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It is likely that a significant proportion of patients seen by primary care providers, including NPs, are using some form of complementary therapies (CTs). While it is tempting to assume that the most likely CT consumer is a non-Hispanic White female, over age 40 with higher education, data indicate that CT usage occurs broadly across racial/ethnic (RE) and socioeconomic groups.1 While CT use is impacted by disposable income for products and services, geographic access to services, and access to information, decisions to use CT also depend upon social networks and family history. For example, African Americans and Hispanics are more likely to use CTs based upon recommendation from friends and family, whereas non-Hispanic White users rely on multiple sources for information about CAM including media and the Internet as well as social networks. The type of CAM modality utilized often relates to cultural patterns within the family. There is greater use of acupuncture, green tea, and soy products among Asian Americans, while Hispanics tend to use a greater number of herbal products.2
Thus, a person's propensity for CT use is informed by the explanatory framework of their cultural heritage and how closely their family of origin adheres to cultural practices. One survey of a culturally diverse sample of women found the most important factor in choosing natural approaches to health was congruency with their personal belief systems.3 Dissatisfaction with conventional medicine, such as bothersome side-effects, was more of a factor in choosing a CAM approach than was cost of conventional medical care, except for Hispanic women. And, patients across racial/ethnic groups experiencing a serious or chronic illness, such as cancer, are more likely to utilize a CAM modality.2
Our recent study of 39 African American and Mexican-origin cancer survivors found that about half (49%) reported using CAM during their cancer treatment, mostly in the form of vitamins, juices, or herbal teas. Only three women had visited a CAM practitioner (acupuncture, homeopathy, and Tradition Chinese Medicine). Of the 51% who did not use CAM, most stated their reason was fear of harmful interactions with chemotherapy. Spanish-speaking Mexican immigrants (N = 15) were the least likely to use a CAM approach, even though they had the lowest income levels and lacked health insurance. They cited fear of interference with conventional cancer treatment and instruction by the oncologist not to take home remedies. Of the women who were using natural health products, half had discussed it with their oncologist and half did not due to the belief that the provider would not endorse it. This is consistent with an abundant body of literature that counsels health care providers about the need to continually ask about the use of complementary therapies and other forms of healing that patients might be participating in.
There is a wide array of CTs that may be unfamiliar to the clinician, particularly when cultural differences exist between patient and provider. Nahin et al1 describe a variety of CAM approaches used across cultural traditions. For example, Qigong (pronounced “chi-gong”) and Tai chi (“tie-chee”) are types of meditative mind-body movements developed from Chinese martial arts, which are popular among Asian populations but are increasingly practiced by non-Asians in the U.S. These practices are classified as mind-body techniques, with evidence linking them to relaxation and reduced stress.4 Types of traditional healers that may be utilized by Hispanic populations include Sobadors, who specialize in massage and limb injuries, and the Hierbero, a person skilled in the use of medicinal herbs. Hispanics, particularly those who are less acculturated, may be more likely to use herbal products. Ortiz et al5 offer a description of herbal remedies often used among Hispanics, along with their uses, potential interactions and adverse effects, which may be a helpful tool for clinicians.
Since patients of any racial/ethnic group may be potential CAM-users, NPs should routinely inquire all patients about current utilization of CAM products. Because a patient's familiarity with the term “complementary and alternative medicine” will probably vary by educational level, it may be helpful to ask specific questions, such as, “Do you use any vitamins, herbs, teas or other natural products?” A respectful style of inquiry, coupled with the NPs rationale for eliciting a CAM history may be more likely to yield open disclosure by the patient. It is important for patients to understand that even commonly used products, such as peppermint tea or Yerba buena used for digestion, may cause drug interactions through activation of cytochrome P450 substrates.4 Patients may be more willing to incorporate treatment recommendations when they understand the reasoning process of the clinician. A collaborative approach to health care will help facilitate mutual treatment decision-making that allows for the safe integration of CAM for patients who value these modalities.
This publication was made possible by grants from the National Center for Complementary and Alternative Medicine (NCCAM) [T32 AT001287 and R13 AT005189-01] and the National Cancer Institute/National Institutes of Health [5R03CA124752-02]. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the NCCAM or the National Institutes of Health.
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