
period.’
CAM includes all such practices and ideas self-defined by
their users as preventing or treating illness or promoting health and
wellbeing’.8 We have added
“T” to CAM to include all forms of Traditional healing
systems.
Many TCAM modalities are not actually classified as
medicines under existing legislation in New Zealand and there is little
regulation over what people use and from where they obtain
them.9 In spite of the growing scientific
evidence that some TCAM therapies may be effective for specific conditions, many
of these therapies may have unanticipated negative consequences or are known to
interact with conventional
medicines.10–13
It is also widely acknowledged nationally and
internationally that disclosure of patients’ usage to health professionals
is limited.4,14 This makes it difficult for
health professionals to know how to advise patients on the use, risks, and
benefits of TCAM because they simply do not know who is taking what, at what
time, and what interactions pharmaceuticals may have.
Even if conventional healthcare providers are aware that
their patients are using TCAM modalities, they ought to also have an
understanding of the scientific literature [evidence base] on potential
interactions, risks, and efficacy. Understanding the prevalence and reasons for
using TCAM are a first step in improved, best practice patient care for those
patients selecting TCAM in addition to conventional treatment.
This study sought to investigate the prevalence of TCAM use
in an inpatient setting, through one-on-one interviews with a small
representative sample of patients at Gisborne Hospital.
MethodsGisborne Hospital is a 120-bedded provincial hospital
on the east coast of New Zealand’s North Island. It has a catchment
population of approximately 45,000 people with 47% identified as Māori in
the 2006 census.15
Patients in the following areas were included in the
study: general surgical, general medical, rehabilitation, maternity, and day
ward.
Patients were not approached if they were being
ventilated, were severely breathless, in severe pain, heavily medicated, had any
condition that impaired adequate communication, or if they could not communicate
comfortably.
Two healthcare assistants were utilised to approach
patients admitted to the medical, surgical, and maternity wards. The healthcare
assistants were in regular discussion with senior nursing staff to determine
which patients were appropriate to participate. The healthcare assistants asked
patients whether they wished to participate in a survey of TCAM use. Those
patients willing to participate were approached by the interviewer. To reduce
variation in approach of questioning, only one interviewer was involved.
The survey took place face to face, either at the
bedside or in an alternative, suitable place.
A standardised questionnaire was developed to include
basic demographic-, disease-, and treatment-related data. The core of the
questionnaire was a list of 25 therapies that the interviewer would list
one-by-one and the patient would name whether they had “heard of” or
“have used” the therapy. If the patient had not used any TCAM in
their lifetime they were asked “would they use them in the future?”
and “if therapies were available in the hospital would they use
them?” If they had heard of therapies they were asked “how they
learnt about them?”
Patients who reported using TCAM were asked about their
reasons for its use; if they thought they were helpful; if they considered them
safe; if they had experienced any side effects; and if they were aware of
interactions between orthodox treatments and TCAM. They were asked their opinion
about whether TCAM should be regulated and questioned about how comfortable they
felt talking to hospital staff about TCAM use; if they had ever been asked by
doctors what alternative methods they may use and whether they felt
“judged” if they admitted to their use.
The final question asked if TCAMs were available in
hospital would they use them and, if so, which ones they would like to
use.
The questionnaire took a minimum of half an hour to
complete and data was entered into an Excel spreadsheet and analysed using SPSS
v13.0 software.
This study was approved by the Northern Y Regional
Ethics Committee, with Locality Assessment by the Clinical Board of Gisborne
Hospital. Further consultation was completed with local Māori health
providers.
ResultsThe interviews were held in hospital wards during January
and February 2006. Hospital staff considered 51 patients too sick to
participate. Of the remaining 156 suitable adult admissions for the period, 92
patients were eventually interviewed: 25 had been discharged between the
healthcare assistants obtaining their interest and the interviewer managing to
get to them; 24 people declined to be interviewed; and 15 were not available on
the ward on the day of the scheduled interview.
Demographics—The average age of the
patients interviewed was 54 years, ranging from 18 to 89. Table 1 summarises the
demographic features of the 92 participants.
Table 1. Demographic characteristics of
participants (N=92)
The participants had a wide range of clinical conditions
that were categorised into Acute or Chronic from the information that the
patient provided the interviewer and not based on their medical records. Acute
conditions represented 40%, Chronic conditions 51%, and the maternity ward
represented 9% of all participants. The patients surveyed were considered
representative of the hospital's general population in age, gender, ethnicity,
and clinical condition.
Utilisation of TCAM—Of the 92
patients interviewed, only 4 (4%) reported no knowledge or use of TCAM. Of the
remaining 88 patients, 79 (90%) reported the use of two or more TCAM
modalities—4 had reported knowledge only and none used vitamins or
spiritual healing only.
Most respondents used more than one modality (Table 2) and
the average number of modalities used by all patients was 6.4 (SE=0.472). Women
averaged eight and men five modalities used. The variety and usage of TCAM
modalities is summarised in Tables 2 and 3.
Table 2. Number of modalities used by
respondents who had some knowledge to TCAM (N=88)
The majority of the 25 modalities listed were used
proportionately equal by ethnicity; however, Māori did have higher usage of
Rongoa Māori/traditional Māori medicine [Rongoa: take care
of, look after, medicine, remedy for
sickness],16 hypnotherapy, spiritual healing,
and imagery/visualisation.
Non-Māori had higher adoption proportionately of yoga,
chiropractic, homoeopathy, osteopathy, and acupuncture. The single Pacific
Islander used traditional Fijian medicine. These outliers can be seen in Figure
3 and Table 4.
The four patients who had not used TCAM but had some
knowledge, were not distrustful of TCAM, but had never felt the need to use
it.
Table 3. TCAM modalities ranked by patient use
(N=88)
Figure 1 shows the variation of TCAM use by gender while
Figure 2 shows TCAM use by ethnicity.
Figure 1. Gender and TCAM use
(N=88)
 Figure 2. Ethnicity and TCAM use
(N=88)
 Table 4: Modalities of TCAM reported used by 88
Patients at Gisborne Hospital
*Crystal and Reiki therapies were added due to the
several specific mentions given by respondents.
Figure 3. Use of TCAM by ethnicity
(N=88)
 Table 5. How did you learn about
TCAM?
TCAM adoption and motivation—Patients
who reported knowledge or use of at least one TCAM (N=88) were asked how they
learnt about these therapies (Table 5), what their reasons were for using them
(Table 6), and what factors influenced their choice of TCAM used (Table 7).
Table 6. Reasons for using TCAM
Table 7. Factors influencing TCAM
choices
Seventy percent thought that TCAM was not at all helpful for
their present condition although 64% reported it was helpful in the past and 86%
would use TCAM in the future. Ninety-seven percent would use them in the
hospital if available. Forty-eight patients named therapies that they would like
to use. The most popular suggestions were massage (48%), followed by Rongoa
Māori (23%) and herbal medicines (19%).
Safety and regulation of TCAM—93% of
respondents believed TCAM was safe: only one person thought not; the remainder
were undecided. Ninety-three percent of respondents denied experiencing
side-effects from TCAM therapies; 30% thought that TCAM could interact with
pharmaceutical drugs, and 67% believed no interactions would take place. Only
two patients said they didn’t know and five people didn’t express a
view. However, when asked, 78% believed that TCAM should be regulated. (To
define regulation the interviewer said; “for example like pharmaceuticals
drugs, you have to have a consultation with a qualified person first before
purchasing any TCAM medicines”.)
The main reasons stated for regulation were: a belief that
“it could be dangerous to take something that you knew little
about”, because “it may not be safe”, that regulation may give
consumers more access to information about the products, and better informed
choice.
The most popular reasons for not making it regulated were:
loss of freedom of choice, lack of control over one's own health, and that
regulation would probably make it too expensive.
Talking about TCAM—10% of TCAM users
reported they would be uncomfortable talking to hospital staff about their use
of TCAM. Very few respondents reported a difficulty talking with the doctor (3
patients), perceiving a lack of interest (5 patients), or fearing disapproval or
ridicule (5 patients).
Only 10 (11%) of all patients reported being questioned by
their doctor on TCAM use and only 6 patients felt telling a health professional
about TCAM use would affect their treatment. Of those willing to discuss TCAM
use, 88% of participants believed they would never be treated differently by
their doctors for disclosure.
TCAM use prior to this admission—43%
of patients had consulted with a TCAM practitioner prior to medical evaluation
in the past, and 14% acknowledged seeing a TCAM practitioner for their current
problem.
DiscussionOur study reports the highest prevalence (91%) of TCAM use
published to date in New Zealand. It differs from other reported studies in its
selection of hospital in-patients and interview technique. Our findings must be
qualified by the fact that this was a small sample using a select group of
patients, so it is difficult to generalise the results. Overseas studies have
described 9% to 70% prevalence of complementary/alternative medicine use with
wide differences in study methodologies and many critical factors poorly
controlled.3 However, it is clear that data
suggests TCAM therapies are used frequently and increasingly even with
considerable uncertainties. New Zealand studies are consistent with these
international results.17,18
Prayer, exercise, and daily vitamin use are often excluded
from prevalence studies.19 Our study did not
distinguish between daily vitamins versus mega vitamin use, nor did it
distinguish between prayer and spiritual healing. However, no patient in the
Gisborne study group reported vitamin or spiritual healing use exclusively and
omitting these modalities would not change our results.
The high prevalence of Māori traditional healing
(Rongoa) does not account for the overall high TCAM prevalence. As found here
patients appear to adopt pluralistic healthcare decisions.
Our study to explore TCAM use is the first in New Zealand to
use face-to-face interviews and to interview hospitalised patients. While
face-to-face interviews have their own bias—participants may seek to
please interviewers—the method enables richer qualitative data,
flexibility, and clarification. We tried to minimise bias from the single
interviewer through non-committal replies and encouragement for the participant
to talk on their personal opinion and experience during the interview. Face to
face technique would be expected to encourage a response: while the potential
for over-estimation of factors exists, this needs to be placed against the risk
of under-reporting known to arise from written questionnaires, especially when
literacy is a factor.
Although subgroup numbers are small in this study and
subjects were not randomly selected, some TCAM modalities may have significant
differences in use when considered by ethnic group. Most of the TCAM modalities
were fairly evenly utilised by Māori and Non-Māori with the few
exceptions seen in Figure 3: most notably, Māori use traditional Māori
medicine (Rongoa Māori) over four times more frequently than
Non-Māori. This rate is far higher than published in New Zealand to
date.17
In our study, over 90% of Maori women reported using
traditional Māori medicine. Traditionally, Māori women have been
difficult to access in conventional healthcare. The potential exists to reach
underserved or groups with health inequalities through culturally integrated
care.20
This research carried out in Gisborne Hospital is typical of
the current health seeking environment, where the majority of the population
seek out TCAM. This popularity of TCAM is reflected in the variety of modalities
used by our inpatient population. There is a further need however to distinguish
between obtaining “over the counter” modalities and consulting a
TCAM practitioner to further delineate patient's behaviour.
Many studies have looked at predictors of TCAM use and have
found that younger age, female sex, higher education, and income were associated
with greater TCAM use.3,18,21 While this study
did not pursue socioeconomic detail, we did find that age and gender trends were
comparable to other research.
As described previously, ethnicity did not emerge as a
determining factor for TCAM use in general but ethnicity was linked to select
types of TCAM—people identifying as Māori were more likely to use
Rongoa Māori, spiritual healing, hypnotherapy, and imagery/visualisation.
We consider this direction a major priority in future TCAM research.
Most of the people interviewed seemed happy with the
orthodox system and sought TCAM for general wellbeing and to make them feel
good, rather than as a secondary use being disappointment in the current medical
system. However, this may have been influenced by their current use of the
orthodox system at the time of questioning or the failure of TCAM to prevent
their hospital admission.
Lack of disclosure by patients of TCAM follows experience
elsewhere. In the absence of doctors or other professionals asking, the
potential for problems exists. Guidance in 2005 from the MCNZ makes this clear,
and our research confirms a gap between policy and
practice.22 This was also found in the 2003
Wanganui study where 82.6% said they would talk to their doctor but 62.5% said
their doctor did not ask them.23
Because the patients do not get this “prompting”
from their health practitioner, they do not say anything, probably (as our study
suggests) because most believe that TCAM therapies are perfectly safe. Only a
small number of patients in this study (7%) felt uncomfortable discussing TCAM
use—broadly similar to the findings from the Wanganui study. The majority
of patients using TCAM are clearly willing to discuss TCAM use and doctors
should be asking.
Knowledge of the inherent potential for interactions between
orthodox and herbal remedies is not new. However, this fact is not reflected in
behaviour of either the public or the professionals. The public appears unaware
and professionals un-inquisitive. Besides drug interactions (for example, St
John’s Wort and many ‘mainstream’ medicines) and bodily
manipulation, risks arising from TCAM are not only those directly due to the
therapies themselves, but indirect risks due to limitations in the TCAM
therapists’ diagnostic and clinical knowledge creating inappropriate
treatment delays or mismanagement.
These are presumably less likely to occur with medically
qualified practitioners, who therefore have an essential role in the development
and delivery of integrated TCAM services. Those medically qualified
practitioners who do practice some form of TCAM ought to have appropriate
training, skill, and oversight in the TCAM modalities they do use.
However, as it appears that most patients consult
complementary practitioners concurrently with conventional medical doctors, it
may underscore the need for greater cooperation between orthodox and
complementary, alternative, and traditional health professionals. This improved
communication will hopefully result in better risk/benefit analysis and informed
choice for patients.
The results of this study also suggest that effective
regulation with emphasis given to public safety, new funding for TCAM research,
increased undergraduate and postgraduate medical education about TCAM, and
better information available for the public are needed in New
Zealand.24,25
We recommend, as do other studies, that physicians and other
health practitioners become more aware of TCAM, make better use of communication
styles that can foster patient self-disclosure, and enable better
multidisciplinary
communication.1,4,14,17,20,21,26
Competing interests: None known.
Author information: Amanda Evans, Medical
Student, University of Auckland, Auckland; Bruce Duncan, Medical Officer of
Health and Public Health Physician, Tairawhiti District, Gisborne; Patrick
McHugh, Emergency Department Medical Director, Gisborne Hospital, Gisborne; John
Shaw, Head, School of Pharmacy, University of Auckland, Auckland; Craig Wilson,
Research Co-ordinator, Tairawhiti Complementary and Traditional Therapies
Research Trust, Te Puia Springs
Acknowledgements: This study was funded by
grants from the JN Williams Memorial Trust and the University of Auckland,
Faculty of Medical and Health Sciences Summer Studentship Awards. We also thank
Linda Hauraki, Linda Clarke (Health Care Assistants at Gisborne Hospital), and
Lynsey Bartlett (Head of Nursing Services, Gisborne Hospital) for allowing
patient access; and members of the Tairawhiti Complementary and Traditional
Therapies Research Trust Technical Working Group for reviewing this
manuscript.
Correspondence: John Shaw, Head, School of
Pharmacy, University of Auckland, Private Bag 92019, Auckland, New Zealand. Fax:
+64 (0)9 3677192; email: j.shaw@auckland.ac.nz
References:
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