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1.  CAM practitioners in the Australian health workforce: an underutilized resource 
CAM practitioners are a valuable but underutilizes resource in Australian health care. Despite increasing public support for complementary and alternative medicine (CAM) little is known about the CAM workforce. Apart from the registered professions of chiropractic, osteopathy and Chinese medicine, accurate information about the number of CAM practitioners in the workforce has been difficult to obtain. It appears that many non-registered CAM practitioners, although highly qualified, are not working to their full capacity.
Increasing public endorsement of CAM stands in contrast to the negative attitude toward the CAM workforce by some members of the medical and other health professions and by government policy makers. The marginalisation of the CAM workforce is evident in prejudicial attitudes held by some members of the medical and other health professions and its exclusion from government policy making. Inconsistent educational standards has meant that non-registered CAM practitioners, including highly qualified and competent ones, are frequently overlooked. Legitimising their contribution to the health workforce could alleviate workforce shortages and provide opportunities for redesigned job roles and new multidisciplinary teams. Priorities for better utilisation of the CAM workforce include establishing a guaranteed minimum education standard for more CAM occupation groups through national registration, providing interprofessional education that includes CAM practitioners, developing courses to upgrade CAM practitioners' professional skills in areas of indentified need, and increasing support for CAM research.
Marginalisation of the CAM workforce has disadvantaged those qualified and competent CAM practitioners who practise evidence-informed medicine on the basis of many years of university training. Legitimising and expanding the important contribution of CAM practitioners could alleviate projected health workforce shortages, particularly for the prevention and management of chronic health conditions and for health promotion.
PMCID: PMC3528465  PMID: 23116374
2.  Consumers' experiences and values in conventional and alternative medicine paradigms: a problem detection study (PDS) 
This study explored consumer perceptions of complementary and alternative medicine (CAM) and relationships with CAM and conventional medicine practitioners.
A problem detection study (PDS) was used. The qualitative component to develop the questionnaire used a CAM consumer focus group to explore conventional and CAM paradigms in healthcare. 32 key issues, seven main themes, informed the questionnaire (the quantitative PDS component - 36 statements explored using five-point Likert scales.)
Of 300 questionnaires distributed (Brisbane, Australia), 83 consumers responded. Results indicated that consumers felt empowered by using CAM and they reported positive relationships with CAM practitioners. The perception was that CAM were used most effectively as long-term therapy (63% agreement), but that conventional medicines would be the best choice for emergency treatment (81% agreement). A majority (65%) reported that doctors appeared uncomfortable about consumers' visits to CAM practitioners. Most consumers (72%) believed that relationships with and between health practitioners could be enhanced by improved communication. It was agreed that information sharing between consumers and healthcare practitioners is important, and reported that "enough" information is shared between CAM practitioners and consumers. Consumers felt comfortable discussing their medicines with pharmacists, general practitioners and CAM practitioners, but felt most comfortable with their CAM practitioners.
This PDS has emphasized the perceived importance of open communication between consumers, CAM and conventional providers, and has exposed areas where CAM consumers perceive that issues exist across the CAM and conventional medicine paradigms. There is a lot of information which is perceived as not being shared at present and there are issues of discomfort and distrust which require resolution to develop concordant relationships in healthcare. Further research should be based on optimisation of information sharing, spanning both conventional and CAM fields of healthcare, due to both the relevance of concordance principles within CAM modalities and the widespread use of CAM by consumers.
PMCID: PMC3349512  PMID: 22490367
3.  How parents choose to use CAM: a systematic review of theoretical models 
Complementary and Alternative Medicine (CAM) is widely used throughout the UK and the Western world. CAM is commonly used for children and the decision-making process to use CAM is affected by numerous factors. Most research on CAM use lacks a theoretical framework and is largely based on bivariate statistics. The aim of this review was to identify a conceptual model which could be used to explain the decision-making process in parental choice of CAM.
A systematic search of the literature was carried out. A two-stage selection process with predetermined inclusion/exclusion criteria identified studies using a theoretical framework depicting the interaction of psychological factors involved in the CAM decision process. Papers were critically appraised and findings summarised.
Twenty two studies using a theoretical model to predict CAM use were included in the final review; only one examined child use. Seven different models were identified. The most commonly used and successful model was Andersen's Sociobehavioural Model (SBM). Two papers proposed modifications to the SBM for CAM use. Six qualitative studies developed their own model.
The SBM modified for CAM use, which incorporates both psychological and pragmatic determinants, was identified as the best conceptual model of CAM use. This model provides a valuable framework for future research, and could be used to explain child CAM use. An understanding of the decision making process is crucial in promoting shared decision making between healthcare practitioners and parents and could inform service delivery, guidance and policy.
PMCID: PMC2680396  PMID: 19386106
4.  Intervention development for integration of conventional tobacco cessation interventions into routine CAM practice 
Practitioners of complementary and alternative medicine (CAM) therapies are an important and growing presence in health care systems worldwide. A central question is whether evidence-based behavior change interventions routinely employed in conventional health care could also be integrated into CAM practice to address public health priorities. Essential for successful integration are intervention approaches deemed acceptable and consistent with practice patterns and treatment approaches of different types of CAM practitioners – that is, they have context validity. Intervention development to ensure context validity was integral to Project CAM Reach (CAMR), a project examining the public health potential of tobacco cessation training for chiropractors, acupuncturists and massage therapists (CAM practitioners). This paper describes formative research conducted to achieve this goal.
Intervention development, undertaken in three CAM disciplines (chiropractic, acupuncture, massage therapy), consisted of six iterative steps: 1) exploratory key informant interviews; 2) local CAM practitioner community survey; 3) existing tobacco cessation curriculum demonstration with CAM practitioners; 4) adapting/tailoring of existing curriculum; 5) external review of adaptations; 6) delivery of tailored curriculum to CAM practitioners with follow-up curriculum evaluation.
CAM practitioners identified barriers and facilitators to addressing tobacco use with patients/clients and saw the relevance and acceptability of the intervention content. The intervention development process was attentive to their real world intervention concerns. Extensive intervention tailoring to the context of each CAM discipline was found unnecessary. Participants and advisors from all CAM disciplines embraced training content, deeming it to have broad relevance and application across the three CAM disciplines. All findings informed the final intervention.
The participatory and iterative formative research process yielded an intervention with context validity in real-world CAM practices as it: 1) is patient/client-centered, emphasizing the practitioner’s role in a healing relationship; 2) is responsive to the different contexts of CAM practitioners’ work and patient/client relationships; 3) integrates relevant best practices from US Public Health Service Clinical Practice Guidelines on treating tobacco dependence; and 4) is suited to the range of healing philosophies, scopes of practice and practice patterns found in participating CAM practitioners. The full CAMR study to evaluate the impact of the CAMR intervention on CAM practitioners’ clinical behavior is underway.
PMCID: PMC4391469  PMID: 25887742
Context validity; Intervention protocol; Curriculum development; Training; Interprofessional education; Tobacco cessation; Chiropractic; Acupuncture; Massage therapist; Community based participatory research
5.  Complementary and alternative health care in Israel 
The paper explores the patterns of coexistence of alternative/complementary health care (CAM) and conventional medicine in Israel in the cultural, political, and social contexts of the society. The data are drawn from over ten years of sociological research on CAM in Israel, which included observation, survey research, and over one hundred in-depth interviews with a variety of CAM practitioners - many with bio-medical credentials - and with policy makers in the major medical institutions. The analysis considers the reasons for CAM use, number of practitioners, the frequency of CAM use and some of its correlates, and how CAM is regulated. The structure of the relationship between the conventional health care system and CAM is discussed in the public sector, which provides two-thirds of CAM services, and in the private sector, which provides about one-third. The history of the development of these structures and some of the dilemmas of their operation are discussed. A number of policy issues are considered against this background: regulation and licensing, CAM in primary care, reimbursement for CAM treatment, and the inclusion of CAM in education and training for the health professions.
PMCID: PMC3424827  PMID: 22913721
6.  Australian women's use of complementary and alternative medicines to enhance fertility: exploring the experiences of women and practitioners 
Studies exploring the use of complementary and alternative medicine (CAM) to enhance fertility are limited. While Australian trends indicate that women are using CAM during pregnancy, little is known about women's use of CAM for fertility enhancement. With the rising age of women at first birth, couples are increasingly seeking assisted reproductive technologies (ART) to achieve parenthood. It is likely that CAM use for fertility enhancement will also increase, however this is not known. This paper reports on an exploratory study of women's use of CAM for fertility enhancement.
Three focus groups were conducted in Melbourne, Australia in 2007; two with women who used CAM to enhance their fertility and one with CAM practitioners. Participants were recruited from five metropolitan Melbourne CAM practices that specialise in women's health. Women were asked to discuss their views and experiences of both CAM and ART, and practitioners were asked about their perceptions of why women consult them for fertility enhancement. Groups were digitally recorded (audio) and transcribed verbatim. The data were analysed thematically.
Focus groups included eight CAM practitioners and seven women. Practitioners reported increasing numbers of women consulting them for fertility enhancement whilst also using ART. Women combined CAM with ART to maintain wellbeing and assist with fertility enhancement. Global themes emerging from the women's focus groups were: women being willing to 'try anything' to achieve a pregnancy; women's negative experiences of ART and a reluctance to inform their medical specialist of their CAM use; and conversely, women's experiences with CAM being affirming and empowering.
The women in our study used CAM to optimise their chances of achieving a pregnancy. Emerging themes suggest the positive relationships achieved with CAM practitioners are not always attained with orthodox medical providers. Women's views and experiences need to be considered in the provision of fertility services, and strategies developed to enhance communication between women, medical practitioners and CAM practitioners. Further research is needed to investigate the extent of CAM use for fertility enhancement in Australia, and to explore the efficacy and safety of CAM use to enhance fertility, in isolation or with ART.
PMCID: PMC2807849  PMID: 20003533
7.  Decisions to use complementary and alternative medicine (CAM) by male cancer patients: information-seeking roles and types of evidence used 
Complementary and Alternative Medicine (CAM) is increasingly popular with cancer patients and yet information provision or discussion about CAM by health professionals remains low. Previous research suggests that patients may fear clinicians' 'disapproval' if they raise the subject of CAM, and turn to other sources to acquire information about CAM. However, little empirical research has been conducted into how cancer patients acquire, and, more importantly evaluate CAM information before deciding which CAM therapies to try.
Qualitative study, comprising semi-structured interviews with 43 male cancer patients of varying ages, cancer type and stage of illness, 34 of whom had used CAM. They were recruited from a range of NHS and non-NHS settings in Bristol, England.
As a result of the lack of CAM information from health professionals, men in this study became either 'pro-active seekers' or 'passive recipients' of such information. Their main information resource was the 'lay referral' network of family, friends and acquaintances, especially females. 'Traditional' information sources, including books, magazines, leaflets and the media were popular, more so in fact than the internet. Views on the internet ranged from enthusiasm or healthy scepticism through to caution or disinterest. CAM information was generally regarded as 'empowering' as it broadened treatment and self-care options. A minority of participants were information averse fearing additional choices that might disrupt their fragile ability to cope. There was general consensus that CAM information should be available via the NHS, to give it a 'stamp of approval', which combined with guidance from informed health professionals, could help patients to make 'guided' choices. However, a small minority of these men valued the independence of CAM from the NHS and deliberately sought 'alternative' information sources and treatment options.
Men were selective in identifying particular therapies to use and sceptical about others, basing their choices on forms of 'evidence' that were personally meaningful: personal stories of individuals who had been helped by CAM; the long history and enduring popularity of some therapies; the plausibility of the mechanism of action; a belief or trust in individual therapies or their providers; scientific evidence. Scientific evidence ranked low in the men's personal decision-making about CAM, while it was recognised as important for NHS support for CAM.
These male cancer patients valued the support and guidance of 'trusted individuals' in making choices about CAM. Trusted health professionals could also play a significant role in helping patients to make informed choices. Any such dialogue must, however, acknowledge the different standards of evidence used by patients and clinicians to evaluate the benefits or otherwise of CAM therapies. Such open communication could help to foster an environment of mutual trust where patients are encouraged to discuss their interest in CAM, rather than perpetuate covert, undisclosed use of CAM with its attendant potential hazards.
PMCID: PMC2000907  PMID: 17683580
8.  Attitudes Toward Antiretroviral Therapy and Complementary and Alternative Medicine in Chinese HIV-Infected Patients 
HIV has become a significant health issue in China, and an increasing number of HIV-infected individuals are in need of care. Current reports confirm more than 230,000 cases of HIV infection and estimate that approximately 700,000 people are now infected with HIV, although approximately 70% of these individuals do not realize they are infected (Gill & Okie, 2007).
China's national antiretroviral therapy (ART) program, Four Frees and One Care, began in 2003, and ART treatment is now widely available in China (Zhang et al., 2007). Under this program, the following services are available to eligible citizens: (a) free ART for all AIDS patients in financial difficulty, (b) free schooling for AIDS orphans and children of AIDS patients, (c) free counseling and prevention measures to prevent mother-to-child-transmission for HIV-infected pregnant women, and (d) free HIV antibody testing and counseling, provided by the Chinese Center for Disease Control and Prevention (China CDC). “One Care” means providing care to AIDS patients and their families (Zhang, Pan, Yu, Wen, & Zhao, 2005). Prior to 2003, only a few people in China had access to ART, and clinical expertise in HIV medicine was limited to the major centers in a few eastern cities (Zhang et al., 2007). When ART is the dominant method of treatment, however, its use is complicated by the presence of complementary and alternative medicine (CAM), which has remained a substitute and supplement for conventional HIV therapy (Hsiao et al., 2003), even after ART became available (Josephs, Fleishman, Gaist, & Gebo, 2007).
CAM is a group of diverse medical and health care systems, practices, and products that are not presently considered to be part of conventional medicine (National Institutes of Health, 2008). Commonly, CAM includes a wide range of practices that do not fit within the dominant allopathic model of health care (Bishop, Yardley, & Lewith, 2007), including but not limited to herbalism, traditional Chinese medicine (TCM), acupuncture, and diet-based therapies (Bratman & Steven, 1997). TCM has been used in Chinese society for more than 5,000 years. In the TCM approach, the body is recognized and treated as a whole entity, and diseases are identified as conditions caused by internal imbalances. The role of doctors is to identify imbalances and then correct them; the body is then expected to be able to heal itself (Tsao, Dobalian, Myers, & Zeltzer, 2005). The balancing factors of the yin and yang, or of the cold and hot forces, govern health and modulate some Chinese eating and pain management practices (Wong-Kim & Merighi, 2007). The integration of ART and CAM therefore has important implications in health outcomes, especially in China where the use of CAM is widespread.
Three types of treatment systems are practiced in Chinese society: (a) allopathic Western medicine offered by health care professionals in clinics and hospitals; (b) Buyao, which is over-the-counter popular medicine and includes teas, soups, tablets, herbal preparations, and tonics, which are similar to herb supplements used in some Western countries; and (c) TCM or Zhongyi, provided by trained Chinese herbalists, which incorporates a wide range of theories, therapies, and practices, some of which are medicinal, some physical, and some supernatural (Ma et al., 2008). Many Chinese people use all three types of treatment simultaneously.
In the West, the use of CAM is widespread among HIV-infected individuals. From 1980 to 1996, 27% to 100% of HIV-infected patients used CAM (Ernst, 1997), and the rates of CAM remained steady when compared with the era before highly active ART (Josephs et al., 2007). Some people living with HIV (PLWH) used CAM to replace the prescribed ART treatment regimen (Owen-Smith, Diclemente, & Wingood, 2007), while others used it as a complement to conventional HIV therapy (Hsiao et al., 2003).
A variety of factors influence an individual's decision to use CAM. In Western countries, women who were more educated and who had lived longer with HIV were more likely to use CAM (Owen-Smith et al., 2007). Pain was a strong predictor of CAM use, and increased pain over time was associated with the use of unlicensed or illicit underground drugs that held a potential for harm (Tsao et al., 2005). Overall, the most common source of information about CAM was from patients' friends (Wiwanitkit, 2003). Generally, CAM users perceived complementary therapies as useful, although there is no evidence to suggest that these treatments are particularly effective. CAM is generally perceived as “safe,” despite evidence of harmful interactions between some herbal medicines and medical treatments and the evidence of associated risks (Ma et al., 2007). Specifically, recent studies have shown that herbal medicines can interact with ART in such a way as to contribute to treatment failure (Ma et al., 2007). Physicians around the world, however, do not routinely discuss CAM therapies with PLWH, despite knowing that CAM therapies are widely used (Ma et al., 2008; Hsiao et al., 2003).
Studies have examined PLWH attitudes toward ART and CAM in different countries (Littlewood & Vanable, 2008). One study described nurses in Uganda using a traditional, nurse-prepared ointment on PLWH as an alternative medication for skin problems because they “know it works” (Hardon et al., 2008). CAM has also been used to treat the psychological and physical effects of illness and the side effects of ART (Kaufman & Gregory, 2007). Studies show, however, that many PLWH do not report CAM use to their medical providers (Hsiao et al., 2003). To date, there has been little research on CAM use in the Chinese PLWH population.
This qualitative study explored issues related to positive and negative attitudes toward both ART and CAM in Chinese PLWH in Beijing, China. The study was part of a larger project examining behavioral interventions meant to enhance ART adherence in PLWH in China (Chen et al., 2007; Starks et al., 2008). Semi-structured, in-depth, interviews were used to explore PLWHA attitudes, experiences, and perceptions about ART and CAM.
PMCID: PMC2684986  PMID: 19427598
9.  Survey of Complementary and Alternative Medicine Practitioners Regarding Cancer Management and Research 
The primary purpose of this survey was to assess the interest and concerns of a group of cancer complementary and alternative medicine (CAM) practitioners regarding CAM research issues. These issues include the CAM modalities used most often by CAM practitioners in the treatment of cancer patients, cancer CAM practitioners’ perceptions of the most promising areas of cancer CAM research, the perceived obstacles to carrying out research objectives in the emerging field of cancer CAM research, the extent of awareness of the National Cancer Institute (NCI) Best Case Series Program, and CAM practitioners’ level of interest in research collaboration with CAM researchers. A cross-sectional survey of a convenience sample of cancer CAM practitioners was conducted. One hundred thirty-four respondents completed the survey. About 72% of the respondents were involved in the care of cancer patients, and these were considered the informative respondents. All results were from the informative respondent group. Respondent practitioners provided care using interventions from all seven of the predefined CAM categories. This care was provided to improve both quality of life and survival. Over two-thirds of the respondents rated research in pharmacologic and biologic treatments, alternative medical systems and nutritional therapeutics for cancer treatment, and symptom/side-effect management as high-priority areas. Although no single obstacle to research predominated as the most significant, the most frequently encountered obstacle was lack of awareness of appropriate funding sources (75.4%). More than 83% of respondents expressed some interest in or willingness to establish research collaboration with a cancer researcher. The results from this survey indicate that many cancer CAM practitioners have shared interests, perceived obstacles, and desired research opportunities. Despite a small sample size and lack of a feasible process for random sampling, this survey highlights avenues to promote and support collaborative research. The NCI/Office of Cancer Complementary and Alternative Medicine will continue to respond to the concerns elucidated by the survey by developing strategies for future program opportunities within the NCI.
PMCID: PMC2719964  PMID: 19476732
cancer complementary and alternative medicine practitioners; complementary and alternative medicine (CAM); practitioner survey
10.  The role of complementary and alternative medicine (CAM) in Germany – A focus group study of GPs 
There has been a marked increase in the use of complementary and alternative medicine (CAM) in recent years worldwide. In Germany, apart from 'Heilpraktiker' (= state-licensed, non-medical CAM practitioners), some general practitioners (GPs) provide CAM in their practices. This paper aims to explore the attitudes of GPs about the role of CAM in Germany, in relation to the healthcare system, quality of care, medical education and research. Furthermore, experiences of GPs integrating CAM in their daily practice were explored.
Using a qualitative methodological approach 3 focus groups with a convenience sample of 17 GPs were conducted. The discussions were transcribed verbatim and analysed using qualitative content analysis.
The majority of the participating GPs had integrated one or more CAM therapies into their every-day practice. Four key themes were identified based on the topics covered in the focus groups: the role of CAM within the German healthcare system, quality of care, education and research. Within the theme 'role of CAM within the healthcare system' there were five categories: integration of CAM, CAM in the Statutory Health Insurance, modernisation of the Statutory Health Insurance Act, individual healthcare services and 'Heilpraktiker'. Regarding quality of care there were two broad groups of GPs: those who thought patients would benefit from standardizing CAM and those who feared that quality control would interfere with the individual approach of CAM. The main issues identified relating to research and education were the need for the development of alternative research strategies and the low quality of existing CAM education respectively.
The majority of the participating GPs considered CAM as a reasonable complementary approach within primary care. The study increased our understanding of GPs attitudes about the role of CAM within the German healthcare system and the use of 'Heilpraktiker' as a competing CAM-provider. It seems to be a need for increased funding for research, better education and remuneration by the Statutory Health Insurance in order to improve access to 'Integrative medicine' in Germany.
PMCID: PMC2442431  PMID: 18549476
11.  Evaluating complementary and alternative medicine interventions: in search of appropriate patient-centered outcome measures 
Central to the development of a sound evidence base for Complementary and Alternative Medicine (CAM) interventions is the need for valid, reliable and relevant outcome measures to assess whether the interventions work. We assessed the specific needs for a database that would cover a wide range of outcomes measures for CAM research and considered a framework for such a database.
The study was a survey of CAM researchers, practitioners and students. An online questionnaire was emailed to the members of the Canadian Interdisciplinary Network for CAM Research (IN-CAM) and the CAM Education and Research Network of Alberta (CAMera). The majority of survey questions were open-ended and asked about outcome measures currently used, outcome measures' assessment criteria, sources of information, perceived barriers to finding outcome measures and outcome domains of importance. Descriptive quantitative analysis and qualitative content analysis were used.
One hundred and sixty-four completed surveys were received. Of these, 62 respondents reported using outcome measures in their CAM research and identified 92 different specific outcomes. The most important barriers were the fact that, for many health concepts, outcome measures do not yet exist, as well as issues related to accessibility of instruments. Important outcome domains identified included physical, psychological, social, spiritual, quality of life and holistic measures. Participants also mentioned the importance of individualized measures that assess unique patient-centered outcomes for each research participant, and measures to assess the context of healing and the process of healing.
We have developed a preliminary framework that includes all components of health-related outcomes. The framework provides a foundation for a larger, comprehensive collection of CAM outcomes. It fits very well in a whole systems perspective, which requires an expanded set of outcome measures, such as individualized and holistic measures, with attention to issues of process and context.
PMCID: PMC1661594  PMID: 17118197
12.  Integration of Complementary and Alternative Medicine into Family Practices in Germany: Results of a National Survey 
More than two-thirds of patients in Germany use complementary and alternative medicine (CAM) provided either by physicians or non-medical practitioners (“Heilpraktiker”). There is little information about the number of family physicians (FPs) providing CAM. Given the widespread public interest in the use of CAM, this study aimed to ascertain the use of and attitude toward CAM among FPs in Germany. A postal questionnaire developed based on qualitatively derived data was sent to 3000 randomly selected FPs in Germany. A reminder letter including a postcard (containing a single question about CAM use in practice and reasons for non-particpation in the survey) was sent to all FPs who had not returned the questionnaire. Of the 3000 FPs, 1027 (34%) returned the questionnaire and 444 (15%) returned the postcard. Altogether, 886 of the 1471 responding FPs (60%) reported using CAM in their practice. A positive attitude toward CAM was indicated by 503 FPs (55%), a rather negative attitude by 127 FPs (14%). Chirotherapy, relaxation and neural therapy were rated as most beneficial CAM therapies by FPs, whereas neural therapy, phytotherapy and acupuncture were the most commonly used therapies in German family practices. This survey clearly demonstrates that CAM is highly valued by many FPs and is already making a substantial contribution to first-contact primary care in Germany. Therefore, education and research about CAM should be increased. Furthermore, with the provision of CAM by FPs, the role of non-medical CAM practitioners within the German healthcare system is to be questioned.
PMCID: PMC3140199  PMID: 19293252
13.  Patients whose GP knows complementary medicine tend to have lower costs and live longer 
Health economists have largely ignored complementary and alternative medicine (CAM) as an area of research, although both clinical experiences and several empirical studies suggest cost-effectiveness of CAM.
To explore the cost-effectiveness of CAM compared with conventional medicine.
A dataset from a Dutch health insurer was used containing quarterly information on healthcare costs (care by general practitioner (GP), hospital care, pharmaceutical care, and paramedic care), dates of birth and death, gender and 6-digit postcode of all approximately 150,000 insurees, for the years 2006–2009. Data from 1913 conventional GPs were compared with data from 79 GPs with additional CAM training in acupuncture (25), homeopathy (28), and anthroposophic medicine (26).
Patients whose GP has additional CAM training have 0–30% lower healthcare costs and mortality rates, depending on age groups and type of CAM. The lower costs result from fewer hospital stays and fewer prescription drugs.
Since the differences are obtained while controlling for confounders including neighborhood specific fixed effects at a highly detailed level, the lower costs and longer lives are unlikely to be related to differences in socioeconomic status. Possible explanations include selection (e.g. people with a low taste for medical interventions might be more likely to choose CAM) and better practices (e.g. less overtreatment, more focus on preventive and curative health promotion) by GPs with knowledge of complementary medicine. More controlled studies (replication studies, research based on more comprehensive data, cost-effectiveness studies on CAM for specific diagnostic categories) are indicated.
PMCID: PMC3482459  PMID: 21695547
Healthcare costs; Life expectancy; Complementary medicine; I11; I12
14.  Stakeholders' perspectives on the regulation and integration of complementary and alternative medicine products in Lebanon: a qualitative study 
The regulation of the markets for Complementary and Alternative Medicine (CAM) products presents a global challenge. There is a dearth of studies that have examined or evaluated the regulatory policies of CAM products in the Eastern Mediterranean Region (EMR). We investigate the regulatory frameworks and the barriers for the proper regulation and integration of CAM products in Lebanon, as an example of an EMR country with a weak public infrastructure.
We utilized a qualitative study design involving a series of semi-structured interviews with stakeholders of the CAM market in Lebanon. Snowball sampling was used to identify interviewees; interviews continued until the "saturation" point was reached. A total of 16 interviews were carried out with decision makers, representatives of professional associations, academic researchers, CAM product importers, policy makers and a media representative. Interviews were transcribed and thematic analysis of scripts was carried out.
There was a consensus among all stakeholders that the regulation of the market for CAM products in Lebanon needs to be strengthened. Thematic analysis identified a number of impediments jeopardizing the safety of public consumption and hindering the integration of CAM therapies into mainstream medicine; including: weak infrastructure, poor regulation, ineffective policies and politics, weak CAM awareness and sub-optimal coordination and cooperation among stakeholders. With respect to policy instruments, voluntary instruments (self regulation) were deemed ineffective by stakeholders due to poor awareness of both users and providers on safe use of CAM products. Stakeholders' rather recommended the adoption of a combination of mixed (enhancing public awareness and integration of CAM into medical and nursing curricula) and compulsory (stricter governmental regulation) policy instruments for the regulation of the market for CAM products.
The current status quo with respect to the regulation of CAM products in Lebanon is not conducive to public safety, nor does it support the integration of CAM products into the healthcare system. The Ministry of Health indeed plays a dominant role in the regulation of these products through a combination of mixed and compulsory policy instruments. Yet, the proper implementation of these regulations requires political resolve coupled with the cooperation of all CAM stakeholders.
PMCID: PMC3175209  PMID: 21871124
15.  Using Basic Science to Develop an Innovative Program in Complementary and Alternative Medicine 
The growing interest in Complementary and Alternative Medicine (CAM) and the increasing incorporation of its modalities in the United States' healthcare system have exposed a number of problems in the field. These include a shortage of qualified CAM providers, scarcity of evidence-based research, lack of trained scientists in the field, and the ubiquitous marketing of frequently uncontrolled CAM products. Thus, the development of a comprehensive and scientifically sound educational infrastructure has become a crucial initial step in redirecting these adverse trends.
With support from the NIH-sponsored curricular CAM initiative, faculty from the department of physiology and biophysics at Georgetown University developed a M.S. program in CAM in 2003. This unique, first of its kind, science-based graduate program offers a master's degree (MS) in physiology with an emphasis on CAM. The CAM-MS degree in physiology is designed to enable students to critically assess various CAM modalities, apply scientific rigor, and carry out evidence-based CAM research. The curriculum includes core science courses and CAM-related classes. Additionally, in order to emphasize the application of academic knowledge and further strengthen problem-solving skills, the students complete an eight-week summer practicum in a professional CAM-related environment.
Here, we report on our innovative and interdisciplinary CAM graduate program where creative teaching is implemented by basic scientists and enhanced by the application of their disciplines in tandem with the clinical expertise of CAM practitioners in the community. Thus, the faculty in the Department of Physiology & Biophysics is developing emerging cross disciplinary areas of study and interest in order to prepare new generations of future physicians, health professionals, educators, and researchers capable of objectively assessing the safety and efficacy of various CAM modalities, and introducing scientific rigor to much needed research into the various aspects of CAM therapies.
PMCID: PMC3019605  PMID: 21243105
Graduate education; Basic science; Complementary and Alternative Medicine
16.  A qualitative study on the term CAM: is there a need to reinvent the wheel? 
As complementary and alternative medicine (CAM) has developed extensively, uncertainty about the appropriateness of the terms CAM and other CAM-related terms has grown both in the research and practice communities. Various terms and definitions have been proposed over the last three decades, highlighting how little agreement exits in the field. Contextual use of current terms and their respective definitions needs to be discussed and addressed.
Relying upon the results of a large international Delphi survey on the adequacy of the term CAM, a focus group of 13 international experts in the field of CAM was held. A forum was also set up for 28 international experts to discuss and refine proposed definitions of both CAM and integrative healthcare (IHC) terms. Audio recordings of the meeting and forum discussion threads were analyzed using interpretive description.
Multiple terms to describe the therapies, products, and disciplines often referred to as CAM, were considered. Even though participants generally agreed there is a lack of optimal definitions for popular CAM-related umbrella terms and that all terms that have so far been introduced are to some extent problematic, CAM and IHC remained the most popular and accepted terms by far. The names of the specific disciplines were also deemed adequate in certain contexts. Focus group participants clarified the context in which those three terms are appropriate. Existing and emergent definitions of both CAM and integrative healthcare terms were discussed.
CAM and other related terms could be used more effectively, provided they are used in the proper context. It appears difficult for the time being to reach a consensus on the definition of the term CAM due to the uncertainty of the positioning of CAM in the contemporary healthcare systems. While umbrella terms such as CAM and IHC are useful in the context of research, policy making and education, relevant stakeholders should limit the use of those terms.
PMCID: PMC3462712  PMID: 22909051
Definition; Term; Focus group; International experts; Integrative healthcare
17.  The utilisation of Complementary and Alternative Medicine (CAM) among ethnic minorities in South Korea 
Race has been reported to affect the use of complementary and alternative medicine (CAM), but there is very little research on the use of CAM by ethnicity in Korea. This study explores the prevalence of CAM use among ethnic minorities in South Korea.
The design is a descriptive and cross-sectional study. A convenience sample of ethnic minorities was recruited from two public healthcare centres in Gyeonggi province. The survey instrument included 37 questions regarding CAM use, factors influencing use of CAM, self-health management, and the socio-demographic profile of study participants.
Sixty-two percent of study participants reported the use of CAM. Multivitamins (53.3%), acupuncture (48.9%), and traditional Korean herbal medicine (38.9%) were popular CAM modalities in our sample. Other notable CAM modalities included herbal plants, therapeutic massage, and moxibustion therapy. The majority of CAM users (52.2%) received CAM services to treat diseases or as a secondary treatment while receiving conventional care. Having positive perceptions toward the effectiveness of CAM was a major determining factor in CAM use.
Physicians need to be aware of the fact that many ethnic minorities use CAM therapies. Many CAM users reported that they want doctors to know about their CAM use and have a basic understanding of traditional medicine in their home country. Overcoming language and cultural barriers will help reduce unwanted medical complications. High prevalence of CAM use among ethnic minorities in our study warrants further studies using larger sample population.
PMCID: PMC3994841  PMID: 24641983
18.  Exploring the roles of librarians and health care professionals involved with complementary and alternative medicine* 
Objectives: The researcher conducted qualitative research about the role of health care professionals and librarians involved with complementary and alternative medicine (CAM). The goals were to identify resources these professionals use to explore the librarians' role as well as their approaches to teaching and searching with respect to CAM, to acquire information about CAM education, and to connect with other librarians in the CAM field.
Methods: Semi-structured interviews with open-ended questions were used.
Results: Sixteen health care and information professionals from ten different institutions in Boston, Baltimore, and Calgary were interviewed. Major themes from the interviews were: CAM funding, integration of CAM and conventional medicine, roles of librarians, “hot” CAM issues, and information access. Information about four aspects of CAM education—technology, undergraduate, graduate, and continuing—is presented. A wealth of information resources was identified.
Conclusions: A CAM librarian's role is unique; many specialize in specific areas of CAM, and opportunities exist for librarians to partner with CAM groups. CAM information professionals' major roles involve information access and retrieval and education. Further study is required concerning CAM consumer health, integrative CAM and conventional medicine models, and the librarian's role in a CAM environment. CAM funding is a major concern.
PMCID: PMC1324776  PMID: 16404474
19.  Mapping the risk perception and communication gap between different professions of healthcare providers in cancer care: a cross-sectional protocol 
BMJ Open  2015;5(9):e008236.
Studies show that patients with cancer who use complementary and alternative medicine (CAM) have a poorer survival prognosis than those who do not. It remains unclear whether this is due to a priori poorer prognosis that makes patients turn to CAM, or whether there is a factor associated with CAM use itself that influences the prognosis negatively. Healthcare providers should assist patients in safeguarding their treatment decision. However, the current non-communication between CAM and conventional providers leaves it up to the patients themselves to choose how to best integrate the two worlds of therapy. In this study, an interactive shared decision-making (SDM) tool will be developed to enable patients and health professionals to make safe health choices.
Methods and analysis
We will delineate, compare and evaluate perception and clinical experience of communication of risk situations among oncology experts, general practitioners and CAM practitioners. To accomplish this, we will develop a pilot and implement a large-scale survey among the aforementioned health professionals in Norway. Guided by the survey results, we will develop a β-version of a shared decision-making tool for healthcare providers to use in guiding patients to make safe CAM decisions.
Ethics and dissemination
Participants must give their informed and written consent before inclusion. They will be informed about the opportunity to drop out from the study followed by deletion of all data registered. The study needs no approval from The Regional Committee for Medical and Health Research Ethics because all participants are healthcare professionals. Results from this study will be disseminated in peer-reviewed medical journals.
PMCID: PMC4563259  PMID: 26338839
20.  Complementary and alternative medicine: A survey of its use in children with chronic respiratory illness 
The high prevalence of chronic illness has prompted many to seek treatment alternatives outside of conventional medicine. Many health care providers, however, may be dangerously unaware of CAM use in their patients due, in part, to nondisclosure or because CAM use is not specifically addressed in the clinic or office. Prompted by the lack of data from Canada, this study investigated pediatric CAM use in respiratory clinics in Edmonton (Alberta) and Ottawa (Ontario).
The use of complementary and alternative medicine (CAM) has increased in recent years, with especially high prevalence in individuals with chronic illnesses. In the United States, the prevalence of CAM use in pediatric asthma patients is as high as 89%.
To investigate the epidemiology of pediatric CAM use in respiratory subspecialty clinics.
A survey was conducted at two hospital-based respiratory clinics in Edmonton (Alberta) and Ottawa (Ontario). Caregivers (most often parents) of children <18 years of age were asked questions regarding child and caregiver use of CAM, including products and practices used, beliefs about CAM, trust in information sources about CAM and characteristics of the respondents themselves.
A total of 202 survey questionnaires were completed (151 from Edmonton and 51 from Ottawa). Pediatric CAM use in Edmonton was 68% compared with 45% in Ottawa, and was associated with caregiver CAM use, poorer health and health insurance coverage for CAM. The majority (67%) of children using CAM had taken prescription drugs concurrently and 58% of caregivers had discussed this with their doctor.
Lifetime use of CAM at these pediatric clinics was higher than reported for children who do not have chronic diseases. CAM practices that are popular may be worthy of further research to evaluate their effectiveness and safety profile with regard to drug interactions. Health care providers should be encouraged to discuss CAM use at every visit, and explore their patient’s health-related beliefs, behaviours and treatment preferences.
PMCID: PMC4456849  PMID: 26078607
Asthma, Complementary medicine; Cystic fibrosis; Pediatrics; Respiratory illness; Survey
21.  Academic doctors' views of complementary and alternative medicine (CAM) and its role within the NHS: an exploratory qualitative study 
There has been a marked increase in the use of complementary and alternative medicine (CAM) in the UK population in recent years. Surveys of doctors' perspectives on CAM have identified a variety of views and potential information needs. While these are useful for describing the proportions of doctors who hold particular attitudes towards CAM, they are less helpful for understanding why. In addition, while the views of non-academic doctors have begun to be studied, the perspective and rationales of academic doctors remains under-researched. It seems important to investigate the views of those with a research-orientation, given the emphasis on the need for more scientific evidence in recent debates on CAM.
This exploratory study used qualitative methods to explore academic doctors' views of CAM and the rationales they provided for their views. A purposeful sampling strategy was used to identify doctors with a dual clinical and academic role in the Bristol area, with an anticipated variety of views on CAM. Semi-structured interviews were conducted with nine doctors. The data were analysed thematically, drawing on the Framework Approach.
The doctors expressed a spectrum of views on CAM, falling into three broad groups: the 'enthusiasts', the 'sceptics' and the 'undecided'. Scepticism or uncertainty about the value of CAM was prominent, except among those practising a form of CAM. A variety of rationales underpinned their perspectives on CAM, a key recurring rationale being their perspective on the scientific evidence base. The main themes arising included: the role of doctors' professional experiences of conventional medicine and CAM in shaping their attitudes towards CAM, doctor-patient communication about CAM and patient disclosure, whether there is a need for training and education in CAM for doctors, a hierarchy of acceptability of CAM and the nature of evidence; and the role of CAM within the NHS.
Despite the caution or scepticism towards CAM expressed by doctors in this study, more open doctor-patient communication about CAM may enable doctors' potential concerns about CAM to be addressed, or at least enhance their knowledge of what treatments or therapies their patients are using. Offering CAM to patients may serve to enhance patients' treatment choices and even increase doctors' fulfilment in their practice. However, given the recurring concerns about lack of scientific evidence expressed by the doctors in this study, perceptions of the evidence base may remain a significant barrier to greater integration of CAM within the NHS.
PMCID: PMC1896178  PMID: 17537248
22.  Inflammatory bowel disease professionals’ attitudes to and experiences of complementary and alternative medicine 
Complementary and alternative medicine (CAM) use in patients with IBD is on the increase. Patients report they use CAM when their condition is unresponsive to conventional medication or when they suffer from side-effects, negative stress and disease-related concerns. CAM use may improve patients’ well-being but it can also lead to side-effects and interactions with conventional medications. Research on attitudes to and experiences of CAM among healthcare professionals working with IBD patients is not well studied. Studies in this area could lead to enhanced awareness of and improved communication about CAM between care staff and IBD patients. The aim of this study was to explore IBD professionals’ attitudes to and experience of CAM.
Sixteen physicians and nurses, 26–70 years old, who had worked with IBD patients for 1–42 years, were recruited. Semi-structured qualitative interviews were conducted. Qualitative content analysis was performed.
Participants stated patients used CAM to improve their well-being generally and there conditions specifically. Participants had a positive attitude towards CAM and respected their patients’ decision to use it, but reported a lack of CAM knowledge. They required education about CAM to be able to meet patients’ needs and provide adequate information. The result of this study indicates that there is a need for CAM education to be implemented in nursing and medical school.
All participants had experience of IBD patients who had used CAM in an attempt to achieve improvement and well-being. Attitudes to CAM were mainly positive, although a problematic aspect was lack of knowledge and evidence in relation to CAM. Implementing CAM education in nursing and medical school will allow healthcare professionals to gain an understanding of therapies widely used by patients with IBD. In clinical practice, using a standard questionnaire regarding CAM use allow healthcare professionals to better understand their patients’ wishes and current CAM use.
PMCID: PMC3867669  PMID: 24325595
Attitudes CAM; Experiences; Healthcare professionals; IBD
23.  The use of complementary and alternative medicine by women experiencing menopausal symptoms in Bologna 
BMC Women's Health  2010;10:7.
The present study describes Complementary and Alternative Medicine (CAM) use amongst Italian women transitioning through menopause. Popularity and perceived effectiveness of CAM treatments, use of pharmaceutical medications, characteristics of CAM users, the extent of communication between medical practitioners and women about their use of CAM, and variables associated with CAM use were also investigated.
Women, aged 45-65 years attending Family Planning and Women's Health clinics or Menopause Centres in Bologna were invited to complete a voluntary, anonymous, self administered questionnaire, which was used in a previous study in Sydney. The questionnaire was translated and adapted for use amongst Italian women. Data on general demographic and health characteristics, menopause related symptoms and the use of CAM and pharmaceutical treatments during the previous 12 months were collected.
In total, 1,203 women completed the survey, of which 1,106 were included in the final sample. Of women who had symptoms linked with menopause and/or used remedies to alleviate symptoms, 33.5% reported to have used CAM. Among these, 23.5% had consulted one or more practitioners and 24% had used at least one CAM product.
Approximately nine out of ten respondents reported medical practitioners did not seek information about their use of CAM; while one third of CAM users did not disclose the use of CAM to their physician. Nevertheless, medical practitioners were the most popular source of information. From the multivariate analysis, variables associated with CAM use were: professional employment, time since the last natural menses, use of CAM for conditions other than menopause, and presence of some severe symptoms.
The relatively high prevalence of CAM use by women transitioning through menopause should encourage research initiatives into determining which CAM treatments are the safest and effective. The increasing and likely concomitant use of CAM with HRT and other pharmaceuticals underlines the need for the implementation of a surveillance system to report and monitor possible drug-herb adverse events. The discrepancy between women preferring to seek information about CAM from their medical doctor and the difficulties noted in communication between doctor and patient should encourage educational initiatives on CAM by health-care agencies and institutions.
PMCID: PMC2846842  PMID: 20187964
24.  Knowledge about complementary, alternative and integrative medicine (CAM) among registered health care providers in Swedish surgical care: a national survey among university hospitals 
Previous studies show an increased interest and usage of complementary and alternative medicine (CAM) in the general population and among health care workers both internationally and nationally. CAM usage is also reported to be common among surgical patients. Earlier international studies have reported that a large amount of surgical patients use it prior to and after surgery. Recent publications indicate a weak knowledge about CAM among health care workers. However the current situation in Sweden is unknown. The aim of this study was therefore to explore perceived knowledge about CAM among registered healthcare professions in surgical departments at Swedish university hospitals.
A questionnaire was distributed to 1757 registered physicians, nurses and physiotherapists in surgical wards at the seven university hospitals in Sweden from spring 2010 to spring 2011. The questionnaire included classification of 21 therapies into conventional, complementary, alternative and integrative, and whether patients were recommended these therapies. Questions concerning knowledge, research, and patient communication about CAM were also included.
A total of 737 (42.0%) questionnaires were returned. Therapies classified as complementary; were massage, manual therapies, yoga and acupuncture. Alternative therapies; were herbal medicine, dietary supplements, homeopathy and healing. Classification to integrative therapy was low, and unfamiliar therapies were Bowen therapy, iridology and Rosen method. Therapies recommended by > 40% off the participants were massage and acupuncture. Knowledge and research about CAM was valued as minor or none at all by 95.7% respectively 99.2%. Importance of possessing knowledge about it was valued as important by 80.9%. It was believed by 61.2% that more research funding should be addressed to CAM research, 72.8% were interested in reading CAM-research results, and 27.8% would consider taking part in such research. Half of the participants (55.8%) were positive to learning such therapy. Communication about CAM between patients and the health care professions was found to be rare.
There is a lack of knowledge about CAM and research about it among registered health care professions in Swedish surgical care. However, in contrast to previous studies the results revealed that the majority perceived it as important to gain knowledge in this field.
PMCID: PMC3373365  PMID: 22498305
Complementary therapies; CAM; Sweden; Surgery; Knowledge
25.  Quality of Life, Perceptions of Health and IIIness, and Complementary Therapy Use Among People with Type 2 Diabetes and Cardiovascular Disease 
To explore perceptions of health and illness, and the use of complementary and alternative medicine (CAM), among people with type 2 diabetes and/or cardiovascular disease (CVD), and relate these to quality of life.
A self-administered survey was delivered by mail and internet. The questionnaire was designed from data generated from qualitative research and other sources, to collect information on health-status, CAM use, and health and illness perceptions. Quality of life was compared among participants using Assessment of Quality of Life (AQoL-4D).
Adults with type 2 diabetes and/or CVD residing in Victoria, Australia, whether or not they used CAM therapies as well as conventional medical treatment.
Outcome measures
Comparisons were made of AQoL-4D utility scores, demographic, health and wellbeing status, care-seeking and health management behaviors, and behavioral and illness perception variables. A range of descriptive statistical and predictive modeling techniques were used to assess significant associations (p<0.01) between CAM-user and non-user populations.
From a sample of 2766 people, 45.1% had used CAM in the past 12 months and the remainder had never used CAM; ages ranged from 20-96 years. CAM-users tended to report lower (worse) quality of life measures than non-users, and a greater number of chronic conditions in addition to diabetes and CVD. Despite this, CAM-users reported their illness perception and behavioral change more positively than non-users. There was little difference between CAM and non-users in use of prescription medications despite CAM-users greater disease burden.
Higher CAM use and low quality of life appear to reflect comorbidity and poor general health. Greater evidence is needed of how CAM use might support chronic illness prevention and complement chronic disease management, with important policy implications concerning the integration of CAM therapies with mainstream health services.
PMCID: PMC3842878  PMID: 23790230

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